1 6 7 8 11 in oklahoma city, oklahoma - the...
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9 ROUND TABLE DISCUS ION ON OPIOID EPIDEMIC IN OKLAHOMA
10 HELD ON JULY 19, 2017
11 IN OKLAHOMA CITY, OKLAHOMA
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13 MODERATED BY: MR. TED STREULI
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25 REPORTED BY: KIMI GEORGE, CSR
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1 PANEL MEMBERS:
2 MS. JULIA JERNIGAN, EXECUTIVE DIRECTOR
OKLAHOMA BEHAVIORAL HEALTH ASSOCIATION
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MR. MICHAEL BURRAGE, ATTORNEY AT LAW
4 WHITTEN & BURRAGE
5 MR. MICHAEL HUNTER, ATTORNEY GENERAL
STATE OF OKLAHOMA
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MS. JESSICA HAWKINS, SENIOR DIRECTOR PREVENTIVE
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OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE
8 ABUSE SERVICES
9 DR. JASON BEAMAN, CHAIR, DEPARTMENT OF PSYCHIATRY AND
BEHAVIORAL SCIENCES
10 OKLAHOMA STATE UNIVERSITY
11 MODERATOR:
MR. TED STREULI, EDITOR
12 JOURNAL RECORD
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1 DISCUSSION
2 MR. STREULI: All right. Well, thanks for
3 being here. I want to start by saying that Brandon
4 Whitten was an all-American kid. He was a football
5 player, a popular student, beloved son, but while
6 playing college football, Brandon became addicted to
7 prescription drugs and alcohol, and addiction would
8 sadly lead to the death of his girlfriend, and three
9 years later, the loss of Brandon's own life.
10 Brandon's untimely death profoundly changed
11 his father's life. At first, Reggie Whitten was
12 depressed, and then he was ignited with purpose
13 starting nonprofit organizations including the
14 Brandon Whitten Institute at East Central University
15 and fighting addiction through education that invest
16 in the lives of others and into fight drug abuse and
17 addiction.
18 Fighting Addiction Through Education better
19 known as FATE has generously sponsored today's event,
20 and the video and print media that will be produced.
21 Before we start today's round table, please
22 join me in thanking Reggie Whitten and FATE for their
23 support and for their commitment to fighting
24 addiction.
25 (Applause.)
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1 MR. STREULI: Our panelists today are all
2 experts on this topic. They all have really great
3 lengthy resumes that we don't have time to do. So
4 they're going to give very brief introductions.
5 Michael Burrage is Reggie Whitten's law
6 partner at Whitten Burrage. He's a former U.S.
7 District judge. He is also the lead attorney in the
8 State of Oklahoma's lawsuit against several opioid
9 manufacturers. Mike, thanks for being here.
10 MR. BURRAGE: You bet.
11 MR. STREULI: Mike Hunter is the Attorney
12 General of Oklahoma and has formed a task force to
13 address the state's opioid epidemic. In addition to
14 the lawsuit against several manufacturers, General
15 Hunter is examining physician disciplinary procedures
16 and retail controls. In June, he charged a Midwest
17 City doctor with five counts of second-degree murder
18 in relation to the death of at least five patients
19 who investigators say received opioid prescriptions
20 without an appropriate medical history, and on
21 Monday, he charged a Tulsa doctor with unlawful
22 possession of opioid medications. Mike, thanks for
23 being here.
24 ATTORNEY GENERAL HUNTER: Thank you.
25 MR. STREULI: Julia Jernigan is the
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1 executive director of the Oklahoma Behavioral Health
2 Association, which advocates for provider-focused
3 public policies that support a system of well
4 financed high quality community-based mental health
5 and addiction treatment centers. Thanks for being
6 here.
7 Jessica Hawkins is the prevention services
8 director for the Oklahoma Department of Mental Health
9 and Substance Abuse Services. Jessica, nice to have
10 you.
11 And Dr. Jason Beaman is the chairman of
12 Oklahoma State University's Department of Psychiatry
13 and Behavioral Sciences at the OSU Medical Center in
14 Tulsa. Among his extensive list of credentials is
15 his board certification in forensic psychiatry.
16 So thank you all for being here today.
17 Our format will be a pretty straightforward
18 question and answer. I will ask one of our panelists
19 a particular question, and then following that
20 answer, if any of our other panelists want to expand
21 on that or add to it, they're certainly welcome, and
22 we'll have to pass you the microphone so that we get
23 your answers recorded.
24 Because we have only an hour, we will try to
25 keep the -- the program moving as best we can.
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1 So, Jessica, I'm going to start with you
2 because, you know, why not? I wonder if you could
3 start out, and Jessica, you may -- Julia, you may
4 chime in on this, too, but I wonder if you can talk a
5 little bit about the opioid problem here in Oklahoma
6 compared to other states around the country. We know
7 we're not the only ones.
8 MS. HAWKINS: Absolutely. Make sure this is
9 on. Can you hear me okay?
10 MR. STREULI: Yeah, I think the mic doesn't
11 have any amplification. It's just for recording.
12 MS. HAWKINS: Okay. Thank you.
13 So good afternoon. Yes, absolutely, the
14 epidemic that is sweeping our nation has really
15 impacted our state here in Oklahoma. We are still
16 among the top of the worst states in the country for
17 things like non-medical use of prescription drugs.
18 We also have had very tragic and terrible
19 consequences related to opioid overdose deaths in
20 Oklahoma which has impacted hundreds of lives.
21 Up until just a few years ago, those
22 overdose deaths were rising rapidly. We've seen the
23 doubling, for example, of heroin overdose deaths in
24 Oklahoma, and we know that even our -- our youngest
25 citizens, high school students, report to us really
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1 alarming rates of non-medical use of prescription
2 drugs.
3 So, in our state particularly, we've been
4 hit hard by this problem, and needing to deploy the
5 right resources, whether that be prevention services
6 locally or treatments that are needed to address this
7 problem. We've had serious challenges in being able
8 to do that.
9 There have been some areas of -- of bright
10 spots I would say. In the last few years, we've seen
11 a small reduction in the amount of opioid overdose
12 deaths in Oklahoma. We hope that will continue to
13 decline. We've also seen an increase in things like
14 medication-assisted treatment in which we're very
15 glad about, but still, those small incremental
16 improvements are certainly not enough, and there has
17 to be more done to address this problem and really
18 resolve the epidemic here in Oklahoma.
