Opening Remarks

MR. RYAN: Good morning, everyone. Welcome to The Washington Post. I'm Fred Ryan, publisher, and I want to thank you for joining us this morning for this important discussion on America's mental health crisis.

More than 46 million adults in the United States struggle with mental illness. Accounting for medical care, disability payments, foregone productivity, these conditions cost our country an estimated $444 billion each year; and the human toll, meanwhile, is incalculable.

In a moment, we'll hear from two prominent lawmakers who are responding to this crisis with efforts to reform the way we provide and pay for mental health treatment.

Senator Debbie Stabenow, a Democrat from Michigan; and Senator Roy Blunt, Republican from Missouri, will talk about their bipartisan plan to improve quality standards for care and increase access to critical outpatient services.

Senator Stabenow and Blunt will be joined by seven-time Academy Award nominated actress, Glenn Close, a mental health advocate and cofounder of Bring Change to Mind, a nonprofit dedicated to confronting the stigma associated with mental illness.

Then, we'll hear from a team of Washington Post reporters who have recently collaborated on an investigative series called "The Fentanyl Failure: An In-Depth Examination of the Nation's Opioid Epidemic."

The National Institutes of Health classifies addiction as a mental illness, meaning the opioid crisis plays a central role in our debates about mental health in America.

Before we begin, I'd like to thank our presenting sponsor, Leidos, and our supporting sponsor, the University of Virginia, and welcome Jonathan Scholl, President of the Health Group at Leidos, to the stage.


MR. SCHOLL: Good morning. My name is John Scholl. I would like to welcome you to this fantastic event, and also thank The Washington Post for giving me a few minutes to offer opening remarks.

I'm the President of Leidos Health Group, and I lead over 7,000 employees who provide services in the areas of health information technology, health analytics, life sciences, and public health.

For example, we perform, every year, thousands of medical examinations for veterans, helping connect them--including mental health screenings--helping connect them to the care that they need.

Needless to say, my team has seen firsthand the devastation and challenges of the mental health issues and addiction issues in our country. By the time I finish my remarks, unfortunately, another person in our nation will have been lost. But we also see the opportunity to make a difference. After receiving an email from an employee inside of Leidos who lost a son to the ravages of addiction, the email challenged our CEO, "What are we going to do about it as a corporation?"

And our CEO, Roger Krone, led our entire company to make a difference in our communities by engaging in the issues of awareness, avoiding stigma, education and the use of NARCAN drug deactivation kits, which you'll find outside, and calling for higher levels of corporate responsibility, including calling for CEOs to make pledges for what corporations can do in this important issue.

There's a mental health crisis in America. Six in 10 Americans are seeking some sort of mental health service for themselves or for a loved one. And more and more, these Americans are lower-income, have a military background. I've seen it firsthand in my family.

Self-harm and suicide are increasingly the outlets for poor access to mental health services. It's a crisis with our teens.

So, we can do more. We must do more. Through our combined efforts and fortitude, we will do more. We can start with us, today. So, in this context, and on behalf of my colleagues at Leidos, I'd like to welcome you to this important meeting.

Thank you.


MR. RYAN: Thank you, Johnathan.

Now, I'd like to ask you to direct your attention to the video screens for a video to set the stage for the conversations with Senator Stabenow, Senator Blunt, and Glenn Close.

America’s Mental Health Crisis

MS. CUNNINGHAM: Well, good morning. I'm Paige Winfield Cunningham, a health policy reporter and author of the Health 202 Newsletter here at The Washington Post.

And I'm delighted to welcome a few guests to the stage, today. We have seven-time Academy Award nominated actress and mental health advocate, Glenn Close. She's cofounder of Bring Change to Mind, a charity dedicated to confronting the stigma associated with mental illness.

We also have Senator Roy Blunt, Republican from Missouri; and Senator Debbie Stabenow, Democrat from Michigan. And they are sponsors of Excellence in Mental Health and Addiction Treatment Expansion Act, which is an extension of a 2014 bill that was effective in increasing mental health and addiction services to patients in select states.

So, let's start off talking a little bit about that legislation, and we've got some good news, which is you've really found some great results from that 2014 bill, which now you're trying to expand and extend.

I'm wondering, Senator Stabenow, can you talk a little bit about the shortcomings that your bill was trying to fix in mental health care?

SENATOR STABENOW: Absolutely. Well, first, thank you to The Washington Post and to you. I also want to give a shout out and thank Glenn Close who has, for the third time, come in to help us with this movement and move it forward.

So, thank you so much.

And to my partner here, Roy Blunt, we couldn't do it without the two of us.

SENATOR BLUNT: Well, we're working together.

SENATOR STABENOW: Working together.

So, bottom line, we don't treat mental health and addiction services the same as we treat physical health services. We like to say we want health care above the neck to be the same as health care below the neck.

And we have at least one in five--we were debating one in five, one in four people, that are impacted by mental illness. Either way, it's a big deal. And less than half of them will get treatment in a year. And we know that the number one cause of death in this country is drug overdose for people under age 50.

