Ep. 31: She's So High

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Welcome to M4 Medicine, mystery,
mayhem, and sometimes murder.

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I'm Andrea Marziano and RN with
35 years of experience across

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various fields.
From direct patient care in

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hospitals to home health,
geriatrics, and injury medicine,

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I face life, death, and
everything in between.

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And I'm Crystal Miller and RN
with 13 1/2 years of experience.

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My work spans home health,
Hospice, emergency care,

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geriatrics, and occupational
health.

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From the chaos of trauma based
quiet moments with patients,

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I've seen stories that defy
explanations.

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We've been friends for over 25
years and as nurses we've shared

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countless stories that have left
us and our families speechless.

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Now we're bringing those stories
and many more to you in

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medicine, mystery, mayhem, and
sometimes murder.

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Each week, we'll uncover cases
that challenge the boundaries of

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medicine, sharing the human
stories behind the science.

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From puzzling medical mysteries
to shocking real life crimes,

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we'll bring you stories that'll
leave you questioning everything

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you thought you knew while.
We're both experiencing these

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nurses.
We want to make it clear we're

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not here to give medical advice.
This podcast is about

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storytelling, education and
exploration, not diagnosing or

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treating medical conditions.
This is medicine, mystery,

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mayhem and sometimes murder.
Let's dive in.

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Hey Crystal, how are you doing?
I'm doing well.

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How are you?
I'm very well.

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Thank you.
Anything exciting going on?

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I have another sister visit, so
that was fun, you know, as we've

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already made well known, I
guess.

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But still, I moved here to
Oklahoma from Utah a few years

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ago and majority of my family is
still in Utah.

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And so I've had a few visitors,
my parents and one of my sisters

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and her daughters and my oldest
sister just came out to visit.

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That's cool.
Yeah.

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It was a lot of fun.
She's an empty nester, so.

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And she is a workaholic.
I think it was fun for her to

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come out and just chill.
And we went to the Cowboy

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Museum, which was really cool.
It's huge.

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It's almost too big to do in one
day, but.

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What is a cowboy museum pray
tell?

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Do you have a bunch of taboo?
Well, yeah, it's a, it's a, it's

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a cowboy of the history of the
Sorry.

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It's a Museum of the history of
Cowboys.

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So like, they had saddles and
hats and lots of beating by

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Native Americans, guns, stories
about Cowboys.

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They had an interactive movie
where it was a 360° movie that

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it was really cool that just
told the history of cowboying.

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They also had a, they had a
bunch of the bunch of stuff

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about westerns and cowboy TV and
movies.

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It was cool.
I never even knew such a place

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existed.
I didn't either until my parents

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told me they had gone to it when
they came out to visit, so we

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decided we'd have a look see and
it was cool.

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And the best part?
Cowboy movie.

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I mean, she did.
She did enjoy it.

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She enjoyed it a lot.
The best part was the movie that

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was narrated by Sam Elliott
because he's the greatest cowboy

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in town, although Tom Selleck is
a close second I will say.

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Yeah, well, Tommy and I have
gone back a long way.

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I.
I do remember.

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You may be unaware of it,
however.

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Sam Elliot is also unaware of of
our special friendship so.

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Oh goodness, those poor men.
I'm sure they have quite a few

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people that would happily be
involved with them anyway, I'm

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sure.
So what do you have for us

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today?
Well, today, unrelated to

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Cowboys, I wanted to talk about
opioids in the opioid crisis,

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and not only opioid crisis, but
just also the complacency that

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kind of came about around
opioids.

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So my sources today are the US
Department of Justice, the

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Purdue Pharma Litigation and
Investigative Reporting, the

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American Medical Association
Journal of Ethics on opioid

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prescribing and regulatory
context, the Rothman Opioid

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Foundation, US congressional
Opioid hearings, and the Gosport

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Independent Panel report from
the UK.

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Wow.
So this episode is not about a

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single event or a single
villain.

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Instead, it's about a chain
reaction, a gradual shift in how

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medicine understood pain, how
clinicians prescribe treatment,

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how corporate incentives
interacted with that shift, and

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what happened when normalization
went largely unquestioned.

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The opioid crisis did not begin
with fentanyl or with criminal

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prosecutions.
It began with a belief that pain

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was undertreated and that modern
medicine could respond more

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compassionately and effectively.
That belief was not inherently

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wrong.
For decades, many, many

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patients, particularly those
living with chronic illness,

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cancer, or post surgical pain,
experienced inadequate pain

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management.
Clinicians were increasingly

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encouraged to treat pain more
seriously, to measure it more

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consistently, and to view relief
as a central component of care.

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Overtime, this belief reshaped
expectations among patients,

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clinicians, and healthcare
systems alike, and those

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expectations influenced
prescribing behavior.

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In this episode, we follow that
shift step by step.

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We examine how the narrative
around pain changed, how

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prescribing expanded in
practice, how some actors

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exploited the environment that
emerged, and how normalization

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could create harm even without
clear malicious intent.

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These stories involving Purdue
Pharma, opioid pill mills,

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Incest therapeutics and the
Gosport Hospital scandal are

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distinct, but they reveal a
shared pattern about systems,

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incentives and trust.
Well, I remember back when I was

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first a nurse in the 80s, late
80s, early 90s, how pain was

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really ignored in a lot of
situations.

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And I'm sure you'll be talking
about some of this, but

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especially people who were end
of life pain situations, as you

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mentioned cancer, because I
think the theory had been and it

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like many things, swings very
far both directions.

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So in the 8 late 80s, as I
remember it, people who are

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having a cancer end of life
experience did not get much in

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the way of pain medications
because people believed that

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they didn't feel the pain,
right.

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But then they'd watch them and
they'd be agitated, they'd be

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all upset and everything else.
So they realized that maybe it

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was pain.
So they started to address the

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pain.
And then people were worried

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about them getting addicted.
And everyone was saying yeah,

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but they're dying.
So.

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Even if they do, in this next 4
hours they're dying, actively

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dying.
So they started to not worry

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about that and really look at
keeping the patient comfortable.

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And then other people who had
chronic pain, I have

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fibromyalgia, so I have chronic
pain and I've never taken pain

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medications for it because I've
seen the slippery slope that my

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clients have been on when they
had this and other pain

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syndromes.
So I've never taken pain

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medication for it because I
don't think, I mean, I would

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love to be out of pain, but I
think that is not the best way

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to go.
There's a lot of things that I

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can do that help me more, I
think and still have quality of

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life, but there's that balance.
And then a lot of the pain

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medicine specialist got on board
and they started being able to

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control it a little bit more.
I'm interested to see what you

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say because I, I've experienced
it for 36 years in the

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profession and to see what kinds
of things you're going to bring

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out today.
So carry on.

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Sure.
In the in the 1990s, medicine

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was increasingly focused on
improving pain treatment.

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Professional organizations,
patient advocacy groups, and

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healthcare institutions
emphasized that pain was

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frequently undertreated and that
clinicians should respond more

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aggressively to patient
discomfort.

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Like you were saying, right, And
this is right.

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About that time, this
environment created a receptive

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context for new pharmaceutical
approaches to pain management,

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including extended release
opioid medications.

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When Purdue Pharma introduced
Oxycontin, it was presented as a

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long acting opioid that can
provide sustained relief and

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improved quality of life.
Marketing materials and

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educational messaging emphasized
convenience, effectiveness, and

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most controversially, suggested
that addiction risk was lower

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when opioids were used
appropriately for pain

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treatment.
That claim later became central

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to litigation and regulatory
scrutiny, but at the time it

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contributed to changing
perception among many

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clinicians.
Well, I was interested in

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interesting in that regard.
What I was taught when I was in

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nursing school is that I'm using
my hands as demonstration

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listeners.
I put one hand up, fingers open,

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the other hand joins that other
and it closes what are

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considered the cogs of pain.
And when those cogs are closed

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and all the pain medication is
going into those spaces, things

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are OK.
And people aren't usually going

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to get addiction because they're
not feeling the high that they

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get when there's extra pain
medication flowing around in the

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system.
And that theory was very well,

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that was very well thought of
and spread in the late 80s,

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early 90s.
So I imagine we've, well, I know

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we've learned a lot since then
that maybe that wasn't as true

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as we thought.
So.

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Well, it, it is true, but
there's a caveat and that is

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let's say you have so, so the
way the opioids work, there's a

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receptor on a cell or whatever.
There's a receptor and that

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receptor is either is filled
with a pain signal or if you're

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taking opioids, it's filled with
an opioid signal.

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So basically those opioids go in
and they fill that receptor spot

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with themselves instead of the
pain signal.

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And so when Andrea was doing
that demonstration with the five

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fingers spread apart and the
kind of the cogs fitting in like

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in a watch works or clockwork,
that is true.

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Those those five areas get
filled in with that opioid pain

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medication instead of instead of
the pain signal.

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But what it turns out our body
does is it then responds to the

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pain or the cause of the pain by
creating another receptor point

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and creating another receptor
point and creating another

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receptor point.
So then suddenly you've got

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quote UN quote, 5 opioids in
your 5 pain receptors that were

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making you feel comfortable, but
now you have 5 opioid signals in

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nine receptors.
So now you've got 4 receptors

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that don't have that and you're
out of opioids, right?

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You only had enough to fill 5
receptors.

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And so now you've got to take
more opioids to fill those new

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receptors and those that grows
and grows.

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And so you can see how that
could go from, I mean, we're

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way, we're way putting the, the
cart before the horse, but I'm

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fine with it.
But you can see how that can go

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from, you know, simply taking
Lortab because you have back

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pain to heroin because it's $8 a
bag instead of $100 a pill for

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oxyglatin right on the street,
street, street prices.

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And so, and so that's the
problem.

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And that's what unfortunately
what was ignored or I don't, I

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don't know.
I didn't look to see when we

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discovered this part of it, but
well, I think it was, I think

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it, I'm not saying it was
ignored by medicine and

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clinicians.
I'm saying it was, it was

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ignored by big pharma, by a.
Pharmaceutical country, I

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totally agree with.
I think that as clinicians, we

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started seeing it backfiring
pretty early on.

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I think it was maybe 5 or 10
years in to the real push of

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let's deal with everybody's
pain, and then we started

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shifting over to things like
biofeedback, meditations, other

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kinds of strategies to deal with
the pain instead of just

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opioids.
That's how it worked in my

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practice anyway.
But the problem with that is in

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a lot of cases, the floodgates
were open and it's very

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difficult to, yeah, it's very
difficult to put a flood back

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into a levy.
Hard to close the gates back up.

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Yeah, so one of the things that
Purdue Pharma did, and I don't

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know if you've seen the movie
Dope Sick with Michael Keaton,

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it's a great, it's a great movie
about Purdue and the Oxycontin

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scandal.
But one of the things they did

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is as they sent out their
pharmaceutical reps, their

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marketing material and their
marketing push was that

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Oxycontin was not Oxycontin
contin.

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Gosh, it's so hard when there's
Oxycontin, oxycodone, Oxycontin.

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So this is Oxycontin with an
NOXYCONTIN.

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They said that Oxycontin was not
addictive, that it was somehow

229
00:12:46,080 --> 00:12:48,760
miraculously, unlike other
opioids, not addictive.

230
00:12:48,880 --> 00:12:53,040
And yeah, well, and they pushed
it and they pushed it hard.

231
00:12:53,120 --> 00:12:56,040
So the result was not an
immediate transformation, but it

232
00:12:56,040 --> 00:12:59,160
was a gradual cultural shift.
Doctors started believing this,

233
00:12:59,160 --> 00:13:01,520
this marketing, right.
Opioids begin to move beyond

234
00:13:01,520 --> 00:13:04,920
their traditional association
with severe or end of life pain

235
00:13:04,920 --> 00:13:08,080
and into routine medical care,
including treatment for chronic

236
00:13:08,080 --> 00:13:11,400
musculoskeletal conditions, back
injuries, and recovery after

237
00:13:11,640 --> 00:13:15,160
relatively common procedures.
Pain assessment became more

238
00:13:15,160 --> 00:13:17,360
standardized, patient
satisfaction measures

239
00:13:17,680 --> 00:13:20,120
increasingly included pain
control, and prescribing

240
00:13:20,120 --> 00:13:24,240
patterns expanded accordingly.
Do you remember the 5th vital

241
00:13:24,240 --> 00:13:26,040
sign?
The pain scale.