19 MR. STREULI: Okay. Thank you. General
20 Hunter, you've formed the Oklahoma Commission on
21 Opioid Abuse. Could you tell us a little bit about
22 your goals for that?
23 ATTORNEY GENERAL HUNTER: Happy to, Ted.
24 We're still working to implore all the appointing
25 authorities to populating the Commission. So we
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1 haven't started our work yet. We're hopeful to do
2 that here in the next few weeks. So, the Speaker,
3 the President Pro Tem, and the Governor will all have
4 appointments to the Commission, and it's intended
5 honestly to bring all of the stakeholders that are
6 really necessary to address this epidemic, and the
7 idea is to let's approach it in a comprehensive way.
8 We're going to look at policy objectives
9 ranging from looking at the treatment opportunities
10 that we have in the state, which honestly, are not
11 sized to fit the problem.
12 So between the federal government and
13 states, there's going to have to be -- there's going
14 to have be investment in rehabilitation, and we'll be
15 speaking to that.
16 Secondly, we're going to be working with the
17 medical community, with prescribers, to see ways that
18 we can strengthen the oversight of prescriptions.
19 You know, I want to say that the problem that exists
20 within prescribers is a minority within a minority
21 within a minority. But from a law enforcement
22 perspective, as you mentioned, we in the AG's office
23 are going to be very tough when we identify somebody
24 who is abusing their authority, and I think we've
25 demonstrated that.
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1 But back on the policy front, we'll be --
2 we'll be looking at ways that we can provide more
3 education in schools so that we can get this stopped
4 before it starts, but there's also going to have to
5 be attention to law enforcement's role in all of this
6 because when you're able to begin to throttle back
7 the availability of prescription opiates, you've
8 still got demand out there, and that demand leads
9 unfortunately people to heroin, black tar heroin, and
10 other things that are honestly deadly.
11 So we're going to have to be -- we're going
12 to have to be tough with respect to how we deal with
13 the dealing that goes on in the street, but again,
14 the hope is with respect to everybody on the
15 Commission, that we come up with a comprehensive set
16 of policy recommendations for the governor and the
17 legislature to adopt next year.
18 MR. STREULI: Okay. Great.
19 Mr. Burrage, what -- you're the lead
20 attorney in this lawsuit. Could you talk to us a
21 little about the legal strategy for pursuing
22 manufacturers and what the cause of action is and how
23 you approach that lawsuit?
24 MR. BURRAGE: Sure. Thank you.
25 The basis of the lawsuit deals with what the
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1 pharmaceutical industry has done with regard to the
2 distribution of opioids, and what brought this about
3 is the pharmaceutical industry made
4 misrepresentations.
5 These misrepresentations were made to the
6 health care industry. They were made to doctors, and
7 the misrepresentations center around that they're not
8 addictive, they can be time-released, and people
9 won't get hooked on them.
10 And this was not only done through drug reps
11 going to see doctors, it was a massive marketing
12 effort started by -- there was three brothers in New
13 York that were psychiatrists, and one of them had had
14 some experience marketing Valium and started to use
15 that as a -- a base model and targeted initially
16 cancer patients, but they went out and got other
17 doctors and -- to write KOLs or key opinion leaders
18 is what they were to go around and, you know, to
19 seminars and other events and, you know, say that
20 these opioids were not addictive and they were useful
21 in the treatment of pain.
22 They went another step. They set up like
23 the industry trade groups like the American Pain
24 Foundation, the American Academy of Pain Management,
25 and various other groups that were actually funded by
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1 the pharmaceutical companies to send the message that
2 the opioids were not addictive.
3 So what happened is doctors were doing what
4 they thought were good things for their patients, and
5 they were following what the pharmaceutical industry
6 had told them with regard to opioids, and it was all
7 false. It was all false.
8 And the genesis of the lawsuit and the basis
9 for the lawsuit are these false and fraudulent
10 misrepresentations that were made to doctors to
11 prescribe opioids so that the drug companies could
12 put billions of dollars in their pockets, not
13 millions, billions. And it's huge sums of money that
14 they have made, and it's cost the taxpayers of the
15 state of Oklahoma tax money as they can go for health
16 care, for treatment, for law enforcement, for
17 criminal justice system, the courts, and so forth.
18 The cost is staggering what it's cost the
19 state of Oklahoma, and so this lawsuit is intended to
20 recoup for the taxpayers the money that they -- the
21 state has been out in dealing with the opioid crisis.
22 MR. STREULI: Great. Thank you. And -- and
23 you touched on a couple of things. I know
24 Dr. Beaman's going to want to talk about, and I know
25 Julia's going to want to talk about especially on
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1 the costs, but we'll get to those in just a minute.
2 Before we do, Julia, I want to ask you if
3 you have some thoughts you want to share about
4 why we're -- opioids aren't new, right? They've been
5 around a long time. Why are we seeing an increase?
6 MS. JERNIGAN: And I think you made a really
7 good point for that. We're seeing an increase
8 because we're seeing doctors that were told that
9 these were non-addictive things. It's interesting
10 because we'll have people walking in saying, you
11 know, my child was prescribed something for their
12 wisdom teeth, and now I'm needing medication-assisted
13 treatment.
14 I mean, the warning was not really put there
15 where it needed to be, and I would not put any blame
16 on physicians, you know. I think that there should
17 have been more education, not only for them, but also
18 for those taking the prescription.
19 And so I think that's why we're truly seeing
20 an epidemic at this point is because it was given so
21 freely without any knowledge, and now we're trying to
22 combat an issue.
23 And it's hard now to be able to get
24 prescription drugs. We're making it more difficult,
25 and so like General Hunter said, people are going to
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1 heroin, and so we're just seeing people increasingly
2 having these issues, and that's why we're seeing the
3 death toll go up, and we're seeing all the different
4 social ails that go with this.
5 MR. STREULI: All right. My next question
6 is for Dr. Beaman, who probably by now has a lot to
7 say. But we're going -- we're going to start with
8 this one.
9 Could you tell us a little bit about what
10 you're -- you're seeing in the medical setting in
11 particular and -- and kind of expanding on the
12 question we asked Julia how it's changing.
