Drug Stories: Covering the Opioid Crisis

>> Where I direct the science hell — health and environmental reporting program and the communication workshops and we are absolutely thrilled to have a great crowd here today and also online.  Those of you who are joining us online.  And we have a really important discussion.  On the agenda, today, and two wonderful speakers and our usual amazing moderator.  Robert will do formal introductions but I want to say how glad that they could both join us.  They both have written extraordinary books.  Some of you have had the opportunity to buy them from our friend Charlie.  But in any case we will get to hear them speak about this topic that feels like yesterday’s news but anything but.  It is more important than ever.  With that I will turn it over to Lee for the formal introductions and to get things going.  Thank you very much.

 

>> So thank you, Dan.  So, welcome to the conversation on science communication and I should know right upfront this is an evening’s exploration made possible by the NYU science, health and environmental reporting program.  Of which Dan is director.  Just to tell you what’s coming up for the rest of the fall here on October 29th, we’ll be delving into the power of the  image science of storytelling with the photographer Pulitzer prize winner on her essay.  And to conclude we’re going to have a very special session on November 12th.  We’ll be having a screening of the new documentary called Bias.  By fill maker Robin Houser who will talk to us about this feature length film on implicit bias and to make it particularly interesting we’ll be joined by a Harvard social psychologist who will then actually do interactive testing on implicit bias with us in the audience as a way of framing the conversation on this very powerful but very subtle influence on our behavior and choices.  And these all will be webcast as is tonight and I welcome those of you who are watching indirectly.  I encourage both everyone here and there I don’t know why I point to the ceiling when I — they have wings to chime in with your questions.  This is a conversation not a lecture.  And those of you who are watching online, can tweet your questions to using the hashtag CAVALEEconvo.  It’s hard to jump into the topic tonight.  Opioids, everyday according to the national institute of drug abuse more than 130 people in the United States die after overdosing on opioids in 2016, just in that year, that was 42,000 people who died.  This past August Johnson & Johnson was ordered to pay for just Oklahoma ‘s addiction crisis.  That was the cost of just one year’s and abatement.  500 million dollars in one not so heavily populated state in our union.  The state prosecutors actually sought abatement coverage for twenty years but they were bargained down.  In Oklahoma alone, in 2015 more than 226 million opioid pills were given out whether they need them or not and that Oklahoma case is just one of 2,000 lawsuits currently pending fraud by state and local governments seeking to hold drug makers, retail pharmacies and distributors accountable and that as many of you may know includes Purdue Pharma which makes OxyContin and the members of the family that own that company.  Just recently reported I think just last week that that — those people receive something on the order between 12-13 billion dollars profit for that legal drug operation.  Now we’re very, very fortunate, Beth Macy, comes to us from Roanoke, Virginia tonight.  Travis Reader, joins us from Johns Hopkins University in Baltimore for what is to be a conversation about opioids, about addiction, about dependence, about profit and pain and about how a cure can become a lethal epidemic.  Beth as many of you know is a journalist of some note, author and award winning writer in 2010 she was a Niemann fellow at Harvard.  Her first published book was a national best seller, so was her second book, True Vine and her third, which we’ll talk about tonight.  Dope Sick debuted.  And was named the winner of the Los Angeles times science and technology book prize.  She also writes essays.

Opeds for the New York Times, she podcasts now.  As so many of us do.  Travis is a faculty member at the Johns Hopkins Berman institute of bioethics.  As a trained low jigs I need to be careful this evening he’s written broadly on climate change, adoption, nanotechnology, his interest in opioids, came about abruptly after a motorcycle accident when he took too many pills for too long and found himself dealing with a profound opioid dependency and he’s the author of a new book called in pain.  A bioethicist ‘s personal struggle with opioids.

I want to start with a question for both of you.  So this is a medical story.  This is a business story.  This is a big Pharma story.  A legal story.  An ethics story, a pain management story, a cautionary tale of substance abuse.  I mean, what kind of story is this opioid epidemic, Beth?

>> It’s a family story.  I think we’ve left it in this nation to the institution of the American family to deal with the worst drug epidemic in our history and as so many people fall through the cracks and can’t get access to treatment or get access to the wrong treatment for many, many dollars, it is often the family that’s left paying the price for this.  Whether they’re still struggling with their person, with opioid abuse disorder or they’re lost them.

>> Travis, how would you answer that question?  What kind of story is this for you?

>> It’s a story about pain.  It’s a story about a country in pain, a country trying to treat all different kinds of pain.  About pain that comes about when the treatment for pain goes awry.  And then the sort of pain that we’re dealing with now where, you know, I would hazard a guess that almost everybody in here, you know, is no more a degree’s separation of someone affected by substance abuse disorder, overdose, addiction.  So, yeah, what it really ties in together for me is that Americans are just suffering really terribly and we really need to figure out why.

>> How did you come to this story, Beth?

>> I was a long time newspaper reporter for the Roanoke Times.  I worked there for 25 years and I wrote about family issues and normally I wrote about kind of marginal ized communities.  Refugees, immigrants, I did hard hitting investigative

enterprise pieces.

But the story I started working on in 2012 was kind of my first introduction into this.  It was interesting because I mostly wrote about things in the inner city but in this case, this heroin cell if you will of users had popped up in a very wealthy suburb called hidden valley.  Boy they sure hid it and they had the money to hide it and it made front page news because a young man who was a private school student, mom was a well-known civic leader, was about to go to prison for his role in selling the heroin that resulted in his former private school classmate’s death and I wrote the three part series.  And readers —

>> Of the Roanoke —

>> In the paper in 2012 and they thought, what?  Wealthy kids are doing heroin?  We had no idea.  That was the start of it and when I decided to pitch it as my third book, I did what I normally do which I take advantage of my contacts.  I am kind of a unicorn in journalism is I reported in the same community for 30 years.  I went back to those folks that I met.  I stayed in touch with Spencer, the young man in prison via the prison system e-mail.  Stayed in touch with his mother and went back to the prosecutors and said what’s going on now and after about an hour I could see a book.  Like, it was huge, and this was 2015 and then that was the year that Case the well-known economist showed that life expectancy was going down and that was largely driven by overdose deaths by so-called diseases of despair, suicide and cirrhosis of the live and things like that and so it turned into a much bigger story.

And so I did what I always did.  Do.  Try to do.  Is I went really deep in three different communities in Virginia because that’s kind of what I can bring to the table and then tried to use those as a microcosm for what was happening all across the country.

>> And so Travis I ask the same question to you.  How did you come to this story?