So, this is something we have to address. And what we propose and what we're now moving forward with, is to mirror the very successful effort of federally qualified health centers, health centers in communities that can accept private pay, public pay services, but are qualified for full Medicaid reimbursement because they provide quality services. And so, a community can be designated. It's not just grants. It's not enough to have grants. We welcome grants as a supplement, but we want to be integrated into the health care system. So, behavioral health centers are doing the same thing.

We were able to get support to start the funding for eight states for two years to demonstrate this work. So, we have eight states that are getting the full funding like a health center.

We have seen psychiatric crisis services, 24-hour services, start up in the community. So, someone's not going to the jail, someone's not sitting in emergency room for hours or maybe days trying to get help, and it's transforming those communities. And so, we've added additional resources. Now, the next step is we want to take this more broadly across the country.

MS. CUNNINGHAM: Could you give a few examples of some of the kinds of mental health services that people haven't been able to access, particularly people on Medicaid, that your bill is trying to address?

SENATOR BLUNT: Well, I think we just think any mental health services you need, need to be accessed and need to be accessed like you access any other health care need, no 14-day limit, no 21-day limit. Just treat mental health like all other health. It's no more complicated than that.

In our state, where we're one of the eight states that were part of the pilot, I think we have 200 different locations in Missouri where people can go and they know that their mental health issue is going to be dealt with just like any other health issue that they have.

And as Debbie said, Paige, one of the things we're trying to do here is really create that body of evidence that shows the impact on your other health issues. You know, if this is one out of four or one out of five adult Americans, imagine all of the other health issues of that 20 or 25 percent of our population. Those issues are much more easily dealt with logically if your mental health issue is being dealt with--so, I think we're going to show not only is this the right thing to do--we went to the floor the last day of October, 2013, the year we started this effort. It was the 50th anniversary of the last bill President Kennedy signed, which was the Community Mental Health Act. And we sort of went through that bill together on the floor. And many of the things that probably should have been closed got closed, but almost none of the alternatives that that bill envisioned 50 years later were out there as an easy access to whatever mental health problem you need.

And again, I think we're going to be able to show in this study--and one reason we want to expand it for another couple of years is to get even a larger body of evidence to show that this is not only the right thing to do--everybody gets that--but it's in the immediate space of health care, the financially smart thing to do, as well. And I believe we're putting that information together in a way that's going to be pretty persuasive, that doing the right thing is also, financially, the cost-effective thing.

MS. CUNNINGHAM: Glenn, I know this is a really personal topic for you. Can you share with the audience what led you to get involved in advocating for mental health care?

MS. CLOSE: My sister came to me, my sister Jessie. She was in her, probably in the middle, beginning of her 40s. She said, "I need your help because I can't stop thinking about killing myself."

And her son had already been diagnosed with schizophrenia and he was in hospital. But even with Calen being diagnosed, our family had absolutely no vocabulary for mental health. We just--we didn't really get it. And when Jessie came to me it was a total shock. I had no clue. She was very good at keeping it--keeping all--you know, what she was going through from all of us.

And we were lucky to be able to help her. And she was finally properly diagnosed when she was 50 with bipolar disorder with psychotic tendencies. And they found, both Calen and Jessie, when they came home, that the stigma around their illnesses was just as painful as the illnesses themselves.

And Calen lost all his friends. Jessie felt that she was frightened to have--to tell parents about her bipolar disorder because she was afraid they wouldn’t allow their children to come and play with her young daughter, at the time.

So, every day they were impacted not only by some behaviors but also by self-stigma because they felt they had been marginalized, they were full of shame. So, we decided to do something about it and we started Bring Change to Mind. And it's made a huge difference in my family. We now know how to support each other, we know all the signs, we're vigilant.

But also, I mean, practically speaking, about the community health centers that we're really advocating for, when my nephew, when he was 17, had a psychotic break--they live in Montana--he had to be put in a straitjacket and driven two hours to the closest place where he could get help.

And of course--and he went to an emergency room and there was, you know, an available bed, but that was lucky. So, we've been very, very aware of the--first of all, the problem of people needing to get help.

I was in the dentist the other day and one of the dental assistants came up to me and said, "Do you know where I can--I need help for my daughter. She's spiraling out of control, and down. Where can I go?" And it's just shocking to me.

So, this plan for me just makes sense and it's so needed for people to know where to go and get comprehensive care for mental health issues, behavior health issues.

And as far as my family is concerned, my sister and my nephew now have productive lives. They have learned how to manage their illnesses, but that's because they have a support group. And these kinds of community centers would provide that kind of support on a long-term basis for people who need it.

MS. CUNNINGHAM: You said your family didn't have the vocabulary for talking about mental illness. Do you know why that was or what--how did you get to--

MS. CLOSE: Nobody talked about it. I mean, we started this ten years ago, nobody was talking about mental health.


MS. CLOSE: Well, mental illness.


MS. CLOSE: Is just--it's been so taboo. It's been so stigmatized.