13 DR. BEAMAN: Yeah, thank you.
14 We've seen -- In the last I would say 15
15 years, we've seen pretty dramatic changes in the
16 scope. We were, about 15 years ago, right at the
17 beginning of this large initiative to start treating
18 pain, and there was a lot of emphasis in the medical
19 community especially among family medicine physicians
20 that you need to start treating pain even to where
21 they created pain as a fifth vital sign. So we had
22 to document it. Every patient in the clinic,
23 patients in the hospital, everyone had to have their
24 pain addressed in some way.
25 And the guidelines of professional
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1 organizations were telling us the best way to do that
2 is with these long-acting pain medications and that
3 the risks were not worse than the benefit. And so a
4 lot of doctors started to go towards that.
5 That's changed definitely over the last five
6 years, but even more so over the last two years. Now
7 there's new guidelines coming not so much from a lot
8 of the professional societies but from organizations
9 like the VA who have really troubled with this
10 problem and also the CDC.
11 And they're telling us now things that for
12 chronic pain don't use the opiates as your first
13 line, and when someone comes in like Julia mentioned
14 with wisdom teeth, there's no need for a 30-day
15 prescription of these medications, and we know that
16 your risk of addiction increases after let's say
17 three days of getting these medications.
18 So a lot of these people that are entering
19 into this problem are your high school athletes who
20 have a back injury or someone going in for a routine
21 dental procedure, but once they get hooked, they get
22 hooked, and like General Hunter said, once you remove
23 their access to the prescription medicines, then
24 unfortunately, we're seeing them go towards the
25 non-prescription, which is right now I think mostly
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1 heroin, but we are -- I know I am and the department
2 are really, really afraid of Fentanyl, which is a
3 synthetic opiate that is -- in a lot of other states
4 that have restricted access to the prescriptions that
5 this synthetic opiate has made its way into the
6 market.
7 So what we've seen over the last 15 years is
8 this kind of roller coaster, and what we're doing at
9 the medical school is now addressing that, and we're
10 trying to teach the young physicians on you have to
11 be very responsible in your prescribing practices.
12 You have to make sure that it's always risk/benefit
13 analysis, and that what we're learning is that the
14 benefits of these long-acting medications is not
15 always going to be worth the risk of the addiction
16 that we know is a possible consequence.
17 And we're also trying to teach them
18 different ways to get involved in the treatment once
19 the addiction has occurred, and that's through things
20 like medication-assisted treatment.
21 MR. STREULI: I'm going to ask a follow-up
22 question. You mentioned a little bit about how
23 medical education is changing a little, which I want
24 to come back to in a few minutes, but I'd also like
25 to know how clinical care has changed to address the
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1 issue. Could you expand on that a little bit?
2 DR. BEAMAN: Yeah, I would say it's come in
3 two ways. One is policy, and the other is through
4 guidelines. So policy, the State of Oklahoma has
5 done a lot of things over the last few years to try
6 to get ahead of this, and one of the things that
7 they've most recently done is there's a database that
8 physicians have access to called the PMP,
9 Prescription Monitoring Program, and the state about
10 two years ago passed a law making it mandatory for
11 every physician to look at that every single time you
12 write a prescription in the out-patient setting that
13 is a controlled substance.
14 So, if I have a patient that I'm going to
15 give a long-acting opiate to, I'm now legally
16 required to access this database and make sure that
17 they're not getting it from somebody else.
18 Also in that database I'm able to look up
19 what pharmacies they're going to, and one of the red
20 flags of someone who is abusing medication is going
21 to multiple pharmacies.
22 So I'm able to access that information and
23 just use that as evidence and information on whether
24 or not the risks or the benefit of the medication
25 works. So there's been a lot of efforts by the State
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1 of Oklahoma to provide physicians with more
2 information to -- to make these important decisions.
3 And then also, like I said earlier, there's
4 the guidelines that the guidelines have first gone
5 from, you know, you should be using these
6 medications, and then now they're to larger national
7 organizations. They're not limited to the specialty
8 colleges of pain management, but now there are larger
9 organizations like the CDC, and they're saying don't
10 treat chronic pain routinely with opiate medications,
11 and now the most recent recommendations have been to
12 not prescribe more than just a few days' worth for
13 routine pain problems.
14 So we've seen a shift in what we're being
15 taught in how we're practicing, and that's just on
16 the prevention arm because on the treatment arm, on
17 how we're dealing with addiction once it occurs, has
18 dramatically changed.
19 And it used to be that it would be limited
20 to authorities in addiction medicine, people who only
21 practiced in that, but now the CDC and the State of
22 Oklahoma are recommending that all physicians get on
23 the front line of this epidemic and don't send a
24 patient dealing with this problem to the expert being
25 they're never going to get in. They're going to have
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1 to travel 400 miles to do so. Keep them in your
2 clinic, get the education and certification to treat
3 their problem in their small town, and do the right
4 thing for your patient.
5 OSU has worked with the Department of
6 Mental Health on a lot of initiatives to help make
7 this happen.
8 MR. STREULI: General Hunter, my next
9 question is for you. Mr. Burrage touched on this a
10 little bit, but you chose to join some other states
11 in suing manufacturers, and I'm curious. We talked a
12 little bit about why the manufacturers might have
13 liability here, but after that, what else are you
14 planning to do and what's next?
15 ATTORNEY GENERAL HUNTER: Well, we're going
16 to focus on -- on the lawsuit that we filed, and that
17 lawsuit speaks for itself with respect to what we're
18 alleging. I think Judge Burrage did a good job of
19 summarizing what we're contending and also
20 underscoring the fact that -- I'll say it if he
21 won't -- we think that this lawsuit involves billions
22 of dollars, not millions, but billions of dollars
23 over the period of time that this oversupply has
24 occurred in Oklahoma.
25 So there's a -- there's a data point here
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1 that just from the CDC, and it's honestly, I think
2 it's as illustrative of the problem as any I've seen.
3 Only about 4.4 percent of abuse painkillers come from
4 drug dealers. 17.3 percent were directly prescribed
5 by a doctor. 66.4 percent come from a friend or a
6 relative. So there's an oversupply of these drugs,
7 and there's a leakage that's occurring.
8 Two-thirds of this supply is leaking into
9 the population, not directly from a prescriber and
10 it's not being sold on the street. If there wasn't
11 this oversupply, if there wasn't this focus on
12 wealth, not health, if there wasn't this focus not on
13 the patient but on profits, we wouldn't have to be
14 addressing this the way we are, but our focus is the
15 pharmaceuticals. They're the source of the problem,
16 and we're going to hold them accountable.
