Revisionist History - In Triplicate

Episode Date: July 7, 2022

A mystery that begins with the half-baked idea of an obscure California bureaucrat in the 1930’s and ends with one of the worst public crises in American history. Chicken Little said the sky was falling. And sometimes Chicken Little is right.  If you’d like to keep up with the most recent news from this and other Pushkin podcasts, be sure to sign up for our email list at Pushkin.fm.See omnystudio.com/listener for privacy information.

Hello, hello, Revisionist History listeners. I'm excited to announce that this season I'm offering a bunch of perks from my most loyal listeners, the ones who subscribe to Pushkin Plus. For those who just can't get enough, we're giving every episode to our subscribers one week early. Plus, we've created many episodes, released weekly, and I'm calling them tangents. And of course, you'll never hear any ads. Subscribe to Pushkin Plus on the Revisionist History Show page in Apple Podcasts or at pushkin.fm. When I was in my 20s, many years ago, I was a reporter for the Washington Post,

a newsroom the size of a football field. Phones ringing, keyboards clattering, the glory days of print journalism. I want you to describe what is the status and position of a Washington Post reporter in Washington, D.C. in 1989? Well, in general, godlike, because the whole city ran on politics and news, and there weren't many organizations that produced it excellently, and the Post was sort of the place that everyone cared about. That's my friend Michael Spector. He and I were both on the health and science beat for the Post. If somebody cured something, discovered something, solved something, or screwed something up, we were on it. In those days, it seemed like everyone read everything we

wrote. Well, they did. I mean, there is an exception, which is we were in the science pod. And at least at the Post, that was considered, like, why would smart people write about science when they could write about the White House and wear yellow ties? But in general, we had big readerships, particularly when we wrote about science policy. We sat at the center of a giant ecosystem of lobbyists, lawmakers, aides, bureaucrats, policy wonks, who tried to get us to see the world their way. If you called someone and said you were from the Washington Post, they called you back. I used to listen to Michael every day, on the phone with a source on Capitol Hill.

That individual had access to everything, but he didn't mind ratting people out. It was like heaven. I had a couple people like that. It was heaven. I remember once where you get the plain brown wrappers with stuff inside of it, because nothing, of course, was digital in those years.

You would get the mysterious phone call, and you'd have to decide whether to return it. So there's one member of this ecosystem that I'm most interested in. Ready? Sid Wolf. Sid Wolf. I love Sid. I loved him then. I love Sid. I loved him then. I love him now.

But, you know, yeah, he is a particular kind of guy. I think I was the most skeptical of Sid. Yeah, because you were like a right-wing lunatic. I was a right-wing lunatic. And it was a right-wing time. Sidney M. Wolf, M.D., versus me 30 years ago when I was a right-wing lunatic. I was different then, which I offer as at least a small explanation for my behavior in the story I'm about to tell you.

My name is Malcolm Gladwell. You're listening to Revisionist History, my podcast about things overlooked and misunderstood. This season is devoted entirely to experiments. And this episode is about what happens when an experiment teaches us an important lesson and we don't listen. Sid Wolf came to Washington, D.C. in the 1960s as a young doctor. He went to work as a postgraduate fellow at the National Institutes of Health, part of the same class as Tony Fauci. One day in 1971, someone told him that half of the saline solution being supplied to American hospitals was contaminated with bacteria.

And Sid said, oh, when are they going to take it off the market? And the person said, they aren't, because if we do, hospitals will run out of IV fluid and we'll have a disaster on our hands. And Sid said, that can't be right. There have to be other sources of IV fluid. He did his research, found out there were other sources, and went public. Called the press, got his friend, the political crusader Ralph Nader, to hold a press conference, and the bad IV fluid was pulled from the market. Sid had found his calling as a consumer advocate. I am sick and tired of the patronizing attitude of the American Medical Association towards American patients. Sid was unstoppable. He started something called the Public Citizens Health Research Group and became one of the angriest voices in Washington.

