In Triplicate

00:00:15
Speaker 1: Pushkin Hello, Hello, Revision's 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 twenties 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 in position of a Washington Post reporter in Washington, DC in nineteen eighty nine.

00:01:20
Speaker 2: 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.

00:01:35
Speaker 1: That's my friend Michael Specter. He and I were both on the Health and science speed 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.

00:01:52
Speaker 2: 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 in the when we wrote about science policy.

00:02:17
Speaker 1: We sat at the center of a giant ecosystem of lobbyists, lawmakers, aids, 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.

00:02:36
Speaker 2: 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.

00:02:45
Speaker 1: 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 had to decide whether to return it. So there's one member of this ecosystem that I'm most interested in, ready, Sid Wolf.

00:03:11
Speaker 2: Sid Wolf. I love Sid. I loved him then, I love him now. But you know, yeah, he is a particular kind of guy.

00:03:18
Speaker 1: I think I was the most skeptical of Sid.

00:03:20
Speaker 2: Yeah, because you were like a right wing lunatic.

00:03:22
Speaker 1: I was a right wing wunatic, and it was a right wing time Sidney M. Wolf MD versus me thirty years ago, when I was a right wing lunatic. I was different then, which I offer as at least a small explanation from 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. Sidwulf came to Washington, d C. 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 Fauci. 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 Sid said, oh, where 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 ivy fluid and will have a disaster on our hands. And Sid said, that can't be right. There have to be other sources of ivy 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 ivy fluid was pulled from the market. Sid had found his calling as a consumer advocate.

00:05:07
Speaker 3: I am sick and tired of the paper attitude of American Medical Association towards American patients patients.

00:05:13
Speaker 1: SID was unstoppable. He started something called the Public Citizens Health Research Group and became one of the angriest voices in Washington.

00:05:23
Speaker 3: As many of you know, our organization has now for twenty five years, been the most outspoken critic of the FDA. More than fifty 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.

00:05:38
Speaker 1: Example, in the c SPAN archives, there's practically a SID division. Sit against the drug companies, sit against the doctors, sit against the FDA.

00:05:48
Speaker 4: It is clear that of the seventeen years since we have been running the Health Research Group and watching the FDA, this is by far the worst period of time ever.

00:05:59
Speaker 1: SID didn't like anyone except those who are willing to join him on the lonely ice flow of his sixties 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 DC.

00:06:33
Speaker 2: Sid's very smart and very colorful and a great quote. But there's only one way in that's Sid's way. You don't have like 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.

00:07:00
Speaker 1: I hadn't thought of Sidwolf 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 nineteen forties, you would hear Madden from time to time on the radio.

00:07:13
Speaker 5: Good Evening, ladies and gentlemen. There may be hotter jobs than breaking up a narcotic brain.

00:07:20
Speaker 6: I don't know.

00:07:21
Speaker 5: I've never seen one. Especially difficult is a job of rounding up a band of narcotic pedlars, including the brains of the gang.

00:07:32
Speaker 1: Madden was a progressive that progressives believed that government could fix things, that 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 quot 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. 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.

00:08:48
Speaker 7: 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.

00:09:04
Speaker 1: David Courtwright, who is America's leading historiander the drug trade, says that people who 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 stading, we're 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.

00:09:32
Speaker 7: 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.

00:09:46
Speaker 1: 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 coding, chloral hydrate, and then he convinces the state legislature to create a new regulation for doctors Chapter three, ARTCA one, Section one one one six six six of the California Narcotics Act, the Madden Amendment of nineteen thirty nine.

00:10:36
Speaker 8: 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, while two of the blanks shall be perforated for removal.

00:11:00
Speaker 1: Meaning every time a physician prescribes one of the listed pain killers, 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 back up 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. At number three had to be mailed by the pharmacist to the Bureau of Narcotic's head office in San Francisco. A record of physician and pharmacist behavior in triplicate a textbook example a 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 one point zero the nineteen thirties edition. Different context and emphasis, of course, but the same place book, 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'm forwarding over to you right now. Call me when you get it right away. This is too big to way.

00:12:24
Speaker 2: So you know, Sid was his hair was always on fire about something.

00:12:29
Speaker 1: My memories of Sid is you would never know when you would get off the phone.

00:12:33
Speaker 2: 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 pile of fax paper on my desk, it'd be like Sid struck.