And for me, the one--we'll say one in five today?


MS. CLOSE: I think the WHO says one in four, but so, one in five--one in five in this room, you know, how free do you feel about talking about what you're dealing with or what your family or friend or loved one is dealing with?

For me, the beginning is to make it--to normalize the conversation--

SENATOR BLUNT: Right, right.

MS. CLOSE: --around mental illness. And I think once we normalize it and realize that it's part of being--of the human condition, then I think we will be more, much more, conducive to doing something about helping people.

SENATOR STABENOW: Paige--oh, go ahead.

SENATOR BLUNT: I think that's happened now. Maybe because we talk about it almost every day, most of us do.


SENATOR BLUNT: But it seems to me that, in the last five or six years, that we've been daily involved in this discussion that it's been much more open about this as just another health problem.

And if you talk about it and deal with it as just another health problem, you're much closer to a solution the minute you get to that part of the discussion than you would be otherwise. You're not worried about having to go have a visit of some kind. You're not worried about being sure you take your medicine. You don't have to act like this is a different kind of health problem than any other health problem.

And again, let me make a point--and also, then, at that point, you deal with your other health problems better, if you're showing up for your appointments, if you're taking your medicine, if you're eating better, sleeping better, feeling better, about yourself.

But I think, Debbie, don't you--


SENATOR BLUNT: --that in the last five or six years, that there is just a much broader willingness to talk about this issue as a health problem and to have the vocabulary to do it that has been such a problem for--not just our society. This is a problem that is around the world, to, well, we don't really talk about that. This is somebody in our family that has a problem but we're not going to discuss with you what that problem might be, where if that problem was cancer or heart problem or something, you'd be very verbal about discussing it with your friends and neighbors.

MS. CLOSE: Cancer used to be a no-no to talk about.

SENATOR STABENOW: Right, that's true.

MS. CLOSE: I remember that.

I love the word "community."



MS. CLOSE: I think human beings die without community. And I love the idea of community centers for mental health, because I think that's a very fundamental part of it. We can change our attitudes but when we change our behavior and open up these centers for people dealing with mental illnesses, then we have accepted a big percentage of our population as being just like us.

No one is their illness, and I think that's one of the things where people get confused.

SENATOR STABENOW: I wanted to just address, as well, that this is about hope. And when Glenn's talking about her sister, Jessie, or talking about her nephew, that they're now involved. I have met both of them and they're extraordinary people and they're living wonderful lives managing a chronic illness.

When you think about somebody with diabetes, we don't say, "Oh, you're diabetic. Oh, you take insulin. Oh, my goodness." You know, we manage it. You get diagnosed, you get the treatment, you get the medication. You go on with your life.

If you are bipolar, it is a chemical imbalance in the brain. Now, I'm very familiar with this. My dad was bipolar at a time in the '60s when we didn't know what it was. And there wasn’t the right treatment, there wasn't the right diagnosis. And I saw what it was like to be misdiagnosed and then to get the right diagnosis, get the medication, and for him to go back to his life.

So, part of this normalization is that this is manageable that when people step up they're able to get the support that they need. They're able to manage a chronic disease, cancer, diabetes, being bipolar, schizophrenia, be able to do what they need to do and go on with their life. So, it's a very hopeful time, I think.


MS. CUNNINGHAM: Senator Stabenow, can you talk a little more specifically about how--what types of Americans your bill is trying to help.

So, this is done through the Medicaid program. Is this primarily lower-income Americans?

SENATOR STABENOW: What we're doing is setting up a structure like health centers where when you go to a health center, if you have private insurance, use that. If you have something else--if you don't have any insurance, you pay very low, sliding scale yourself, but Medicaid is a part of that. And so, it's not the same in mental health and addiction services in terms of saying, "You meet quality standards. You will get fully reimbursed for the doctor, the nurse, the psychologist, the social worker."

So, we want structurally for this to be the same. You know, as we've said before, it's not just grants. You can't just say to somebody--you would never say, "You need heart surgery. So sorry, the grant ran out." We say that in mental health and addiction every day.


SENATOR STABENOW: So, what we want to do is have a structure that, you know, regardless of how they come in terms of financially, that they will be able to be treated and that it will be done comprehensively: physical health, mental health, prevention, primary care, and so on.

So, it's really anybody: It's children, it's seniors.

MS. CUNNINGHAM: So, it could be anybody [unclear]--


SENATOR BLUNT: I think the answer, which Debbie says, is no, it's not focused at Medicaid. It's not focused at Medicare. It's not focused at adults. It's focused at whoever needs that help. And the model, the federally qualified health center model, is designed to serve anybody that that's the best, easiest place for them to go. You know, it's community--again, by definition, usually close. If you don't have private insurance, if you're not on a government program, a sliding pay scale based on what your income is that's very manageable.

And so, anybody that walks in, whether they're in a state that has covered single adults with Medicaid--those individuals could still be part of this program. And if they have no income, they have no charge. If they have a little income, they have a very, very small charge. If they have more income and that's where they want to go and they have--and no other program.