As many of you know, our organization has now for 25 years been the most outspoken critic of the FDA. More than 50 times we've submitted petitions, sometimes resulting in lawsuits against the agency to try and get them to do what we think the law requires them. In the C-SPAN archives, there's practically a Sid division. Sid against the drug companies, Sid against the doctors, Sid against the FDA. It is clear that of the 17 years since we have been running the health research group and watching the FDA, this is by far the worst period of time ever. Sid didn't like anyone except those who were willing to join him

on the lonely ice flow of his 60s radicalism. Okay, that's not fair. It's not that Sid disliked people. It was never personal for him. Sid's battle was with institutions. Sid believed that bureaucracies and companies and legislatures would behave better only when constrained by the right laws, the right regulations, and the right kind of relentless nudging from people like Sid. He was the nudge of Washington, D.C. Sid's very smart and very colorful and a great quote, but there's only one way, and that's Sid's way.

You don't have a deep, meaningful conversation on both sides with Sid, but some people, and he was one, were just excellent at knowing what we needed and what we wanted and how to package it. And that was Sid. I hadn't thought of Sid Wolf in years. But then I started reading about someone named Paul Madden, one of those forgotten figures from the mid-century. If you lived in California in the 1940s, you would hear Madden from time to time on the radio. Good evening, ladies and gentlemen. There may be harder jobs than breaking up a narcotic ring.

I don't know. I've never seen one. Especially difficult is the job of rounding up a band of narcotic peddlers, including the brains of the gang. Madden was a progressive. The progressives believed that government could fix things, that systems and regulations and rules, properly written, could make the world a fairer place. Progressives were activists, full of zeal.

In 1939, Paul Madden was appointed to run the California Bureau of Narcotic Enforcement. He was the man responsible for stopping the use of illegal drugs in the state of California, a job he tackled with enthusiasm and his customary hyperbole. Let me quote directly from his writing on the effects of marijuana. Madden wrote that the user might, quote, believe himself so small that he is afraid to step off the curbstone into the street, or he may feel himself of enormous size and of superhuman strength and passion, and in that condition commit crimes altogether foreign to his nature, unquote. But because Paul Madden was a progressive, he didn't just fulminate against a problem. He had

a whole carefully thought out scheme for using the enlightened power of government to fix it. Consider the great fear of anti-drug crusaders of that era, which was that doctors might be driving drug addiction. What if the person gets the script from the doctor and goes down and keeps some of the drugs for himself and then sell some of the drugs on the street, then you're going to have the problem of the initiation of new addicts, potentially, if that happens. David Courtright, who is America's leading historian of the drug trade, says that people were worried that patients could walk into the doctor's office asking for an addictive drug like morphine, and the doctor would just give it to them. So, say there were a small number of doctors who are relatively unscrupulous, who are simply writing prescriptions for maintenance, and much of that drug may end up being diverted. How would I identify the doctor who's doing that. So one of the things you might do is send an informer to the doctor, and he would try to persuade, typically it was a he, he would try to persuade the doctor to write a prescription.

In California, Paul Madden looks at that practice of running sting operations against shady doctors and says, that's a crude and inefficient way of dealing with the problem. Remember, he's a good progressive, a man who believes in systems and procedures. So Madden decides to create a bureaucratic solution. First, Madden makes a list of all the prescription painkillers that he considers dangerously addictive. Morphine, opium, codeine, chloral hydrate. And then he convinces the state legislature to create a new regulation for doctors.

Chapter 3, Article 1, Section 11166.06 of the California Narcotics Act. The Madden Amendment of 1939. in triplicate with one blank attached to the book in such a manner that it will be readily removed, while two of the blanks shall be perforated for removal. Meaning, every time a physician prescribes one of the listed painkillers, they have to use a special state-issued prescription pad, where every prescription page comes equipped with two additional carbon copies. To use a contemporary turn of phrase, he wants to create a backup of every narcotic prescription in the state.

