The Other War on Drugs
The latest on the World Cup gender discrimination lawsuit; inside the fight over the last hospital in D.C.’s poorest neighborhood; and are we finally starting to have an opioids conversation that acknowledges chronic pain? Subscribe to Off-Kilter on iTunes.
This week on Off-Kilter: With the U.S. women’s soccer team in contention to win the World Cup this year, a class action lawsuit hangs in the air, alleging gender-based discrimination by the U.S. Soccer Federation against the players. The lawsuit highlights inequities in travel conditions, promotion of games, staffing, support, development, and a significant gender pay gap to boot. For the latest on where the players’ lawsuit stands and a look at what it means for women’s professional sports — and the pay equity debate more broadly — if the players prevail, Rebecca talks with Erica Ayala, a freelance writer who covers women’s pro sports.
Next up: Inside the fight over the last hospital in Washington D.C.’s poorest neighborhood — United Medical Center in Southeast DC, the only hospital not located in D.C.’s comparatively rich, white Northwest quadrant — and the larger trend it embodies, of hospitals closing, consolidating, and moving out of low-income urban neighborhoods in favor of neighborhoods with richer residents. Rebecca talks with Pat Garofalo, managing editor of TalkPoverty, about his recent article looking at the hospital’s closure and what’s at stake for D.C.’s low-income residents.
And finally: Is “the other war on drugs” finally turning into the opioids conversation we should be having? At long last, the tide finally appears to be turning in the opioids debate — to acknowledge the perspective of chronic pain patients, after years of well-intentioned but misguided policymaking and medical practice that’s put thousands of pain patients’ health, wellbeing, and even lives at risk. Rebecca talks with one of the patient advocates who’s been leading the charge, Kate Nicholson, a former federal prosecutor at the Department of Justice, a longtime civil rights lawyer specializing in enforcement of the Americans with Disabilities Act, and a chronic pain patient herself about a spate of recent developments on the opioid front that led the Centers for Disease Control, or CDC, to release a sweeping set of corrective guidance to protect people living with chronic pain, and the advocacy, public education, and strange bedfellows that led to this important and much-needed shift.
This week’s guests:
- Erica Ayala, freelance writer who covers women’s pro sports (@elindsay08)
- Pat Garofalo, managing editor, TalkPoverty (@Pat_Garofalo)
- Kate Nicholson, former federal prosecutor, civil rights lawyer, and chronic pain patient (@speakingabtpain)
For more on this week’s topics:
- Read more from Erica Ayala: “The U.S. Women’s Soccer Team Is Fighting for Better Pay — and the Rest of Women’s Sports Depends On It” — and dig in to the U.S. women’s World Cup class action (New York Times), plus more on the WNBA pay gap (Dallas News), and more on the #ForTheGame movement in women’s hockey (Sporting News)
- Check out Pat Garofalo’s TalkPoverty piece on the closure of United Medical Center, “Inside the Fight Over the Last Hospital in DC’s Poorest Neighborhood”
- Read more from Kate Nicholson on the chronic pain perspective of the opioid crisis (LA Times); on the dangers of one-size-fits-all policymaking (Washington Post); on why we need to treat both pain and addiction and not pit the two sides against each other (LA Times); and on the CDC’s recent set of clarifications (with Dr. Stefan Kertesz) (StatNews)(twitter thread from Kate)
This week’s transcripts:
♪ I work and get paid like minimum wage
sights to hit the class by the end of the day
hot from downtown into the hood where I stay
the only place I can afford ’cause my block ain’t saved
I spend most of my time working, trying to bring in…. ♪
REBECCA VALLAS (HOST): Welcome to Off-Kilter, the show about poverty, inequality, and everything they intersect with, powered by the Center for American Progress Action Fund. I’m Rebecca Vallas. This week on Off-Kilter, the fight over the last hospital in Washington D.C.’s poorest neighborhood, United Medical Center in Southeast D.C., and the larger trend it embodies of hospitals closing, consolidating, and moving out of low-income urban neighborhoods in favor of neighborhoods with richer residents. I talk with Pat Garofalo, managing editor of TalkPoverty. Later in the show, the story behind how the tide has finally turned, or started to turn, in the opioids conversation to acknowledge the perspective of chronic pain patients, which previously was pretty much nowhere to be found. I talk with one of the chronic pain patients and advocates who’s been leading the charge to bring that other perspective to the opioids conversation, Kate Nicholson.
But first with the U.S. Women’s World Cup soccer team in contention to win the World Cup, a class action lawsuit hangs in the air alleging gender-based discrimination by the U.S. Soccer Federation. The lawsuit highlights inequities in travel conditions, promotion of games, staffing, support, and development, and a significant gender pay gap to boot. For the latest on where the players’ lawsuit stands and a look at what it means for women’s professional sports if it prevails, I’m joined by Erika Ayala, a freelance writer and project manager at the Westchester Children’s Association who’s the author of a recent article at TalkPoverty about the subject.
Erica, thanks so much for taking the time to join the show.
ERICA AYALA: Of course. Thank you for having me.
VALLAS: So, just for starters, would you share a little bit of background on this class action lawsuit? What is this lawsuit about? What are the basic facts here?
AYALA: Sure thing. So, this is actually the second lawsuit that players from the U.S. women’s national team, the women’s soccer team, have filed. They did file a lawsuit against their federation, U.S. Soccer Federation, back in 2016. And so, that lawsuit never ended up going anywhere. There was a collective bargaining agreement that happened between the Players Association for the national team players and the federation. And here we are again. This is an additional lawsuit that was filed on, I believe, on International Girls & Women in Sport Day, of all days. It’s very, very historic and has a lot of meaning on the lawsuit coming out then. And it just reports that despite what happened in that 2017 collective bargaining agreement, that U.S. Soccer Federation, in the eyes of the women’s national team and all 28 players within their system at the time, that there is not enough being done to close the gender gap that exists within the U.S. Soccer Federation. These women are listing their accomplishments as a national team and even comparing those to what we see on the men’s side. And because of the revenue that they were able to bring in, especially because of the 2015 World Cup win and a few other things they are contesting, that not only should they, at minimum, receive equitable treatment when it comes to training facilities and marketing, but that there is a case to be made for them to be compensated as a team that is winning, and also, at least for a period of time, has helped to create a surplus of money as opposed to a deficit for U.S. soccer.