So, it's not designed to focus on any group, just like behavioral health problems aren't focused on people who are lower-income or upper-income or middle-income. These are problems that are pervasive through the society.

And you know, on the opioid front, too, one thing we've seen in our state, with the ability to have access as long as you need it to the mental health component, that's a big advantage if you have an opioid--if you're addicted.

If you don't have a behavioral health problem before you become addicted, and some people do, some people don't, you have a behavioral health problem once you're addicted. And having that mental health component--


SENATOR BLUNT: --that's unlimited, that--you know, you can't solve these problems in 14 days or 21 days, like many states have if you're a Medicaid patient.

You might have some access, but it's a very defined access. We don't envision that, don't have that in states that have moved in this direction.

MS. CUNNINGHAM: Well, and what--

SENATOR STABENOW: You know, I was going to also just mention that a lot of folks self-medicate. I know you've talked about Jessie in terms of drinking and alcohol and so on. Very common, someone will excessively drink or become an alcoholic because they're trying to manage the mental illness. And so, it's very connected.

MS. CLOSE: I think also what's really important is in these community centers somebody with a serious mental illness will be able to form a connection that they can go back to and back to, to get--because it takes time to get the balance.


MS. CLOSE: It really takes time to get the balance. And you can't just expect somebody to be put into an emergency room, get a couple of doses and thrown out.


MS. CLOSE: Or in jail, there's that terrible cycle of they can get medication and then they're out and then they go off it.

So, I think it will create real bonds or connections where people know they can go until they can manage their illness, and then their life.

And to me, to have it in a community center, there's nothing better than that.


MS. CUNNINGHAM: Well, in talking--speaking of emergency rooms, you've talked about how this would lighten the load on emergency rooms and law enforcement--


MS. CUNNINGHAM: --and can you talk a little bit about that, how you--the need to sort of transfer care from those folks over to the mental health professionals.

SENATOR STABENOW: We have law enforcement officials here today that I know can speak to this very well.

I'll never forget calling up the head of the Cook County--the Sheriff in Cook County, largest jail, I think, in the country, in Chicago, and he had just hired a psychiatrist as the director of the jail.

And I just--we were working on our bill and I called him and I said, "Talk to me a little bit about this." And he said, "Well, it's real simple. Over half the people in my jail have mental health problems. So, it made perfect sense to hire a psychiatrist to direct my jail." And I'm sure there's stories, I mean, constant stories, about that and what's happening. So...

SENATOR BLUNT: This is Police Week. So, lots of police in the nation's capital this week. But for the better part of 50 years the emergency room and law enforcement have been the de facto mental health delivery system in the country. And nobody is well satisfied--well served by that or satisfied by that.

And more and more of our law enforcement agents in the country take crisis intervention training, realizing that so many of the moments they're involved in involve somebody who is not intending to do something wrong but has a mental health problem that needs to be dealt with.

And this gives--we need to have and we hope we're creating more options than, as Glenn said, a trip to the emergency room, which is a very, very, very short-term solution.

The more places law enforcement have to work with, including drug courts and mental health courts, but the more places they have to work within--my hometown, Springfield, Missouri, the crisis intervention officers have, for several years now, carried an iPad that gives them 24/7 access to the Burrell mental health center.

And I've been with the crisis intervention officers when they have been dealing with somebody. And interestingly, they open that iPad and they've got the person at the mental health center there to have a conversation with them right on the iPad. Suddenly, you've got--as a law enforcement officer, you've got a mental health professional right there with you that you have access to. And it makes a big difference in how that person is dealt with at that moment and maybe the right thing is more likely to be said.

But law enforcement, probably the biggest beneficiary of--in addition to the emergency room--of moving forward in the right way on this important topic.

MS. CUNNINGHAM: Glenn, you mentioned your nephew was taken to the emergency room. But can you envision it turning out differently, I suppose, if he had been able to access treatment before that, could have prevented that--

MS. CLOSE: Yeah, I think--yes, it would have been incredible. He wouldn't have had to go so far from home and it wouldn't have been so terrifying for him. You know, for one thing, people who are in whatever state they're in that they're confronted by police or--they're terrified. I've learned that from Calen. We can be scared of them because we're reading on their face this look that says you're either going to hurt yourself or you're going to hurt me.

But what Calen has taught me is most of the time is that look is, "I am terrified and I'm in this place and I don't know what to do. I'm aware of it but I--" So, yes, if there was a place where he could have gone to locally or certainly not two hours away, it would make a big difference.

MS. CUNNINGHAM: Let's zoom out for just a minute. So, we know cases of mental illness are on the rise in the U.S.

Why? I mean, I know this could be because of many factors, but do you see any big causes of this or do we have any idea why we have more cases of mental illness?

SENATOR STABENOW: You know, I'm wondering sometimes--I mean, obviously, there's a little bit of stress going on. But sometimes I wonder if it's more--or it's just that we are more open in identifying it, you know, is what I was saying.