The first copy was to be kept at the office of the prescribing physician for a minimum of two years, available for scrutiny at any time by one of Madden's team of inspectors. Copy number two had to be kept by the pharmacist for two years. And number three had to be mailed by the pharmacist to the Bureau of Narcotics head office in San Francisco. A record of physician and pharmacist behavior in triplicate. A textbook example of progressive Big Brother in action. Now, why did I think of Sid Wolf when I heard about Paul Madden? Because Madden seemed to me like Sid 1.0, the 1930s edition.

Different context and emphasis, of course, but the same playbook, the same urgency, the same relentlessness. The government needs to fix things. And here is my 29-point plan to accomplish that, which I'm forwarding over to you right now. Call me when you get it. Right away. This is too big to wait. So, you know, Sid was, his hair was always on fire about something. My memories of Sid is, you would never know when you would get off the phone. That's true. That's true. I mean, I've even talked to him recently about some stuff I've done. And he'll not just talk to you.

Then the information starts flowing. In those days, the facts started to churn because that's how we got stuff. But Sid was like, I would go out to lunch and if there was a a pile of fax paper on my desk, it would be like, Sid struck. How many forests were sacrificed to feed Sid's fax machine? God only knows. In any case, I moved on. I left the Washington Post and forgot all about Sid and his fixations. And then I heard about an experiment.

And it all came flooding back. Once you've found the right doctor and have told him or her about your pain, don't be afraid to take what they give you. Often, it will be an opioid medication. Beginning in the late 1990s, a catastrophe unfolded in cities and towns around the United States. Opioid overdoses. People suffering a cascade of terrifying effects. Pinpoint pupils. Labor breathing. Respiratory arrest. Choking. Purple lips. Loss of consciousness. And, in what has now been over 800,000 cases, death. strongest pain medicines are the opioids. They don't wear out, they go on working,

they do not have serious medical side effects. And so these drugs, which I repeat, are our best, strongest pain medications, should be used much more than they are for patients in pain. At the heart of the crisis was a class of new powerful painkillers that came on the market in the 1990s, especially OxyContin. Launched in 1996 by the Purdue Pharmaceutical Company, OxyContin is highly addictive, and Purdue promoted it to doctors more heavily than any other painkiller in history. By 2002, Purdue had thousands of salespeople around the country pushing OxyContin. This went on for more than a decade, until doctors were prescribing $3 billion worth of OxyContin a year.

But even after 20 years of the opioid epidemic, there were all kinds of questions. Like, was OxyContin the cause of the overdose epidemic, or just a symptom of something deeper? And, even more puzzling, why didn't opioids cause the same level of devastation everywhere? Take Massachusetts and New York, two states side by side, if you run every significant fact about Massachusetts and New York through an algorithm, you'll find there are almost no two states more alike. Same population profile, same basic economy, same levels of poverty, very similar rural-urban mix. You'd think they would have had similar experiences with overdoses. They didn't. Massachusetts has had a bloodbath. New York,

not so much. Same thing with New York and New Jersey, super similar states by any measure. So why did New Jersey suffer so much more than its neighbor? Purdue would end up in bankruptcy court as a result of multiple lawsuits launched against them for misleading marketing practices. And not long ago, four economists, Abby Alpert, William Evans, Ethan Lieber, and David Powell, realized that the mountains of internal Purdue documents unearthed in those lawsuits might hold some answers. I mean, so there were hundreds and hundreds of pages of documents, some of which was not very interesting. That's Abby Alpert,

lead author of the paper the four of them ended up publishing, Origins of the Opioid Crisis and Its Enduring Impacts. But then when we happened upon the focus group research especially and the launch plan, that really was the basis for a lot of what we talk about in this paper. Buried in that mountain of documents was an internal Purdue report on a lot of what we talk about in this paper. Buried in that mountain of documents was an internal Purdue report on a series of focus groups that the company held with physicians. This was in the spring of 1995, right before the launch of OxyContin.