VALLAS: Now, you’re TalkPoverty post actually has one passage that outlines sort of side by side the accomplishments for the women’s national team and then the sort of comparative points for the men’s team. And it just, it blows the reader away. You’re talking about three World Cup titles, four Olympic gold medals, being ranked number one in the world for 10 of the last 11 years. And then you’ve got the men’s national team, which has no World Cup titles, no Olympic medals, and hasn’t even qualified for the Olympics since 1988. But you’ve got the women still being paid less.
AYALA: Yes. And again, that’s exactly what these players are referring to in their lawsuit. They have proven on the pitch, and certainly within the eyes and some would even say the hearts of the country, they’ve proven to be a successful team. And now they’re asking for, again, to be treated as professional athletes as determined by U.S. Soccer Federation, which they believe on the basis of their gender, as of right now, they are not. But then also to take that a step further and to consider all of the accolades that they do bring to the federation, even though they don’t receive equitable treatment when it comes to, again, things like training or even pay and compensation.
VALLAS: Now the World Cup lawsuit here, and especially because of the timing of the World Cup, has gotten some renewed attention and has really shone a spotlight on the sport of professional soccer. But it’s not just professional soccer where we see this kind of gender-based discrimination being alleged and being documented in the world of professional sports. It also stretches into other professional sports as well. One is a sport that you actually do extensive reporting on, and that’s the sport of professional hockey, where we’re seeing a tremendous movement with a hashtag for the game arising out of similar types of allegations. What’s going on in the hockey space?
AYALA: Yes, and I think it’s absolutely correct: there is a lot happening in women’s sports. But there are a few similarities I think and also some distinct differences that are important to point out. The first is that the game comes on the heels of #BeBoldForChange. That was a hashtag that, again, the national team that was under the Federation or USA Hockey though the women’s national team, as they were preparing for the 2018 Olympics, which as we know now, they went on to win gold for the first time in 20 years. But ahead of that and ahead of the 2017 World Championships hosted in the United States, an international tournament, the players of the hockey team had been in negotiations for a contract to make sure that they themselves were able to receive compensation for playing and dedicating so much time to the national team. They were also looking for things like a maternity clause that they didn’t have. Again, these are women that some either have families or want to have families. And in women’s hockey at the time, up until 2017, that was something that they felt they had to essentially plan, that they had to family plan around the ambition that they had on the ice because there were no protections. Which of course, now we’re hearing a lot about Nike and even Nike and how they treat women and how they deal with pregnancy for some of their athletes.
But so, flash forward to that. They were able to, with the help of the National Hockey League, to get USA Hockey to provide stipends of about $70,000 per player. They did include things like maternity leave. And you have two players, actually, that just were on maternity leave after having their first children, the Lamoureaux twins, as it would be that both delivered their first children this past offseason. But now, when we move to, for the game, what the national team players are trying to do, is they’re trying to create a lot of the securities that they just recently got from USA Hockey. They’re trying to transfer that over to women’s professional hockey through the National Women’s Hockey League. And the National Women’s Hockey League was the first women’s league to pay players. And unfortunately, the CWHL, the Canadian Women’s Hockey League, folded on May 1st. And there were a lot of people that felt with the CWHL no longer being an option in North America, and with the NWHL having a lot of challenges, including in 2016, slashing salaries upwards of 60 percent, that there was not a viable option for these women to play.
So, they coordinated, and they unified, for the most part, to say that they were not going to sign NWHL contracts. And so, they’re trying to create, through their own players’ association, which is a non-profit model, not a formal union, they’re trying to find investors and to make a case to make sure that the next version or a newer version of women’s professional hockey in North America will include a livable wage, will include full insurance, and will also include things like travel and better travel accommodations for professional athletes.
VALLAS: And it’s not just hockey. Basketball as well has emerged as part of this debate and part of this ongoing conversation too, with similar allegations in the WNBA.
AYALA: Yes, absolutely. And in the WNBA, again, we hear about travel. The one thing in the WNBA that’s extremely important, or interesting perhaps, is that in the collective bargaining agreement, the CBA that the WNBA has currently, there’s no clause that protects these women from traveling through multiple time zones and then being given a certain amount, a minimum amount of rest as they travel through multiple time zones before they then are asked to play a game. The NBA in their contract, there is a clause that exists. So, an NBA player would never travel 25+ hours through a multiple time zones and then be expected to have a tip off within that same 24-hour period. Unfortunately, that did come to play when it came to the Las Vegas Aces. There were an expansion team, or I should say they relocated with a new team. The franchise relocated from Texas to Las Vegas, and they did have that problem. And the WNBA offered a one-hour delay on the tip. But instead, that team opted not to show up for that game and ultimately was issued a forfeit. And that team, the Las Vegas Aces, as they relocated in their first year as the Aces, missed out on the playoffs by one game. Now, who’s to say that that one forfeit would have made or broken their season. They still had games to play. But again, you’re one game out of the play offs, and one of those games, the team opts to not play because they were more concerned about their long-term health than making a playoff run.
VALLAS: Is the fact that there’s the sort of confluence of all of these different and multiple professional sports arenas where the same kind of, or similar kind of, echoes of the same conversation are all playing out at the same time, is there significance there when it comes to how these fights are proceeding? And for example, is the fact that discrimination is being alleged in other professional women’s sports, is that adding at all to the motivation behind the World Cup lawsuit? What’s your take on the fact that all of these things are happening at the same time? Are they informing each other?
AYALA: I think they are informing each other. If you go back to the 1919, 1999, excuse me, World Cup, the piece that we have coming out for TalkPoverty is going to talk about that really being a part of a movement, certainly in women’s soccer, but that informed the creation of the first domestic soccer league for women. It then informed the national team, the women’s national team in hockey, who eventually was able to negotiate, and through their #BeBoldForChange movement, finally get USA Hockey to create some of those different supports, as I mentioned earlier. It also goes back to, again, the collective bargaining agreement of the WNBA and looking and comparing what they have to the NBA.