242
00:13:26,520 --> 00:13:31,000
Yeah, the so one of the things
that was actually a came from

243
00:13:31,000 --> 00:13:32,960
marketing was this fifth vital
sign.

244
00:13:33,240 --> 00:13:36,880
So we have, you know,
traditionally we had heart rate,

245
00:13:37,120 --> 00:13:41,200
blood pressure, temperature and
oxygen saturation, right?

246
00:13:41,440 --> 00:13:45,000
That right for I think.
We had some.

247
00:13:45,320 --> 00:13:47,760
Yeah, yeah.
And then they started, they

248
00:13:47,760 --> 00:13:50,200
started into, they started
calling it the 5th vital signs

249
00:13:50,200 --> 00:13:53,920
where, you know, you had to, it
was part of what was required in

250
00:13:53,920 --> 00:13:56,800
every assessment, which is fine.
I think that that's still is

251
00:13:56,800 --> 00:13:59,040
accurate.
But it's the commercialization

252
00:13:59,040 --> 00:14:02,520
of it and the gimmicking of it
that I disagree with from the

253
00:14:02,640 --> 00:14:04,800
from these pharmaceutical
companies, right.

254
00:14:05,600 --> 00:14:07,640
You know, it's an important,
it's important to recognize that

255
00:14:07,640 --> 00:14:09,280
most clinicians were acting in
good faith.

256
00:14:09,680 --> 00:14:12,360
They were responding to evolving
guidelines, to patient needs, to

257
00:14:12,360 --> 00:14:15,280
professional expectations.
However, once prescribing norms

258
00:14:15,280 --> 00:14:17,280
shift, they tend to reinforce
themselves.

259
00:14:17,800 --> 00:14:20,840
Patients come to expect relief,
clinicians seek to avoid under

260
00:14:20,840 --> 00:14:23,680
treatment, and healthcare
systems adapt workloads to

261
00:14:23,680 --> 00:14:27,520
reflect prevailing practices.
Over time, something that once

262
00:14:27,520 --> 00:14:30,840
felt exceptional can begin to
feel routine, even when long

263
00:14:30,840 --> 00:14:32,640
term risks are not fully
understood.

264
00:14:32,960 --> 00:14:38,040
I remember when I got my first
tattoo long time ago, I was able

265
00:14:38,040 --> 00:14:42,160
to get Lortab to have that
tattoo, to get that tattoo and.

266
00:14:42,200 --> 00:14:44,400
You mean you were actually on
Lortab when they gave you the

267
00:14:44,400 --> 00:14:47,080
tattoo?
I got Lortab to have the tattoo.

268
00:14:47,080 --> 00:14:48,160
I didn't, yeah, I didn't tell
the.

269
00:14:48,160 --> 00:14:50,360
I didn't tell the tattoo people.
As a Lortab, they wouldn't give

270
00:14:50,360 --> 00:14:52,760
me a tattoo.
I know that's what I was

271
00:14:52,760 --> 00:14:55,080
thinking because.
Back actually way, way earlier.

272
00:14:55,080 --> 00:14:59,280
This just reminded me way, way
earlier, way earlier in the

273
00:15:00,160 --> 00:15:02,560
Let's see if let me do a little
head math.

274
00:15:03,120 --> 00:15:06,320
In the late 90s, I was able and
I say able.

275
00:15:06,320 --> 00:15:09,600
I didn't ask for this, but I was
able to get Lortab for

276
00:15:09,600 --> 00:15:13,440
migraines, which I, you know, I
know now Lortab can't touch a

277
00:15:13,440 --> 00:15:15,840
migraine.
Like that's those are apples and

278
00:15:15,840 --> 00:15:19,000
oranges.
It can also make it worse.

279
00:15:19,480 --> 00:15:23,560
Yeah, that was actually my first
experience with taking an opioid

280
00:15:24,400 --> 00:15:30,400
and not getting pain relief from
it and just feeling like weird.

281
00:15:30,400 --> 00:15:34,520
And it was my that was like my,
that was my point, right?

282
00:15:34,520 --> 00:15:35,520
Where I could have gone either
way.

283
00:15:35,560 --> 00:15:39,240
I think I could have gone like
oh this weird is good but I was

284
00:15:39,240 --> 00:15:41,920
like this weird sucks and I did
not like it.

285
00:15:43,160 --> 00:15:45,960
I think people tend to be on one
side of the fence or the other.

286
00:15:45,960 --> 00:15:48,080
I don't think a lot of people
are right in the middle.

287
00:15:48,360 --> 00:15:50,640
Yeah, I agree.
As the narrative around pain

288
00:15:50,640 --> 00:15:52,600
changed, behavior changed
alongside it.

289
00:15:52,800 --> 00:15:55,200
Prescribing patterns do not
transform overnight.

290
00:15:55,200 --> 00:15:57,800
They shift gradually through
daily clinical decisions,

291
00:15:58,080 --> 00:16:00,400
patient expectations and
institutional practices.

292
00:16:00,880 --> 00:16:03,600
This incremental change created
an environment in which high

293
00:16:03,600 --> 00:16:06,680
volume prescribing became more
plausible and in some cases,

294
00:16:06,680 --> 00:16:08,680
less likely to trigger immediate
concern.

295
00:16:09,120 --> 00:16:12,360
It's within that environment
that opioid pill mills emerged.

296
00:16:13,320 --> 00:16:16,400
The term pill mill can invoke
images of overtly illicit

297
00:16:16,400 --> 00:16:19,320
operations, but many of these
clinics appeared outwardly

298
00:16:19,320 --> 00:16:21,160
conventional.
They operated in office

299
00:16:21,160 --> 00:16:23,800
settings, employed medical
staff, and conducted patient

300
00:16:23,800 --> 00:16:25,440
visits that resembled standard
care.

301
00:16:25,800 --> 00:16:28,160
The defining characteristic was
thought appearance.

302
00:16:28,160 --> 00:16:31,560
But prescribing behavior,
specifically the provision of

303
00:16:31,560 --> 00:16:34,480
large quantities of controlled
substances without adequate

304
00:16:34,480 --> 00:16:37,440
evaluation, monitoring or
medical justification.

305
00:16:38,640 --> 00:16:41,560
Common warning signs eventually
became widely recognized,

306
00:16:41,760 --> 00:16:46,000
including cash only payment
models, Yikes times, Yikes to

307
00:16:46,000 --> 00:16:51,000
the Yikes degree, extremely
brief appointments, minimal

308
00:16:51,000 --> 00:16:53,720
diagnostic testing, and
prescription volumes that far

309
00:16:53,720 --> 00:16:55,520
exceeded typical clinical
practice.

310
00:16:55,760 --> 00:16:58,880
In some regions, certain clinics
developed reputations that

311
00:16:58,880 --> 00:17:01,680
attracted patients traveling
significant distances,

312
00:17:01,720 --> 00:17:04,920
suggesting that high volume
prescribing was both visible and

313
00:17:04,920 --> 00:17:08,400
at times tolerated before
regulatory intervention

314
00:17:08,560 --> 00:17:11,000
occurred.
So have you seen their

315
00:17:11,000 --> 00:17:14,839
representations of pill mills
television or maybe even seen

316
00:17:14,839 --> 00:17:15,760
one in real life?
I don't know.

317
00:17:15,800 --> 00:17:18,319
I haven't seen one in real life.
Yeah, well, I heard about him,

318
00:17:18,319 --> 00:17:21,920
especially as I was living
through this as a nurse, where

319
00:17:22,240 --> 00:17:27,400
the doctors were pulling back on
the prescriptions because they

320
00:17:27,400 --> 00:17:30,120
realized that there was a big
problem being created.

321
00:17:31,080 --> 00:17:36,240
So people started pill shopping.
They go to these places for the

322
00:17:36,240 --> 00:17:38,560
pills.
And it was before there was a

323
00:17:38,560 --> 00:17:42,520
nationwide system saying who was
on what and the pharmaceutical,

324
00:17:42,760 --> 00:17:44,600
I don't know what, I can't
remember what it's called, but

325
00:17:44,600 --> 00:17:47,080
where it's all connected on the
computer.

326
00:17:47,080 --> 00:17:50,440
So someone would get flagged if
they have another opioid

327
00:17:50,440 --> 00:17:53,080
prescription.
It was really easy to pill and

328
00:17:53,080 --> 00:17:56,080
or doctor shot.
So we did see it and we saw some

329
00:17:56,080 --> 00:17:58,680
of the results of it and we saw
a lot more people becoming

330
00:17:58,680 --> 00:18:01,640
addicted or staying addicted.
I'd I should probably say that

331
00:18:01,640 --> 00:18:04,040
staying addicted rather than
becoming addicted because they

332
00:18:04,040 --> 00:18:06,360
already were addicted in most
places.

333
00:18:06,720 --> 00:18:09,800
Well, the thing that gets me
part of the problem with this

334
00:18:09,800 --> 00:18:14,640
opioid epidemic that we've had
in the US is that how many, how

335
00:18:14,680 --> 00:18:18,920
many news stories have you seen
where the car is in the middle

336
00:18:18,920 --> 00:18:23,240
of an intersection and both the
driver and the passenger are

337
00:18:23,240 --> 00:18:26,400
just doped out?
Like they've shot up at the

338
00:18:26,400 --> 00:18:30,000
intersection at the red light.
And they've been a lot, a lot,

339
00:18:30,000 --> 00:18:32,960
unfortunately, far too many
where a child is in the car,

340
00:18:32,960 --> 00:18:37,080
right.
It's astounding to me how far

341
00:18:37,360 --> 00:18:42,480
this has gone to the point where
suburban neighborhoods have a

342
00:18:42,480 --> 00:18:45,960
heroin problem.
You know, the affluent have a

343
00:18:45,960 --> 00:18:49,400
heroin problem like, and it all
stems from, and we're going to

344
00:18:49,400 --> 00:18:52,560
get into this a little bit more,
but it all stems from this cry,

345
00:18:52,560 --> 00:18:57,080
this call for change, which I
think was legitimate.

346
00:18:57,080 --> 00:18:59,520
Like you were saying, we need to
treat pain better.

347
00:18:59,520 --> 00:19:03,800
We need to be more responsive to
people's complaints of pain.

348
00:19:04,240 --> 00:19:08,720
And the people who took
advantage of that by saying,

349
00:19:08,840 --> 00:19:10,760
hey, we have an answer.
That's a miracle.

350
00:19:10,800 --> 00:19:12,600
I mean, frankly, that's what
they were saying.

351
00:19:12,600 --> 00:19:14,240
Whether they use that word or
not, that's what they were

352
00:19:14,240 --> 00:19:15,520
saying.
We have an answer.

353
00:19:15,520 --> 00:19:18,880
We have an answer to this call.
And that answer was actually

354
00:19:18,880 --> 00:19:22,800
when ice picked to the eyeball.
The existence of pill mills

355
00:19:22,800 --> 00:19:25,960
reflects a complex intersection
of factors rather than a single

356
00:19:25,960 --> 00:19:28,440
cause.
Chronic pain is real and often

357
00:19:28,440 --> 00:19:31,240
difficult to treat, and many
patients sought relief in a

358
00:19:31,240 --> 00:19:33,440
healthcare system that
increasingly emphasized

359
00:19:33,440 --> 00:19:36,520
addressing pain.
At the same time, expanding

360
00:19:36,520 --> 00:19:39,000
prescribing norms altered
expectations and created

361
00:19:39,000 --> 00:19:41,480
pressures that affected both
clinicians and patients.

362
00:19:41,600 --> 00:19:45,320
Long term opioid therapy became
more common, and in that

363
00:19:45,320 --> 00:19:48,840
context, high volume prescribing
could appear less anomalous than

364
00:19:48,840 --> 00:19:50,760
it might have been earlier
decades.