The focus group report runs to almost 60 pages, and in that long, buried document, one phrase kept popping up again and again. The phrase coined by Paul Madden half a century earlier. Triplicate prescriptions. So I had never heard of a triplicate program, and it's not something that was being discussed in the research on opioids. I mean, why would it be? Nobody really liked triplicates. For decades, no one followed California's lead in imposing this special requirement for prescribing painkillers. Drug makers, of course, hated the idea. So did doctors and state lawmakers.

In the early 1980s, the state of Texas did start a triplica program, and the state narcotics division in Austin had to hire 33 data entry clerks, who in the first year mailed out 27,800 triplica prescription pads to doctors around the state. The doctors then had to write a check for $7 for every pad they used, mail the check back to Austin, use the special pad every time they prescribe anything off the restricted list, keep the pink copy in their office for two years, send the green and the blue copy with the patient to the pharmacist, etc., etc. I mean, triplicate was the kind of bureaucratic nitpickiness that drives people in the medical

world crazy. The few states that did try out triplica programs usually dropped them. By the early 1990s, there were just five states with triplica programs in place. California, the pioneer, Texas, which somehow managed to stick it out, and then Illinois, Idaho, and New York. Five states with warehouses full of carbon copies of doctors' prescriptions. Every time you pick up that prescription pad, it was like, boy, I'm prescribing and someone's watching me. And that's what a lot of folks call the chilling effect.

Linda Wastilla, who teaches at the University of Maryland School of Pharmacy, she did her dissertation on triplicate programs. The chilling effect she's talking about was the knowledge that physicians in those states had that their behavior was being watched, that there was a permanent record of every prescription they wrote in three places on paper, not in some abstract, invisible computer file up in the cloud. Presumably, each physician has got a filing cabinet in his or her office, not in some abstract, invisible computer file up in the cloud. Presumably, each physician has got a filing cabinet in his or her office just full of prescription forms, which they're holding onto for years.

Right. So it's a powerful psychological reminder of the way you have handled this specific kind of medication. Exactly. And the doctor knows that there's a corresponding filing cabinet somewhere in the state capitol with a team of investigators attached who can look at every prescription and see the name of the patient, the name of the pharmacist, and the name of which doctor has the biggest bulging file. A file that says just by its size, something fishy may be going on.

This is exactly what Purdue Pharmaceutical discovered when it did its focus group with doctors in 1995, just prior to the launch of OxyContin. One of their sessions was in a triplicate state in Houston, Texas, and Purdue's takeaway after meeting with a group of Houston doctors was clear. Quote, the triplicate laws seem to have a dramatic effect on the product usage behavior of the physicians. It went on, the mere thought of the government questioning their judgment created a high level of anxiety in the focus group room among the doctors. Unquote.

Purdue looked at that high level of anxiety and asked, is it even worth marketing OxyContin in triplicate states at all? Years later, Abby Alpert's group of economists finds this long-forgotten focus group report, and they realize they'd stumbled on a beautiful example of a natural experiment. Natural experiments are the economist's dream. You don't have to create a treatment example of a natural experiment. Natural experiments are the economist's dream. You don't have to create a treatment group and a control group, then laboriously compare what happens to the two groups. Someone else has created the experiment for you. In this case, the someone else was Purdue. A third of the American population lived in the triplicate states.

Those states got passed over by the Purdue marketing squads. The rest of the American population lived in states without Big Brother looking over their doctor's shoulders. They got the full Purdue treatment. If you wanted to know how much of the opioid crisis was caused by OxyContin, all you had to do was compare what happened to the triplicate states with everywhere else. So that's what Albert did. And what she and her colleagues found was that the tri fact, the non-triplicate states had much more OxyContin use per capita than the triplicate states, almost twice as much in most years. More OxyContin means more OxyContin overdoses. And not just that, because many of those who

got addicted to opioids with OxyContin went on to get addicted to heroin and fentanyl. We see very quick increase in overdose deaths in the non-triplicate states and much slower growth in the triplicate states. And these trends continue even 20 years after the launch. Let's go back to comparing outcomes in New York and Massachusetts. New York was triplicate. Massachusetts was not. So how much of a difference did that single requirement make? The two extra carbon copies on the New York prescription pad? Well, if New York had Massachusetts opioid overdose rate between the years 2000 and 2019, an additional 25,000 New Yorkers would have died of overdoses.