>> Not in a very nice way.  I got hit by a van on my motorcycle.  I was working on different things, I wasn’t researching pain or opioids, I was work on climate change and sustainability and I went out for a motorcycle ride on Memorial Day weekend and made it about three blocks from my house and a young man just didn’t see me and pulled through an intersection without stopping and T-boned my motorcycle and crushed my foot.  This was a very strange series of events that happened.  By profession I worked at Johns Hopkins, my job is to think about ethical and policy issues that arise in medicine and health care and then I was inducted into this health care system as a patient.  I wake up in a trauma bay.  They tell me I’m going to lose my foot.  I start on surgeries and I kept my foot but I was in the hospital medicated for quite a long time and I ended up developing this really profound dependence on opioids and then that led me to wean aggressively and have withdrawal.  I really don’t recommend this for anyone who is looking for a way as a writer to find your next subject.  I really don’t.  This is not a great way to find a research program but it turned out it worked and so when I came out of withdrawal, which maybe we’ll talk about more or not.  But I spent four weeks in just hellacious opioid withdrawal and when I came out I took some time to kind of gain some distance from the trauma of the experience.  And then my partner and I very slowly started to share this secret, this intimate personal story with people close to us.  And it didn’t take long before people were like, you know, you’re a bioethicist, you have to think about these things for a living and so I started writing and that was four years ago and that’s basically all I’ve done since.

>> I’m curious though at what point did you decide as an academic, one thing that strikes me about the two of you is you’re approaching this as we intend from vastly different vantages.  Beth, you’re a community based journalist and you sir are an academic with issues and looking for peer review publication and what at point did you decide, Travis, that you were exhibit A in a book about opioids?  And how did that shape how you wrote, what is in many ways a policy book?

>> I —

>> I say that in no way to discount it.  It’s a fascinating and compelling book.  And — but, I think you understand what I’m talking about.  Because you do have to play by different rules.

>> We don’t that’s right and so this was a work combined with scholarship in a way.  I want to use my story as a vehicle to get people to understand some pretty difficult concepts.  How does the brain work and what do opioids do and how do they get us in trouble and how does that explain what’s happening in the country.  To answer your question, what I decided is when I decide I was going to risk my career because as you say, it’s not a peer-reviewed publication.  I had to decide whether to write for everybody or to write for my colleagues.  And I very much care about writing for my colleagues and being held to the standard of rigorous scholarship but I also recognize that having 12 people with Ph.D.s read something that I wrote doesn’t always enact the change that I want and this story felt like the sort of thing we should talk about together.  And so I decided to take a chance.  Luckily they haven’t fired me yet so I think they’re okay with it so far.

>> No, but it’s interesting because one of the things as part of these conversations that we’re very interested in is in these days for lots of obvious reasons is communications technology, more and more researchers, more and more people who are in medicine, who are in science are themselves able and eager to take their own stories, their own work, directly to the public but there’s a whole different set of professional risks and professional barriers.  One thing I was very curious about, I would be interested in hearing the two of you talk about how you were able or not able to approach sources and the kinds of relationships that you were able or not able to develop.  Travis, I would like you to answer that first and then Beth, I will ask you about it.  As an academic, you have to live by a different set of rules than a journalist conventionally speaking.  Tell us about that.

>> That’s right.  So — that would be considered empirical research.  It would be qualitative data collection.  And a really important feature is that I’m not an empirical scientist so I don’t know how to do that.  I don’t know how to do it responsibly.  So one of the reasons to use my story and then when I was able to find in the literature to show that it’s not unique, to show that it’s not, I’m not an outlier, I’m every person.  Right?  I had to find that in the literature because I wasn’t able to go out and do data collection.  I’m not trained as a journalist or an empirical scientist.  It was a different sort of project and that probably gets to some of what you’re asking about that it led me to be very, very candid with my own experience because that’s what I had to work with.  Right?  I had my experience and what’s in the literature and so I had to eventually decide not to hold anything back.

>> Did you worry about embarrassing yourself in front of your colleagues?

>> Oh, yeah, all the time.  I still do.  Yeah, no.  It was terrifying and I did it for the first time in January 2017 I published a paper that was in an academic journal but included a piece of my story.  And I appreciated the writing that hey, people will read this.  As academic things go it kind of went viral in the medical community.  Hundreds of people read it.  But that really is what changed my career because I joke about, you know, whether I had to worry about tenure.  I have a lot of support at my institution especially from my director and there’s growing recognition, not enough and not fast enough but there’s recognition that we need to talk to everybody and academia can’t be an ivory tower that’s purely insular.  Yeah.

>> So Beth you’re coming to this as a community based journalist.  You know your way around the nonfiction part.  But this is really from a relationship standpoint, very challenging, how did you approach developing your sources?

>> So the first thing I said as I would meet people that were maybe going to be subjects of my book, I would say, I would just be totally transparent.  I would say, I don’t know what I’m doing yet.  I’m working on a proposal.  I mean, just be honest about the littlest thing.  I’m working on an article for my NYU class.  I’m not sure if it’s going to be published or not and I started casting my net wide.  I went back to those original sources and then a friend of mine found a dog running loose one day.  So she calls me up and she said, Beth, I just returned a dog to a household that’s in total disarray because here’s this woman in her 60s, a young grandmother, a hospital nurse, doesn’t know whether she could leave her heroin addicted daughter home alone with a newborn baby.  And she — the dog got loose, my friend Elizabeth returns the dog and my friend Elizabeth is quite a character and says oh, my friend Beth is thinking of writing a book about heroin, would you be interested in talking to her?  And she said that and they said, yes, because nobody knows — nobody understands what a hard place we’re in.  Like I don’t even know if I can go to work.  She can’t get her medicine she’s trying to get.  If she loses custody of her baby she will lose her medicaid.  This were all these complicated factors.  I waited a few weeks and my friend Elizabeth said did you call them back and they were familiar with my first book.  That helped.  I’d been a journalist in that town for 30 years and her dad knew my work and they’re divorced and I said I’m wrote I a book proposal, I don’t know if you’ll be in it or not and I’ll let you know along the way.  You can teach me a lot about this issue.  And she did.  And at the end of that first conversation — this was with Tess Henry, the young heroin addicted mother and her mom Patricia.  Was three hours long they told me the whole story and I said would you mind — I’d like to have a way to touch base with you on a regular basis so I can see how your story unfolds.  All I ask of you is that you be completely honest with me and I’ll do the same and as — and I did that.  As I knew that they were going to be a major part of the back.  I would be in touch with them.  But I said, can we do a weekly check in.  Is there something you do every week.  She said I’m supposed to go to NA meetings it’s a condition of my medicated assistive treatment but I don’t have a care and I said can I drive you and interview you along the way and she said sure.  So with her permission I would put my iPhone in my cup holder and record our conversations and I would walk her baby around in the back of the room when he got fussy and in that way, I got to see her as she was struggling with this and then eventually definitely fall through the gaps of care and ended up homeless, prostituting for drugs, lost custody of her son, lost her access to her insurance, sent to a very expensive rehab center that didn’t allow her to take her medicine and eventually she was murdered two and a half years after I met her.  Her body was discovered at the bottom of a dumpster by another homeless person addicted to heroin who was foraging for cans to sell for drugs.  And I will just say that, like, I got the call the day after Christmas from her mother who was sobbing and said I am so sorry I had to make this call.  She’s apologizing to me because we had been through so much together at that point.  And I didn’t know what to do.  Like what do you do when the main person you’ve been following for two and a half years is murdered?  And I called a friend of mine.  She said you should put your notebook down.  And be a friend.  And so then I thought, well what do I do?  What do I do?  What would I do if this was a friend?  So I made soup.  Which felt totally stupid.  Impotent.  Not effective at all but it made me feel better and I took it up there and she actually was hiking on the trails at the moment and I saw her son but the next day she asked me if I would go to the funeral home because she said it wasn’t the next day, it was actually a week later, she said good-bye to her daughter’s body which it had taken funeral home technicians two days to prepare her to be witnessable.