00:12:57
Speaker 1: 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 and his fixations, and then I heard about an experiment and it all came flooding back.

00:13:31
Speaker 9: 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.

00:13:42
Speaker 1: Beginning in the late nineteen nineties, a catastrophe unfolded in cities and towns around the United States. Opioid overdoses people suffering a cascade of terrifying effects, pinpoint pupils, labored breathing, respiratory arrest, choking, purple lips, loss of consciousness, and, in what has now been over eight hundred thousand cases, death.

00:14:07
Speaker 10: 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 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.

00:14:26
Speaker 1: At the heart of the crisis was a class of new powerful painkillers that came on the market in the nineteen nineties, especially OxyContin, launched in nineteen ninety six by the Purdue Pharmaceutical Company. OxyContin is highly addictive, and Purdue promoted it to doctors more heavily than any other pain color in history. By two thousand and two, Purdue had thousands of salespeople around the country pushing OxyContin. This went on for more than a decade, until doctors were prescribing three billion dollars worth of OxyContin a year. But even after, for twenty 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 Perdue would end up in bankruptcy courts result of multiple lawsuits launched against them, for misleading marketing practices, and not long ago, four economists Abbey Albert, William Evans, Ethan Lieber, and David Powell realized that the mountains of internal Purdue documents unearthed in those lawsuits might hold some answers.

00:16:27
Speaker 11: I mean, so there were hundreds and hundreds of pages of documents, some of which was not very interesting.

00:16:32
Speaker 1: That's Abby Albert, lead author of the paper The for them ended up publishing origins of the opioid crisis and its enduring impacts.

00:16:41
Speaker 11: 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.

00:16:53
Speaker 1: 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 nineteen ninety five, right before the launch of OxyContin. The focus group report runs to almost sixty 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.

00:17:23
Speaker 11: So I had never heard of a triplicate program, and it's not something that was being discussed in the research on opioids.

00:17:31
Speaker 1: 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. Drugmakers, of course, hated the idea, so did doctors and state lawmakers. In the early nineteen eighties, the state of Texas did start a Tripica program, and the state Narcotics Division in Austin had to hire thirty three data entry clerks who in the first year mailed out twenty seven eight hundred Tripica prescription pads to doctors around the state. The doctors then had to write a check for seven dollars for every pad they used, mailed 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 pharmacists, etc.

00:18:21
Speaker 5: Etc.

00:18:22
Speaker 1: I mean, triplicate was the kind of bureaucratic nitpickiness that drives people in the medical world crazy. The few states that did triotriplicate programs usually drop them. By the early nineteen nineties, they 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 doctor's prescriptions.

00:18:58
Speaker 12: 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.

00:19:07
Speaker 1: Linda Westilla, who teach which is 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 just full of prescription forms which they're holding on to for years. So it is 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 nineteen ninety five, just prior to the launch of OxyContin. One of their sessions was in a tripicate state in Houston, Texas, and Purdue's takeaway after meeting with a group of Houston doctors was clear, quote the triplicate laws seemed 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. Prideue looked at that high level of anxiety and asked, is it even worth marketing OxyContin in tripicate states at all? Years later, Abbey Albert's group of economists finds this long forgotten focus group report, and they realized that stumbled on a beautiful example of a natural experiment. Natural experiments are the economists 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 Tripicut states with everywhere else. So that's what Albert did, and what she and her colleagues found was that the triplicate rule was everything.

00:22:08
Speaker 11: What we found was that, in fact, the non triplicate states had much more oxycon use per capita than the Triplicut states, almost twice as much.

00:22:19
Speaker 1: 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.

00:22:34
Speaker 11: 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 twenty years after the launch.

00:22:48
Speaker 1: 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 death 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 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 than nontripicate states, health outcomes of babies are better, and violent crime is lower in triplicate states, astonishingly lower as much as twenty five percent. Exactly eighty 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. Wolf, MD. In the early nineteen nineties, someone in the White House wondered what was known about the value of triplicate programs. The requests 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 Westilla, who had done her dissertation on triplicates, was one of the attendees.

00:24:33
Speaker 12: I do remember the venue, and I do remember this is really ridiculous. We couldn't have coffee.

00:24:38
Speaker 1: NIDA was very hardcore about these kinds of things.

00:24:42
Speaker 12: 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.