I'm not sure. I'd love to hear from the people that look at the numbers. But in other diseases where we identified there was treatment, other things available, then we suddenly saw the numbers go up. But it's not always clear as to whether or not that is because of the actual numbers.

My guess is, growing up in a small, rural Michigan community, northern community, where my dad was trying to find help, there were a lot of people that were in his situation that didn't come forward. They didn't have a wife that was a nurse that was trying to help them get care and so on.

And so, I'm not sure. I would be open to what others think. But sometimes I'm not--I'm not sure the numbers are increasing as much as we're identifying.

MS. CLOSE: I think for chemical--you know, we're chemical creatures and I think there's the body politic--we feel things, I think, as a unit. And there are so many factors now going in. There is so much more noise in the world than there was even when I was growing up. So much information, you know, so many people telling you what you should do, so many--and I just think it's harder for people to deal with and we haven't evolved yet maybe where we're capable of taking in all the information and stress. I personally think that's one of the reasons. And also, maybe with--slowly with people come--being more willing to come out, there's more people being identified, but it's still a big problem, people feeling like they can't.

MS. CUNNINGHAM: So, I don't know if you watch Netflix, but there was a show on Netflix that prompted some controversy a couple of years ago called "13 Reasons Why," which is about a teenage girl's suicide.

And recently, there was some more buzz about it because a study came out in the Journal of the American Academy of Child and Adolescent Psychiatry which suggested that teen suicide rates actually spiked after that show came out.

Now, we should caveat, they can't actually prove that that's the cause, but it does raise the question of how do you--how do you talk about the issue more without it becoming a trigger for people? Any thoughts on that?

SENATOR BLUNT: Well, I think there's a difference in talking about your mental health challenges and talking about suicide and showing people in suicidal situations and--I didn't watch that show, but I've read the reports, and it would be an unbelievable coincidence if that spike in teen suicides just happened to occur right after that show was on for the next 60 days.

We don't want--you don't want to not talk about mental health problems because you don't want to glorify or focus on suicide, and I think there are two really different things.

I think we do have to be more thoughtful. There is so much information out there and so much information coming at people all at once. And there's almost no gatekeeper. No matter how good you are as a parent, your kid is smarter when it comes to figuring out the social media and access to media. And I think it's a concern and I think it could be one of the reasons that people experience so much more stress, that they just see so many things coming at them all the time and it's a stressful world.

But I do think things like 13 Reasons are a problem and people should be thinking about the consequences of the kinds of things they focus on.

Now, Glenn would have a much greater sense of how that--

SENATOR STABENOW: Right, well, Bring Change to Mind is--

MS. CLOSE: I think it was irresponsible. I really do. I mean, my sister went through suicidal ideation. She tried to end her life twice. And I think you have to take responsibility in the--because there's so much potential for impact with our social media. You really have to take responsibility for the stories that you tell.

I think also we now, in Bring Change to Mind, are concentrating on high schools, we're in--we're creating these clubs in high schools, and they've been wildly successful, where kids go peer-to-peer with, obviously, an adviser. But and they are--they go into a stigma-free zone. They can talk about everything and anything that they're living--that they're dealing with. And they can help their friends, as well, and train each other, you know, how to be vigilant within their schools, because they're dealing with it.

It's, you know--I don't know if there is a school in this country that hasn't had a suicide of some sort, but--"some sort"--yeah, but two things. I think the kids get it, they really get it, the kids.

And I think, again, to come back to these community health centers, that is going to impact kids, as well. We've created a place where it's okay to go. Hopefully they'll have a place in their school that's okay to go. But I think that's what we really have to concentrate on.

MS. CUNNINGHAM: Do you think Hollywood, though, has a positive role to play in how we talk about mental illness and sort of bringing it forward and sort of normalizing as the Senators--

MS. CLOSE: I do. I think it has huge power. Yes. And I, you know, hope people will do that.

MS. CUNNINGHAM: Do you think we've seen more focus in Hollywood on mental health issues or more openness to maybe portray what people go through in perhaps film or television?

MS. CLOSE: I think there's probably more interest. I think in the past it's been so easy to make somebody with a mental illness the antagonist, you know, because every story needs a good guy and a bad guy. It's so easy to make somebody with a mental illness a bad guy, having been one of the great bad guys--


SENATOR BLUNT: Of all time, exactly.

MS. CLOSE: Of all time.

SENATOR STABENOW: You know, I would want--

MS. CLOSE: It's more of a challenge to try to figure out how to tell stories--


MS. CLOSE: And again, as we normalize it, we will have more and more characters who are living with it and it's okay.

SENATOR STABENOW: I was just going to mention when Bradley Cooper did Silver Linings Playbook. He actually came into D.C. and did an event with Patrick Kennedy and I on mental health, and talking about this. And you know, he played somebody who is bipolar in the community, all the struggles he went through, and yet, but came out on the other side and was living in the community. It was a very different view of someone than One Flew Over the Cuckoo's Nest, you know. I mean, just very different, and so I hope we're going to see more of that in terms of how people struggle, manage, live their life, you know, go on.

