Summer: snacks, a to z, brought to you by mon chef, goat cheese, avocado, bring blueberry lemon Kerry, crumble, dress up desserts, easy for feisty flavors early, go on biscuits, barry and tensor interest, jalapeno honey, king of cake. Do you love, or the logs sunshine, makes multiple next to nothing, obviously pair with protests for plenty of possibilities. Quality remarkable seeking summer snack try to go, treat uncertain, visit us where x marks the spot your zero. In on zipcode, just tell them find much of it, retailers near you, pushed hello, hello, religious history, listeners. I'm excited to announce at this season, I'm offering a bunch of perks from my most loyal listeners. The ones who subscribe to push compel us for those

you just can't get enough, were giving every episode to our subscribers. One week early plus we ve created many episodes released, weakly and I'm calling them tangents and, of course, you'll never hear any adds subscribed to Pushkin plus on the revision. Is history show page in apple pod, gas or pushkin derive him. When I was in my twenties many years ago, I was a rapporteur for the washington. a newsroom the size of a football field? Phones ringing, keyboards, clattering the glory days, a print journalism, I want you to describe what is the status and position of a washington post reporter in Washington dc in nineteen. Eighty nine well in general godlike, because the whole city ran on politics and news in their work,

Many organisations that produced it excellently in the post was sort of the place that everyone cared about. That's my friend Michael spectre. He and I were both on the health and sign speak 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 while they did, I mean there is an exception which, as we the science pod and at least out the posts that was considered like. Why would smart people write about science when they could write about the white house and when yellow ties, but in general we had big readership, particularly in the when we read about science policy, we sat at the centre of a giant ecosystem of lobbyists, lawmakers aids bureaucrats policy walks who tried to get us to see the

their way. If you called someone and said you are from the washington post, they called you back is to listen to Michael every day on the floor the source on capitol hill, that individual had access to everything. But he didn't mind, riding people out, it was like Heaven I had a couple people it was I remember once where did 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 you to decide whether return it said as well, and member of this ecosystem that I most interested in. Having said wolf, whoops. I love said 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 said yeah cause. You are

like a right wing in it. I was arriving lunatic and it was a right wing time. Sidney am wolf, Andy verses me thirty years ago, when it was a right wing lunatic I was different, then, which I offer as at least a small explanation for my behaviour in the story. I'm about to tell you. My name is Malcolm Gladwell. You listening to revision is history. My podcast about things overlooked and misunderstood. This season is devoted in time only to experiments, and this episode is about what happens when an experiment teaches us an important lesson and we don't listen.

The sidwell came to washington dc in the nineteen sixties. 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 Fahey. One day in nineteen, seventy one, someone told him that half of the saline solution being supplied to american hospitals was contaminated with bacteria and cid 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 I v fluid and will have a disaster on our hands and sit said that can't be right. There have to be other sources of I v 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

It's conference and the bad ivy fluid was pulled from the market said, had found his calling as a consumer advocate. I am sick and tired of the patronising attitude of the american medical association towards american patients. Patients said easily and it was unstoppable doctor. He started something called the public citizen's health research group and became one of the angriest voices, washington licensing feed has made. You know. Organization has now for twenty five years, been the most outspoken critic of the FDA. More than fifty times we have submitted. and sometimes resulting in lawsuits against the agency to try and get them to do what we think the law requires them example in the c span, archives is practically a cid division and set against the drug companies set against the doctors set against the f D. A has. It is clear that of the seventeen years since we have been running, Research will be watching you have to do. This is by far the worst

in the time ever said, didn't like anyone, except those who were willing to join him on the lonely ice floe of his sixties, radicalism. Okay, that's not fair! It's not! That said, disliked people, it was never personal for him, since battle was with institutions. Said believed that Ah crises 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 exit. He was the knowledge of washington, d c, sits very smart and very colorful in a great quote but there's only one way and that Sid's way you dont have like a deep, meaningful conversation on both sides with said, but some people in he was one.

We're just excellent it knowing what we needed and what we supported it and how to package it, and that was said. I hadn't thought of said wolf in years. But then I started reading about someone named Paul Madden, one of those forgotten figures in the mid century. If you lived in California, Nineteen forties- you would imagine from time to time on a radio good evil. Lady got on my behalf, jobs and breaking up a narcotic right. I don't know I've never seen one especially difficult job. rounding up a band of narcotic deadly, including the brain of a gay man, was a progressive progresses, believed that government could fit

things: it systems and regulations and rules properly written could make the world a fair place. Progressives were activists full of zeal, in nineteen, thirty nine 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 have 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 of new addicts potentially, if, if that happens, David cartwright, who is America's leading historian?