17 MR. STREULI: Okay. Mr. Burrage, your job
18 in this particular case is to prove liability. You
19 talked a little bit about some of the facts and the
20 history of the case that -- that you can use to
21 pinpoint that -- that liability in this case.
22 But could you talk -- I would think one of
23 the defenses has to be here that both the doctors
24 prescribing the medications and the patients have a
25 role here and have the opportunity to exercise some
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1 free choice, don't they, and -- and -- and how do you
2 answer that?
3 MR. BURRAGE: Well, I think you back up and
4 say, Why do we have the problem? And it's well
5 documented why we have the problem. We've got the
6 pharmaceutical industry's own documents setting
7 forth, you know, that these are not addictive, these
8 opioids are not addictive.
9 Now, doctors were told that by the drug
10 company, a rep from the drug company, you know, he
11 lied, and so it's changing now, of course, but back
12 then when all of these fraudulent misrepresentations
13 were being made, all these industry groups were
14 saying that this is safe. That's what they were
15 acting on.
16 So I think the problem starts with the
17 pharmaceutical industry's misrepresentations and
18 fraudulent misrepresentations that are about the
19 effects of opioids, and that's -- that's what started
20 the problem.
21 Now, you know, can you try to spread the
22 blame around? I guess in any situation you can, but
23 the doctor didn't start the problem. The doctor was
24 acting in good faith on what he was told and what he
25 believed he was doing was right. So that's where the
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1 problem is.
2 MR. STREULI: And is there a case to be made
3 against the less scrupulous doctors or pharmacists
4 who are -- who are not checking the list or who are
5 prescribing opioids without a reasonable medical
6 reason or history to do so, are those other potential
7 cases on this point?
8 MR. BURRAGE: There's certainly liability
9 there if you're abusing the system or breaking the
10 law. You know, that's not the situation this lawsuit
11 addresses. This lawsuit addresses why we have these
12 opioids in the state in such huge amounts, how they
13 got here, and why they're here. That's where the
14 lawsuit goes.
15 We're going to focus on the lawsuit and
16 what's in the lawsuit because we think that we have
17 identified people who caused the problem, we've
18 identified the misrepresentations, and we're going to
19 go after them.
20 And, yes, it does involve the 2005 study by
21 the governor and attorney general's task force that,
22 you know, monatized what it's costing the taxpayers
23 of the state of Oklahoma, and it's -- you know,
24 there's the direct cost and indirect cost, but it's
25 over 4 -- $4.3 million a year back then, the direct
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1 cost to the state, to the taxpayers because of
2 opioids.
3 MR. STREULI: Okay. Dr. Beaman, I'm going
4 to come back to you for -- for just a minute, and
5 you -- you touched on this earlier, but I'd really
6 like you to elaborate on this.
7 We -- Over the last at least couple of
8 decades I think it's fair to say we have seen doctors
9 sort of default to medication when someone comes in
10 with a pain problem, and in addition to marketing
11 efforts of manufacturers, why have so many doctors
12 sort of defaulted to that as opposed to other
13 remedies like physical therapy or occupational
14 therapy?
15 DR. BEAMAN: Well, I think doctors always --
16 hopefully they always want to do what's best for
17 their patients, and we've already discussed some of
18 the reasons why they were prescribing pain medicines
19 and thinking that they were doing what's best for
20 their patients.
21 But a lot of times patients are wanting the
22 medications. They're demanding them sometimes very
23 forcefully, and the physicians are under increasing
24 pressures for documentation and to see more patients
25 in shorter amount of times and to talk to the
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1 patients about the alternative treatments for pain
2 like what physical therapy can do for you or to
3 perform osteopathic manipulative treatment which can
4 relieve a lot of the pain conditions and to talk to
5 them about the non-addicting methods takes more time,
6 and it's easier to write a prescription.
7 And I think one of the tenets of osteopathic
8 philosophy is even though it's easier to write a
9 prescription, it's not always the right thing to do,
10 and that's why we're trying to reframe our doctors to
11 realize is that it's an easy fix to write them a
12 prescription and it might get them out of your
13 office, but you're not doing what's right for that
14 patient. You may be destroying their lives and the
15 lives of everyone around them, and that you need to
16 take that extra time.
17 Also, you need to -- you're ethically
18 obligated to stay up-to-date on the latest
19 guidelines. So you might have graduated medical
20 school 30 years ago, but that doesn't relieve your
21 responsibility to educate yourself because medicine
22 is ever changing, and the doctors have to receive so
23 much education a year to keep their license.
24 The osteopathic board mandates that some of
25 that education is in proper prescribing methods and
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1 manners, and so the doctors are obligated to realize
2 what the newest guidelines are and realize that maybe
3 now the opiates are not an acceptable solution like
4 they used to be and that you do have to take that
5 extra time with your patients.
6 So hopefully we're seeing more of those
7 discussions happening, and I know that they've
8 happened all along. As a family medicine physician,
9 I've had that talk with my patients several times
10 over the last 15 years. Some patients like it. Some
11 patients don't like it, but it -- hopefully, now
12 we're just seeing a lot more of those conversations
13 happening.
14 MR. STREULI: I'm going to follow up on the
15 education component of that both for medical students
16 and practicing physicians.
17 How do you get that message out? How do you
18 get either that new training or that retraining to
19 kind of a different mindset when it comes to pain
20 management?
21 DR. BEAMAN: Well, so it starts with the
22 medical students, and make no doubt that this
23 epidemic is the public health crisis of our
24 generation. So just like the plague in the 14th
25 century and then HIV in the early '80s, this is what
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1 we're dealing with now, and medical education has had
2 to adopt in real time -- adapt in real time and adopt
3 new guidelines for training future physicians.
4 So we're changing things every day. One of
5 the things that we've done at OSU is we now have an
6 entire course directly related to addiction.
7 So just like they would learn cardiology and
8 gastroenterology, pediatrics, now we have to teach
9 our students just on addiction because it's that
10 prevalent, and it's that important for them to get
11 that education right at the beginning of their
12 medical career.
13 And then when they go out on their rotations
14 for clinical experiences, now we have to put them in
15 addiction hospitals. We have to get them exposure to
16 patients with those disorders because we know that
17 there's no way for them to not see them as they get
18 older and further along in their career.