MS. CUNNINGHAM: Well, I think that's all the time we have, although this has been a great conversation. Thank you so much. I'd love to thank Glenn Close and Senators Stabenow and Blunt for joining us, and now I'd like to turn it over to my colleagues for the next segment.


[End Panel 1]

[Begin Panel 2]

The Fentanyl Failure

MS. ZEZIMA: Hey, everyone. Thanks for coming. It's hard to take the stage after Glenn Close, but we're going to do our best.

I'm Katie Zezima. I'm a national reporter here at the Post. And my colleagues and I are here to talk about our reporting on fentanyl, which is now the leading driver of drug overdose, nationwide. We've been looking at this topic for quite some time, and there is a lot more to come.

So this morning we're going to talk about why we decided to go down this line of reporting and what we found so far as part of our series, which is called the "Fentanyl Failure." We'll also talk about how stigma--how, like the panel before us discussed, that stigma is a huge issue when it comes to talking about the opioid crisis.

So I'm here with my colleagues, investigative reporter Scott Higham, investigative reporter Sari Horwitz, investigative reporter Steven Rich.

So we're going to start with you, Scott. We're wondering just pretty basic but complex question: How did the opioid epidemic begin? And we actually have a graphic that we're going to show about the waves of the epidemic and how it has evolved over the past few decades.

MR. HIGHAM: Thanks, Katie. Good morning, everybody, and thanks for coming to the citadel of American journalism.

This graphic is quite stunning and really kind of tells the story. This epidemic really began about 20 years ago, a little bit more than 20 years ago, when a company named Purdue Pharma created a drug called OxyContin. I'm sure all of you have heard of this drug, and this company has been in the news lately.

But this drug was an incredibly addictive, although it was marketed heavily toward doctors and the public as being less addictive than other drugs that were on the market. It was overprescribed. It was prescribed in very high amounts. Lots of doctors were prescribing this all around the country for things they probably shouldn't have been prescribing it for.

And very quickly, people became addicted to this drug. Purdue Pharma's profits started going up. Other drug manufacturers saw the spikes in profits. They began producing generic versions of OxyContin: oxycodone, hydrocodone, Vicodin. These drugs started to just pour into communities across the country. Corrupt doctors were writing prescriptions. Pill mills started opening up all across the country, many of them in Florida. Internet pharmacies started popping up. So if you had an internet connection, you could get drugs delivered to your house. It was starting to get out of control.

The drug companies were manufacturing more and more opioids. Drug distribution companies were sending hundreds of millions of tablets downstream into communities with very few questions asked. Pharmacies were filling prescriptions without doing their due diligence and asking the right questions about the people who were coming in to fill these prescriptions.

And then finally, the DEA, in the mid-2000s, around 2005, 2006 started cracking down. They shut down the internet pharmacracies. They shut down the pill mills. And they started going after the companies. They started going after the manufacturers. They started going after the distributors. They started going after the big chain pharmacies. They were all fined for not doing their due diligence, for failing to report suspicious orders of drugs that were flowing downstream and hundreds of millions of these pills were winding up in the streets in places like Florida, and Pennsylvania, and Ohio, and West Virginia, New Hampshire, Rhode Island. So there was--basically an entire country had become addicted to these drugs.

But suddenly, with the DEA's crackdown, these drugs were harder and harder to get. Doctors were being a lot more careful about prescriptions. The internet pharmacies were gone. The pill mills were being shut down. And the most commonly prescribed pill was the 30 mg tablet of either OxyContin, hydrocodone, or oxycodone. So that is six times the strength of a pill that maybe your dentist would give you for minor oral surgery. And a lot of these doctors were prescribing people to take this pill two or three times a day. So 60 to 90 mg of this drug when many of us have probably had this pill prescribed to us as just 5 mg.

So that pill suddenly, it used to cost a couple bucks on the street, now is costing $30, a dollar a milligram, and a lot of people couldn't afford it. And the Mexican drug cartels saw an opening. They're very clever, very smart. They started sending heroin into these very same communities. And so people who were spending $30 on an oxycodone pill were now spending $30 on a bag of heroin. And for that same price, they could get three times as many highs out of that bag of heroin. The highs were higher, they were more intense, and that began the second wave of this epidemic. And you will see on this graphic how the prescription overdose rates started to flatten out and the heroin rates start to pop up.

And then, in 2013 or so, the third wave of this epidemic began, and that is the deadliest epidemic of all. And that epidemic so far, between 2013 and 2017, has claimed more than 67,000 lives, just fentanyl alone. And that is more than the number of U.S. personnel who died in the Vietnam, Iraq and Afghanistan wars combined. I mean, just think about that: 67,000 people to one drug alone in a very short period of time, and there doesn't seem to be any end in sight.

MS. ZEZIMA: And now we're at fentanyl.

You know, Sari, how did the idea for the project originate and what did you find in the first story?