And again, the thing that I think is the absolute through line is that these are women. These are women in sports. And I think the general through line is that, and if we’re being kind, at minimum what we’re seeing is that there’s an afterthought when it comes to what is required or what women in sport are worthy, “worthy” of when it comes to certain supports and protections that men never have to think about. And unfortunately, that’s not just in the sports arena. That does seep out and follows the trend in society that often, if we’re looking to cut corners economically, we as a culture might look to do that in a way that impacts women more directly than men. If you think about things like taxing birth control and not taxing Viagra, or women even in the justice system having to pay for sanitary napkins and things of that nature. Unfortunately, this is something that really perpetuates throughout society.
VALLAS: In the last couple of minutes that I have with you, Erica, is this lawsuit likely to prevail? I mean you and I talked a little bit about some of the basic facts and allegations in this case, and they sound incredibly compelling and cut and dried when you start to lay them out in terms of the inequities that are being documented here. Do you think that the players are going to win? And if so, what’s the significance for the rest of professional sports and for the ongoing conversation around pay equity more broadly?
AYALA: It’s definitely to be seen. Of course with any lawsuit, the person being sued — in this case of U.S. Soccer Federation — can file their response, essentially a retort, if you will. And of course, U.S. Soccer does not agree with a majority of the claims made. However, we also see that Hope Solo who is no longer with the U.S. women’s national team, she has her individual lawsuit happening. And there have been strides made in her case, which again, will set precedent and will perhaps allow some of what’s being explored when it comes to gender discrimination to also follow in this lawsuit against U.S. Soccer Federation. So, it’s definitely to be seen. But I think yes, all eyes are on the U.S. national team as they look to go for their fourth star out in France in the 2019 World Cup. But certainly once they return, as many of the domestic leagues here, including the WNBA, the NWSL, which is the domestic soccer league, and the future of women’s hockey are looking to see if they too can learn from this lawsuit, particularly if they’re successful.
AYALA: I’ve been speaking with Erica Ayala. She’s a freelance writer. She’s also a project manager at the Westchester Children’s Association, and she’s the author of a recent article at TalkPoverty about the gender pay gap and other disparities in professional sports. You can find it at TalkPoverty.org and also of course, on our nerdy syllabus page. Erica, thank you so much for your reporting on this and for taking the time to join the show.
AYALA: Thank you so much for having me.
VALLAS: Don’t go away. More Off-Kilter after the break. I’m Rebecca Vallas.
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You’re listening to Off-Kilter. I’m Rebecca Vallas. Arnel Jean-Pierre has been a nurse at Washington D.C.’s United Medical Center for seven years, and he’s seen a lot. But if D.C. Council gets its way, the hospital is at risk of having to shut its doors for good in the coming years. According to Jean-Pierre, that’s going to cause a lot of avoidable pain for the residents of D.C.’s poorest neighborhoods. The end result, he said, is, “A lot of people are going to suffer.” So writes Pat Garofalo, managing editor of TalkPoverty.org in a recent article digging into the fight over the last hospital in Washington D.C.’s poorest neighborhood, which is at risk of closing. That hospital is called United Medical Center. And I sat down with Pat to talk about what the debate over UMC, as it’s often called, and the larger trend of hospitals closing, consolidating, and moving out of low-income urban neighborhoods in favor of neighborhoods with richer residents is all about. Pat, thanks so much for taking the time to join the show.
PAT GAROFALO: Hey, thanks so much for having me back.
VALLAS: So, just for starters, United Medical Center is an institution in D.C. and a place that D.C. residents are probably well familiar with. But for listeners outside of the D.C. area, talk to me a little bit about this hospital. Who does it serve? What is the significance of United Medical Center for D.C.’s community?
GAROFALO: So, I think the first place to start is to just get a sense of D.C. geography. For those who don’t live, here the city is divided into four quadrants: northwest, northeast, southeast, southwest. Southeast, which is where United Medical Center is, is the poorest quadrant in the city. It is majority black. It is sort of used as shorthand for the economic struggles of the city. When you talk about southeast, you are generally talking about the people who’ve been left behind in the economic boom that D.C. is experiencing. So, something to know about Washington D.C. is that it currently has five general hospitals. Four of them are in Northwest, which is the richest, whitest quadrant. So, you have quite the contrast here in which the richest, whitest part of a historically majority-black city has the bulk of the health care services. Adding some insult to injury, UMC is not only on the brink of closing, but has been treated badly for years and years and years and years.
VALLAS: And the population that it serves is also majority black and also is disproportionately people who are paying with Medicaid and with Medicare.
GAROFALO: Yeah, exactly. This is, the only place they have to go is this hospital, and they’re a population of the city that has just been left behind in many, many, many ways.
VALLAS: So now, what’s going on that’s actually got the hospital on life support, to make a horrible pun?
GAROFALO: So, the mayor’s office asked for $40 million to keep UMC running until a new hospital gets built in that part of the city. There’ve been sort of long-term plans to build a new hospital there. The city council came back and offered $15 million, which is not 40. So, there was a back and forth, the mayor’s office fighting with the city council. City council eventually agreed on $22 million per year for the next bunch of years and set an end date of January 2023 to close this hospital down for good.
Couple of problems here. 22 million is still not 40 million. So, this inevitably means that the hospital is going to have to cut back on services and cut back on staff. They’ve already circulated layoff notices. This is going to make the hospital worse in the interim before it closes down. The other important point is that while there is a date certain for the closing of UMC, the plan to open a new hospital is half-baked, to be generous. There is no deal to really build the new hospital. It exists in the minds of the city council and in the minds of the people who want to build it, but nothing concrete has been done. And so, you have this situation wherein the only hospital serving the poorest part of the city has this explicit end date, and yet the plan to replace it is basically nonexistent. And so, you sort of can’t imagine that happening in the richer, whiter parts of the city. Those parts of the city would never be in the situation of losing their hospitals and having this amorphous, vaporware plan to replace it.
VALLAS: Now, when you think about a hospital closing, it’s not an overnight matter, right? So, part of what your piece actually describes is how, what will happen, according to some of the folks who work at the hospital and others following this debate is a cutback in services that happens over a span of time and that will, for starters, mean longer wait times. I mean just to get really concrete here, we’re talking about really awful stuff when you think about this in human terms.