>> Open casket.

 

>> Yeah.  Yeah.  Just — this was just good-bye for the mother and the grandfather and, again, I just had my notebook out and I — I didn’t want her to forget that I was a reporter but also I had to be a human first so that’s what I did and then things happen.  Like there was one moment when Tess wanted me to pick her up out of a drug house and I decided that was a line I couldn’t cross.

>> Well both of you in different ways have written incredibly intimate accounts and as part of the power of your versions of this story.  Your vantage points.  But as a journalistic matter, as a craft matter, you’ve just demonstrated you grew incredibly close to these very damaged people that you were covering.

At what point did you, I know you told us you made soup but have you really put down your notebook mentally?  How do you hold onto your journalistic objectivity?  A  moment like that?

>> Well I think you have to be a human being first, right?

Like, that’s why we’re here.  And so I did the best I could.  As I said, I did have my notebook out the next time I saw her but that day I just made her soup and I took it to her house and I was there for her as she wanted me to drive her to the funeral home and you know was an interesting family dynamic.  I was there when the family took out the urn, recording with my notebook and my phone as I had been all along so that was still there as a reminder and did I cross the line?  I don’t think so.  I mean there were moments when I had to make a decision and I would just tell the reader, she asked me to pick her up from a drug house and I didn’t know what to do and I talked to my husband about it and told her mother instead that that’s where she was.  And her recovery coach.  I felt like transparent was key in that situation but people say you took her to the meetings and when she needed you you didn’t get her.

>> Did you seek counseling?

>> I did.  Before the book came out I was having trouble sleeping.  My doctor thought maybe I had PTSD.  I talked to a friend of mine who by the way wrote the definition for PTSD who said he thought I had secondary trauma.

>> It is interesting increasingly at least in the last year or two journalistic mainstream publications who cover distressing events are being offered counseling.  It’s a real professional shift in attitudes toward how covering crises affects the people who cover them.  I’d like to just shift the subject for a second.  In addition to the remarkable personal stories that you stared with us.  There’s a personal-personal story and yours the personal stories of the people who are dependent, addicted in the communities but both of you each in your own way identify a supply chain in a larger set of influences working on this.  And you each bring, I have to say, it’s quite interesting, the vantages of your professional character.  I mean, and I wonder, Travis, when you look at the opioid epidemic, the opioid crisis, whatever you want — you’re very strong on the idea that what you’re looking at is dependence, that takes place in a formal medical setting with, you know, doctors who are trying to do the right thing and pharmacists who don’t want to give you anymore than you’ve been assigned.  Anymore pills than you’ve been prescribed.  From that vantage point, can you tell us what the problem is here?  I mean —

>> Well I guess it depends on which problem you’re pointing to, right?

 

>> Well, I have five fingers.

>> Yeah.  So I was inducted into the health care system and so the first problem that I saw had to do with what happened to me.  Right?  And it was this very intimate story of carelessness amongst some of my prescribers and, you know, I was treated at world class institutions.  The fact that I have a foot is a miracle.  Just so you understand they took a piece of my thigh and made it part of my foot.  These are magicians as far as I can tell and yet I had more than twelve clinicians writing prescriptions and none of them knew how to get me off the medications they prescribed and that’s the thing I couldn’t get over in the wake of the withdrawal, in the trauma my family experienced as I sunk to the depths and started thinking about killing myself to escape this pain, we finally get away from that and I think how can that happen?  How in the world did we get here?  How did we get to a place where we are so bad at the pain medication that we use everyday that the world class doctors who put me back together couldn’t figure out how to get me off the medication they prescribed?  And that was the subject of the first essay I put in this health policy journal.  It was like, docs, look MPs, look clinicians, if you put a patient on a drug that has predictable long-term side effects you’re on the hook.  You have entered into a relationship that comes with only  —  obligations and this is the most obvious thing I’ve said in my career.

To this day clinicians don’t understand that.  They prescribe all these drugs that cause physiological dependence and cause withdrawal when you take them away without knowing how to taper them.  That was the first thing I found.  It was a fairly describable problem.  And then what really happened was I started looking at the health care system and trying to figure out how we got here.  And then it just exploded.  Because the answer is so complicated and it raises so many problems that we are not just recklessly overprescribing opioids we’re also underprescribing them so we have people denied medication that they ought to be prescribed because we’re so afraid of all this over prescribing that killing people.

We have parents who are on long-term medication who are stable who are being abruptly cut off because doctors are afraid of the DEA.  The problem is a hundred times more complicated than I thought when I saw this tiny slice and you go further out there’s two and a half people more struggling with this opioid use disorder and whatever we do with the health care system and suppose I become king of the world and I say fix health care it doesn’t solve opioid crisis because the cat’s out of the bag.  People are struggling with addiction right now who are either going to die when they take their next dose of fentanyl laced heroin or not.  And this is all trying to figure out what the problem is when it comes to pain and opioids and drugs is incredibly messy because there’s all these different pieces.

>> So Beth you come at it again, as I keep harping from, your perspective as a seasoned journalist.  What’s the problem from your standpoint?  Travis is talking about pain management, clinical ignorance problem.  What’s the problem that you found?