19 Once you've graduated and you are a
20 practicing physician, a lot of times you kind of lose
21 that lifeline, especially in Oklahoma and at OSU
22 where we train our doctors to go out into small towns
23 and rural areas, you don't have that lifeline.
24 And so what we've done is -- and this is a
25 collaboration with the Department of Mental Health is
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1 we have this initiative called Project Echo. Project
2 Echo provides an opportunity for family medicine
3 physicians -- really any physician anywhere in the
4 country, but we gear it towards Oklahoma doctors to
5 join us by a teleconference once a week. Present
6 your patient with addiction, present it to the
7 experts, addictionologists, a psychiatrist, a case
8 manager, psychologist, present your patient and let
9 us give you expert guidance in how to treat that
10 patient. We don't want you to refer that patient to
11 us. We want you to treat them, keep them in their
12 hometown where we know they'll get better outcomes.
13 So, as part of that, we also provide them
14 with about 20 minutes of up-to-date most recent
15 evidence, literature, and guidelines on how to treat
16 their patient in addiction.
17 MR. STREULI: You used the word disorder,
18 and I don't think that's a surprise probably to
19 anybody in this room today, but could you maybe just
20 spend a minute talking about the -- the physical
21 component of addiction as opposed to choosing to do
22 something for fun.
23 DR. BEAMAN: Yeah, it's very important to
24 highlight that addiction is -- is not what we've been
25 engrained to think it is through the media --
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1 MR. STREULI: Careful.
2 DR. BEAMAN: Not necessarily the news media.
3 But that it is a bona fide medical problem that we
4 recognize it through the disease process.
5 We can show you imaging where individuals'
6 brains change because of addiction. I want to very
7 much stress that addiction is not a moral failure.
8 These are not weak individuals that can just quote
9 walk it off. That once they've had that substance,
10 it has forever changed their brain, and I have seen
11 individuals that have been addicted to everything,
12 and they try to take any medicine.
13 So you remove the addiction -- addicting
14 medication, and then they're trying to use some
15 non-addictive medications to try and change the way
16 they feel, and once you do that, they still want to
17 go outside, stare at the sun and spin around 13 times
18 just to feel different than the way they feel right
19 now.
20 So this is a real medical problem that we're
21 dealing with and sometimes incredibly challenging.
22 I've seen husbands spend $2 million on their wives
23 for years and years of rehab and still not be able to
24 make a single dent in that person's addiction.
25 I've seen mothers lose their sons trying
28
1 everything that they can. It really is an
2 unavoidable problem in some individuals. Some people
3 can take pain pills and have no problem. Some people
4 take one pain pill and their brain changes for the
5 rest of their life.
6 MR. STREULI: Thank you.
7 Ms. Jernigan, I want to know if you can talk
8 a little bit about what both the health care
9 community in the state and -- and maybe even more
10 particularly the legislature is doing or considering
11 to try to address the problem.
12 MS. JERNIGAN: I think that you brought up a
13 great piece with the PMP, the Prescription Monitoring
14 Program. That was something that the legislature did
15 to really try to start combating the issue, but our
16 providers, especially when you bring up the rural
17 communities, are seeing this epidemic firsthand in
18 not having always the resources to be able to see
19 everyone that walks in the door.
20 As a state right now, we have a waiting list
21 to get into some places. So, if I walked in today
22 and said I'm ready to have treatment, there might not
23 be the funds for me there to be able to receive them.
24 And so that's what we're really seeing is
25 the biggest issue in our health care community, you
29
1 know, the safety net providers. When someone walks
2 in the door, they might want to treat them. They
3 might want to help them, but if we don't have the
4 space or we don't have the ability to, we're going to
5 have to say, you know, come back when you're a little
6 bit worse.
7 And so, unfortunately, that's what we're
8 seeing as time goes on is the funding is, you know,
9 decreasing, but we're seeing the rise in individuals
10 coming through the door. And we want people to come
11 through the door. We want to break that stigma of
12 that addiction is something, you know, morally wrong
13 with you and then change it to it's a disease, and we
14 can cure this because treatment works.
15 We're seeing it every single day and all
16 across the state, in our providers' clinics, and so
17 we're wanting them to come in and get the help that
18 they need. It's just not always the resources there
19 that allow them to be able to get that treatment.
20 MR. STREULI: A lot of that answer had to do
21 with money, and Judge Burrage earlier talked about
22 the real cost nationally and to the state. Can you
23 answer that a little bit about what the real costs
24 are in Oklahoma?
25 MS. JERNIGAN: Oh, I mean we're seeing it
30
1 when we have a rise in individuals in our prison
2 system, you know, that are costing $21,000 a year.
3 We're seeing it in foster care with children being
4 put into a system that costs us $23,000 a year.
5 We're seeing a rise in all these different social
6 ails that costs the state and taxpayers thousands
7 upon thousands of dollars. And so, you know, yes,
8 pharmaceutical companies are probably making billions
9 of dollars, but at what cost to us, the taxpayers?
10 And so, when we're saying that we need more
11 resources and more funding, it's truly because there
12 are more people coming in the door, and it's not only
13 touching health care providers that are giving these
14 services, it's so many different places. You're
15 seeing it in schools. You're seeing it in foster
16 care, in DHS. You're seeing it in our prison
17 systems, and so it's not just one area needing the
18 resources. It's now multiple areas that are now
19 trying to combat this issue in trying to be able to
20 pull resources in to be able to give the services
21 again that people need.
22 MR. STREULI: Okay. Thanks.
23 Ms. Hawkins, back to you. We've been
24 talking most recently here about money, and I --
25 we've certainly all heard about the state's financial
31
1 problems, especially the last couple of years.
2 Can you talk a little bit about how the --
3 the budget woes have affected your agency and
4 specifically your prevention efforts?
5 MS. HAWKINS: I think that many of the
6 panelists have -- have touched on this already, and
7 it really can't be underscored enough that for the
8 7, 800 people in Oklahoma on any given day that have
9 asked for treatment, who need treatment, who are
10 ready to engage in treatment and cannot get services,
11 it's really alarming, and it's also telling about how
12 difficult it will be to overcome this epidemic
13 without the appropriate prevention and treatment and
14 resources in the community.