GAROFALO: Yeah. And this is already happening. This hospital was like — I don’t want to oversell how this wasn’t a spectacular hospital to begin with. It’s always been in pretty dire financial straits. In 2010, it was privately owned and went into bankruptcy, and that’s the only reason city owns it now at all. So, they’ve been cutting back and cutting back and cutting back. The people I talked to at the hospital now say that with this new funding level, which is just not sustainable, they are going to have to cut back services. They’re going to have to cut back staff. That’s going to mean longer wait times. And the people I spoke to are most concerned about the people for whom seconds and minutes really matter. They specifically called out heart attack victims, stroke victims, and gunshot victims, and they said those people are going to be worse off and are going to die because of these funding shortfalls.
VALLAS: You were describing where the other hospitals are and that there are other hospitals that are all in northwest. But to get super, super nuts and bolts about this, because as you said minutes and seconds can matter when you’re calling an ambulance and needing to get to the hospital. But the nearest hospital, if UMC doesn’t exist, is nine miles away, which as your reporting points out, can mean more than an hour stuck in rush hour traffic. Think about that.
GAROFALO: Yeah, absolutely. We threw in that note about how long it can take to drive there because nine miles out, it’s not that far, right? You can do that in 10 minutes. No, we’re talking about an urban environment where if you are just in the backseat of the car and had a heart attack and are trying to get to the hospital, it could take you forever to get there. And that really, really matters. Even an ambulance. You know, we’ve all been in those situations in a city where an ambulance is stuck behind cars in a tunnel or on a bridge and can’t get through. So, those nine miles, it’s a really long way for someone for whom five minutes is the difference between life and death.
VALLAS: There was a quote that really stuck with me in the piece that just so perfectly captured exactly the point you were making before. You can’t imagine something like this playing out in northwest, right, for the obvious reasons that who lives there, and we’re talking about a much richer, much whiter area of the city. But the quote goes, “They’re paying taxes just like the folks in Georgetown. Why should they have the delay in health care when they face a stroke?”
GAROFALO: Absolutely. It’s almost absurd to think that this situation would ever occur in the richer parts of the city. It would never even be suggested because the politics of it would be so untenable. The only reason that this situation exists is because the political power in the city is not in those poor, black neighborhoods.
VALLAS: Now this is part of a larger trend that we’re seeing play out across the country. We’re talking about D.C., where this debate, in many ways, is sort of a microcosm of what we’re seeing happen in communities and states and cities across the U.S. And your piece actually puts some numbers to that.
GAROFALO: Yeah. So, one of the interesting things about doing this piece was we’ve heard a lot in the last bunch of years about rural hospital closures: rural hospital crisis. They’re closing all over. And that is absolutely true, and I’m not underselling that at all. But this same thing is happening in cities as well. Hospitals are closing left or right. So, if you actually look at what’s going on, it’s not an urban versus rural thing; it’s a poor versus rich thing. Hospitals are closing in poor neighborhoods and in poor counties. And so, the number that I pulled out is the number of hospitals in major U.S. cities fell by nearly half between 1970 and 2010. But in that time, two thirds of the new hospitals that were built, were built in affluent neighborhoods. So, you’re seeing them leaving poor neighborhoods, moving into affluent neighborhoods. Another number that I found was really striking: a study that looked at hospitals that closed, public hospitals that closed, between 1990 and 2010. The ones that closed were in neighborhoods with significantly higher percentages of black residents. If you knew nothing about the hospital except that it was a public hospital and the percentage of white versus black residents in the neighborhood, you could predict if it would close or stay open. If it was in a majority black neighborhood, it probably closed in those decades. And if it wasn’t, it probably stayed open.
VALLAS: Now people can probably speculate as to what’s going on here, but you actually report a little bit on that in this piece. It has something to do with a trend of not just closures but actually of hospital consolidation and mergers. What’s going on here, and how are we watching this kind of hospital chasing the dollar that seems so explicitly to be going on?
GAROFALO: It’s two things happening. On the one hand, cities wanting to get out of the public provisioning of health care. They’re saying, we don’t want to be in this business anymore. While at the same time, health care corporations and health care companies and health care insurers have gotten bigger and bigger and are gobbling up more and more and more hospitals. You’ve seen this across the country. You know, cities that used to have five and six different companies providing health care are now down to two if they’re lucky, oftentimes one. So, these two trends at the same time have led to this sort of catastrophic moment wherein government has gotten out of the health care business. Private corporations have swooped in, consolidated, gotten bigger, and they do not want to be in the poorest neighborhoods anymore. So, while the public has retreated, the private has decided to go to the richest parts of the cities and the counties. And this is, again, this is happening in both rural and urban areas.
VALLAS: And we talk a lot about income and racial disparities when it health care. But this seems to be missing from that conversation, right, that we’re actually ending up with health care deserts in a lot of ways.
GAROFALO: Oh, absolutely. And it’s not just hospitals. When a hospital closes, there are knock-on effects. Doctors don’t go into that area. Dentists don’t go into that area. Other health care practitioners don’t go there because networks build up around a hospital, which makes sense. And when the hospital leaves, all sorts of other stuff either leaves with it or never goes there in the first place, right? You can see a doctor who is planning to open a new office is going to look around and say, oh, well, all the hospitals are in northwest. So I’m going to go open my practice there too. And none of them are going to go into southeast.
VALLAS: So, what’s next for the D.C. fight? Do we know?
GAROFALO: A little bit. The hospital received its inadequate funding for the next bunch of years, so it really depends on if this new hospital ever comes into being. Of most people I talked to, no one really thought that anyone would, that ultimately UMC would close for good, shut the doors, no one else come in without a new hospital being built. It’s more about the slow bleeding of this hospital over time and just having it serve fewer and fewer and fewer people and having the waits get longer and longer and lower and leaving it a husk of its former self. And it’s possible to be in a situation in 15, 20 years where UMC is still open in the barest sense of the word, and the new hospital doesn’t exist, and these people in those neighborhoods are in this horrible situation of having to decide if it’s worth driving across the city to get health care.
VALLAS: So, is part of what we actually expect to happen here that we watch this slow bleed, as you described: the hospital just ends up becoming less and less able to keep its doors open in a full sense, wait times get longer, quality of care gets lower, and effectively, we just watch health care in this area of the neighborhood get worse and worse and worse, absent the opening of some new hospital. Is that basically how this goes?