>> Well, I trace the whole beginnings of the opioid epidemic back to the introduction of OxyContin back in 1996 and Purdue’s unethical criminal misbranding that eventually admitted guilt to.  Exaggerating the safety of the drug and down playing the risks.  Right?  So they hire an army of sales rep to go all  over the country.

But they pay particular attention to impoverished places like coal mining towns, logging, these are my people, this is where I work from, right?  So when you put that opioid, that — you’ve got all these reps going to these towns where people are also losing their jobs, they have legitimate injuries, many of them and the doctors are lied to.  They’re told the drug is safe when it isn’t.  Then you have people who are getting genuinely addicted but in these poor communities they are also seeing OxyContin as a way to pay their bills.  They can go to multiple doctors, especially in the early years, they call it they’ll “write you” and then they can sell half and take half and that became a way, became like modern day moon shining, you know?

>> Modern day moon shining.

>> A side hustle.  Right?  And a way to pay the bills and crime in these impoverishing communities takes off shortly after the introduction of OxyContin.  Almost every family I interviewed the day they remembered starting to lock their doo — doors.  A man at the bank was shot and killed.  Just crime at another level.

The jails were full and all this was happening and then the late  90s.  This was before most people knew about  the opioid crisis.

And I felt lucky because I am from Roanoke and that is actually the place where the nascent federal investigation began in the early 2000s that ended with the criminal misbranding Purdue — a plea by Purdue in 2007 so I had those sources to go back and I could draw the story.  My goal was to tell the story of the the arc of the epidemic and then telling it through the case and through those first people who were fighting back.  The first doctors.  A bunch of activists and some of the early parents of the OxyContin and then I pick up the story in Roanoke where I actually picked it up in the early teens.  When I started writing about hidden valley and then more recently I wrote about this heroin ring that landed in a little farm community that to me exemplified that this could happen

here it could happen anywhere.

And that allowed me to talk about mass incarceration and the failed war on drugs because a drug dealer had landed in this small town and went from having a handful of known users to hundreds overnight.  But really without the overprescribing of opioids, this heroin epidemic doesn’t exist.  That’s what started it.  Purdue changed the narrative.  We knew for most of the 1900s, we had a huge opium epidemic after the Civil War we knew it should only be used in cases of extreme pain and they flipped the narrative with the introduction of OxyContin to say, no, it’s safe, the FDA allows us to make this fishy claim as if it was gospel and hired all these folks to sort of spread the gospel.

>> Both of you have something in common here I think which is you’re writing books not to entertain, not for a nice quiet snooze afternoon.

>> Mine is a great beach read.

>> These are acts of activism.  You are looking for change, you are ringing a bell in a literate and journalistic way.  And I’m curious, again, because of your different perspectives on this how comfortable is it for you as a journalist and vaguely if not objective at least kind of fair, you know, to step out as an activist.  You have something you’d like to accomplish here.

 

>> Yes, I think our job the to hold power accountable.  There’s the DEA, Congress, on and on and on and it was initially kind of uncomfortable but I started being interviewed, NPR asking me what I think about the crisis and so I had to sort of step into this activist/expert role that nobody trained me how to do but I feel that having spent seven years sort of in the thick of this and getting this view that a lot of people don’t have I felt a responsibility to say what I’m seeing on the ground.

>> Because you haven’t let go of this.

>> No.

>> It’s not solved yet.

>> I read today sometime after 2020 now they’re saying 2025 still going to keep going up until 2025.

>> I’d like to get your answer to that because of course you’re supposed to be Mr. Peer review,  mister, you know, but you’ve got an agenda.

>> Yeah, I would like to not call it an agenda but I have a view that I think is right when you recognize —

>> Right.  Right.  And numbered bullet points.  I think it makes it an agenda.

>> So I have a joint — an affiliate faculty appointment at something called the center for public health about advocacy and a lot of advocates would be uncomfortable with that.

Faculty appointment in public health advocacy.  I’m not uncomfortable in the least and I will tell you why.  Before I got to opioids and pain I was thinking a lot about climate change and there was this really interesting thing happening in the early part of my career as I was finishing my Ph.D. and publishing that climate change scientists like Michael Man were really stepping forward and saying I’m not just going to tell you the science but I’m going to tell you what to do because you’re not doing your job because I know these things.  I know the world is pointed at catastrophe and the division of labor was supposed to be easy.  I give you the data and you policymakers figure out what to do.  You are falling out on the job so I have to do all of it for you and I thought that was pretty powerful and pretty plausible as a response by an academic but I have even less compulsion about it than Michael because my job is never to be objective in the same way he was.  I’m an ethicist.  I’m trying to come up with arguments that are logical and sound.  It follows the rules of logic but the conclusion is you ought to do something.  We ought to do something.  The country would be better if doctors would live up to their obligations if.  That’s what I do for a living.  And so now I flip it on its head a little bit when I think about aren’t you uncomfortable being an advocate?  I’d be uncomfortable not being an advocate because my job is to figure out what we ought to do and if I do and I say, yeah, you take it from here I feel like a hypocrite.  I would feel lazy or relaxing in my ivory tower so why did I write a trade book?  Because I want change and, look, my colleagues are stepping up and they’re responding and I’m presenting this at academic conferences and talking to doctors.  They’re doing the thing I want them to do which is taking it seriously as an argument but I’m also getting other people to read and we’re not going to change our response to the doctor overdose epidemic unless an entire nation of people says we’re tired our or friends and loved ones dying, let’s do something about it.  I don’t have any strong feelings about this as you can see.

 

>> Dan in the darkness there has a question.

>> Hi.  Yes, in an effort to encourage further questions I’ll ask the first one so speaking of normative, there’s a bunch of journalists in the audience here who would really like to cover this story but they need fresh takes for the story that’s been around for a very long time as you guys made clear, you know, you could go back to the Civil War or ordinarily and certainly talk about the last 25 years with the earlier peaking in the 60s.  Anyway people need fresh takes and there are — they come in two forms its.  One is just sort of correct the stories.  Ideas that are out there that are wrong.  And the other would be new things that are arising based on changing circumstances, changing laws, so how about some fresh angle, some fresh ideas about what reporters are overlooking and what you think need to be in the stories.

>> So especially in smaller and medium sized markets as jobs go away and there are fewer people to tell the stories, what I see happening in Roanoke which is a region of about a quarter of a million people is I see reporters rely too much on the traditional beat sources.  Like cops, courts, not even health as much and my goal now is to tell stories around the solutions to this crisis which are largely where public health and the court system and our criminal justice system, this gaping hole in the middle and where people fall into that hole is when they die.  And so I am writing about people who are out there pushing the boundaries.  I have a story come out in the at LAN — Atlantic in a couple months who cracked the code on MAT.  Medically assistive treatment.  This can be controversial in XHURL  — CHURL communities.