25,000. Not only that, it turns out that economic growth is higher in triplicate states than non-triplicate states. Health outcomes of babies are better, and violent crime is lower in triplicate states. Astonishingly lower. As much as 25%. Exactly 80 years after Paul Madden

wrote his amendment to the California Narcotics Act, his bureaucratic nitpicking gets vindicated by social science. And who else gets vindicated? Sidney M. Wolfe, M.D. In the early 1990s, someone in the White House wondered what was known about the value of triplicate programs. The request got kicked over to the National Institute of Drug Abuse, NIDA. And NIDA rounded up everyone who might know something about triplicates and invited them to a conference at a hotel near its headquarters in Rockville, Maryland. So you attended the

symposium? Yes. Linda Wastilla, who had done her dissertation on triplicates, was one of the attendees. I do remember the venue and I do remember, this is really ridiculous, we couldn't have coffee. NIDA was very hardcore about these kinds of things. They wouldn't sponsor anything that had an addiction potential, including caffeine. So at any rate, what I remember about that was sort of the excitement of this is the first big thing we've had about trying to control opioid use in the United States. This is 1991. OxyContin will be introduced in 1996, five years later. But opioid overdoses were still high enough in those years that people were starting to get worried about the problem. I was a pharmacist with a Ph.D. There weren't many pharmacists with PhDs.

So it was like, wow, this is it. And I believed in a lot of these policies. The pain specialist Russell Portnoy was at the NIDA symposium. He would later do as much as anyone to promote the aggressive use of OxyContin. He talked about the problem of under-prescribing opioids. Someone from the American Pharmaceutical Association was there to say how strongly the industry's biggest trade group was opposed to any kind of federally mandated triplicate requirement. After all, this was 1991. Why were we promoting some half-baked idea from 1939? But here and there, there were other voices. An African-American doctor who worked in a tough neighborhood in Brooklyn,

Gerald Dees, said this, I wish that anyone who opposes triplicate prescription programs could walk with me into the real world where these regulations are saving lives. Unquote. And then, at the end of the meeting, who gets up to speak? Sid Wolf, of course. Because what is Sid's great cause in the late 80s and early 90s? It's triplicates.

Sid has decided that what America needs is a national version of Chapter 3, Article 1, Section 11166.06 of the California Narcotics Act. Sid, how are you? It's been a long time. So when I see Sid's name in the conference proceedings, I realized I had to talk to Sid again, after all these years. So I called him up. Sid always answers his phone.

And right away, he reminds me of how we used to run into each other in the Adams Morgan neighborhood of Washington, D.C. We once played pool together. Dan's pool room. The last time I went into Dan's, you couldn't walk in there because there were about 10 people chain-smoking, so I'd never been in there again. I think it's no longer around. Just hearing that voice again, that low rumble,

the eyebrow raised at Dan's pool room brought back all kinds of memories. I think I was nervous. Thank you for joining me. I would like to take a walk down memory lane with you, and I want to talk about triplicate prescriptions. I know this has been an issue that occupied you at various points in your career, but I just wanted you, I want to start at the beginning. When did the subject of triplicate prescriptions first come to your attention? I became aware of it, I would say, in the early 80s, late 70s, something like that. Even back in the 1980s, you are concerned about the problems being caused by opioids. 30 years before the current opioid

epidemic, this is something that's very much a matter of concern for you. Well, it's a matter of concern for several reasons. I would attend FDA advisory committee meetings, and not a small number of them had to do with opioids. And there were already some problems with opioids in those days. And Sid, like Paul Madden two generations before him, had become convinced that focusing on doctors was a big part of the solution. Let them know they were being watched with a few file cabinets of carbon copies. I mean, the data which you've seen showing what happens in a very short period of time after some of these states implement these triplicate prescription programs is astounding.