GAROFALO: Exactly, yeah. It’s just the slow bleed out of health care services in this neighborhood. And we’ve already seen it. I don’t want to go by the fact that the cancer clinic in the hospital has already gone. The maternal health care ward is already gone. They’re already seeing effects of inadequate funding that have gone back years and years. So, this is only going to take a bad situation and make it worse.
VALLAS: The piece closes on, I think, exactly the most powerful note that one could in this context. You close, again, with a quote by Jean-Pierre, the UMC nurse who whose words I opened with. And Jean-Pierre says, “We are trained to do no harm. But the D.C. Council does not live by the same code of ethics. Based on this cutting, they’re doing a lot of harm.” Really horrible to see this happening and really appreciate your reporting to lift this up, given that it’s getting drowned out in new cycles that are about everything else.
GAROFALO: Thanks for having me.
VALLAS: I’ve been speaking with Pat Garofalo. He’s the managing editor of TalkPoverty.org. He’s also the author of the piece Inside the Fight Over the Last Hospital in D.C.’s Poorest Neighborhood. You can find it at TalkPoverty.org or of course, on our nerdy syllabus page. Pat, thanks so much for taking the time.
GAROFALO: Anytime.
VALLAS: Don’t go away. More Off-kilter after the break. I’m Rebecca Vallas.
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You’re listening to Off-Kilter. I’m Rebecca Vallas. Finally, to round out this week’s episode, about a year ago, I spoke with a friend of the show and a friend of CAP’s Disability Justice Initiative, Kate Nicholson. She’s a former federal prosecutor at the Department of Justice, a civil rights lawyer, and a chronic pain patient advocate. I spoke with her about what she put as the other side of the opioid epidemic and how a well-intended crackdown on prescription opioid painkillers was having serious and devastating, and in some cases, even lethal unintended consequences for people struggling to manage chronic pain. In the year since we spoke on this show, the national opioid conversation and the policymaking flowing from it has started to become a lot more nuanced and reflective of that “other side of the conversation.” That’s thanks in large part to the work of Kate and other chronic pain patient advocates. So, I thought it was time to have Kate back on the show for an update and for a look at the advocacy and public education behind that important and much-needed shift. Let’s take a listen.
Kate, thanks so much for coming back on the show.
KATE NICHOLSON: My pleasure to be here.
VALLAS: So, for starters, I feel like it’s helpful for people who aren’t familiar with you and with your work to know about your personal experience and how you come to the issue of chronic pain and of opioids. So, would you be comfortable sharing a little bit of your own personal story?
NICHOLSON: Absolutely. So, I am someone who has had long-term pain. I was working at the Department of Justice, ironically in some ways, enforcing the Americans with Disabilities Act. And one day, I was sitting my desk just putting the finishing touches on a document due to court. My back started to burn really badly, and very quickly, I ended up in a full-body seizure on the floor. And pretty much after that point, I was unable to sit, stand, or walk and in quite severe pain for the next 15 years. It turns out it was related to a surgical injury in which a doctor had severed part of my spinal cord, but I didn’t feel the symptoms until the nerve started to grow back, and I got scarring and neuromas in my spinal cord. I tried lots of different methods to treat pain, probably 37 different things and really didn’t want to use opioids. But at one point, after numerous treatments had really failed to sort of restore my function, my doctor said, “Listen. You really need to consider this.” They had tried a repeat surgery, and that had failed. And they just didn’t have anything else to offer me. So, I did.
And taking opioids for pain really helped me. I still couldn’t walk or sit, but I was able to have a career in the disability rights section at the Department of Justice. I was able to argue cases from a reclining folding lawn chair and oversee cases from a video teleconference screen in U.S. attorneys’ offices around the country, and draft regulations and do all of those things that lawyers even though I couldn’t ever stand and was pretty limited. And eventually, about 15 years in, because of improvements in medical devices and also in surgical techniques, they were able to sort of shift some of the problems. And I was able to learn to walk again and improve, and I got off of opioids without any problem once my pain was at a level that I didn’t need to take them anymore.
But that was not before one final chapter in my experience with opioids, which is really what brought me into concern for people today and into this conversation. I had left D.C. and moved to Colorado when I was rehabilitating for a healthier lifestyle. And I went in to see my doctor one day, and I was already learning to walk again and improving and going down on the opioids. So, I wasn’t off of them, and she said, “I’m not going to prescribe opioids anymore, and you won’t find anybody else in town willing to either.” And what had happened was that a local physician who was well-respected had prescribed opioids to someone who was a drug enforcement agent who was posing as a pain patient, and that caused him to come under investigation. And it really had a chilling effect through the entire community. And so, I said, “Well, let’s talk. Can you just give me a taper plan?” Because it’s actually very dangerous to abruptly stop opioids. Anybody who takes them becomes physically dependent, which is not addiction. It just means that you can’t, like with blood pressure medication and some anti-depressants, it’s dangerous to stop them quickly. And she said, Nope. Not prescribing them anymore.” And I was fortunate because I had a treatment team back in D.C., and I flew back. And they gave me a taper plan and that was that. But it did — that was in 2014 — and it did sort of allow me to see what was coming in the environment. And in fact, things have just gotten much, much worse for patients today.
VALLAS: And you’ve shared in a lot of detail what happened to you, but to be abundantly clear, yours is not some exceptional case. Your story is something that happens to people across this country each and every day because of the way that the conversation around the opioid crisis, or the opioid epidemic as it’s often called, has played out. And also because of some very specific steps that’ve been taken within the health care world. A lot has to do with some guidance that came out of the CDC, the Centers for Disease Control. So, take us to that part of the story of what set the stage for the way that the opioid conversation has been playing out in the past several years.
NICHOLSON: Absolutely. So, I would definitely affirm, first of all, what you’re saying. This is a systemic issue. It is happening across the country. I get hundreds of emails from complete strangers every day. And I will read some of them to you later. But just to frame it, what happened to me has really accelerated since 2016 when the Centers for Disease Control and Prevention issues what was guidance designed her primary care physicians. And the reason that they issued that guidance is that there are a lot of studies that show that primary care physicians, not physicians who are trained in pain management, really have very little training in how to treat pain. It’s ironic and kind of hard for people to really believe that very little education in medical school goes into treating pain, since pain is second only to the common cold as the reason people seek medical care. But that is in fact, the case. And so, what was happening is that a lot of primary care doctors were prescribing opioids, some of them not well-trained in prescribing. And so, the CDC issued these guidelines.