the drug trade says that people were worried that patients could walk into the doctors office asking for an addictive drug like morphine, and the doktor would just give it to them. So city were us, 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 again to find the doktor, 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 upon that and 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 Maddon decides to create a

your craddock solution. First madden makes a list of all the prescription painkillers that he considers dangerously addictive morphing hope you coding coral hydrate, and then he convinces the state legislature to create a new regulation for doctors chapter three article, one section, one one, one: six, six dot, o six of california narcotics act, the madden amendment of nineteen, thirty, nine, the prescription blanks shall be printed. on distinctive paper. Serial number of the book being shown on each form and also each form

being serially numbered each prescription. Blank shall be printed in triplicate, with one blank attached to the book in such a manner that it will be readily removed by 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 wherever 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 description in the state. The first copy was to be kept at the office of the prescribing position for a minimum of two years available for scrutiny,

any time by one at madden's team of inspectors. Copy number two had to be kept by the pharmacist. For two years. A 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 inaction. Now, why did I think of Sid Wolfe when I heard about paul Madden, because madden seemed to me like sit one point: oh the nineteen thirties 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 twenty nine point plan to accomplish that which I am forwarding over to right now. Call me when you get it right away. This is too big to wait so

you know said was his hair was always on fire about something, my memories of cities. You would never know when you get off the phone. That's true, that's true mean I've even talk to recently about some stuff, I've done and he'll hill. Not just talk to you. then the information starts flowing in those days. The tax burden to churn, because that's how we got stuff but sit, was like I would go out to lunch, and if there was a pile of facts paper in mind it would be like said, struck how many forests were sacrificed to feed, sits, 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.

The summer snacks, a to z, brought to you by Michele gucci's, add avocado, bring blueberry lemon kerry crumble, dress up desserts, easy for feisty, flavored, early girl or biscuits barry and tensor interest. Jalapeno honey, king of care, lest you love or the logs sunshine, makes multiple next to nothing, obviously pair with protests for plenty of possibilities. Quality remarkable seeking summer snack, try, topco tree uncertain visit us where x marks the spot. Your zero in on Zipcode just tell them find much of it. Retailers near you. 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 kitchen beginning in the late nineteenth nineties. A catastrophe unfolded in

he's in towns around the united states, opiate overdoses, people suffering, a cascade of terrifying effects, pinpoint pupils, labour, breathing respiratory arrest, choking purple lips loss of consciousness and in what has now been over eight, hundred thousand cases death. There's no question that our best strongest pain medicines are the opioids they don't wear out. They go on working. They do not of serious medical side effects, and so these drugs, which, I repeat, are our best strongest pay medications- should be used much more than they are for patients and at the heart of the crisis, with a class of new, powerful painkillers. The came on the market in the nineteen nineties, especially proxy content, launched in ninety ninety six by the purdue pharmaceutical company. Oxy content is highly addictive.

And produce promoted to doctors more heavily than any other pink color in history. By two thousand and to produce Thousands of salespeople around the country pushing oxy content. This went on for more than a decade until doctors were prescribing three billion dollars worth of oxy content a year, but even after twenty years of the opium epidemic, there are all kinds of questions like was oxy content, the cause of the overdose epidemic or just a symptom of something deeper and even more puzzling. Why didn't opiates cause the same level of devastation everywhere? Take massachusetts and new york two states side by side. If you run every significant fact about me,

The two sits in new york through an algorithm you'll find there are almost no two states more alike: saint 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 neighbour purdue would end up in bankruptcy court as result of multiple lawsuits launched against them for misleading marketing practices are not long ago for economists, heavy albert, William Evan.

Ethan Leber and David Powell realized that the mountains of internal purdue documents unearthed in those lawsuits might hold some answers and instead there are hundreds and hundreds of pages of documents, some of which was not very interesting. That abby alpert lead author of the paper. The for them ended up, publishing, origins of the the crisis and its enduring impacts, but then we when we happened upon the focus group research, especially and end the lunch plan. That really was the basis for a lot of what we talk about a newspaper. Buried in that mountain of documents. Was an internal purdue report on a series of focus groups that the company help with physician This is in the spring of nineteen eighty five right before the launch of oxy content. The focus group report runs to almost six pages and in that long very document one phrase kept popping up again and again