365
00:19:52,120 --> 00:19:54,880
Like we were saying, research
indicates that exposure to

366
00:19:54,880 --> 00:19:58,200
prescription opioids played a
meaningful role in the product

367
00:19:58,200 --> 00:20:02,240
trajectory of the opioid crisis,
including increased risk of

368
00:20:02,240 --> 00:20:05,680
dependence for some individuals.
Pill mills contributed to this

369
00:20:05,680 --> 00:20:08,400
exposure by amplifying
prescribing patterns beyond what

370
00:20:08,400 --> 00:20:12,080
was medically appropriate.
However, they did not create the

371
00:20:12,080 --> 00:20:14,720
environment in which such
practices could occur, they

372
00:20:14,720 --> 00:20:17,560
operated within it.
As prescribing volume increase,

373
00:20:17,560 --> 00:20:20,560
the influence of financial and
systemic incentives became more

374
00:20:20,560 --> 00:20:22,800
pronounced.
Setting the stage for more

375
00:20:22,800 --> 00:20:24,920
deliberate forms of
exploitation.

376
00:20:25,840 --> 00:20:32,120
So I'm curious to know if you've
heard of Incest I Insys, INSYS

377
00:20:32,120 --> 00:20:35,680
Therapeutics or their product
Subsys?

378
00:20:36,760 --> 00:20:38,360
Don't think so.
OK.

379
00:20:38,360 --> 00:20:40,360
I hadn't heard of it before I
did this research either.

380
00:20:40,880 --> 00:20:42,720
I'd heard of Purdue a lot,
right?

381
00:20:42,760 --> 00:20:46,640
But Insys, I'd never heard of.
So Insys Therapeutics represents

382
00:20:46,640 --> 00:20:50,320
a later phase in this, in this
trajectory in which existing

383
00:20:50,320 --> 00:20:53,000
prescribing norms created
opportunities for targeted

384
00:20:53,000 --> 00:20:55,440
manipulation.
The company's primary product,

385
00:20:55,440 --> 00:20:59,040
Subsys, was a fentanyl spray
approved for breakthrough cancer

386
00:20:59,040 --> 00:21:01,480
pain.
Fentanyl has legitimate medical

387
00:21:01,480 --> 00:21:04,920
uses but is significantly more
potent than many other opioids,

388
00:21:05,160 --> 00:21:07,880
making careful prescribing
oversight particularly

389
00:21:07,880 --> 00:21:10,160
important.
A lot of St. drugs have fentanyl

390
00:21:10,160 --> 00:21:12,480
in them now too.
A lot that's.

391
00:21:13,320 --> 00:21:15,920
Why people are dying?
Right now, Yep, Yep.

392
00:21:16,640 --> 00:21:19,760
It's so bizarre to me because
why are you killing your

393
00:21:19,760 --> 00:21:21,480
customers bro?
Right.

394
00:21:21,480 --> 00:21:23,520
That doesn't seem like it could
business strategy.

395
00:21:24,000 --> 00:21:27,160
I digress.
Federal Investigations letter

396
00:21:27,480 --> 00:21:30,880
later demonstrated that INSYS
implemented programs that

397
00:21:30,880 --> 00:21:34,240
incentivize prescribing through
speaker events that in numerous

398
00:21:34,240 --> 00:21:37,600
instances functioned as payments
linked to prescription volume.

399
00:21:38,800 --> 00:21:41,280
While speaker programs are
common within pharmaceutical

400
00:21:41,280 --> 00:21:44,520
markets, evidence presented in
court showed that some events

401
00:21:44,520 --> 00:21:47,680
had little substantive
educational content and that

402
00:21:47,680 --> 00:21:50,680
prescribing patterns were
closely tied to participation.

403
00:21:52,120 --> 00:21:55,120
I'm really curious to know if
you've ever been to a speaker

404
00:21:55,120 --> 00:21:57,280
event.
I know you're not a prescriber,

405
00:21:57,280 --> 00:22:00,720
and I'm not a prescriber, but I
have been to 1.

406
00:22:01,040 --> 00:22:04,640
I wish I could remember the drug
that it was for, but I remember

407
00:22:04,640 --> 00:22:08,440
I was there because I was the
director of nursing for a

408
00:22:08,440 --> 00:22:11,760
nursing home.
The speaker event is for people

409
00:22:11,760 --> 00:22:15,400
who are only drug reps or
doctors.

410
00:22:15,440 --> 00:22:18,040
Usually it's for doctors, it's
for prescribers.

411
00:22:18,160 --> 00:22:22,680
It's for prescribers.
OK, so the doctor that was the

412
00:22:22,920 --> 00:22:26,440
the medical director of my
facility had invited me to this

413
00:22:26,440 --> 00:22:32,520
one and it was crazy.
I like I said, I don't remember

414
00:22:32,520 --> 00:22:36,960
what drug it was for, but it was
this high end meal like like

415
00:22:36,960 --> 00:22:41,360
Ruth's Chris high end meal and
widened and dined.

416
00:22:41,400 --> 00:22:44,880
And then while we were eating,
they passed out Flyers and

417
00:22:44,880 --> 00:22:46,760
talked about how great their
drug was.

418
00:22:46,760 --> 00:22:49,640
And I remember at the time, I
don't, I wish I could remember

419
00:22:49,680 --> 00:22:52,840
what drug it was, but I remember
at the time being like, they're

420
00:22:52,840 --> 00:22:55,280
really pushing this drug that I
don't think we need in our

421
00:22:55,280 --> 00:22:57,600
facility.
Yeah, yeah.

422
00:22:58,000 --> 00:23:00,880
And I feel like that's why they
had me there was so that I would

423
00:23:00,880 --> 00:23:03,000
basically back up the medical
director.

424
00:23:03,800 --> 00:23:07,360
Do you think all the drugs that
are now on TV, do you think

425
00:23:07,680 --> 00:23:10,120
instead of doing those speaker
events, they've now brought it

426
00:23:10,120 --> 00:23:12,040
to the public?
So the public demands it.

427
00:23:13,160 --> 00:23:15,440
I wouldn't be surprised.
I mean, I don't know that, but I

428
00:23:15,440 --> 00:23:18,120
totally wouldn't be surprised
because yeah, it felt, it felt

429
00:23:18,120 --> 00:23:21,160
clandestine.
And I mean, it felt akin to

430
00:23:21,160 --> 00:23:23,480
being in a Speakeasy during
Prohibition, you know what I

431
00:23:23,480 --> 00:23:24,480
mean?
Like it was.

432
00:23:24,800 --> 00:23:28,960
Did you need your password?
Yeah, you need your password.

433
00:23:28,960 --> 00:23:31,880
You needed your gold.
You needed your gold gilded

434
00:23:31,880 --> 00:23:34,520
invitation.
Oh my goodness, that's wild

435
00:23:34,520 --> 00:23:35,720
though.
It was wild.

436
00:23:35,760 --> 00:23:40,600
It was wild.
So in 2019, multiple executives

437
00:23:40,600 --> 00:23:43,720
were convicted in a racketeering
conspiracy involving physician

438
00:23:43,720 --> 00:23:47,600
bribery and deceptive practices
related to insurance approvals,

439
00:23:47,600 --> 00:23:49,800
according to the US Department
of Justice reporting.

440
00:23:49,880 --> 00:23:52,560
That reminds me, did you know
that there's also a website

441
00:23:53,000 --> 00:23:56,680
where you can go and see what
incentives your doctor is

442
00:23:56,680 --> 00:23:59,440
getting for specific
prescription medications?

443
00:24:00,880 --> 00:24:03,560
So they're not kickbacks because
kickbacks are illegal.

444
00:24:03,800 --> 00:24:06,480
That's right.
There is a work around.

445
00:24:06,480 --> 00:24:09,720
Yeah.
There's a loophole where your

446
00:24:09,720 --> 00:24:14,640
doctor can be incentivized in
some way to prescribe a certain

447
00:24:14,640 --> 00:24:16,600
brand of medication.
And you can.

448
00:24:16,600 --> 00:24:18,640
I wish I knew what that was.
You can look it up.

449
00:24:18,960 --> 00:24:20,600
Can look up what incentive?
What?

450
00:24:21,000 --> 00:24:23,120
I don't remember any of my
doctors names anymore that I

451
00:24:23,120 --> 00:24:26,280
worked with, but I just
remembered one.

452
00:24:26,280 --> 00:24:28,680
That's funny.
Anyway, if I find it, I'll put

453
00:24:28,680 --> 00:24:31,640
it in the show notes because
it's really interesting to go

454
00:24:31,640 --> 00:24:34,560
and look and see what what
incentives folks have.

455
00:24:35,200 --> 00:24:37,000
That's crazy.
And that's not to say that, I

456
00:24:37,000 --> 00:24:39,720
mean, you know, they can be
incentivized whether they were

457
00:24:39,720 --> 00:24:41,960
going to prescribe it or not,
like, right, there are going to

458
00:24:41,960 --> 00:24:45,680
be some drugs that that are are
that makes sense to prescribe

459
00:24:45,680 --> 00:24:47,800
and just happen to also have an
incentive.

460
00:24:47,800 --> 00:24:51,400
I don't want to vilify doctors
by any stretch, but I mean, if

461
00:24:51,400 --> 00:24:55,200
you if I were to look up my
doctor and they were

462
00:24:55,200 --> 00:24:58,320
incentivized to prescribe a
whole bunch of medications from

463
00:24:58,320 --> 00:25:01,440
only one pharmaceutical company,
I might question it.

464
00:25:01,440 --> 00:25:03,160
And this is almost my personal
opinion.

465
00:25:03,160 --> 00:25:05,520
Again, I don't want to vilify
doctors as a whole.

466
00:25:05,520 --> 00:25:08,800
But anyway, there was a time
when it was actual bribery.

467
00:25:08,920 --> 00:25:11,040
Like I said, multiple
executives, executives were

468
00:25:11,040 --> 00:25:13,720
convicted.
I'm rack and tiercing on

469
00:25:14,760 --> 00:25:17,600
racketeeracy.
That's the new that's the new

470
00:25:17,600 --> 00:25:19,200
phrase for racketeering
conspiracy.

471
00:25:19,200 --> 00:25:23,200
It's Racketeeracy.
Very serious.

472
00:25:23,360 --> 00:25:28,120
And these convictions marked a
notable shift in accountability,

473
00:25:28,120 --> 00:25:31,800
as pharmaceutical misconduct had
historically resulted more often

474
00:25:31,800 --> 00:25:34,560
in corporate settlements than in
criminal convictions for

475
00:25:34,560 --> 00:25:37,120
leaderships.
Yeah.

476
00:25:37,120 --> 00:25:39,440
Court records also indicated
that employees sometimes

477
00:25:39,440 --> 00:25:42,160
Vikram's.
Why can't I talk today?

478
00:25:42,680 --> 00:25:45,560
I don't know.
Court records also indicated

479
00:25:45,560 --> 00:25:49,360
that employees sometimes
misrepresented patient diagnosis

480
00:25:49,680 --> 00:25:52,120
to facilitate insurance coverage
for the drug.

481
00:25:53,000 --> 00:25:57,320
Oh no.
Yeah, So INSIST did not create

482
00:25:57,320 --> 00:25:59,480
the prescribing environment that
allowed this strategy to

483
00:25:59,480 --> 00:26:03,160
succeed, but it leveraged it.
The healthcare system, already

484
00:26:03,160 --> 00:26:06,160
accustomed to broader opioid
prescribing, became vulnerable

485
00:26:06,160 --> 00:26:09,000
to incentives that promoted
stronger medications and higher

486
00:26:09,000 --> 00:26:11,920
volumes.
This phase of the opioid crisis

487
00:26:11,920 --> 00:26:15,040
highlights the distinction
between systemic pressures and

488
00:26:15,040 --> 00:26:17,840
intentional misconduct,
illustrating how structural

489
00:26:17,840 --> 00:26:21,280
change can create conditions
that some actors choose to

490
00:26:21,280 --> 00:26:23,440
exploit.
And I want to reiterate that

491
00:26:23,440 --> 00:26:26,640
when I say the distinction
between systemic pressures and

492
00:26:26,640 --> 00:26:29,160
intentional misconduct, I'm
specifically saying that

493
00:26:29,200 --> 00:26:33,080
necessarily not intentional
misconduct from the prescribers,

494
00:26:33,360 --> 00:26:37,720
I think that both Insist and
Purdue were behind systemic

495
00:26:37,720 --> 00:26:40,920
pressures and, and frankly,
intentional misconduct.