And a lot of what was in the guidelines were very sensible: don’t prescribe opioids as a first line of treatment. Try more conservative approaches first. If you’re prescribing, then you should prescribe it at the lowest effective dose for the shortest period of time. I don’t think anyone has any problems with those provisions. But what happened is, in sort of the haste to try and contain the overdose deaths that we’re seeing on the streets, which by the way, since 2016 have not really been related to prescription opioids very often. They’re much more related to illicit fentanyl and heroin, and increasingly, stimulants. But there was this view that if we could sort of put the genie back in the bottle and take the prescription opioids away, we would solve the crisis.
And so, what happened is a couple of provisions in that guideline were translated sort of strictly into one size fits all policies because they were numbers. There was a provision that said you often won’t need more than three to seven days to treat acute pain. And there was a provision about how to dose, how to provide, how to dose a new patient, someone who hasn’t ever been exposed to opioids before. Because there was a concern that people were raising the dosage too quickly, and so it provided a range of numbers, of basically morphine milligram equivalents. And those numbers were sort of lifted by policy makers and translated into laws, about 33 states translated into policies at pharmacies. All the major pharmaceutical chains, all the major insurance companies have adopted them. And also, law enforcement agents are sort of using just those numbers as a way of flagging patients as either over-utilizes or their physicians, their treating physicians as over-prescribers. So, they’re using those numbers as a way to say, oh, this could be a pill mill. This could be a doctor who is overprescribing opioids. And they’re using only dosage as a basis.
So, what’s happened is these are fine tools for what they were designed to do, but they were never intended to apply to people who currently take opioids and have been them and stable on them for many years. The numbers lack context entirely. There’s no connection to whether someone is using an opiate for an opioid use disorder, in which case they need higher doses, or is using an opioid for cancer treatment or sickle cell treatment or a number of things. There’s no, they’re just looking at the numbers. They’re not looking at what kind of condition the person has. And they’re certainly not looking at what kind of patient population a doctor is treating or whether alternative treatments are covered by these patients’ insurance policies or available to them.
VALLAS: So, more of a one size fits all approach that’s based on a not very sophisticated understanding of a lot of numbers that have very specific meanings.
NICHOLSON: Right. And taking those numbers out of context, first of all, because they were never even intended to apply to people currently taking opioids. That’s pretty clear. And then just, yes, using a single number to describe an entire human, the condition of human suffering, or an entire social problem is not a particularly sophisticated way to go. But it was a quick and dirty way to look, you know, for policymakers to feel like they were doing something about the crisis. And what’s happened as the result is that people who use opioids as a medication for pain, whether that’s pain from cancer or sickle cell or other conditions or disabilities, are basically being denied their medication. They’re going to pharmacies and being flagged and being told that they can’t fill their prescription. Their insurance company is deciding that they’re not supposed to take that medication. And they are also, because their doctors fear this government oversight, are being abandoned in care by their physicians and forced off their medication.
VALLAS: And Kate, you mentioned that you hear from people all the time. Because of your visibility on this issue, you’re often out there speaking. Your TED Talk got a lot of attention. You write a lot on this issue. And so, people know to reach out to you to share their stories. Would you be willing to share a few of the types of e-mails that you receive from people in this type of situation to help put a face on how this plays out?
NICHOLSON: Sure. I’d be happy to. I mean what really happens to people is they lose their ability to work or function, they deteriorate medically, and some commit suicide or turn to illegal opioids when their medication is denied. And so, these are the kinds of things that I see when I open my email in the morning. I get emails that like this one that says, “I was independent. Now I have to get my kids to help me because I’m bedridden and in pain. So, I get disability now, and I’ve lost my house.” Or, “The tears grieving financial loss cannot be described with my husband bedridden in immense pain. I am so tired now, and we are financially devastated.” I also get a lot of emails from patients who are acutely suicidal. Here’s one: “I’m a pain patient who can no longer get treatment for my pain caused by a spinal cord injury. I do not want to end my life. I want to live. I want to see and hold my grandchildren. But if I can’t get help from someone somewhere, I will not be here next week.”
VALLAS: I —
NICHOLSON: I also hear — Go ahead.
VALLAS: I’m just reacting as you’re reading these. I mean they’re absolutely heartbreaking, one after the other. But I’m sorry. You’ve got more to share.
NICHOLSON: Well, I was just going to share one more. I don’t want to over — But yes, I mean this is happening. I mean like I said, I receive hundreds of these. I sort of bristle before I open my email every day. And that is what shows me that it’s a systemic problem. Not just the fact that it’s in laws all over the country, which is evidence of a systemic problem. But the fact that I hear from people from every walk of life, veterans and teachers and professionals and from all different states all over the country every day, suggests to me that this has become a really serious systemic problem. I can read this last one. I just also hear from families who’ve lost loved ones who do actually commit suicide or turn to illegal drugs. So, here’s one. And he just says, “Hello. It has been about three weeks now that my brother, 31, took his life.” Or another: “My brother passed away. Over the last year, his doctors began to significantly cut down his pain medication. He was truly at the end of his rope.” Yeah. This is what’s happening today because some of our policy choices. And that is not to suggest that we shouldn’t be doing lots and lots of things to address people who have become addicted to opioids or people who use drugs. There are a lot of things we can be doing. But we’ve swung, as we do often in this country, too far to one extreme by prescribing opioids perhaps too liberally. And now we’ve swung to the other extreme trying to fit the genie back in the bottle by taking them away from everyone. But we are really harming people who take these medications for appropriate medical reasons.
VALLAS: Now Kate, as I mentioned up top, a lot has changed in the way that this conversation and the way that policymaking in this space has progressed in the years since I’ve had you on this show. The tide has firmly turned, it feels, towards a much more nuanced conversation that doesn’t just have one side, but that actually does include what you’ve termed the other side of the opioid epidemic, which is the experience of living with and struggling to manage chronic pain. We’ve watched public health agencies now, including the CDC, which we spoke about before, looking like it appears to try to get right on opioids, to put it in that way, and issuing a series of really, really significant clarifications of their former guidance. You’ve been doing a lot to educate the public and policymakers and medical professionals about the clarifications coming out of the CDC. Tell us a little bit about what we’re hearing from that agency and what they’re now saying that changes their tune from before.