She’s learning how to get judges and probation officers and police officers to start to treat these people who their whole adult lives are just circling — cycling in and out of jail, they’re coming out of jail, they’re getting on probation, they’re not getting MAT or health care and they get a dirty drug screen and go back to jail and she figured out a way around it and it’s pretty amazing and she’s doing it through Indiana medicaid.  She set up a nine hour week of intensive outpatient treatment inside the courthouse which forced the judges and the probation officers to get to know these people.  And to get — for them to get to know the social workers and the health care people that she employs.  There was — so it was — I’m out there and I’m trying to find where the edge of change is and that’s what I would suggest to you.  Instead of just try to find somebody who is doing something really difficult and using the best science.  And — but is figuring out a way to get around that cavernous gap where people die and maybe it’s a police chief talking about change.  Maybe in New York you don’t see that as much but in much of the rest of the country the idea of a syringe exchange in some of these places they can’t abide by it at all.

>> Travis, where do you stand, in the cavernous gaps in coverage that we might be able to exploit with fresh angles and stories.

>> I think my answer rhymes a lot with Beth’s and I was telling her before we started I was really struck by the last third or so of her book as she does this impressive thing which is she starts to weave the public health evidence into those stories with people who won’t always accept the sort of evidence that she’s presenting to the reader and so this comment about, you know, a lot of the country, syringe exchanges are still pretty philosophically scary so here’s a word to put to it.  Harm reduction.  That’s really scary in this country.  The part of the story I think we don’t have to talk a lot about more is Pharma and distributors and we’re going to have to keep covering the news but Purdue going bankrupt is not going to solve the problem.  We have two and a half million people plus living with this disorder and we have good evidence on how to keep them alive.  I want to say something to hold in your head and take home with you.  You do not have to die from addiction to opioids.  This is not a fatal condition in the right circumstances.  You die because of stigmatized, you’re driven to the shadows and the corners.  What’s the evidence?  The evidence is when we open safe injection sites not weed in the U.S. because we don’t do that.  The first safe injection site was open in Vancouver in 2003.  They’ve had millions of injunctions supervised in a health care space with naloxone on hand, how many people have overdosed? Thousands.  How many people have died?  Zero.  You absolutely don’t have to die from opioids.  We have medication that works, we have harm reduction that, WOS and now — works.  And now we go back to Beth’s book that I was talking about.  We have a huge part of the country that is facing the tragic aspects of this crisis.

They’re touched daily by people who are dying and the evidence isn’t infull traiting and I don’t know what to do.

>> They still see them as bad people.

>> Well there’s some of that.  But even I talk to a lot of people that don’t see their children as bad people and lose their children if you give them a place to do drugs you think you’re enabling it and there has to be a conversation about how do we move forward in a way so that using the opioids isn’t a death sentence in a country where a whole bunch of people won’t embrace the policies that will  actually fix it.

I don’t have the answer.  I’m like crowd-sourcing now.  I’m like this is my research.  I don’t have the bandwidth to solve this on my own.  The more the merrier.  Let’s figure this out.

>> There are these little winds that are happening and they are exciting to talk about.  I told you about the program in Indiana.  The hospital system where I live, largest employer and the last person I interviewed for these hospitals he said I don’t believe in medical assisted treatment.  I don’t think it’s in the purview of my ED.  Emergency department.  And the science — I wasn’t as firm about it then but I have it recorded so I’ve listened to itten  — it recently.  They’ve gone back and looked at the data and they totally  flipped their policy around.

So now a young person like Tess shows up in the ER they don’t just Narcan her and send her back in the streets.  They give her meds in the ER and — so when I say to him, and then they get them into — outpatient treatment which they beefed up within the first month they had 24 people in the treatment that they hadn’t had before and it was the same as the court.  It was the same people they were seeing over and over and they were having success.  He said we read your book, and then we looked at the data and we said, how can we not be doing that?  And I said what does it feel like to know you potentially saved 24 lives in one month he said I feel like doing cart wheels everyday.  And so one of the things I say when I go out and talk and maybe the old newspaper journalists, Beth Macy wouldn’t have done this, but one of the things I say when I speak to a group is if you know a court judge, a probation officer, if you know a doctor, somebody, a gate keeper in our public health talk to them because once they start to see that they’re having success, it gets really exciting.  And they love their job again.

And they can make a difference.  But people are so afraid and I find myself saying didn’t it used to be my job to tell people what they should don’t just like it wasn’t Dr. Burton’s job just because it wasn’t your job a year ago doesn’t mean it shouldn’t be your job now and maybe that shouldn’t be my job.  But I’m having these conversations all the time.  With people I’m interviewing.

>> You know, in the early days of this opioid what we call opioid epidemic there was a bit of a back swell where people would say, this is great.  Now it’s affecting small town white people.  And it’s a big national problem that we should all do something about.  When it was a heroin epidemic, you know, up in Harlem or in other inner city neighborhoods it was just simply a terrible criminal thing and we should just jail those people.  And withhold treatment as part of the punishment package.  How do you broker that legacy as you approach this subject?  I mean, do you recognize that?

>> I do recognize that.  African Americans were initially protected from the opioid epidemic because of racism, doctors didn’t trust them to responsibly take opioids.  And more recent data is showing now that there are more deaths in the inner cities now because African Americans are getting heroin that’s been cut with more get NOL and also less likely to call 911 because of policing issues.  I’m sure you have thoughts on that.

>> We identified you mentioned three different national epidemics of opioid related misuse.

You mentioned the morphine after the Civil War we just eluded to the heroin epidemics in the inner cities of the 50s and 1960s and now small town America’s struggling with this.  What’s the problem here?  What is it that journalists and policy ethicists are unable to do if I can claim the  — blame the two of you because you’re here that would drive the essence of these things home.

You’re talking of 100 years of very hard experience.  Is this about our attitude toward drugs, toward addiction, toward pain?

>> Yeah.  All of those.  I’m glad you brought this up.  It’s a big part of the last third of my book.  Every talk I give it has to be said that our response to the drug overdose crisis is laced with racism and classism.  And if you don’t acknowledge that, you’re perpetuating it and if you don’t look forward and say, how do you respond to this without contributing to that legacy of racism and classism then you’re part of the problem and so one of the things that I think we have to do is we have to recognize that people take drugs for reasons and when I say this I’ve given a bunch of academic talks where people with Ph.D.s, people with various disciplines in the audience have said, sure, you’re saying this very politically correct thing where we respond to crisis because people in the small towns start diagnose — dying.  But when it was the white people in the suburbs it was OxyContin described by the doctors and we needed to treat it.