MS. HORWITZ: Well, last year we all saw these staggering numbers that Scott just told you about, and we were wondering, how did this happen. How did we get here? Where did it start?

And so we began researching and interviewing people and digging and talking to the DEA and other law enforcement agencies, and health policy professionals, and we determined that this began--this latest fentanyl epidemic, the third wave, as Scott said--began in 2013 in Rhode Island.

What happened in Rhode Island was there was a cluster of overdose deaths, they thought opioid overdose deaths. And when the toxicology reports came back, it was clear that these were all from fentanyl. And public health professionals were really surprised and alarmed because they knew about fentanyl as being a drug that was used in the hospital for cancer patients, for surgery, for severe pain, but they hadn't seen it on the streets. So Rhode Island officials went to the Centers for Disease Control, CDC, and reported this. The CDC then put out an alert.

Then what happened is in 2014, it began to spread, through New England at first--New Hampshire, Massachusetts, and then Pennsylvania, and then Florida, Ohio, West Virginia, and the CDC put out another alert. And the drug enforcement administration put out an alert in 2014, 2015. So the alarm bells are ringing.

But in Washington, this is not really on the radar of top officials. There is not a sense of urgency at the highest levels of government, is what we found. And part of the problem, we were told by many health professionals, and people inside and outside the Obama administration, is that fentanyl in those early years was seen as an add-on, an appendage, if you will, to the two waves Scott spoke about: the prescription pill crisis and the heroin crisis. It wasn't seen as a unique problem that needed its own unique, different strategy.

But it was a unique problem. It was coming into this country a different way. It was coming from China. People were ordering fentanyl in small amounts over the internet. It was coming through the postal service, so coming in a different way and difficult to detect through the mail.

It was a more powerful drug. Scott said 50 times more powerful than heroin. And so people who were taking this drug—first of all, it's just like the equivalent of four grains of salt of fentanyl can kill a person pretty much instantly. And it was being blended into heroin and now cocaine and meth and other things, but originally being blended into heroin and many drug users didn't even know they were taking fentanyl.

And the other huge problem is it was being put into counterfeit drugs, so not only affecting addicts on the street, people struggling with addiction, with heroin addiction. But, for example, college kids may go to a party where there's pills being pass around, pills that have been gotten on the street, and they could have fentanyl in them. And there have been fatal overdoses that way. So everything about this particular synthetic opioid made in laboratories in China was different.

And what we found in our first story in this series is that there was really a failure of government at many levels. The U.S. Postal Service wasn't prepared. They didn't require electronic monitoring of all the packages from China, for example, during those early years. Customs and Border Protection was not prepared. They didn't have dogs that could detect fentanyl. They didn't have the right kind of equipment. They didn't have enough officers.

Congress was not appropriating significant funding to the fentanyl issue--the opioid issue in general, but also fentanyl. The CDC, the data coming from the CDC that would show across the country the number of deaths--so coming from coroners--was lagging a year behind, so a lot of coroners weren't even testing for it. So, basically, it wasn't being treated as the epidemic that it was.

MS. ZEZIMA: And you know, Steven, the data is showing that this is actually getting worse. It's not abating. How many people are dying from fentanyl, and who and where are they? And before you answer, we're actually going to have another graphic for you guys to check out from our talented colleagues in the graphics department.

MR. RICH: So we know that the fentanyl deaths increased very rapidly in the places that they increased. One of the most terrifying aspects of the epidemic is right now about 90 percent of deaths are concentrated among 10 percent of the population. So we're not seeing fentanyl in all areas of the country. It's largely in the Northeast, the Midwest, and almost nowhere else. So this is killing—in 2017, it killed nearly 30,000 people in just that area of the country. And realistically, if it starts to spread beyond that, there is no telling what the actual ceiling for deaths could look like in this country.

One of the things that we've seen in sort of coverage of the opioid crisis in general is that there's a concentration on it being in rural areas, the victims being largely white. But the truth of this is that these deaths cross every demographic. We're seeing in cities like Philadelphia and cities like D.C., fentanyl deaths are going through the roof. So this is not just a problem for a small subset of our communities. It's everyone. It can affect everyone.

And what we know sort of about how this is spreading is that where fentanyl used to be a cause of death along with other drugs, we're starting to see it more often as a cause of death by itself, which means that people are taking fentanyl by itself. That's the only drug that they're taking. They're not mixing it with things. They're not doing anything else. They just want fentanyl, and that's what they're getting.

And what we really don't know is what the upper bounds of this could look like. Some of these communities are devastated by this problem. We really--unless things start to turn around, most of these places are not actively getting better, yeah.

MS. ZEZIMA: You know, Scott, the previous panel spoke about the nexus between mental health and opioid addiction. How has the stigma around addiction affected the response to the fentanyl epidemic and the opioid epidemic?

MR. HIGHAM: I mean, it's huge. The stigma is killing people in the same way that it's killing people with mental health issues, the same way that it killed people who had AIDS and have AIDS today, although that stigma has slowly subsided.