NICHOLSON: Sure. Well, I actually met with them in March, along with a researcher from Human Rights Watch. Because Human Rights Watch did a big report about what’s happening to pain patients today as well, and a physician who’s been very active in pointing out these harms, Stephan Kertesz. And we really urged them to make a strong public-facing statement correcting the situation, clarifying what the guidelines do and don’t say, and how they are being, in essence, misapplied. And in April, they did just that in a series of directives. One of them was from the CDC director, and he made it very clear that the guideline does not endorse forced, mandated, or abrupt tapers. And those are attempts to reduce people on their medication very quickly or take them off ,which is what’s been happening to patients today as a result of these sort of duration-limited dose limits that have been placed in the sort of laws and policies. He was very clear that that’s not the case; that the recommendation’s for clinicians to work with patients to taper only — in bold — he wrote, it’s only appropriate when patient harm outweighs patient benefit. He made clear that the dosage guidance was really intended just for starting someone out on opioids and that the guidelines have a completely different recommendation for people who are currently using. And so, really, a lot of what they did was come out and sort of clarify and say, no, this is what we said, and this is what we didn’t say. But they did want to be very clear that mandating people getting off of their opioids was not approved by the CDC because it poses serious risks for patient harm, which they also said.
The FDA also issued a warning and a label change to all opiate pain medication to argue against abruptly cutting people off of opioids. They said, “The U.S. Food and Drug Administration has received reports of serious harm in patients who are physically dependent on opioid pain medications suddenly having these medications discontinued or their dose rapidly decreased. These harms include serious withdrawal symptoms, uncontrolled pain, psychological stress, and suicide.” So, the government agencies are sort of starting to receive these reports as well. I mean I certainly brought them to the CDC’s attention, but they are starting to pay attention to the suicides and to people turning to illegal substances and just to the deterioration and loss of health that’s happening because that’s not really a net good in the health care system to take someone and leave them worse off than you found them. It’s not generally what we try to do in the health care system.
There were a couple of other clarifications that the CDC came out with. One of them was addressed to a bunch of cancer doctors and hematologists who had made the point that a lot of people with cancer and sickle cell were unable to get medication, and the CDC guideline really wasn’t designed to apply to them. And the CDC made very clear that that was in fact the case. And in that sort of public-facing letter, they also said, “And our guidelines did not intend in any way to limit to anyone with chronic pain access to opioid pain medication.”
VALLAS: You’re listening to Off-Kilter. I’m speaking with Kate Nicholson. She’s a former federal prosecutor, a civil rights lawyer, and a chronic pain patient advocate who’s been a big part of changing the national conversation and improving the national conversation when it comes to the so-called opioid crisis and how policies stemming from previous actions by the CDC and others have led to unintended consequences for people struggling to manage chronic pain. And Kate, you’ve been talking a little bit about some of the clarifications, and I want to let you continue to walk through those. But part of what’s been incredibly powerful to watch has been it hasn’t just been a matter of watching the CDC and the FDA and other agencies start to really try to shift the pendulum themselves with these changes in guidance. But we’ve also started to see the policy landscape shift, thanks to these types of clarifications. That’s true at the federal level. That’s also true at the state level. Part of that actually stems from a really important victory in Oregon.
NICHOLSON: Right. Well, it was very helpful. In Oregon, there was a proposal to force taper everyone. It started out to be force tapering anyone on Medicaid who had any type of chronic pain off of their opioids. Over the course of a year, it shifted a little bit to people with certain diagnoses, but it was still going to effect 80 to 100,000 people. And a lot of us worked very hard to advocate against that policy. And it was really nice to have this clarification from the CDC come out just before Oregon was set to vote because they did indeed slow down forced tapering everyone off of their opioids. So, that was terrific. The CDC guidance, the clarifications have certainly been helpful in providing fodder to block a couple of federal proposals to do sort of what the states are doing, what a couple of state laws have done, which is to sort of apply some absolute numbers to limiting opioid prescribing. And so, that’s great. In terms of the forward-looking policies or things that are already in process, those clarifications have been enormously helpful.
The tough battle from here is that because the policies are in, like I said, virtually every major pharmacy chain, virtually every insurance company, because they are being used in every U.S. attorney’s office in the country to survey prescribing practices by physicians, dismantling the rest of the system is going to take some time and some effort. And strategically, it’s a little harder to know how to go about it, although I think we have some ideas about how to do that. We also have some great allies: the AMA has really stepped up as have a number of other physicians who are, finally, I think for a long time, felt shamed about what happened with liberal prescribing, but are starting to step up to sort of argue for the ethical treatment of their patients.
VALLAS: The AMA being the American Medical Association.
NICHOLSON: Sorry. Yes, exactly. So, there was one positive development that we just learned about very recently, and that is that the Senate committee — So, there are committees on the House side and committees on the Senate side that deal with pretty much health and health policy. And the one on the Senate side, the acronym the HELP committee, is actually going to do a series of hearings that works into this. And so, that will really help. And it will look at, among other things, drug enforcement agents’ practices. So, that will, I think, really help because something has to shift to allow doctors to feel like they have breathing room to treat patients again.
I think patients have really been converted into liabilities, patients on opioids, and really patients with chronic pain, period. Human Rights Watch and others have found that doctors are dropping and unwilling to treat people with pain just because of the fear that they might need opioids in the future. So, the treatment of pain has really gotten too hot to handle, and we need to shift the policy environment further in order to sort of restore individualized treatments based on specific health conditions and the unique situation of the patient, as opposed to a law that applies the same number to every patient with every condition.