496
00:26:40,920 --> 00:26:41,960
I they knew what they were
doing.

497
00:26:41,960 --> 00:26:45,280
And, and that's been proven
through, you know, many lawsuits

498
00:26:45,280 --> 00:26:49,960
and, and other historical
events.

499
00:26:50,200 --> 00:26:54,680
So, So what happens when our
culture changes?

500
00:26:54,680 --> 00:27:00,640
What happens when our culture
shifts and opioids are not a

501
00:27:00,880 --> 00:27:04,200
last resort?
So much of our public discussion

502
00:27:04,200 --> 00:27:07,080
on the opioid crisis crisis
focuses on addiction

503
00:27:07,080 --> 00:27:08,600
distribution of corporate
behavior.

504
00:27:09,040 --> 00:27:12,320
However, opioid related harm can
also emerge within routine

505
00:27:12,320 --> 00:27:15,480
clinical care through patterns
that develop gradually and

506
00:27:15,480 --> 00:27:19,400
become normalized over time.
The Gosport case illustrates how

507
00:27:19,400 --> 00:27:22,480
prescribing culture,
institutional hierarchy, and

508
00:27:22,480 --> 00:27:24,680
delayed accountability can
intersect in ways that are

509
00:27:24,680 --> 00:27:26,720
difficult to detect while they
are unfolding.

510
00:27:26,880 --> 00:27:29,440
So before I start with this
story, I want to make it very

511
00:27:29,440 --> 00:27:35,840
clear that the Godsport Hospital
case is not a direct result of

512
00:27:35,840 --> 00:27:40,960
the United States opioid crisis.
It's just another example of how

513
00:27:41,680 --> 00:27:47,480
complacency and small shifts and
changes can turn into large

514
00:27:47,640 --> 00:27:51,120
scale problems.
Boiling the frog as it were,

515
00:27:51,120 --> 00:27:52,480
right?
You drop the frog in boiling

516
00:27:52,480 --> 00:27:54,520
water, it's going to pop out as
fast as it can.

517
00:27:54,520 --> 00:27:58,000
You put a frog in water and
start it to boil, it'll it'll

518
00:27:58,000 --> 00:28:01,760
let itself become soup.
There are some medical scandals

519
00:28:01,760 --> 00:28:05,000
that begin with a clear event, a
single mistake, a whistleblower

520
00:28:05,000 --> 00:28:07,800
document, a lawsuit that exposes
everything at once.

521
00:28:08,280 --> 00:28:10,200
Gosport was not that kind of
story.

522
00:28:10,560 --> 00:28:13,360
Gosport unfolded slowly,
quietly, and in ways that were

523
00:28:13,360 --> 00:28:17,520
easy to overlook in real time.
Gosport War Memorial Hospital in

524
00:28:17,520 --> 00:28:20,800
Hampshire, England, was not an
acute emergency hospital.

525
00:28:21,120 --> 00:28:23,840
It was a Community Hospital that
primarily cared for older

526
00:28:23,840 --> 00:28:27,720
patients who were recovering,
stabilizing, or transitioning

527
00:28:27,720 --> 00:28:30,080
from hospital treatment to home
or long term care.

528
00:28:30,960 --> 00:28:33,880
Families expected
rehabilitation, monitoring and

529
00:28:33,880 --> 00:28:36,880
supportive care.
Many patients admitted there

530
00:28:37,120 --> 00:28:39,880
were vulnerable, but they were
not necessarily dying.

531
00:28:40,240 --> 00:28:42,360
Would this be like our rehab
facilities here?

532
00:28:42,360 --> 00:28:43,720
Yeah.
This would be like our rehab

533
00:28:43,720 --> 00:28:46,160
facilities, exactly like
Medicare rehab facilities.

534
00:28:46,160 --> 00:28:48,600
So somewhere you would go for
like a knee replacement to

535
00:28:48,600 --> 00:28:53,800
recover, hip replacement, orif,
you know, fracture repair like

536
00:28:53,800 --> 00:28:55,880
that.
In the late 1980s and throughout

537
00:28:55,880 --> 00:28:58,720
the 1990s, one thing began
happening that families struggle

538
00:28:58,760 --> 00:29:02,000
struggled to explain.
Relatives would be admitted for

539
00:29:02,000 --> 00:29:04,800
recovery, sometimes after
surgery, sometimes after

540
00:29:04,800 --> 00:29:07,800
illness, and their condition
would deteriorate rapidly.

541
00:29:08,280 --> 00:29:11,200
In a number of cases, death
followed soon after admission.

542
00:29:11,600 --> 00:29:14,800
Individually, these deaths did
not always appear suspicious.

543
00:29:14,960 --> 00:29:18,000
The patients were elderly, many
had complex health issues.

544
00:29:18,400 --> 00:29:20,640
Medicine often involves
uncertainty, and unexpected

545
00:29:20,640 --> 00:29:23,040
decline is not uncommon in older
populations.

546
00:29:23,600 --> 00:29:27,080
What made Gosport different was
the pattern families begin

547
00:29:27,080 --> 00:29:30,360
noticing similarities,
particularly around medication.

548
00:29:30,400 --> 00:29:33,800
One of the This kills me, one of
the medications repeatedly

549
00:29:33,800 --> 00:29:38,520
raised in concerns was
diamorphine, powerful opioid

550
00:29:38,800 --> 00:29:42,680
used legitimately in end of life
care and severe pain management.

551
00:29:43,200 --> 00:29:45,200
So do you know what diamorphine
is?

552
00:29:45,680 --> 00:29:47,920
I remember hearing of it, but I
don't really know.

553
00:29:48,480 --> 00:29:55,200
It's heroin, full stop.
Yes, it's medicinal heroin, so

554
00:29:55,200 --> 00:29:57,920
at Gosport, opioids were often
administered using syringe

555
00:29:57,920 --> 00:30:00,560
drivers, which deliver
continuous medication over time.

556
00:30:00,560 --> 00:30:03,400
Syringe drivers are standard
tools in palliative care, but

557
00:30:03,400 --> 00:30:05,400
their use carries significant
implications.

558
00:30:05,520 --> 00:30:08,440
Initiating strong opioids can
indicate that a patient is

559
00:30:08,440 --> 00:30:11,880
nearing end of life, and dosing
decisions must be carefully

560
00:30:11,880 --> 00:30:15,480
individualized.
Families later reported that

561
00:30:15,480 --> 00:30:17,760
these medications were sometimes
started without clear

562
00:30:17,760 --> 00:30:20,520
explanations and in situations
where their relatives were not

563
00:30:20,520 --> 00:30:23,840
believed to be dying.
I'm described being told that

564
00:30:23,840 --> 00:30:26,640
medication was being used to
keep patients comfortable, only

565
00:30:26,640 --> 00:30:28,800
to see rapid deterioration
afterwards.

566
00:30:29,320 --> 00:30:33,160
Over time, these experiences
accumulated into a shared

567
00:30:33,160 --> 00:30:35,840
concern that something
systematic might be occurring.

568
00:30:36,200 --> 00:30:39,960
So imagine your mother is in
rehab because she had a hip

569
00:30:39,960 --> 00:30:46,280
replacement and she's not only
strung out because she's high,

570
00:30:47,640 --> 00:30:51,160
but she's she's dying.
My mom's had two, two knee

571
00:30:51,160 --> 00:30:52,800
replacements.
She had them at the same time.

572
00:30:52,800 --> 00:30:57,640
And I saw her in rehab and I
cannot imagine her not being

573
00:30:57,640 --> 00:31:00,240
alert and oriented and just
chilling and talking with us.

574
00:31:00,240 --> 00:31:03,680
You know what I mean?
Like horrible.

575
00:31:04,480 --> 00:31:06,680
The case that eventually brought
broader attention involved

576
00:31:06,680 --> 00:31:10,280
Gladys Richards, who died in
1998 after admission for

577
00:31:10,280 --> 00:31:12,240
rehabilitation following a hip
fracture.

578
00:31:12,440 --> 00:31:14,920
Her family questioned the
medication she received,

579
00:31:15,200 --> 00:31:18,480
particularly the use of opioids,
and pursued answers through

580
00:31:18,480 --> 00:31:20,800
formal channels.
Their persistence became one of

581
00:31:20,800 --> 00:31:23,160
the catalysts for ongoing
investigation.

582
00:31:23,560 --> 00:31:26,440
What followed was not immediate
clarity.

583
00:31:26,840 --> 00:31:29,640
Instead, Gosport became a story
defined by delay.

584
00:31:30,120 --> 00:31:33,280
Multiple investigations were
launched over the years, police

585
00:31:33,280 --> 00:31:36,800
reviews, internal inquiries,
professional assessments, yet

586
00:31:36,800 --> 00:31:39,560
none produced definitive
accountability at the time.

587
00:31:40,160 --> 00:31:43,440
Families repeatedly encountered
explanations that framed deaths

588
00:31:43,440 --> 00:31:46,720
as clinically understandable,
even when patterns suggested

589
00:31:46,720 --> 00:31:49,480
otherwise.
As more records were reviewed

590
00:31:49,520 --> 00:31:52,720
and more families connected with
one another, concerns

591
00:31:52,720 --> 00:31:55,160
increasingly centered on
prescribing practices.

592
00:31:55,800 --> 00:31:58,800
Reports described routine
initiation of strong opioids,

593
00:31:59,040 --> 00:32:01,920
sometimes without detailed
documentation of pain assessment

594
00:32:01,920 --> 00:32:05,080
or end of life decision making.
The language used in records,

595
00:32:05,280 --> 00:32:11,040
including instructions such as
quote, make comfortable, appear,

596
00:32:11,040 --> 00:32:13,600
frequently raising questions
about whether assumptions about

597
00:32:13,600 --> 00:32:16,040
prognosis were influencing
treatment decisions.

598
00:32:16,760 --> 00:32:22,960
Can you imagine a doctor giving
you full access to opioids with

599
00:32:23,000 --> 00:32:26,440
the only instruction being make
comfortable, not a dosage, not a

600
00:32:26,640 --> 00:32:28,880
not a time frame make
comfortable.

601
00:32:29,400 --> 00:32:32,880
No, because also, if for no
other reason, what the heck does

602
00:32:32,880 --> 00:32:35,720
that mean, right?
What's comfortable from my

603
00:32:35,720 --> 00:32:37,560
perspective?
I mean, in my perspective,

604
00:32:37,560 --> 00:32:41,520
comfortable means your pains
probably no more than a four or

605
00:32:41,520 --> 00:32:44,600
five out of 10.
Some people make comfortable

606
00:32:44,600 --> 00:32:47,440
might mean 0.
Out of 10, right out of 10.

607
00:32:47,760 --> 00:32:49,200
And that's going to be a whole
different.

608
00:32:49,200 --> 00:32:52,800
Place maybe it's make myself as
a nurse comfortable so if my.

609
00:32:52,840 --> 00:32:55,360
So you don't pay me?
If my patients not right, if my

610
00:32:55,360 --> 00:32:57,760
patients not crying out in pain,
I'm much more comfortable,

611
00:32:58,280 --> 00:32:58,760
right?
Exactly.

612
00:32:59,800 --> 00:33:03,440
That's a wild horrible Yeah.
I can't even see how that could

613
00:33:03,440 --> 00:33:06,360
have been a thing.
So, decades later, the Gosport

614
00:33:06,360 --> 00:33:08,480
Independent Panel was
established to examine the

615
00:33:08,480 --> 00:33:12,000
evidence comprehensively.
Its 2018 report became the most

616
00:33:12,000 --> 00:33:13,680
authoritative account of what
occurred.