00:25:01
Speaker 1: This is nineteen ninety one. OxyContin will be introduced in nineteen ninety six, five years later, but opioid overdoses were still high enough in those years that people were starting to get worried about the problem.

00:25:13
Speaker 12: I was a pharmacist with a PhD. There weren't many pharmacists with PhDs. So it was like, Wow, this is it, and I believed in a lot of these policies.

00:25:23
Speaker 1: The pain specialist Russell Portnoy was at the Nightis 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 triplicut requirement. After all, this was nineteen ninety one. Why will we promoting some half baked idea from nineteen thirty nine. But here and there there were other voices. An African American doctor who worked in a tough neighborhood in Brooklyn, Gerald d'es 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 will of course, because what is Sid's great cause In the late eighties and early nineties, it's triplicans. SID has decided that what America needs is a national version of Chapter three, Article one, Section one one one six six six of the California Narcotics Act. Sid, how are you.

00:26:42
Speaker 6: It's been a long time.

00:26:45
Speaker 1: 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.

00:27:02
Speaker 6: Together Dan's pool room. The last I wanted to Dan's you, I couldn't walk in there because there were about ten people change smoking, so I've never been in there again. I think it's no longer around.

00:27:16
Speaker 1: 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 with 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.

00:27:51
Speaker 6: I became aware of it, I would say, in the early eighties, late seventies, something like that.

00:27:59
Speaker 1: Even back in the nineteen eighties, you are concerned about the problems being caused by opioids, thirty years before the current epidemic. This is something that's very much a matter of concern for you.

00:28:14
Speaker 6: What's a matter of concern for several reasons. I would attend FDA Advisory Committee means, and not a small number of them had to do with opioids. And there were already some problems with opioids in those days.

00:28:29
Speaker 1: 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.

00:28:43
Speaker 6: 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 tripical prescription programs is astounding.

00:28:54
Speaker 1: At the night of meeting in nineteen ninety one, SID stood up and made the case for a national triplical 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 whatnot it was saying in ninety one, what all you guys were saying back in ninety one, we would have had a very different and much less damaging opioid epidemic of the last twenty years.

00:29:26
Speaker 6: Right, there's no question about that, because it's a clear public health problem.

00:29:32
Speaker 1: He's right. A national triplicate program would clearly have slowed the advance of OxyContin. Eight hundred and forty one thousand people have died of drug overdoses since the nineteen nineties. How many of those would now be alive. In nineteen ninety three, 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?

00:30:02
Speaker 7: No?

00:30:05
Speaker 1: I don't know why I bring us up on because and one of the reasons this issue interested me so much was that in the early nineties, 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 for the Washington Post was me.

00:30:30
Speaker 6: That's how we met.

00:30:33
Speaker 1: We met, But back then my sympathies did not lie with the Sid Wolves 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 twenties, 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 that I thought you were just a kind of crazy sixties radical who was always 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 nineteen ninety one.

00:31:47
Speaker 6: Well, all I can say is I certainly have been thought by a number of other people that I'm some sort of a sixties radical. So I do not blame you or anyone else that thought that I was some wild eyed.

00:32:04
Speaker 1: But said I blame myself. It is almost certainly the case that that might ponograph you wrote about Triplica 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.

00:32:32
Speaker 6: Even a book about it, or.

00:32:35
Speaker 1: Even a book about it. I didn't do any of those things. In the nineteen thirties, the rest of America dismissed what Paul Madden was saying because they thought Paul Madden was overbearing and hysterical. In the nineteen nineties. 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.

00:33:10
Speaker 9: 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.

00:33:19
Speaker 1: Sidwolf said the sky was falling back in nineteen ninety one, and guess what the sky fell. Revisionist History is produced by Elvis Linton, Leeman Gesteu, and Jacob Smith, with Taly Emlin and Harrison VJ. Choi. Our editor is Julia Barton. Our executive producer is mie La Belle. Original scoring by Luis Kira, mastering by Flon Williams, and engineering by Nina Lawrence. Fact checking by Keishaw Williams. Our voice actor was David Glover. I'm Malcolm Glava. Well, thank you so much. This has been so much fun and interesting. I think I can find that memory serves. I think I read at least part of your monograph from the art I can say.

00:34:14
Speaker 6: The only thing I downloaded it. It's in one PDF which i'll send you. Do I have your email address