At the NIDA meeting in 1991, Sid stood up and made the case for a national triplicate program. He said, in effect, California started an experiment, New York and Illinois and others have joined, and the results of the experiment are clear. It works. In a perfect world, had everyone listened to what NIDA was saying in 91, what all you guys were saying back in 91, we would have had a very different and much less damaging opioid epidemic of the last 20 years, right? There's no question about that because it's a clear public health problem. He's right. A national triplicate program would clearly have slowed the advance of OxyContin. 841,000 people have died of drug overdoses since the 1990s.

How many of those would now be alive? In 1993, Sid published a monograph reiterating the need to get serious about opioid prescriptions. It almost certainly made its way to the Health and Science Desk at the Washington Post. Did anyone take you up on it? No. Why not? I don't know why.

I bring this up only because one of the reasons this issue interested me so much was that in the early 90s, when you were thinking very seriously about the importance of triplicates, the person covering the FDA, the health bureaucracy, and science, all those kinds of medical science, and all that for the Washington Post was me. That's how we met. We met, but back then, my sympathies did not lie with the Sid Wolfs of the world.

I didn't share Sid's belief that government could fix everything. I thought medicine was full of trustworthy, judicious professionals who did not need Big Brother looking over their shoulder. In my time on the health and science desk at the Washington Post, I was in my 20s, a kid, too young for nuances. Sid was just the guy who called me up and wouldn't let you off the phone and sent you so many papers and reports and polemics that you gave up and just threw them in the trash. Sid Wolf was so alert to the frailty of institutions that he seemed to me like Chicken Little.

I'll be candid. At the time, I thought you were way off to the left. I thought you were, you know, my position was much more sympathetic to big pharma. I thought you were just a kind of crazy 60s radical who was always radical who didn't believe in drugs. Now I realize no one was more wrong than me on this issue. I mean, hundreds of thousands of people have died in this country because we didn't pay attention to what you were saying in 1991. Well, all I can say is I certainly have been thought by a number of other people that I'm some sort of a 60s radical. So I do not blame you or anyone else that thought that I was some wild-eyed.

But Sid, I blame myself. It is almost certainly the case that that monograph you wrote about triplicate prescriptions was sent to me at the Washington Post. It is almost certainly the case that I did not read it. And it is almost certainly the case that had I read it, and had I taken it seriously, and had I called you up, and had I educated myself, and had I written a story about it in the Washington Post, that maybe it would have made some small difference. Or even a book about it. Or even a book about it. Or even a book about it. I didn't do any of those things.

In the 1930s, the rest of America dismissed what Paul Madden was saying because they thought Paul Madden was overbearing and hysterical. In the 1990s, I dismissed what Sid Wolf was saying because we thought Sid Wolf was overbearing and hysterical. We violated, all of us, the first rule of learning from experiments, which is to judge the message, not the messenger. Once you've found the right doctor and have told him or her about your pain don't be afraid to take what they give you Sid Wolf said the sky was falling back in 1991

and guess what? the sky fell Revisionist History is produced by Eloise Linton, Lehman Gistu, and Jacob Smith, with Tali Emlin and Harrison Vijay Choy. Our editor is Julia Barton. Our executive producer is Mia Lobel. Original scoring by Luis Guerra,

mastering by Flan Williams, and engineering by Nina Lawrence. Fact-checking by Keisha Williams. Our voice actor was David Glover. I'm Malcolm Gladwell. that, if memory serves, I think I read at least part of your monograph from the old magazine online. I can send you the whole thing. I downloaded it. It's in one PDF, which I'll send you.

Oh, good. Do I have your email address?