617
00:33:14,400 --> 00:33:19,000
The panel concluded that at
least 456 patients had their

618
00:33:19,000 --> 00:33:21,760
lives shortened after receiving
opioids in ways it considered

619
00:33:21,760 --> 00:33:23,880
inappropriate and that.
In that facility.

620
00:33:24,240 --> 00:33:26,040
Yes.
Oh my heavens.

621
00:33:26,200 --> 00:33:28,440
But wait.
But Gladys died, I presume.

622
00:33:29,200 --> 00:33:31,800
Gladys died, yeah.
OK, because we never talked

623
00:33:31,800 --> 00:33:34,120
about her, we just said her
family was wondering.

624
00:33:34,840 --> 00:33:37,800
She was the catalyst for like
her family was the first to

625
00:33:37,800 --> 00:33:40,720
really speak up and be like, yo,
what happened here?

626
00:33:41,040 --> 00:33:43,240
And she'd already died when they
started speaking up.

627
00:33:43,640 --> 00:33:45,520
Oh, I see.
I she died in 1998.

628
00:33:45,960 --> 00:33:47,880
Yeah.
I I didn't catch that part.

629
00:33:47,880 --> 00:33:49,640
I wasn't sure how Gladys played
into this.

630
00:33:49,760 --> 00:33:50,400
I'm sorry.
Go ahead.

631
00:33:50,400 --> 00:33:52,120
She.
Was she was the one that she had

632
00:33:52,120 --> 00:33:55,120
the loudest family?
Yeah, yeah, I got that.

633
00:33:55,120 --> 00:33:57,880
Her family's asking questions.
I just didn't realize that she

634
00:33:58,000 --> 00:34:02,680
died from it. 400 and how many?
People, 456 patients.

635
00:34:03,400 --> 00:34:05,800
Oh, I haven't, and I have no
idea how many they cycled

636
00:34:05,800 --> 00:34:07,960
through, but that seems like a
really high amount.

637
00:34:08,000 --> 00:34:10,080
Well, that number could be
higher because they're missing

638
00:34:10,080 --> 00:34:13,120
records.
So that's 456 that we know about

639
00:34:13,120 --> 00:34:16,120
that we were able to document.
So the whole hospital is a

640
00:34:16,120 --> 00:34:19,600
serial killer.
Yeah, so important.

641
00:34:19,600 --> 00:34:21,760
It's important to note that a
significant proportion of those

642
00:34:21,760 --> 00:34:25,760
patients were not admitted for
end of life care, like they were

643
00:34:25,760 --> 00:34:29,280
admitted to recover and died
instead.

644
00:34:29,760 --> 00:34:32,639
So the panel described the
prescribing pattern as an

645
00:34:32,639 --> 00:34:35,360
institutional practice rather
than isolated error.

646
00:34:36,080 --> 00:34:38,480
This characterization is
critical because it reframes the

647
00:34:38,480 --> 00:34:40,760
story.
Gosport was not simply about

648
00:34:40,760 --> 00:34:44,400
individual clinical decisions.
It was about how practices can

649
00:34:44,400 --> 00:34:47,440
become normalized within a
system, particularly when

650
00:34:47,440 --> 00:34:49,719
hierarchical structures
discourage questioning and

651
00:34:49,719 --> 00:34:51,679
oversight mechanisms respond
slowly.

652
00:34:52,159 --> 00:34:56,000
While families played a central
role in bringing attention to

653
00:34:56,000 --> 00:34:59,160
Gosport, the story cannot be
understood without acknowledging

654
00:34:59,160 --> 00:35:01,800
the nurses who raised concerns
from inside the hospital.

655
00:35:02,320 --> 00:35:05,240
One of the most important
figures was staff nurse Allison

656
00:35:05,240 --> 00:35:07,800
McCourt.
In the early 90's, the court

657
00:35:07,800 --> 00:35:10,240
began to feel that prescribing
practices on the ward were

658
00:35:10,240 --> 00:35:12,520
unsafe.
She observed patients being

659
00:35:12,520 --> 00:35:15,560
started on strong opioids in
circumstances where she did not

660
00:35:15,560 --> 00:35:19,280
believe they were appropriate.
Nurses often have close,

661
00:35:19,360 --> 00:35:21,080
continuous contact with
patients.

662
00:35:21,080 --> 00:35:23,600
Often.
Often nurses.

663
00:35:24,240 --> 00:35:27,840
Nurses, mostly for their entire
career, have close, continuous

664
00:35:28,200 --> 00:35:32,080
contact with patients, placing
them in a position to notice

665
00:35:32,080 --> 00:35:34,560
patterns that may not be
immediately visible through

666
00:35:34,560 --> 00:35:37,360
episodic physician visits.
The court raised concerns

667
00:35:37,360 --> 00:35:40,160
internally, questioning
medication decisions and

668
00:35:40,160 --> 00:35:42,520
documentation.
According to later

669
00:35:42,520 --> 00:35:45,640
investigations and reporting,
these concerns were not

670
00:35:45,640 --> 00:35:48,640
effectively acted upon.
Instead, she experienced

671
00:35:48,640 --> 00:35:51,440
professional difficulty.
After speaking up, her career

672
00:35:51,440 --> 00:35:54,080
progression was affected, and
she eventually left the

673
00:35:54,080 --> 00:35:56,800
hospital.
The pattern of raising concerns

674
00:35:57,040 --> 00:36:00,480
encouraging resistance is common
in healthcare whistleblowing

675
00:36:00,480 --> 00:36:02,640
narratives.
It reflects structural

676
00:36:02,640 --> 00:36:05,080
challenges rather than
individual conflict alone.

677
00:36:05,720 --> 00:36:08,680
Hierarchy, uncertainty and fear
of professional repercussions

678
00:36:08,680 --> 00:36:11,440
can make it difficult for staff
to challenge prescribing

679
00:36:11,440 --> 00:36:15,440
decisions, particularly when
those decisions are framed as

680
00:36:15,440 --> 00:36:17,880
compassionate care.
They didn't say anything about

681
00:36:17,880 --> 00:36:21,200
this in Gosport.
But there's also the level of

682
00:36:21,400 --> 00:36:24,640
certainly as a nurse, I'm sure
you've experienced it too.

683
00:36:24,640 --> 00:36:28,240
I've had experiences of
essentially I'm the doctor,

684
00:36:28,240 --> 00:36:31,960
you're the nurse, shut up.
And I not always that directly,

685
00:36:31,960 --> 00:36:35,160
but you know, sometimes
indirectly and sometimes passive

686
00:36:35,160 --> 00:36:38,240
aggressively.
But that's that's the thing that

687
00:36:38,240 --> 00:36:43,240
absolutely definitely happens.
This idea of I, I had more

688
00:36:43,240 --> 00:36:44,640
education than you, so I know
more.

689
00:36:44,640 --> 00:36:46,040
So I don't want to hear your
opinion.

690
00:36:47,400 --> 00:36:49,880
Another defining feature of
Gosport is the length of time

691
00:36:49,880 --> 00:36:53,320
families waited for recognition.
Many spent years, sometimes

692
00:36:53,320 --> 00:36:56,200
decades, seeking answers about
what happened to their

693
00:36:56,200 --> 00:36:58,160
relatives.
Investigations reopened

694
00:36:58,160 --> 00:37:01,440
repeatedly, new evidence
emerged, and public attention

695
00:37:01,440 --> 00:37:03,480
fluctuated.
For families, uncertain

696
00:37:03,680 --> 00:37:05,880
uncertainty itself became part
of the harm.

697
00:37:06,000 --> 00:37:09,440
And that's another thing that I
think is interesting is that the

698
00:37:09,440 --> 00:37:11,960
fact that they were closing and
reopening investigations.

699
00:37:12,120 --> 00:37:15,040
When you see something in the
news long enough, it's old news,

700
00:37:15,040 --> 00:37:16,640
right?
I'm trying to think of a good

701
00:37:16,640 --> 00:37:18,440
example.
It's not controversial.

702
00:37:18,440 --> 00:37:20,880
I'm sorry you.
Can think of a lot of

703
00:37:20,880 --> 00:37:23,960
controversial.
Ones so could I you know, let's

704
00:37:24,280 --> 00:37:27,560
well.
No, I get it.

705
00:37:27,600 --> 00:37:32,000
And if we hear, OK, even just
think about things like major

706
00:37:32,000 --> 00:37:35,200
storms and things like that that
are less controversial.

707
00:37:35,800 --> 00:37:39,720
And when I hear about when
you've got hurricane season or

708
00:37:39,720 --> 00:37:42,280
tornado, you have tornadoes,
right, tornadoes in your area.

709
00:37:42,400 --> 00:37:45,520
Yeah.
So when it's tornado season, it

710
00:37:45,520 --> 00:37:49,040
almost becomes unimportant, I
think.

711
00:37:49,240 --> 00:37:51,640
It just becomes another thing.
Yeah, just because another thing

712
00:37:51,640 --> 00:37:54,320
that you're hearing about.
And not only that, there's also.

713
00:37:54,760 --> 00:37:57,160
Yeah, exactly.
And so you become accustomed to

714
00:37:57,160 --> 00:38:01,480
it, just like drugs.
It's also, there's also just the

715
00:38:01,520 --> 00:38:03,600
the idea that other things can
over shadow it.

716
00:38:03,600 --> 00:38:04,760
Right.
When you've heard about this

717
00:38:04,880 --> 00:38:07,840
Gosport Hospital news for three
weeks in a row and then suddenly

718
00:38:07,840 --> 00:38:10,920
somebody's murdered in the West
End, that's much more

719
00:38:10,920 --> 00:38:14,680
interesting and new and, you
know, not as boring as boring

720
00:38:14,680 --> 00:38:18,880
old Gosport Hospital.
Like, I'm not saying it's boring

721
00:38:18,880 --> 00:38:20,280
to the families, because it's
not.

722
00:38:20,280 --> 00:38:23,720
But like, I can see why public
public attention would

723
00:38:23,720 --> 00:38:25,520
fluctuate.
Who's on also?

724
00:38:25,720 --> 00:38:28,400
Pharma right now, right?
You and I are, but who else?

725
00:38:28,800 --> 00:38:32,840
Well, but also back back to the
Gosport thing, if my family

726
00:38:32,840 --> 00:38:36,840
wasn't in there, it doesn't
really affect me, as cold as

727
00:38:36,840 --> 00:38:38,440
hard as that is.
And especially if I don't

728
00:38:38,440 --> 00:38:40,280
understand what is really being
said.

729
00:38:41,280 --> 00:38:44,440
Because it could be my family,
it could be could be me, it

730
00:38:44,440 --> 00:38:46,720
could be my children, it could
be any of those things.

731
00:38:46,880 --> 00:38:49,640
But that's a different story
because it didn't affect me that

732
00:38:49,640 --> 00:38:50,400
day.
Right.

733
00:38:50,720 --> 00:38:53,440
The Gosport story therefore sits
at the intersection of medicine,

734
00:38:53,440 --> 00:38:55,360
ethics and institutional
accountability.

735
00:38:55,920 --> 00:38:58,520
It highlights how powerful
medications can shift from

736
00:38:58,520 --> 00:39:01,520
appropriate use to problematic
practice when assumptions go

737
00:39:01,520 --> 00:39:05,120
unchallenged, documentation is
incomplete, and concerns raised

738
00:39:05,120 --> 00:39:07,920
by staff or families fail to
trigger decisive action.

739
00:39:08,080 --> 00:39:09,120
You know, I always go back to
you.

740
00:39:09,120 --> 00:39:10,960
If you didn't document it, it
didn't happen.

741
00:39:11,560 --> 00:39:13,520
Exactly.
Unfortunately, that has a

742
00:39:13,520 --> 00:39:17,520
reverse effect that if you did
it and you didn't document it,

743
00:39:17,680 --> 00:39:20,720
there can be horrible results,
right?