If that’s where we start that’s not great.  We take heroin for reasons, what is heroin?  An analgesic, patented by bayer in 1898 as a replacement for morphine it works really well in exactly the same way that oxy codon and fentanyl work.  And the most heartbreaking stories start with yes, I started taking heroin, I took it because it was easier and cheaper than going to a doctor and getting painkillers.

People take pills for reasons and if you think starting with OxyContin makes you a different kind of person than starting with heroin then I think we’re starting with some biased assumptions that we ought to reflect on.  These drugs cause some people problems, not other people problems and we have to be really clear that when we move forward, the goal is to repair what we’ve done in the past and respond in a way that’s not discriminatory.  It doesn’t solve just the epidemic this the suburbs.  It solves the epidemic everywhere.

>> My question, that delves nicely with what you were saying Travis about people taking drugs for a reason.  For a long time sobriety was the end of the road —

>> Can you step more into the mic?

>> Yep.  Is that better?

>> Thanks.

>> And obviously in getting access to medication assisted treatment there’s a lot of triaging happening.  Just making sure that that’s possible in a lot of places is the edge of change as Beth was describing so what I’m wondering is do we have a sense longitudinally of what the outcome is going to be for people with medically assisted treatment and what we can push for as well and if medically assisted treatment is our best option is it only the option and is it a magic bullet?

>> Is that to me or —

>> To both.

>> You go and then you go.

I know you were working to some — the thing you were doing this week. .

>> Yeah, the vaccine.

>> I want to clarify the science is really clear that 65%, more likely not to overdose, relapse, die, if you’re taking medication assisted treatment.

And I had a researcher call me out of a talk I was giving in Kentucky and they say call it medicine.  It’s medicine the same way a diabetic would take insulin and often perhaps for the rest of their lives.  The science isn’t yet clear on duration.  We do know that the longer people today on it, even when they come off, after they’ve been on a long time they’re still at more risk of relapse and overdose.  You see it over and over again in my book.  Versus abstinence only which is about 58%.

>> People should get access to medication that works for them.  No questions asked.  But the data that Beth is sharing right now the gold standard is medication, MAT.  There is an abstinence based medication and you have to be abstinent first otherwise it casts you into withdrawal because when you have it on board it keeps the opioids that you put in your body from reacting to your receptors.  So you can’t get high and people really like that.  Law enforcement they really like this drug because it’s abstinence focused and I do not care if someone is abstinent if they don’t care.  We don’t what happens to you if you’re on it for 30 years.  It’s a really important piece of data that we don’t have that we should be collecting that will go in the hopper of pros and cons of going on medication but the most important thing that I want to say is that if staying on medication for longer keeps you alive, it’s obviously the right thing to do for you and a lot of people want to taper off because they don’t like the experience of being on it because they felt it would be better for them somehow if they didn’t.  But menu, on demand, whatever’s right for you.  Right?  In thing Beth was talking about is I just came down from Syracuse where I was participating on the ethics and regulatory issues around an opioid vaccine.  In the — going into clinical trials there’s something — they’re calling a heroin vaccine.  And basically I just gave you like my talk I gave them which is, I’m really suspicious of our love affair with abstinence based programs the idea of an opioid vaccine sounds great to the Justice Department.  They’re like, yay, a vaccine, that means you can’t get high you won’t be affected.  It’s not a vaccine, it just keeps the drug from reacting to your body.  I don’t think there’s a particular moral valence with drug use.  If you know anyone on an SSRI from depression and anxiety.  Those drugs cause independence.  I have taken lex  — lex pro everyday.  This is not seen as a drug of abuse.  If you have to take BU promean everyday to make you feel well it’s a good drug for you.

>> I’m hearing neuroscience stories I’m hearing sociology stories.

Actually, I’ve heard like five stories just in the last fifteen minutes.  But both of you now have told us what policy you like.  I guess what I’d be interested in hearing specifically, can I make things up but I’d like to hear from you, okay, what’s the story that you should do to advance that policy that you two believe in?  You just did this piece for Atlantic that’s going to come in the couple months and I appreciate you sharing with that us but when you go back to Roanoke, this is right outside of Roanoke, right?  Where you live, what’s the story that’s in that community that you know so well, having already told so many stories.  What’s the story that you can tell that advances that policy that you want to see enacted?

>> Well, a story I’m noodling right now, I was — I go all around the country talking about the book and usually when I go to a rural area there’s not enough access to MAT but I went to this little town in North Carolina.  It’s may berry, it’s the Andy Griffith, fictional town, very much still exists around this mythology of the 50s era.

And unlike every other small town I’ve spoken at they actually have a lot of positions for MAT that go unfilled.  When they looked at it, what was going on, they had the highest overdose rate in North Carolina and they can’t get people into this treatment that they’ve all set up.  The issue was they were living too far out and it was a simple transportation issue.  The other part was stigma.  So I am following the guy who’s been hired to turn around this town that has — I mean, I can’t believe it has the highest overdose rate in North Carolina.  May berry, right?  So they hire this guy who is former DEA, law enforcement, Marine Corps, comes out of retirement to take this opioid response job.  Is totally on board with harm reduction and all the science.  Can recite it as well as you and I can and he can’t get anything done because — he has a meeting, calls all the churches together.  We have people.  And some lady hijacks the meeting with, well, I think when they relapse we should just let them die and take their organs so he’s running into that stereotype, right and left that you all don’t see in New York but I see it out in — I want to say the real world, all the time.  All the time.  And he is a sheriff that is spending 750,000 dollars a year to incarcerate extra inmates in the next county over and he’s got — doesn’t want to do BU Poe nor fifteen in the new jail because he’s trying to raise money for the new jail.

So there’s that whole incarceration budget trumping the moralism, trumping the science.  Every timetime.

 

>> So for you it’s a profile.

>> It’s a profile but it’s getting into the psychology of this and showing people what works and what doesn’t work and, yes, I hope to follow him over time and see the community start to see the kind of changes that I was talking about with Dr. Burton doing cart wheels but I think that’s a story that’s happening all over America and I found this particular illuminate ing place to talk about.

>> Are you going to retreat back into the peer-reviewed literature or what’s the story that you can tell that will advance your sense over solution?

>> Well I have to do both all the time because I do like to have a job.

And so I do have to keep doing that peer-reviewed thing but, no, I will keep telling stories only.  Let me cheat a little bit.  Let me start a new story that’s more than what we’ve talked about so far so I mentioned earlier that one of our problems is that we’re not just, we didn’t just overprescribe bills for a long time and start a — spark a new epidemic.  We’re also now simultaneously underprescribing so one of the things I’m talking about with clinician that we are so bad with pain and we do this in every hospital in the country.