15 I think it also speaks to the stigma that we
16 have with this particular disorder. It's kind of a
17 strange notion to think that people for who are
18 either in crisis or who have overdosed or who have a
19 serious substance abuse disorder cannot get the care
20 that they need on demand in the community that they
21 live in.
22 We wouldn't do that, for example, if
23 somebody who suffered from a heart attack and tell
24 them to come back later when we could treat them, or
25 that maybe a service for them wouldn't be available
32
1 near where they live.
2 So really at all levels in order to get
3 ahead of this problem, not only are we going to have
4 to take on strategies that have been discussed
5 already about really increasing cautious prescribing
6 and scaling down the number of people who are
7 becoming opioid addicted in the first place, but
8 there really is probably no way out of this epidemic
9 without the appropriate treatments that people need.
10 We've seen many promising things by way of
11 family care providers and other providers providing
12 office space, medication-assisted treatment that
13 Dr. Beaman referenced. We need a whole lot more of
14 that.
15 We also need the ability for the local
16 non-profits and agencies who are serving and
17 partnering with those local doctors' offices to
18 provide the top therapy for those patients.
19 We need more services there as well. So,
20 unfortunately, in Oklahoma, the budget problems and
21 also the ability to fully fund prevention and
22 treatment services at the scale that they need to be
23 funded is a historical problem. This is a legacy
24 problem that continues to compound.
25 It hasn't improved, but the demand has
33
1 increased, and particularly with the opioid problem,
2 I would say what we're dealing with here is really an
3 issue of scale.
4 Dr. Beaman talked about it as the epidemic
5 of our generation. I would agree. The sheer number
6 of people who are becoming opioid addicted in our
7 country and in our state is -- is completely
8 overwhelming and unlike what we've seen before, and
9 we need to be able to have the resources to address
10 that effectively.
11 MR. STREULI: Could you -- your work is
12 mostly in prevention. Can you, No. 1, talk about
13 what we -- we lay people can do if we have a concern
14 about a family member, a co-worker, whatever, what --
15 what can we do to identify a potential problem and
16 help do something to prevent it from becoming worse?
17 And then any other information you can share about
18 treatments, anecdotes, medical emergencies that
19 family members or co-workers should know, what would
20 you tell them?
21 MS. HAWKINS: Sure. So, first of all, as a
22 preventionist, I always want to be as upstream as
23 possible and not suffer from sort of downstream
24 thinking, you know, where we wait for a problem to
25 occur and then try to figure out how to address it.
34
1 So, in terms of preventing the problem from
2 occurring in the first place, I think we've talked a
3 lot already about probably one of the top important
4 interventions that the CDC is recommending and that
5 states have seen promise is in really improving the
6 prescribing. We need fewer prescriptions. We need
7 fewer days. We need less high-risk prescribing such
8 as co-prescribing benzodiazepines and opioids
9 together. We need more patient education and
10 counseling about mixing certain drugs that can
11 produce a fatal very risky event.
12 We also need parents and people in
13 communities to understand how that circulation of
14 excessive amount of prescription opioids can impact
15 their family and young people.
16 So, for example, stocking medications that
17 have expired or are no longer being used, we ought
18 not be part of that cycle of -- of creating a place
19 and access for young people and adults alike to be
20 able to access and divert that medication further
21 into the community.
22 So one of the efforts that we have
23 undertaken at the local level is to really work with
24 not only local law enforcement, schools, nursing
25 facilities, also pharmacies about safe take-back
35
1 locations, also places where people can dispose of
2 their medication and doing a lot of community
3 education on takeasprescribed.org and through local
4 channels to educate people about how risky opioids
5 are, that they are addicting and that they're
6 dangerous, and we cannot have them in our homes and
7 communities unmonitored and also unsecured.
8 So disposal and storage is a real actionable
9 thing I think that many people throughout Oklahoma
10 can do. Also, we have to talk about overdose risks
11 because one of the most tragic consequences that
12 we're seeing because of the opioid addiction problem
13 is opioid overdose, and thankfully, in our state,
14 we've had some infusion of resources through the
15 state to work on a program for overdose prevention
16 where we are equipping first responders like local
17 law enforcement and also local programs with naloxone
18 kits.
19 Naloxone is a medication that's used to
20 reverse an opioid overdose. It's safe. It's
21 effective, and we have about two dozen sites
22 throughout the state now that are providing naloxone
23 kits for free to families, to the walk-in public, who
24 want to come in who may have a loved one using
25 opioids or at risk for opioid overdose otherwise and
36
1 need to have a kit.
2 That is something that every Oklahoma can
3 think about, can consider, and can take action on
4 locally to prevent this problem.
5 I would say, too, it's important to know
6 that there are resources and supports for families
7 out there who are concerned about a loved one or who
8 need more information about how to get treatment
9 services.
10 For example, by calling 211, operators can
11 have a conversation with families and with loved ones
12 about how to navigate that and also how to intervene
13 appropriately.
14 We have resources on the
15 takeasprescribed.org website which will direct you
16 locally to treatment providers, naloxone sites and
17 other things in your area that can help you with
18 those problems.
19 MR. STREULI: Thank you.
20 General Hunter, you've only been in office
21 for a few months, and this was a -- a topic that you
22 dove into immediately in kind of a cause célébri for
23 you, I guess.
24 Can you tell us a little bit about why this
25 particular cause, why this particular topic was so
37
1 high on your agenda?
2 ATTORNEY GENERAL HUNTER: I think that I
3 would say first that I was aware of the syndrome
4 because I had observed the tragedy sort of secondhand
5 with respect to a couple of little boys that I'd
6 coached as youngsters.
7 And in one case, you know, we've heard this
8 story repeated through no fault of his own, young
9 athlete gets injured, is prescribed opiates, and
10 becomes immediately addicted. And ultimately this
11 little boy is completely recovered, but it was a real
12 tragic episode, you know, for those of us who knew
13 the little boy, those of us who observed the impact
14 on his family.
15 But early in my first -- I guess I'm almost
16 five months now, Ted -- I had the opportunity to
17 begin really understanding this issue with the good
18 graces of a small group of people, very fine people,
19 who've experienced it firsthand.