744
00:39:20,960 --> 00:39:25,880
If I go and give somebody
oxycodone and I don't write it

745
00:39:25,880 --> 00:39:28,400
down, and you come in on a shift
and you see that they were due

746
00:39:28,400 --> 00:39:30,520
for oxycodone, guess what you're
going to do?

747
00:39:30,520 --> 00:39:33,360
You're going to give them
another one because they were

748
00:39:33,360 --> 00:39:34,800
due for it.
There's no indication they

749
00:39:34,800 --> 00:39:36,480
received it.
Right, right.

750
00:39:36,840 --> 00:39:39,440
And maybe you'll bring this up,
but to backtrack, in this

751
00:39:39,440 --> 00:39:42,960
hospital, did they have
incentivized medication

752
00:39:42,960 --> 00:39:45,280
distribution It was this part
of?

753
00:39:46,000 --> 00:39:49,600
This was not a part of it.
So this was just an example of

754
00:39:49,920 --> 00:39:52,840
this is, you know, this is just
another example of how without,

755
00:39:53,000 --> 00:39:57,360
without, without external
pressures can still happen.

756
00:39:57,360 --> 00:40:00,280
It can become an
institutionalized norm without.

757
00:40:00,280 --> 00:40:03,400
Didn't did they ever say why
they were doing this?

758
00:40:03,400 --> 00:40:07,120
Because it seems if there's not
an incentive financially for it.

759
00:40:07,120 --> 00:40:09,320
As far as I could tell, because
they could.

760
00:40:09,840 --> 00:40:12,160
I really think that even though
we were being tongue in cheek a

761
00:40:12,160 --> 00:40:15,360
little bit, I think to some
degree it was like, if they're

762
00:40:15,360 --> 00:40:18,600
not calling my name, then I'm
more comfortable.

763
00:40:18,960 --> 00:40:20,440
Right.
Because why would you give

764
00:40:20,440 --> 00:40:23,400
somebody recovering?
I mean, you and I both had hip

765
00:40:23,400 --> 00:40:25,960
replacements.
Why would you give somebody

766
00:40:25,960 --> 00:40:29,000
recovering from that basically
medicinal heroin?

767
00:40:29,920 --> 00:40:34,160
Yeah, I did just fine with
whatever I was on the Percocet,

768
00:40:34,160 --> 00:40:37,960
maybe for for a few days.
Yeah.

769
00:40:38,040 --> 00:40:40,680
Not for, not for.
Yeah, exactly.

770
00:40:41,160 --> 00:40:45,280
It may have just been that that
it became an it started as an

771
00:40:45,280 --> 00:40:48,320
easy way out and then became the
norm.

772
00:40:48,320 --> 00:40:51,600
I, I it didn't really say
specifically other than just

773
00:40:51,600 --> 00:40:54,480
that.
I mean, again, it goes back to

774
00:40:54,480 --> 00:40:57,520
the whole the order of keep
comfortable.

775
00:40:58,640 --> 00:41:02,720
That's not a prescription that's
it becomes so subjective.

776
00:41:03,080 --> 00:41:05,920
Like we already said, what is
comfortable and comfortable for

777
00:41:06,000 --> 00:41:08,000
who and to what degree of
comfort.

778
00:41:08,000 --> 00:41:11,400
And I mean, it's so open-ended.
And I think that's that's how it

779
00:41:11,400 --> 00:41:14,360
happened.
And when you think about drugs

780
00:41:14,400 --> 00:41:18,040
that have been in air, quote
Vogue, you think of people who

781
00:41:18,040 --> 00:41:20,840
were literally using cocaine
back in the.

782
00:41:21,440 --> 00:41:24,720
Ages 80s, yeah.
Even before that for a long

783
00:41:24,720 --> 00:41:26,280
time.
Well, the 80s was the heyday.

784
00:41:27,120 --> 00:41:30,760
Yeah, they had their muscle
boxes through forever and they

785
00:41:30,760 --> 00:41:33,320
were taking cocaine, apparently,
which everyone.

786
00:41:33,320 --> 00:41:35,120
But it was in all their
medicines, right?

787
00:41:35,120 --> 00:41:37,680
Yeah.
Because it was healthy, right?

788
00:41:37,680 --> 00:41:40,920
So I wonder, I think about this
and if I had a Doctor Who

789
00:41:40,920 --> 00:41:45,680
ordered me to give a medication
that I knew was medicinal

790
00:41:45,680 --> 00:41:50,800
heroin, and they asked me that
today, I I wouldn't feel like I

791
00:41:50,800 --> 00:41:54,320
could give that medication
because I've seen so much about

792
00:41:54,320 --> 00:41:57,680
heroin and what it does and how
it kills people and all of the

793
00:41:57,680 --> 00:42:00,200
things.
So I wonder if the people who

794
00:42:00,200 --> 00:42:02,720
were giving it really knew what
they were giving.

795
00:42:02,960 --> 00:42:05,680
I think if this is in the UKI
don't even know if medicinal

796
00:42:05,680 --> 00:42:09,120
heroin is available in the US.
This was in the UK and I don't

797
00:42:09,120 --> 00:42:10,360
even know if it's still
available.

798
00:42:10,520 --> 00:42:12,800
But I mean, I wonder if when
they were administering it, they

799
00:42:12,800 --> 00:42:15,000
knew what it was and what its
potentials were.

800
00:42:15,320 --> 00:42:18,000
I would think not because I
think that wasn't really figured

801
00:42:18,000 --> 00:42:20,040
out till later, but I'm not
sure.

802
00:42:20,600 --> 00:42:22,320
Possibly it was.
It didn't.

803
00:42:22,320 --> 00:42:25,200
It was had a name, right?
That wasn't heroin, it was I

804
00:42:25,200 --> 00:42:28,920
just diamorphine.
Diamorphine sounds a lot like

805
00:42:28,920 --> 00:42:33,480
morphine, which we do use.
Yeah, I wouldn't know if I would

806
00:42:33,480 --> 00:42:34,800
have thought anything different
about it.

807
00:42:34,800 --> 00:42:38,200
It's just somebody made another
crazy name for a drug 'cause.

808
00:42:38,200 --> 00:42:40,840
They're all crazy names, 'cause.
They're all crazy names.

809
00:42:40,880 --> 00:42:42,800
Exactly.
Yeah, most of them.

810
00:42:42,800 --> 00:42:44,440
I can't pronounce them anyways.
All right.

811
00:42:46,120 --> 00:42:49,000
So although these cases differ
in geography, actors, and

812
00:42:49,000 --> 00:42:51,560
specific mechanisms, they reveal
A consistent pattern.

813
00:42:52,040 --> 00:42:54,840
Changes in professional beliefs
can influence clinical behavior,

814
00:42:54,840 --> 00:42:57,880
which can create opportunities
for both unintentional overuse

815
00:42:57,880 --> 00:43:01,000
and deliberate exploitation.
Financial incentives,

816
00:43:01,000 --> 00:43:04,320
institutional pressures, and
regulatory delays appear across

817
00:43:04,320 --> 00:43:07,120
all four stories, contributing
to environments in which

818
00:43:07,480 --> 00:43:10,560
responsibility becomes diffuse
and corrective action occurs

819
00:43:10,560 --> 00:43:12,240
slowly.
Healthcare systems depend

820
00:43:12,240 --> 00:43:15,760
fundamentally on trust, trust in
professional judgement and

821
00:43:15,760 --> 00:43:18,640
regulatory oversight, and in
shared norms about appropriate

822
00:43:18,640 --> 00:43:20,520
care.
When prescribing practices

823
00:43:20,520 --> 00:43:24,400
evolved rapidly, that trust can
mask emerging risks.

824
00:43:24,800 --> 00:43:27,440
Harm often develops
incrementally through processes

825
00:43:27,440 --> 00:43:30,440
that appear reasonable in
isolation, making it difficult

826
00:43:30,440 --> 00:43:33,320
to identify systemic problems
until they are widespread.

827
00:43:33,640 --> 00:43:36,240
What makes these stories
particularly unsettling is not

828
00:43:36,240 --> 00:43:39,040
simply the presence of
wrongdoing, but the role of

829
00:43:39,040 --> 00:43:42,240
normalization.
Many of the decisions described

830
00:43:42,240 --> 00:43:45,040
occurred within ordinary
workflows, documented through

831
00:43:45,040 --> 00:43:47,800
standard procedures, and framed
and language consistent with

832
00:43:47,800 --> 00:43:50,280
patient care.
This does not diminish

833
00:43:50,280 --> 00:43:53,360
accountability where misconduct
occurred, but it highlights how

834
00:43:53,360 --> 00:43:56,760
systemic change can produce
unintended consequences

835
00:43:56,760 --> 00:44:01,160
alongside intentional actions.
The opioid crisis was not the

836
00:44:01,160 --> 00:44:03,320
result of a single decision or
actor.

837
00:44:03,720 --> 00:44:06,960
It emerged through cumulative
shifts in belief, practice,

838
00:44:06,960 --> 00:44:10,320
incentives, and oversight.
Examining these shifts together

839
00:44:10,560 --> 00:44:13,800
helps explain why the crisis
developed gradually and why

840
00:44:13,800 --> 00:44:16,360
recognition often lagged behind
impact.

841
00:44:17,360 --> 00:44:20,560
Ultimately, these cases raise an
enduring question for healthcare

842
00:44:20,560 --> 00:44:24,200
and other complex systems.
When practices become routine,

843
00:44:24,480 --> 00:44:27,040
what mechanisms help
professionals recognize when

844
00:44:27,040 --> 00:44:29,880
those practices no longer
aligned with patient safety?

845
00:44:30,360 --> 00:44:33,000
The challenge is not only
identifying clear misconduct,

846
00:44:33,120 --> 00:44:36,000
but also noticing the subtle
points at which normalization

847
00:44:36,000 --> 00:44:37,560
begins to obscure risk.
Wow.

848
00:44:37,680 --> 00:44:42,560
Well, you know, I have an
opposite thing where when I did

849
00:44:42,560 --> 00:44:47,120
have my second hip replacement,
I was in, I had gone through

850
00:44:47,120 --> 00:44:50,800
recovery and I was in a room
because they were keeping me to

851
00:44:50,800 --> 00:44:53,120
make sure, I'm sorry, no, it was
my knee.

852
00:44:53,360 --> 00:44:55,160
So they were keeping to make
sure that we had good pain

853
00:44:55,160 --> 00:44:58,040
control.
And I was in tense pain.

854
00:44:58,080 --> 00:45:00,120
I mean, really, really intense
pain.

855
00:45:00,440 --> 00:45:02,960
And I've been told that the knee
was a lot harder than the hip.

856
00:45:02,960 --> 00:45:05,200
So I just thought, OK, well, I
guess that's it.

857
00:45:05,800 --> 00:45:09,760
And so much pain that I was
throwing up, my blood pressure

858
00:45:09,760 --> 00:45:14,680
was sky high and everything was
going on and I just wasn't OK.

859
00:45:14,680 --> 00:45:18,040
And I said, could you guys talk
to my doctor about what's being

860
00:45:18,040 --> 00:45:21,440
ordered for pain and because
it's not working?

861
00:45:21,920 --> 00:45:23,920
And they said, well, we're
giving you Tylenol.

862
00:45:25,600 --> 00:45:28,720
And I said, wait, what?
You're giving me Tylenol and I'm

863
00:45:28,720 --> 00:45:30,760
just out of a total knee
replacement.

864
00:45:31,320 --> 00:45:34,040
Well, yeah, we thought you must
have had an addiction problem.

865
00:45:35,800 --> 00:45:38,920
And I said, well, First off,
nobody asked me and I don't.

866
00:45:39,920 --> 00:45:41,960
So they had.
What had happened is the

867
00:45:41,960 --> 00:45:44,640
medication sheet had gotten
separated from the orders.

868
00:45:45,640 --> 00:45:48,600
And we're.
Giving me Tylenol.