In a single hospital I was denied more pain medication by a stigmatizing judgey NICU wait, that WOUFSH  — would have been interesting.  ICU attending and then three hours prescribed into oblivion.  That started me down the road of dependence and withdrawal.  This road shows me we are completely incapable of responding to pain with nuance, response — responsibly, and I will talk to doctors and they tell me they can’t have nuance.  That the pendulum’s either give it out or withhold them.  If they can’t do medicine with nuance they’re in the wrong freaking business, right?

It turns out pain is hard to treat.  I don’t know if you realize this, pain is complex.  Pain is really hard.  It’s hard to think about.  It’s hard to treat.  Also, something we didn’t recognize for a long time.  Opioids are really hard to understand.  Pharmacology’s really complex T side effects are really interesting and unpredictable.

You know what we just learned being on opioids can make your pain worse?  We just learned this in the last five years.  We have a signal.  But now we think this is really coming.  Okay, that was a lot of preamble.  Here’s a bunch of stories.  We’re enacting policies all over the country that is hurting some of those vulnerable people.  Pain patients, people suffering everyday are being denied access to care and some of them maybe shouldn’t have been prescribed opioids in the first place but now they’re being cut off and abandoned.  Those stories aren’t getting picked up.  The people trying to tell those stories are the people affected and nobody’s listening, they’re screaming into the void.  They screamed loud enough with a few of us that the FDA both issued a corrective, a real sort of like, hey, the whole thing where you stop prescribing just cold, like ham fistedly.  You can’t do that to patients.

And those mea culpa kind of corrections are not having any affect.  You’re hurting communities.  There’s a bunch of stories that need told.  I would love the air waves to be flooded with stories about you can’t solve a drug overdose crisis but not giving pain care with any nuance or compassion.

 

>> How many hours did you say the average doctor has training in medical school for pain.

>> Seven or nine hours.

>> Say that again?  No, say that, like, let us hear that.

>> Yeah.  So the study is now several years old but it’s something like 7-9 is the average number of hours that physicians get on pain medication in medical school.  The study was done at Johns Hopkins before my time but about half of medical school students come with zero hours because pain medication isn’t required as part of the curriculum.

>> Is that part of what you’re doing when you speak to medical groups?

>> Yeah.  Got it.

>> I have a question.  Very patiently waiting to be asked.

>> In a world where you get rid of all the judgment and bias that are built into reasons why we don’t deal with this effectively and give people medication assistive treatment do you think that our health care system, the way it exists now, could accommodation the need for medication assistive treatment and if there were no barriers besides like, I don’t know, if there were none of that kind of like social or stigma related barriers.  Do you think that we could treat all those people?

>> Not even close.

>> Is it because of like gaps in coverage?  Yeah.

>> You saw 14 states that haven’t passed the medicaid expansion but I would still say and I think you said this in my paperback version that stigma is still the number one blocker to turning this crisis back because everything falls under it in one way or another.

>> Well, and stigma is part of the reason that those exist.  Right?  So if we magically got rid of the stigma that by itself wouldn’t do anything but that would allow us to fill in.  So the surgeon general’s report came out a few years ago and said one in ten people with substance use disorder actually gets specialty treatment.  We have a failure of 90% for this health condition.  Just think about in other health condition you would be cool with that.  90% of you aren’t going to get care.  We need a whole bunch of practitioners who can do this.  We have to fill in the education gap, now stigma’s a block to all of that.  That’s part of the reason it’s underfunded, people are not interested in going indict  — into it.  I was going into withdrawal I was a hot potato.  If it magically went away we have to rebuild the health care system.

>> Well that’s no small task.

>> We talk about treatment.  We have adults talking about this is a way of life.  How do we change the narrative of this isn’t the way of life and prevent them from using opioids in the first place.

>> That’s a good way to talk about the representative of rural America.

 

>> The data that came out of the Trump election showing the states, the redder states and also happened to be the places that had some of the higher opioid overdose rates.  Were places where the workforce participation is really, really low.  And one of the things I did as I was pulling those three communities together that when I decide I had these three buckets of geography that represented the three phases of the epidemic is I got is sociologist to pull all this data with the distressed farming community and the data was so clear that in areas where men mainly, the workforce participation has plumed in rural areas.  So we have to start with education.

Better education.  There’s a story in my book where a seventh grader is asked what he wants to be when he gross  — grows up and he said I want to be a drawer.  I want to draw.  It was only the thing he could imagine for himself because it was what he saw being modelled.

And so if you haven’t been to Appalachia community you’ll be shocked.  My friend gave a TED Talk recently about reparations in Appalachia and said we have our projects.  Purdue can fund some of our art projects in Appalachia but he’s trying to create art based on the storytelling model that’s always been strong in Appalachia.  He collects stories of people who have been affected by this and then they, he writes plays and think perform them in a theater group called higher ground which is amazing.  So you have people on stage telling stories about the opioid crisis as a call for conversation but these are actually people in recovery themselves and public defenders working on their behalf and there’s just so much work that needs to be done.  In terms of education and making these places vibrant again.

>> Did you have something you want to contribute.

>> I think that’s a lot of it.  If we’re thinking about prevention —

>> We’re changing the narrative I think is what she was asking.

>> Yeah one of the things that the U.S. is good at — good at is the wrong way to put it.  One thing we think about is supply.  We say we need to prevent addiction.  We need to prevent drug overdose.  The way to do that is to stop the supply.  If we flood communities with pills and heroin and that’s what killed everyone you think the solution is supply.  One thing that Beth is drawing out nicely is there’s another side to this.  It’s demand.  Let’s use our full economics picture here.  If we use the language of supply there’s another half.  Now I’m a broken record.  People take drugs for a reason.  What are the reasons people take drugs?  Quick anecdote for why supply doesn’t tell the whole story.  The second highest per capita prescribing of opioids in the world goes to Germany.  It’s the U.S., clear and away.  And then Germany.  How big is Germany’s problem with addiction and overdose?  Very, very small.  Not only is it very small but over the last four decades, as we’ve had all these change in pharmacotherapies it hasn’t changed at all.  Their addiction and overdose rate has been low, is low, hasn’t changed in 40 years.  Here’s a really important question, y’all, what are they doing that’s so different from us?  Right?  Here’s the hypothesis.  Not a whole lot of data.  Health care.  You know, lack of endemic poverty.  Hope.  Like looking towards the future.  The places in the U.S. that have been hit hardest by the drug overdose crisis have these features of not seeing a whole lot of other things to do with your life.  Right?  I know what it feels like to take opioids.  I know how good it feels.  I know how bad it feels when you stop.  The reason I was able to stop taking opioids because I had a one and a half-year-old daughter who absolutely meant the world to me.  A supportive partner who dragged me across the finish line and a support system like nobody’s business.  That’s how I got across the finish line.