20 And so the catalyst for me was people who I
21 respect and admire who dealt with it on a firsthand
22 basis who'd lost family members, and honestly, I just
23 want to say for the record, one of the things that
24 motivated me to tap Judge Burrage as lead counsel in
25 this case is I knew I wasn't just getting a great
38
1 lawyer and a great Oklahoman, I knew I was getting
2 somebody who would put their heart and soul into this
3 because Mike lost his niece to this.
4 So after -- again, after honestly being
5 inspired by people like Mike and others, it just
6 became something I knew I had to do on behalf of the
7 state, and we're serious about this lawsuit. It's
8 not a sue and sow.
9 These -- these pharmaceutical companies have
10 hurt the state. They've hurt its people, and they've
11 caused the deaths over just the last three years of
12 almost 3,000 Oklahomans, and we're going to hold them
13 accountable.
14 MR. STREULI: Okay. Thanks.
15 We have about nine or ten minutes left.
16 One -- one thing that came up in our conversation
17 that I got curious about was whether there's a
18 difference in this problem between rural Oklahoma and
19 the Metro areas, either in treatment or in addiction
20 rates or in availability, and -- and demand of the
21 opioids, and I welcome anyone who wants to take a
22 shot at that question to answer it.
23 DR. BEAMAN: I think that we do see a
24 difference, but make no mistake there's no corner of
25 the state that's not affected by this epidemic.
39
1 Rural areas in Oklahoma face unique
2 challenges. Usually it's one doctor who is
3 delivering babies and taking care of everyone up
4 until the end of life. Those doctors are forming
5 personal relationships with patients, and they're
6 also treating all conditions. They don't have the
7 benefit of a referral.
8 If you're in a big city and someone has knee
9 pain, you can go send them to a knee specialist, but
10 if you're in the far reaches of the state, you don't
11 necessarily have that opportunity.
12 So a lot of times it falls on them to use
13 these medicines. Also, in bigger cities, you have
14 access to more resources such as conferences and
15 education in academic centers where you can help to
16 stay up-to-date on the most recent guidelines and
17 education.
18 In small towns, you have to run your clinic
19 Monday through Friday. It's hard for you to get away
20 for conferences, and so it kind of limits your
21 ability.
22 With that being said, the rural areas of the
23 country historically have been hit hardest by this
24 epidemic. It's rural West Virginia and Kentucky,
25 Appalachia, and then Oklahoma. So there is some
40
1 rural component, and I think that goes into
2 historical trauma and the other reasons why
3 individuals are seeking a substance to feel
4 different than they do right now.
5 MR. STREULI: Okay. Thank you. Anybody
6 else want to weigh in on that, rural America?
7 MS. HAWKINS: I want to just -- I would just
8 echo what you're saying about the availability and
9 services and resources, but in addition to that, when
10 looking at overall prescribing, there are differences
11 in our counties throughout the state.
12 The CDC just put out a report that showed
13 that although prescriptions are going down, they're
14 still way too high, and we have about 28 counties in
15 Oklahoma that fall into the top category among the
16 country for the highest number of prescriptions.
17 And many times when we look at several
18 different types of indicators, for example, like
19 overdose death or treatment admissions, we see some
20 of the same counties illuminate on the map with a
21 particular higher level of risks.
22 So there is no single one county in Oklahoma
23 that has not been touched by this problem, but there
24 are some distinct differences in regions of the state
25 where there may be particular drivers that are --
41
1 that are contributing to the problem.
2 MR. STREULI: Okay. Thanks.
3 ATTORNEY GENERAL HUNTER: I would just
4 mention real quickly, Ted, back to the complexity of
5 this problem. Missouri doesn't have a prescription
6 monitoring program. That new attorney general, I
7 just had a discussion with him, and my question was,
8 What's up? And he just sort of rolled his eyes about
9 the Missouri legislature.
10 So the leakage that's occurring across the
11 state line is cognizable because you can -- you can
12 physician shop in Missouri just across the state
13 line.
14 So there's honestly a little bit of a
15 phenomenon in that part of the state with regard to,
16 you know, frequency of overdoses. So he and I are
17 going to jointly appeal to the Missouri legislature
18 to look hard at a PMP this next session.
19 MR. STREULI: You unwittingly just gave us a
20 segue to my next question, which was about
21 neighboring states and different rules in different
22 states and how that affects prescribing or filling of
23 prescriptions or availability of those drugs, and
24 obviously there's a concern on the Missouri border.
25 What about the other neighboring states
42
1 and -- and how big a problem is it to -- to go
2 shopping in different -- different states?
3 ATTORNEY GENERAL HUNTER: All the PMPs
4 aren't identical. Actually, ours is a pretty strong,
5 pretty effective one. I think we can make it
6 stronger and more effective.
7 But I will just tell you I'm having
8 conversations with my colleagues in surrounding
9 states, and we're seeing other states join in
10 litigation against the pharmaceuticals, but there's a
11 lot of interest in having a regional approach to
12 policy that can address just what you've identified
13 that there's not -- there's not appropriate
14 similarity. There's not appropriate correlation and
15 coordination between these programs that are in
16 bordering states.
17 MR. STREULI: This, again, could be a
18 question for several of you. So whoever wants to
19 grab it, would be great, but we've mentioned several
20 times leakage in different context, and the first
21 place that came up was that the supply of opioids
22 that are available. And you mentioned, General
23 Hunter, a -- rather astonishing percentage of the
24 opioids that fall into someone's hands who were not
25 prescribed by a doctor but came from a friend or
43
1 family member.
2 How -- how do we curtail that, and maybe
3 more importantly, what -- what does the early form of
4 addiction look like when it isn't just someone going
5 to the doctor, getting a prescription for some kind
6 of pain, and then getting hooked on the medication?
7 What does it look like when there's a supply of the
8 drug hanging around that's getting passed around to
9 friends or family members who then become addicted?
10 What -- In real life, what does that look like in
11 somebody's house, or on the playground, or at the
12 school, or at the workplace, or where and how is that
13 happening?
14 MS. JERNIGAN: So that can be in different
15 forms, you know. If you do have medication that's
16 left over, and Jessica made a really good point. I
17 feel like that's going to be the best thing to start
18 combating is getting rid of it. Along with the
19 over-prescribing facts, you know, you can be around
20 the water cooler at work, and someone said, you know,
21 my back's really been hurting me lately. Well, I
22 have Percocets from when my shoulder had a problem.