869
00:45:49,560 --> 00:45:51,880
Oh.
My goodness, six hours after a

870
00:45:51,880 --> 00:45:54,520
total knee.
Oh, I cannot imagine.

871
00:45:54,960 --> 00:45:59,920
I can and it was terrible, but I
didn't want to be a big whiner

872
00:45:59,920 --> 00:46:02,240
baby because I'm like, well,
they said it was going to hurt

873
00:46:02,240 --> 00:46:05,960
more and then they called my
doctor and he was livid.

874
00:46:06,520 --> 00:46:09,000
I'm sure he said no, that's not
right.

875
00:46:09,280 --> 00:46:13,200
I mean, I was having violent
emesis because I was so much

876
00:46:13,240 --> 00:46:17,600
worse.
And anyway, he ended up giving

877
00:46:17,600 --> 00:46:19,000
me his phone number because he
said.

878
00:46:19,000 --> 00:46:22,080
That's never going to get by the
way is puking her guts out.

879
00:46:22,520 --> 00:46:25,080
There's it was.
Awful.

880
00:46:25,480 --> 00:46:27,480
I could go into more detail, but
we don't need that.

881
00:46:27,720 --> 00:46:32,840
Anyway, he came in that night
and apologized to me for that

882
00:46:32,840 --> 00:46:35,720
happening because it was.
It was unacceptable.

883
00:46:36,240 --> 00:46:39,880
But what it showed to me is
there's that swing the other way

884
00:46:39,880 --> 00:46:43,280
too.
And a lot of cases where they

885
00:46:43,280 --> 00:46:46,800
thought it was probably because
I was had been a drug addict and

886
00:46:46,800 --> 00:46:50,200
I couldn't have any, well,
nobody thought to ask me right?

887
00:46:50,280 --> 00:46:53,720
If that was the situation,
because if it is, what else can

888
00:46:53,720 --> 00:46:55,080
we do?
Can we assist you with deep

889
00:46:55,080 --> 00:46:56,720
breathing?
Can we whatever.

890
00:46:56,720 --> 00:47:01,160
I mean, there are other besides
Tylenol for a major surgery that

891
00:47:01,200 --> 00:47:03,400
could have helped.
I mean, even if I need more

892
00:47:03,400 --> 00:47:05,200
nerve block or something like
that.

893
00:47:05,480 --> 00:47:07,920
But nobody asked me.
And the only reason I finally

894
00:47:07,920 --> 00:47:12,360
demanded for them to talk to my
doctor because not only I was

895
00:47:12,360 --> 00:47:15,040
getting worried about my blood
pressure because it was like 170

896
00:47:15,040 --> 00:47:16,640
/ 120.
It was terrible.

897
00:47:17,680 --> 00:47:19,760
And it was just my body saying,
hey, something's.

898
00:47:20,320 --> 00:47:23,560
We don't like this.
Yeah, that side of it too.

899
00:47:23,880 --> 00:47:26,160
And then I finally got the
medication I needed and it was

900
00:47:26,160 --> 00:47:28,960
still painful because it was a
painful procedure, but at least

901
00:47:28,960 --> 00:47:33,000
it was tolerable at that point.
I just, I couldn't believe it.

902
00:47:33,240 --> 00:47:35,280
And people might say, well,
you're a nurse, didn't you read

903
00:47:35,280 --> 00:47:37,720
your orders?
No, I was also a patient post op

904
00:47:37,720 --> 00:47:42,120
on narcotics, I thought.
And so it wasn't my job to make

905
00:47:42,120 --> 00:47:45,000
sure my medications were right.
It was my job to.

906
00:47:45,000 --> 00:47:45,920
That's funny.
Yeah.

907
00:47:46,280 --> 00:47:48,240
When I had my hip replacement,
they said that to me.

908
00:47:48,240 --> 00:47:50,520
They're like, I know you're a
nurse, but I'm your nurse.

909
00:47:50,680 --> 00:47:52,680
So I'm going to give you your
medications.

910
00:47:52,680 --> 00:47:54,480
I'm going to tell you what they
are and I'm going to give them

911
00:47:54,480 --> 00:47:56,040
to you when they're when they're
scheduled.

912
00:47:56,360 --> 00:48:02,640
I'm like, OK, no problem, right?
But it's interesting, right?

913
00:48:03,360 --> 00:48:06,360
Oh, I was just going to say it,
but when I was coming out of

914
00:48:06,600 --> 00:48:09,960
surgical recovery and surgical
medications, it didn't occur to

915
00:48:09,960 --> 00:48:13,480
me to to check my orders.
Your chart, right?

916
00:48:13,480 --> 00:48:15,840
Could I please make sure you're
doing it right?

917
00:48:16,240 --> 00:48:20,560
Right, so something interesting
that happens drug seeking is is

918
00:48:20,600 --> 00:48:24,360
a big part of the opioid crisis
and just opioid problems in

919
00:48:24,360 --> 00:48:25,880
general.
And we didn't really cover that

920
00:48:25,880 --> 00:48:29,000
much other than like pill mills
and and pill shopping and doctor

921
00:48:29,000 --> 00:48:31,120
shopping.
But it's something that people

922
00:48:31,120 --> 00:48:33,200
watch for, particularly in the
emergency room.

923
00:48:33,600 --> 00:48:36,280
And my sister had an experience
where she went into, she went

924
00:48:37,240 --> 00:48:41,000
into the emergency room and she
was lashing out and she was

925
00:48:41,000 --> 00:48:44,280
grouchy and she was crying and
she was being just a jerk.

926
00:48:44,760 --> 00:48:48,960
And they decided that she was
drug seeking.

927
00:48:49,440 --> 00:48:51,720
And so they were, they kept
coming in and asking her

928
00:48:51,720 --> 00:48:54,120
questions about I'm, I'm
intentionally burying the lead

929
00:48:54,120 --> 00:48:56,960
by the way they kept, they came
in and they were asking her, you

930
00:48:56,960 --> 00:48:59,440
know, kept asking her the same
questions in different ways,

931
00:48:59,440 --> 00:49:01,600
trying to get out of her what
she really wanted.

932
00:49:02,080 --> 00:49:05,280
And she was just being
belligerent and not answering

933
00:49:05,280 --> 00:49:07,880
their questions, just basically
being a jerk.

934
00:49:08,080 --> 00:49:10,840
She kept telling them, I have
diabetes, I have diabetes.

935
00:49:10,840 --> 00:49:14,560
And they kept just coming in and
being like, now you know, what's

936
00:49:14,560 --> 00:49:17,600
your level of pain?
Anyway, Long story short, she

937
00:49:17,600 --> 00:49:21,160
was in DKA or diabetic
ketoacidosis, which basically

938
00:49:21,160 --> 00:49:25,160
means she was dying and the
blood to her brain was not

939
00:49:25,320 --> 00:49:32,080
sufficiently insulin.
Her blood sugar was almost 800.

940
00:49:33,240 --> 00:49:37,600
So her brain just wasn't working
because it wasn't being fed the

941
00:49:37,600 --> 00:49:41,400
proper blood, right?
Just her blood was all jacked.

942
00:49:41,880 --> 00:49:45,760
So they finally got her blood
sugar and they put her on 2

943
00:49:45,880 --> 00:49:49,400
separate bags of Ivsi mean of
Ivs, 2 separate IV bags of

944
00:49:49,400 --> 00:49:51,600
insulin.
She had insulin going into both

945
00:49:51,640 --> 00:49:55,720
of her arms.
And and so for those lay people

946
00:49:55,720 --> 00:49:59,680
who don't know, IV insulin is
rare and a big deal.

947
00:49:59,720 --> 00:50:03,520
And so to have it going in two
arms at the same time is huge.

948
00:50:03,760 --> 00:50:06,400
Anyway, So, yeah, so just like
the egg on their face and they

949
00:50:06,400 --> 00:50:09,920
had to come in the next day and
apologize for basically treating

950
00:50:09,920 --> 00:50:12,720
her like a drug addict.
And I think, you know, I know

951
00:50:12,720 --> 00:50:17,120
that there's, I know that we
have to, we can't just give in

952
00:50:17,120 --> 00:50:19,880
to drug seekers all the time.
I totally get that.

953
00:50:20,000 --> 00:50:22,480
But I do feel like a lot of
people have become jaded with

954
00:50:22,480 --> 00:50:25,600
the drug seekers and that
they've lost some of their

955
00:50:25,600 --> 00:50:29,960
compassion, right?
It's just really like, again,

956
00:50:29,960 --> 00:50:34,120
it's just another nuance and
side effect of this crisis of

957
00:50:34,120 --> 00:50:40,240
this epidemic that we've been in
since the 90s of of opioid abuse

958
00:50:40,240 --> 00:50:44,240
and overuse.
And I don't know that there's

959
00:50:44,520 --> 00:50:46,760
there is a place in medicine for
opioids.

960
00:50:46,760 --> 00:50:49,600
I want to say that like you and
I, we just talked about how

961
00:50:49,600 --> 00:50:51,960
we've had surgeries and we've
used them after surgery

962
00:50:52,480 --> 00:50:56,080
effectively, though I'm not, I'm
not vilified opioids themselves,

963
00:50:56,120 --> 00:51:00,120
but I do think that I do hope,
this is just my hope.

964
00:51:00,120 --> 00:51:02,800
I hope that pharmaceutical
companies can come up with some,

965
00:51:03,080 --> 00:51:07,880
some things that are not that
don't have such high risks to

966
00:51:07,880 --> 00:51:09,640
them, right?
And I know that they're

967
00:51:09,880 --> 00:51:14,240
developing all the time and I
just, it would be nice to see

968
00:51:14,560 --> 00:51:20,520
pain control be less scary and
less less of a tightrope walk.

969
00:51:21,840 --> 00:51:24,760
Well, and also I think in the
surgeries I've seen people

970
00:51:24,760 --> 00:51:28,960
coming out of, there are a lot
more nerve blocks being used and

971
00:51:28,960 --> 00:51:34,080
lower levels of narcotics and
the heavier meds being used.

972
00:51:34,440 --> 00:51:37,520
And I just want to clarify for
our listeners, drug seeking

973
00:51:37,520 --> 00:51:41,120
behavior is someone coming in to
an emergency room, a clinic, a

974
00:51:41,120 --> 00:51:45,320
doctor's office looking for the
stronger narcotics to be able to

975
00:51:45,720 --> 00:51:48,080
control their pain.
And I don't even say that in an

976
00:51:48,080 --> 00:51:51,000
air quote kind of way, because
if a person is addicted to a

977
00:51:51,000 --> 00:51:54,320
pain medication, when they start
coming off of it, their pain

978
00:51:54,320 --> 00:51:58,480
levels can be very well it's.
Like I said, right, with the

979
00:51:59,040 --> 00:52:02,120
more receptors, more receptors,
more receptors, I mean, consider

980
00:52:02,120 --> 00:52:06,680
how much pain you're in.
If you let's say you knock your

981
00:52:06,680 --> 00:52:10,360
shin into something, right?
And you're that hurts acutely a

982
00:52:10,360 --> 00:52:12,440
lot, right?
And you might have to be 10 out

983
00:52:12,440 --> 00:52:16,560
of 10 pain for five seconds.
Well, consider that they've gone

984
00:52:16,560 --> 00:52:18,600
way past 10 out of 10 pain at
this point.

985
00:52:18,760 --> 00:52:23,640
I know that that's an oxymoron,
but like their ten now is your

986
00:52:24,000 --> 00:52:26,120
10,000.
Right, right.

987
00:52:26,440 --> 00:52:29,320
It's a legitimate pain that they
can have.

988
00:52:29,760 --> 00:52:33,840
However, solving the problem is
not the use of narcotics.

989
00:52:33,840 --> 00:52:36,560
Usually there are a lot of
things that can happen in

990
00:52:36,560 --> 00:52:39,920
between and that should happen.
I think one of our other

991
00:52:39,920 --> 00:52:44,440
problems in our society is that
saying, OK, you're now addicted

992
00:52:44,440 --> 00:52:47,000
to these meds, so you don't get
them anymore at all, goodbye.