>> And an amazing job.

>> I wanted to be a faculty member, I wanted to be everything I trained for.  Take that away and what happens to me?  I keep taking those pills.  So why do people take drugs? They take drugs for reasons.  Let’s figure out what those reasons are and try to change that.  Try to change the demand.

>> Sir, you’ve been patient.

>> Hi, this is a question from twitter actually and we glanced at it throughout the evening.  Do you think patients’ trust in doctors has declined as a result of the opioid crisis?

>> Did we all hear that?

>> Do you want me —

>> Yeah, let’s hear —

>> I want to hear both.  I want to hear both.

>> My trust in doctors has declined.

>> Yeah, me too.

>> Yeah, sure.  So one of the things I hear a lot from patients is they reach out to me.  Now that I have this kind of public persona as claiming to know something about and it say, I’m going in for a knee replacement surgery, my doctor is going to prescribe me 120 familiar — pills is that reasonable.  No, it’s not.  We pull back the mask and we find they have no background in treating pain and they’re completely ill-equipped for.

Has declined some.  I’ve seen that.  Normatively it probably should decline when it comes to treating pain and addiction we’ve just made it super clear to the unKUN — country that these things we need we are not addressing that.

>> I was working with doctors about two months before the book came out.  I had this necklace that Tess’s mother gave to me that represented the way she felt about her son on the outside and a picture of her on the inside and they asked me to speak to this medical school panel in the same place where they didn’t want to do but pronor fifteen and I thought this is my chance.  And I was a little worked up.

My voice maybe was shaking and I said I feel like any of you all who ever took a free item from pharmaceutical company should feel morally compelled to become part of the solution.  You know, we haven’t talked about the waiver but there’s this pretty — a lot of doctors say they don’t want to do this eight hour training thing to get the waiver to become BU pro nor fifteen describers.  It’s not much work but a lot of them don’t want to do it because they don’t want “addicts” in their waiting room and what I said was you all have, I don’t like to use that word.  They’re in your waiting room.  You maybe didn’t directly cause it but you participated in it.  And more importantly, you should become part of the solution.  And when I said this, the response was strict  — crickets.  Four months later they changed their tune a bit.

So that was good and it did make me feel good and that, you see that starting to spur other changes in our community.

>> What happened four months later?  You got crickets.

>> Then they did start becoming BU prenor fifteen profiders.  It was the same health system that I was talking about earlier where they now do BU prenor fifteen in the ER where prior to that they didn’t even want to discuss it in a public forum but now they’re saying the same thing.

>> I think two questions here are waiting.  So I want to go to those but I have a question.  But I want to get in line.  So, please.

>> You especially early — mentioned earlier that the burden remains on the families.  What kind of policies are there to alleviate that.  It seems like there are limit to what one family can do to help people.

>> Right.  One of the things if more doctors were waivered to prescribe this treatment, then people like Tess that I wrote about wouldn’t have to wait months and months to  get an appointment and go to a cash only PRIESH.  — prescriber.

All the things we are talking about fall within that rue pick — rubric.

>> We talked quite a bit about medication assisted treatment and also the preventive aspects but I’m curious what role you think mental health plays in this crisis and why people turn to heroin.  Travis you mentioned that there’s much less stigma around SSRIs now than there has been in the past and there’s also an eagerness to prescribe them.  Do you think there’s a potential for the same kind of pill happy approach?  In addressing the mental health aspect of this and also if you got to be king of the U.S. health care system how would you make that part of the solution in.

>> Oh, boy, that’s a really good question.  So, yeah, just to make super clear of the stakes.  Some of the best predictors is comorbidities.  We have to have a broad approach to health if we will address it at all.  I do worry about the pill happy approach but not because I’m antipharmacology at all.  This is one of the next projects.  The same thing that I described with opioids and to some degree benzodiazepines.  The drugs that we highly stigmatize because they’re drugs we “abuse”.  The same drugs that we prescribe them and let them go.

So there’s a write and forget mentality.  I have a DEA license.  Can I prescribe opioids, let me go.  The same thing is true with psych meds.

There’s a lot of excitement about prescribing medications that the folks who are prescribing have much less education and are doing a proper taper, doing long-term management, knowing what to do when the medication eventually its the tolerance ceiling.  So worried about the pill happy approach not because antipharmacology but just because the same move is going to have to be made here.

We need to have a sense of seeing the entire length of treatment basically.

>> I have a practical question.  I very much appreciate the solutions and remedies that the two of you have been talking about but for you in particular, Beth, we’re all, some of us here, journalists, some of us are established, some of us are starting out.  In the end, you’re a freelancer, and how do you sustain yourself as a freelancer with a cause?

>> I try to find really great stories that editors can’t say no to.  And where those great stories align with my values, where this epidemic is concerned is my jam.  Right?  So I’m always looking for lately those stories.  I also sustain myself with speak ing like Travis does.  We both have speaking agencies.  I hope to continue writing books for the rest of my career.

It’s been agreement.  I always loved long form but when I was scrambling as a feature writer at a daily newspaper, you would work, work, work.  So lucky if you get a month or six weeks to work on something and then as soon as you were done it would publish and it was like, oh, what do you have for me tomorrow?  You know?  So I really appreciate that not only do I get to work on something for a year, two years, two and a half years, then I get to go spend the next year talking about it and in the case of this book in particular learning more about the next step, the next phase, the solutions.  So it’s been great.  I recommend it.  I speak out mentors a lot.  I was at a writing conference at Texas in July which I don’t recommend.  There was warning signs about snakes in the hotel lobby.  But I met Sonya who, wonderful, she used to be with you guys, right, the Wall Street Journal who wrote Enrique’s journey and I watched her go from journalist to book writer to spends a lot of time giving activist speeches and now writes for the opinion section Sunday review section and I was like, that’s what I want to be in five years so I sought her out.  I kind of create my own little support team and I did it with the back.  I already asked Travis if I can interview him for my next project.  I am always looking for an opportunity that will help me find that sweet spot.

>> You have helped us tonight, both of you.  Find the sweet spot in a terrifying disconcerting national crisis.  And the sweet spot is your commitment and your honesty and integrity that the journalism that the two of you each in your own way has accomplished.  Thank you so much for sharing it with us tonight.  Thank you.  Thank you.