23 And so it's very innocently where, you know,
24 individuals can say, you know, talking to a friend,
25 talking to a family member, oh, like this hurts or
44
1 I'm having this issue. Oh, I didn't ever get rid of
2 my medication from this surgery or this issue as
3 well. Happy to give you one. And something that
4 just kind of occurred.
5 The other thing is with our young people is
6 they're looking at this as, you know, going into mom
7 and dad's cabinet. You know, what else do they have
8 access to? And if maybe dad had a back surgery from
9 two months ago but never threw away the medication,
10 you know, little Johnny can then go in and try it and
11 seen what happens.
12 And so it's this very innocent idea of just
13 medication laying around, but it really has that big
14 impact on not only the individuals that are taking
15 it, but those that are getting addicted.
16 MR. STREULI: So somebody mentioned disposal
17 being a real issue earlier. That sounds like that is
18 part of the solution there is educating people on how
19 to properly deal with medications they no longer
20 need.
21 Okay. We have like two minutes left, and I
22 just want to invite each of you maybe to pass the
23 microphone down the line and take just 20 or 30
24 seconds to give us any final thoughts or follow-up,
25 and I also would like to invite all of you back in
45
1 about six months for a follow-up and see what kind of
2 progress you made, but take either end and send the
3 microphone down.
4 MS. JERNIGAN: I would say the biggest thing
5 is realizing again that this is a disease. I think
6 sometimes stigma is our biggest issue not only when
7 we're asking for taxpayer dollars, or if we're just
8 having conversation over coffee.
9 And so continuing that conversation of this
10 is an illness, this is a disease just like kidney
11 failure or heart problems, and we need to be able to
12 treat it such that way because we would never ask
13 anyone with diabetes to wait until you were in a
14 coma. No, we would instantly treat you, and I think
15 that's the biggest thing as a state and as citizens
16 of this state that we need to start being able to
17 help our fellow people in realizing that this is like
18 diabetes or anything else and they need to be able to
19 get the health care they deserve.
20 MR. BURRAGE: Well, you know, when you hear
21 the word drugs, there's a stigma attached to it like
22 you were talking about. What the pharmaceutical
23 industry has done is really caused some bad things to
24 happen to good people and they need to be held
25 accountable, but you -- it's hard to go out when this
46
1 subject comes up, anybody you talk to, if they have a
2 family member that, you know, that's experienced this
3 problem.
4 And so, hopefully, in addition to the
5 financial aspects of this lawsuit, there can be
6 changes in the way that the pharmaceutical industry
7 conducts itself, and they need to be told and have
8 restrictions put on them that the almighty dollar is
9 not the only thing that's -- you know, that's
10 important because what they have done has affected
11 many lives, and it's been tragic in some cases.
12 ATTORNEY GENERAL HUNTER: Well, I've always
13 tried -- I've been in public service for a while, and
14 I've always tried to be a lawyer first and a
15 politician second, and please don't roll your eyes,
16 but I just want to underscore, we're serious about
17 this lawsuit. We've -- we've put a fantastic legal
18 team together on your behalf and on the state's
19 behalf. We're serious about this, and we're going to
20 be successful, and we're going to hold these
21 companies accountable.
22 MS. HAWKINS: I would just say I think that
23 we -- we are in the middle of a culture change, and
24 anything that each of us can do within our own
25 sectors or spheres of influence to help with that
47
1 would be appreciated.
2 I know when I started this work in the area
3 of opioids just four or five short years ago, we
4 really were talking about how to safely use, and
5 probably it's a small portion of people who are
6 abusing and who are the problem, and we have to make
7 sure we don't increase or harm people in pain by
8 addressing this issue.
9 And now flash forward to today, we really do
10 understand from the evidence and from the outcomes
11 that opioids are highly addictive. They are
12 dangerous. We have to be very cautious in our
13 prescribing and also in our sharing and not
14 stockpiling our homes with them where we can have
15 negative consequences.
16 So we're all in the middle of helping to
17 reorient ourselves to this problem and find
18 actionable solutions in our every day lives to -- to
19 help contribute to solution.
20 I would just add further that this
21 particular epidemic, how we solve this is how we
22 solved other health epidemics. We know what works,
23 we know that most effective treatments like
24 medication-assisted treatment are highly impactful.
25 They make a difference. People recover. We know how
48
1 to prevent the problem.
2 It's -- it's time to bring those resources
3 together, and just also I want to thank the panelists
4 and those of you that put this together. It's
5 exciting to be in this field to see so much positive
6 energy and interest and willingness to work on a
7 problem like this. So thank you.
8 DR. BEAMAN: And I would just finish with
9 saying that I think everyone here has spoken to the
10 critical roles that physicians have -- are playing in
11 this problem in that OSU has picked up the banner and
12 are going to fight the good fight not only in the
13 education of treating the pain and safe prescribing
14 practices, but also in the learning and education
15 that goes around addiction and how to treat addiction
16 once it's occurred.
17 Not only are we doing the education but then
18 also the critical component is the treatment of
19 addiction, and we are dramatically expanding our
20 services not only in treating patients one-on-one,
21 but we're trying to provide the same services
22 throughout the rural community in the state of
23 Oklahoma so that we can reach the most amount of
24 people possible.
25 MR. STREULI: You can learn more on the
49
1 topic. We will have a transcript from today's
2 conversation posted to the Journal Record website,
3 journalrecord.com, as soon as it's available. We'll
4 also publish and print excerpts from that transcript
5 from today.
6 We'll post both the hour-long video and
7 segments from the video on specific topics that are a
8 little more digestible. Those will be available to
9 some others including our sponsor today. You can
10 find them at fate.org. We're very appreciative for
11 their support, and I'd ask you before you leave this
12 afternoon to please join me in thanking our panelists
13 for their time and expertise today.
14 (Applause.)
15 MR. STREULI: Thanks very much for coming.
16 Enjoy the rest of your afternoon.
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1 C E R T I F I C A T E
2 STATE OF OKLAHOMA ) SS:
3 COUNTY OF OKLAHOMA )
4 I, Kimi George, the officer who prepared the
5 foregoing transcript, do hereby certify that the
6 transcript was taken by me in shorthand to the best
7 of my ability and thereafter reduced to typewriting
8 under my direction.
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Kimi George
13 Certified Shorthand Reporter
Certificate No. 0335
14 Expiration Date: December 31, 2017
(Stamp on File)
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