993
00:52:47,600 --> 00:52:50,480
And that's not a good solution
either because they still have

994
00:52:50,480 --> 00:52:52,840
the same problem.
They just don't have any way to

995
00:52:52,840 --> 00:52:54,920
get through it.
And so there are a lot of

996
00:52:54,920 --> 00:52:58,880
medications now that can be used
to bridge that time.

997
00:52:59,000 --> 00:53:02,200
But some of those medications,
Suboxone and stuff are not not

998
00:53:02,200 --> 00:53:05,840
really any less dangerous.
They just fill a spot.

999
00:53:05,880 --> 00:53:08,640
Getting off of these things can
be very challenging and a lot of

1000
00:53:08,640 --> 00:53:11,600
people are afraid or embarrassed
if they have this issue.

1001
00:53:11,720 --> 00:53:15,000
Addiction does tend to run in
families, but it doesn't always

1002
00:53:15,000 --> 00:53:17,360
have to.
So when we ask, have you had

1003
00:53:17,360 --> 00:53:19,880
anyone in your family has ever
had any any problems with

1004
00:53:19,920 --> 00:53:22,200
medications?
That means any problem with

1005
00:53:22,200 --> 00:53:24,320
medication, whether it means
they get sick, they get

1006
00:53:24,320 --> 00:53:27,360
addicted, they have whatever the
allergic reaction, whatever,

1007
00:53:27,520 --> 00:53:31,080
whatever it is.
Well, if if the person has a

1008
00:53:31,080 --> 00:53:34,680
family history of it, that is
definitely a red flag potential.

1009
00:53:34,680 --> 00:53:37,680
Let's talk about it.
And there's times where I've

1010
00:53:37,680 --> 00:53:40,560
known people when I was working
as a case manager who came in

1011
00:53:40,560 --> 00:53:43,640
for surgery and refused
narcotics all together because

1012
00:53:43,640 --> 00:53:45,680
they had a personal addiction
problem.

1013
00:53:46,000 --> 00:53:48,640
Some of them I couldn't believe
they had the surgery they did

1014
00:53:48,640 --> 00:53:50,280
and didn't have narcotics on
board.

1015
00:53:50,280 --> 00:53:54,360
But they said it is not worth
the risk to me to go back down

1016
00:53:54,480 --> 00:53:56,200
that road.
And I get it.

1017
00:53:56,240 --> 00:54:00,360
We used other medic other
methods we talked about as as as

1018
00:54:00,360 --> 00:54:03,160
I had mentioned before, things
like biofeedback, 10s units,

1019
00:54:03,160 --> 00:54:07,280
things like that, that are
really distraction methods.

1020
00:54:08,160 --> 00:54:12,040
But sometimes that can get a
person through a situation and

1021
00:54:12,040 --> 00:54:14,720
it is a devastating situation.
I know several people who have

1022
00:54:14,720 --> 00:54:18,840
died of overdoses and it's
devastating.

1023
00:54:18,840 --> 00:54:22,120
And when a person is an
addiction pathway, it's horrible

1024
00:54:22,120 --> 00:54:24,280
for their family, it's horrible
for their friends.

1025
00:54:24,280 --> 00:54:29,440
They it's horrible for them.
They even though they're air

1026
00:54:29,440 --> 00:54:31,760
quote solving a problem, they're
not.

1027
00:54:31,920 --> 00:54:35,920
A lot of the unhoused are in
drug addiction situations or

1028
00:54:35,920 --> 00:54:40,360
have been and the problem is
huge and to my knowledge we

1029
00:54:40,360 --> 00:54:41,840
don't have a really great
solution.

1030
00:54:42,400 --> 00:54:44,040
We don't.
We definitely don't.

1031
00:54:44,600 --> 00:54:47,360
Devastating on the other hand,
is like many things, like we

1032
00:54:47,640 --> 00:54:51,440
also alluded to, that for people
who are having legitimate pain,

1033
00:54:51,560 --> 00:54:54,000
pain appropriate for the
circumstances, it can be very

1034
00:54:54,000 --> 00:54:55,600
hard to get the medications they
need.

1035
00:54:55,800 --> 00:54:59,320
There's got to be, I think the
pendulum as always swings really

1036
00:54:59,320 --> 00:55:00,880
far one way, really far the
other.

1037
00:55:00,880 --> 00:55:03,920
And hopefully it's getting a
little bit more centered so that

1038
00:55:04,200 --> 00:55:09,120
pain control is maintained,
however, addiction is reduced.

1039
00:55:09,320 --> 00:55:12,200
I appreciate.
That you pointing out that we

1040
00:55:12,200 --> 00:55:17,400
need to be vigilant in reducing
the stigma for people who are

1041
00:55:17,400 --> 00:55:21,560
have addiction to opioids or
issues like that, because a lot

1042
00:55:21,560 --> 00:55:25,720
of times it's not something that
they actively chose.

1043
00:55:26,760 --> 00:55:30,480
It's a circumstance that
basically came upon them through

1044
00:55:30,920 --> 00:55:33,200
sometimes their own actions,
sometimes the actions of others,

1045
00:55:33,200 --> 00:55:36,280
a combination of both.
But always I put out a call for

1046
00:55:36,640 --> 00:55:39,800
empathy and kindness.
One of the things from the

1047
00:55:39,800 --> 00:55:41,600
Course of Miracles, I don't
think I've ever said this in

1048
00:55:41,600 --> 00:55:45,360
this podcast, but Course of
Miracles is just a a book that's

1049
00:55:45,360 --> 00:55:47,120
a spiritual book that I'm not
going to go into.

1050
00:55:47,120 --> 00:55:50,360
But one of the things I love
from it is that it says that

1051
00:55:50,680 --> 00:55:54,480
everything in the world is
either love or a call for love.

1052
00:55:55,280 --> 00:55:59,240
And you know, I like to live my
life always answering calls for

1053
00:55:59,240 --> 00:56:01,440
love with love.
Now, am I perfect?

1054
00:56:01,440 --> 00:56:03,400
No, I'm not.
Can I be a jerk sometimes?

1055
00:56:03,400 --> 00:56:07,080
Absolutely, yes.
But like that is my guiding.

1056
00:56:07,640 --> 00:56:12,440
That is my guiding idea of that.
Sometimes when somebody's just

1057
00:56:12,440 --> 00:56:17,600
being a real jerk, it's really
that they just they're just

1058
00:56:17,600 --> 00:56:19,320
asking for love.
And do you have to go over and

1059
00:56:19,320 --> 00:56:21,280
give them a hug?
No, but you can.

1060
00:56:21,280 --> 00:56:26,400
You can show love by not
responding with anger or

1061
00:56:26,640 --> 00:56:28,560
unkindness or whatever.
So.

1062
00:56:28,560 --> 00:56:32,400
Well like the example of your
sister who was really being wack

1063
00:56:32,400 --> 00:56:37,080
a doodle in the emergency room.
Maybe ask yourself, why would

1064
00:56:37,520 --> 00:56:41,040
this person?
You can put other adjectives

1065
00:56:41,040 --> 00:56:42,840
about it.
Why would this beautiful,

1066
00:56:42,840 --> 00:56:45,400
loving, compassionate person act
like this?

1067
00:56:45,600 --> 00:56:47,800
Or just why would this person
act like this?

1068
00:56:47,800 --> 00:56:50,360
This is.
This seems unusual.

1069
00:56:50,360 --> 00:56:52,640
Well, why does this person keep
telling you they have diabetes?

1070
00:56:52,640 --> 00:56:54,000
That's one thought, right?
Like.

1071
00:56:54,200 --> 00:56:55,840
OK, so you have diabetes, Big
whoop.

1072
00:56:55,840 --> 00:56:57,000
Like why should I care about
that?

1073
00:56:57,000 --> 00:56:58,360
Why should I care about that,
right?

1074
00:56:58,440 --> 00:57:00,880
Like.
It can cause behavioral issues.

1075
00:57:01,400 --> 00:57:04,760
I think that a lot of times we
jump to conclusions and many

1076
00:57:04,760 --> 00:57:07,080
times the conclusion is probably
correct.

1077
00:57:07,400 --> 00:57:10,760
However, the person is in that
situation as we were just

1078
00:57:10,760 --> 00:57:14,200
talking about, not even
necessarily because of something

1079
00:57:14,200 --> 00:57:17,200
they actively chose to get to
this point at some time in their

1080
00:57:17,200 --> 00:57:18,800
life.
I don't think there's anybody

1081
00:57:18,800 --> 00:57:20,800
who took drugs the first time
and say, gosh, I hope I'm

1082
00:57:20,800 --> 00:57:24,160
addicted and unhomed and dying
of some weird thing.

1083
00:57:24,360 --> 00:57:26,840
Yeah, that sounds good.
I don't think that happens.

1084
00:57:27,080 --> 00:57:30,160
I think most people who have
addiction issues have other

1085
00:57:30,160 --> 00:57:32,960
problems that they have not been
able to deal with appropriately,

1086
00:57:32,960 --> 00:57:36,240
whether it's a mental health
issue or even a physical issue.

1087
00:57:36,640 --> 00:57:39,640
Sure, this is what they created
as a result.

1088
00:57:39,880 --> 00:57:42,600
Now for whatever reasons, this
another whole podcast.

1089
00:57:43,160 --> 00:57:48,400
But if we can, as people in our
communities, families,

1090
00:57:48,400 --> 00:57:51,320
environments can look at it a
little bit differently, maybe we

1091
00:57:51,320 --> 00:57:54,400
can be a little more proactive
and assisting for solutions

1092
00:57:54,400 --> 00:57:56,840
instead of just blaming the
problem.

1093
00:57:57,200 --> 00:57:58,800
Yeah, just judgment.
Yeah, I agree.

1094
00:58:00,440 --> 00:58:02,280
Wow.
Well, this was not a very

1095
00:58:02,280 --> 00:58:04,560
cheerful episode, but it really
gives some food for thought.

1096
00:58:05,760 --> 00:58:08,920
Give some food for thought and
maybe looking at ways that we

1097
00:58:08,920 --> 00:58:10,480
can support each other a little
bit better.

1098
00:58:11,080 --> 00:58:12,480
Yeah, I agree.
Great.

1099
00:58:12,920 --> 00:58:14,360
Well, thank you.
Thank you.

1100
00:58:14,680 --> 00:58:17,320
All right, if you've made it
this far, clearly you like a

1101
00:58:17,320 --> 00:58:18,960
little mayhem with your
medicine.

1102
00:58:19,280 --> 00:58:21,800
Or you just enjoy hearing us
ramble about weird medical

1103
00:58:21,800 --> 00:58:24,000
mysteries.
Either way, we'd love you for

1104
00:58:24,000 --> 00:58:26,200
it.
So hit that follow or subscribe

1105
00:58:26,200 --> 00:58:27,600
button wherever you're
listening.

1106
00:58:27,720 --> 00:58:29,720
And toss us a rating or review
while you're at it.

1107
00:58:30,040 --> 00:58:32,600
Helps other curious weirdos find
the show.

1108
00:58:33,280 --> 00:58:35,360
And we know there are a lot of
you out there.

1109
00:58:35,680 --> 00:58:38,200
Oh so many.
Come join the chaos.

1110
00:58:38,240 --> 00:58:41,400
Thanks for listening to
Medicine, Mystery, mayhem, and

1111
00:58:41,400 --> 00:58:44,040
sometimes Murder.
Do you have an idea for an

1112
00:58:44,040 --> 00:58:46,920
episode of this podcast?
Just want to say hi?

1113
00:58:47,280 --> 00:58:50,320
You can get in touch with us at
our M4 pod.

1114
00:58:50,800 --> 00:58:57,280
That's OURM
thenumberfourpod@gmail.com.

1115
00:58:57,880 --> 00:59:01,800
We read every e-mail, and
sometimes we even respond just

1116
00:59:01,800 --> 00:59:04,560
like real professionals.
Because we are.

1117
00:59:04,720 --> 00:59:09,680
Old friends with new twists and
lots of body bags.