Praise coined by Paul madden half a century earlier triplicate prescriptions, so I had ever the triplicate programme, and it says something that was being discussed in the research on opiates. I mean why would it be nobody really liked triplicate for decades? No one followed california in imposing the special requirements for prescribing painkillers, drug backers, of course, hated the eddie so to doctors and statement. It goes in the early nineteen eighties. The state of Texas did start a triplicate program and the state narcotics division in Austin had to hire thirty three data entry clerks, who

the first year mailed out twenty seven thousand eight hundred typical prescription pads to doctors around the state, the doctors and had to write a check for seven dollars for every pad. They used mail. The check back to austin used 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 nit picking the drives people in the medical world crazy. The few states states did did trial. Triplicate programs usually dropped by the early nineteen nineties. They were just five states with triplicate programs in place. California, the pioneer texas, which somehow managed to stick it out and then illinois, idaho and new york. Five states with were

warehouses full of carbon copies of doctor's prescriptions. Every time you pick up that prescription pad it was like boy, I'm prescribing in someone's watching me. That's what a lot of folks call the chilling effect linda was stiller, 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 positions 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 They each position has gotta filing cabinet in his or her office, just full of prescription forms MR holding onto for years, but it been a powerful. Psychological reminder of the way

You have handled this specific kind of medication. Exactly and the doctor knows that. There's a correspond in the filing cabinet somewhere in the state capital, 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 it's size something fishy may be going on. This is exactly what purdue pharmaceutical discovered when it did. It's focus group with doctors in nineteen, ninety five just prior to the law.

of oxygen content. One of their sessions was in a trip of state in Houston, texas and produce take away after meeting with a group of Houston, doctors was clear quote the triplicate laws seem to have a dramatic effect on the product usage behaviour 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 oxy content in triplicate states at all years later, abbe operates. Group of economists finds this long forgotten focus group report and they realise that stumbled on a beautiful example of a natural experiment. Natural experiments are the economist stream. You dont have to create a treatment group and a control group. Then laboriously compare what happens to the two groups so

What else has created the experiment for you in this case the some one 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 the doctor's shoulders got the full produce treatment. If you wanted to know how much of the opium crisis was caused by oxy content, all I 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 at the trip Rule was everything what we found was that in fact, the non triplicate states had much more actually can use per capita. Then the triplicate states

almost twice as much and most years, more oxycontin means more oxy content overdoses, and not just that, because many of those who got addicted to opiates with oxy content went on to get addicted to heroin and fentanyl. We see It's very quick increase in overdosed ass in the non triplicate states. slower growth and the triplicate states, and

trends continue even twenty 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 to death single requirement make the two extra carbon copies on the new york prescription bad. Well. If new york had massachusetts, opiate overdose rate between the years two thousand and twenty nineteen, an additional twenty five thousand new yorkers would have died of overdoses, twenty five thousand, not only that It turns out that economic growth is higher in triplicate states. The non triplicate states, health outcomes of babies are better and violent crime is lower in triplicate. States stunningly lower as much as twenty five percent exactly eighty,

after Paul, Madden wrote his amendment to the california narcotics act, his bureaucratic nit picking, gets vindicated by social science and who else gets vindicated sidney m wolf, yeah the. summer, snacks, a to z, brought to you by mon chef, goat cheese, avocado, bring blueberry lemon Kerry, crumble, dress up desserts, easy for feisty flavors, rarely go on a biscuits, barry and tensor interest, jalapeno, honey and king of care. Less do you, love are the logs chef makes multiple next to nothing, obviously pair with protests for plenty of possibilities. Quality remarkable seeking summer snack try to go, treat uncertain, visit us where x marks the spot. Your zero in on Zipcode just tell them find much of that retailers near you. In the early nineties nineties, some in the white house wondered

what was known about the value of triplicate programmes, the requests got kicked over to the national institute of drug abuse. Nita a niner, rounded up everyone who might know something about triplicate and invited them to a conference at a hotel near its headquarters in rockville maryland, so you attended. The symposium yes Linda stiller, who had done her dissertation on triplicate, was one of the attendees. I do remember the venue- and I do remember this- is really ridiculous. We couldn't have coffee, neither was very hard core about these kinds of things. They wouldn't sponsor anything that had an addiction potential, including cafe or 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 over. You would use in the united states. This is ninety. Ninety one oxy content will be introduced in ninety ninety six, five years later, but opiate overdoses we still high enough in those years that people were starting to get worried about the problem. I was a pharmacist with me. Hd. There were many forms system phds, so it was like. While this is it, and I believed in a lot of these policies, the pain specialist russell port noise was at the night a symposium. He would later do as much as anyone to promote the aggressive use, a proxy content. He talked about the problem of under prescribing opiates, 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 tripucka requirement. After all, this is one thousand nine hundred and ninety one. Why will be promoting some half baked idea for one thousand, nine hundred and thirty nine? But here and there they were other voices and african american doctor who worked in a tough neighborhood in Brooklyn Gerald. He's said this: I wish that anyone who opposes tripucka prescription programs could walk with me into the real world where these regulations are saving lives. On quote and then at the end of the meeting, said well, of course, because what is sets great cause in the late eighties, an early nineties, its triplicate said, has decided that what americanese he's a national version of chapter three