VALLAS: Now before we started taping, you and I were talking a little bit about some of the experience you’ve had along this journey in changing this conversation and in bringing in the perspective of chronic pain. And you were describing some of the incredibly strange bedfellows that have cropped up along the way. There are some real similarities between where the chronic pain patient part of this conversation and how that changes the overall opioid conversation away from just the pendulum having swung all the way in the other direction, as you were describing before. There are some real similarities between that shift and the shift that we’ve seen in the criminal justice reform space, you were pointing out, away from tough on crime or the War on Drugs towards a more nuanced and smarter and better public policy, more humane approach that now has bipartisan and really trans-partisan support politically. And you were pointing out that in some ways, this has been the other War on Drugs.
NICHOLSON: Ye. I really do think that’s the case. I mean yeah, there are strange bedfellows. But as we’ve said, that’s very fortunate that in some senses, pain is not a political issue, nor should addiction be, really. It affects people of every political persuasion. And some of our great advocates have been on the sort of libertarian side of drug policy and certainly in the Republican Party as well. Lamar Alexander is the head of the Senate Health Committee who is going to have hearings, for example. What I find interesting and troubling: interesting is that there has been this wonderful alignment of the right and the left on criminal justice reform, on acknowledging that the way in which we have waged the War on Drugs in the past with a very strict focus on the supply side of things has had sort of horrible consequences for the people who are most affected in the communities that were most devastated. And in the case of the sort of War on Drugs, we talk about when we look in the rearview mirror that then, historically people of color, and we are now trying to dismantle some of the criminal justice efforts that cause people of color to be incarcerated and prosecuted at a much higher rate even though Caucasian people use drugs equally and actually deal drugs more often, which is a higher crime, right? So, and there’s a long history of, even when we re-promulgated our drug laws. They had a lot to do with xenophobia and racism, even when we drafted the laws in the first place. So, that is a very rife history.
What I see is that as a difficult parallel is that this, right now, this sort of focus on containing the opioid crisis by taking away prescription opioids and by prosecuting doctors and pharmaceutical companies. And I certainly believe the bad actors need to be prosecuted, and I have no problem with that. But that sort of focus only on the supply side and on broad restrictions, feels very familiar. The global commission on drug policy looking backward decided that supply-side efforts did nothing to curtail demand or use, and they actually really harmed a lot of people. And we’re kind of doing the same thing again, even as we’re looking in the rearview mirror and saying, oh, that was a terrible thing to do. So, it’s challenging watching this same history repeat itself in sense. And we are certainly talking about addiction and overdoses in people who use drugs using more compassionate language, but there’s still, on that side of the opioid crisis, a lot of work to be done in terms of dismantling legal barriers to treatment and how we stigmatize people and how we criminalize certain conduct.
VALLAS: Kate, in the last minute or so that I have with you, you mentioned that the debate at the federal level is going to continue in the form of some hearings over in the Senate HELP Committee, airing the perspective of the chronic pain patient community, which is going to be incredibly powerful and important for policymakers in Washington to hear that perspective and for that to be aired. But do you think that there are other lessons and broader lessons to be taken away from this, the past several-year-long story that you just summed up into about 20-ish minutes of a policy conversation that went very, very wrong before it started to improve and get back to the place that can actually inform good policymaking?
NICHOLSON: Yeah. I mean I absolutely do. I mean I actually see — of course, my background is in policy — but actually see a lot of what has happened as being sort of started by bad policy or overly-simplistic policy. Even in the ’90s, we did recognize that pain was undertreated, but instead of addressing comprehensively some of the big systemic issues like the fact that doctors were not educated well in how to treat pain, like the fact that 50 million people with our most prevalent public health problem have pain daily or near daily, and 20 million are disabled by pain, but we only spend about 1 percent of our research dollars on pain. Or the fact that what we call multidisciplinary care providing a lot of different treatment modalities that are used in combination is the gold standard for how to treat pain, but that wasn’t covered by insurance. Very few treatments for pain other than drugs are well-covered by the insurance system. And so, we didn’t address any of the systemic problems. Instead, we just took a simple numerical tool, kind of like what we did today, which is called the pain scale, and we incentivized it and made every doctor use that and really tried to drive down pain scores without looking at a more sophisticated way at what people were experiencing or what treatments might be best for them. That definitely helped cause some of the problem with opioid addiction in this country.
So, the extreme on the other side is using numbers again and devising them again in a very simplistic way. And what we really need, in my view, is to certainly continue to have policies that stem the immediate harm, but more broadly, to have policies that address some of these big infrastructural problems with respect to pain and with respect to addiction. Because they are two of the most prevalent health issues we have. They affect an enormous number of people. They are highly stigmatized. They’re incredibly poorly understood. And a lot of people don’t really understand that because everybody experiences pain and pain is a necessary part of staying alive, if you don’t experience pain, you don’t live very long. But when pain becomes chronic or very severe, it changes. And those biologically protective mechanisms start to switch and damage the body. So, that’s why it’s treated more like a disease, and that’s why it needs to be treated not just so you don’t suffer, but because it affects every system in your body and your health deteriorates. So, there’s dramatic misunderstanding about pain. There’s certainly dramatic, just misunderstanding about addiction as a disease. And until we address both of these comprehensively, I think we’re going to continue to have problems.
VALLAS: Kate Nicholson is a former federal prosecutor, a civil rights lawyer, and a chronic pain patient advocate. You can read lots of her writings and lots more of the specific things she was referencing from the CDC, the FDA, and others on our nerdy syllabus page. Kate, thank you so much for the tremendous work that you and others have been leading on this and for taking the time to come back and share so much of it on the show.
NICHOLSON: Oh, it’s absolutely my pleasure. And thank you so much for airing this issue. You were one of the first to actually pay attention to it a year ago, and that it so richly appreciated by all of us.
VALLAS: And Kate can be found on Twitter and is a must follow on Twitter @SpeakingABTPain. That’s speaking A B T Pain. Kate, thanks again.
And that does it for this week’s episode of Off-Kilter, powered by the Center for American Progress Action Fund. I’m your host Rebecca Vallas. The show is produced by Will Urquhart and David Ballard. Find us on Facebook and Twitter @OffKilterShow, and you can find us on the airwaves on the Progressive Voices Network and the We Act Radio Network or any time as a podcast on iTunes. See you next week.
♪ I want freedom (freedom)
Freedom (freedom)
Now, I don’t know where it’s at
But it’s calling me back
I feel my spirit is revealing,
And now we just trynta get freedom (freedom)
What we talkin’ bout…. ♪