one section, one one, one: six, six out, o six other California, narcotics act sit how It's been a long time. So when I see said name in the conference proceedings, I realized I had talked to citizens. After all these years, so I called him up said always answers his phone and run away. He reminds me of how we used to run into each other in the Adams, morgan, neighbourhood of washington d c. We once play pool together, dares poolroom the last less owen dance, you couldn't walk in their cause, a robot. Ten people change smoking sign, never been in there. Yet I think it's no longer round up just hearing advice again that low rumble the eyebrow raised dan's poolroom 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 prescription, I know this has been an issue that occupied you at various points in your career, but I just wanted you to start at the beginning. When the subject triplicate prescriptions for his come to your attention became aware of wherever I would say in the early eighties, late seventies, something like that. Even back in the nineteen eighties You are sir, and about the problems being caused by opiates thirty years before the current opiate at epidemic you. This is something that's very much. Americans and for you what's the matter concern for several reasons. I would attend. Fda advisory committee meetings

And not a small number of them had to do the appeals, and there are already some probe problems with barriers in those days and said, like Paul Madden, two generations before him had become convinced that focusing on doctors was a bit part of the solution. Let them know they were being watched with a few file cabinets of carbon copies, amend the data. Would you same showing what happens in a very short period of time. After some, these states implement these trooper to prescription programmes is astounding, at the night. A meeting in ninety ninety one said stood up and made the case for a national triplicate programme. 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 at night. It was saying and ninety one. When are you guys, you're saying back and ninety one? We would have a very

different and much less damaging, opioid epidemic in the last twenty years. Right. is no question about that, because it's a clear public health problem he's right. A national triplicate programme clearly have slowed the advance of content. Eight hundred and forty one thousand people have died of drug overdoses since the ninety nineties. How many of those would now be alive. imaginary three said published a monograph reiterating the need to get serious about opium prescriptions. It almost certainly made its way to the health and science desk at the washington post. Genuine. Take you up on it no what why I don't know why I ve been top only because I and one of the reasons this issue interest me. So much was that in the early nineties.

When you were thinking very seriously about are certificates the person covering the FDA help bureaucracy and science. All those guns, medical set off for the wash deposed was me. That's how we met we met, but back then my sympathies did not lie with the cid wolves to the world. I did not share, sits 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 signs task at the washington post, I was in my twenties. A kid too young for nuances said was just the guy who called me up and wouldn't let you off. The phone has sent you so many papers and reports and polemics that you gave up and just through them in the trash sid Wolfe was similar 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, is much more sympathetic to big farmer there. I thought you were just a kind of crazy sixties. Cole, who was always who didn't believe in drugs, now I realize new? 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 and nineteen. Ninety one will. All I can say, is certainly have been taught by a number of other people around some sort of a sixties radical, so I do not blame you or anyone else that thought that I was Some wild eyed, 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 how to take it seriously, and had I called you up and had I educated myself and had written a story about it in the washington post than me. It would have made some small difference or even a book about it. We live in a book about it. I didn't do anything things in the nineteen thirties, the rest of america dismissed Paul madden was saying because they thought Paul Madden was overbearing and hysterical in the nineties these are dismissed. What said wolfe was saying, because we thought said: Wolfe was overbearing and hysterical. we violated all of us. The first of learning from experiments, which is to judge the message. Not the messenger

once you found the right doctor and of 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 and ninety ninety one guess what the sky fell. Revisionist history is produced by elouise lynton, leaving, astute and jacob smith We totally evelyn and harrison vision. Choi are is Julia barton. Our executive power sir, is mere la belle original scoring. Whether we scared mastering lifeline willie. and engineering by Nina lawrence fact checking by quichua Williams. Our voice actor was David lover. I mountain rubber, Well, thank you. So much of this has been so much fun an interesting. I think I can find

that for memory serves, I think I read at least part of europe. Monograph from I guess I download it's in one pdf, which I'll send you, good. Do I have your email address. summer, snacks, a to z, brought to you by mon chef, goat cheese, avocado, bring blueberry lemon Kerry, crumble, dress up desserts, easy for feisty flavors, rarely go on a biscuits, barry and tensor interest, jalapeno, honey and king of care. Less do you, love are the logs chef makes multiple next to nothing, obviously pair with protests for plenty of possibilities. Quality remarkable seeking summer snack try to go, treat uncertain, visit us where x, marks the spot. Your zero in on Zipcode just tell them find much of that retailers near you