You know, Katie and I traveled for this project to Staten Island earlier--I guess late last year.

MS. ZEZIMA: Late last year, yeah.

MR. HIGHAM: And we met with a guy named Luke Nasta, who runs the largest rehab facility on Staten Island, which has been devastated by heroin and fentanyl. And Luke was a heroin addict in the 1970s in New York City, so he was a hardcore guy on the streets, shooting up heroin with a lot of other people, sharing needles. And when the 80s hit, a lot of his friends who had survived heroin started dying of AIDS because of all the needles that were being shared.

And so Luke said to us that this is very reminiscent of the AIDS epidemic, this epidemic, because of the stigma that is attached to the mental health issues that underly addiction. And I think almost everybody who is addicted to drugs has a mental health issue that underlies that. And then the addiction itself is something that a lot of people don't want to talk about. Families don't talk about it. You'll see obituaries where it's like "died suddenly." And that's starting to turn, but it's not turning fast enough.

It didn't turn fast enough with the AIDS epidemic either. And you know, Luke reminded us that it took the death of a teenage heterosexual boy named Ryan White to change people's perception of the AIDS epidemic. Before that, the AIDS epidemic was seen as a gay disease. There were big televangelist preachers who were saying that it was God's revenge for people for practicing homosexuality, that this was a lifestyle choice and they had it coming.

And then Ryan White had a blood transfusion, and the parents at his high school didn't want their kids coming into the school because they thought just being in his presence that they would somehow contract AIDS, which was completely ridiculous.

But that was a pivot point, and then a lot of other people started to organize. There was a group called ACT UP, some of you may remember. There was the AIDS Quilt. There was a rising up of people saying enough, the stigma is killing people, we need to talk about this, the government needs to treat this as an epidemic.

And as Luke says, this is an epidemic just like the AIDS epidemic. In fact, this epidemic is killing more people than AIDS right now. And it should be treated like an epidemic.

MS. ZEZIMA: And how do you think stigma may have contributed to the lack of government response that we've seen?

MR. HIGHAM: Yeah, I mean, I think that is a big thing because, you know, people don't want to be seen as--and a lot of politicians have said this to us. The people who have been on the front lines of this have said they had a really hard time getting their colleagues on Capitol Hill to sponsor legislation or to put money aside because, well, it's just a bunch of drug addicts. You know, this is their choice. They decided to use and they decided to take pills. They decided to take heroin, and so whatever they've got coming to them, they've got coming to them, and this is not, you know, our problem. But it clearly is our problem.

MS. ZEZIMA: You know, as Scott said, we've been traveling the country, looking at this issue as well.

So, Sari, what does the fentanyl epidemic look like on the ground in communities that are being decimated by it?

MS. HORWITZ: Well, we've all tried to get out of the bubble of Washington and have been talking to people on the phone, and then we've traveled to hard-hit areas. We've talked to people, all of us have, in Ohio, West Virginia, New Hampshire, and just trying to understand what's happening on the ground despite what's being said in the halls of Congress or the White House--what's the real story.

And we have talked to people, men and women struggling with addiction, struggling mightily with addiction. One girl recently said to us, you know, "There's a really fine line." Because she kept overdosing and continuing to take drugs. And we said, you know, "Why do you keep doing this?" And she said, "There's a fine line between euphoria and death."

We've spoken to the families and to the friends of people struggling. In these communities we've gone to, everyone's touched by it. Everybody knows someone or has someone in their family who is dealing with addiction. And it devastates the communities. It devastates the school system, the foster care system, the police departments, the fire departments.

Scott and I traveled last year to New Hampshire, and New Hampshire, NARCAN, which can reverse an overdose, is standard issue in some school systems for the teachers to have. In Manchester, people are overdosing on the sidewalks, the public parks. People are found slumped over their cars overdosing in traffic, slumped over their cars.

The fire department, firefighters and paramedics nearly every day are going to fentanyl overdoses. There is a fire station in Manchester that has started a really successful program called Safe Stations, where addicts can come, people struggling with addiction can come and feel like it's kind of refuge. There's not going to be a judgment. They're not going to get arrested. And the firefighters will try to find them some kind of treatment in the community, and they have helped thousands of people in this way.

We've also traveled to small rural areas where the jails are virtually detox centers. People are arrested who are using drugs. There's really no treatment available in these areas, or very little treatment. You know, there's waiting lists with 200 people on them. And so people are withdrawing in the prisons. They're just sitting there withdrawing from fentanyl.

And as all of you know who worked in this field, if someone asks for treatment, you need to really get it to them right away. They can't wait for weeks or months because it may be too late or they may not want treatment then. So that's a very important issue.

And drug treatment is a huge issue in these communities. I guess what's most concerning is that while federal money is now starting to get out to states and localities, the really hard-hit ones, what we're hearing is that it's not coming fast enough and it's not enough money.

MS. ZEZIMA: So, Steven, you get the last question. Where do we stand right now with the number of fentanyl overdose deaths, and do the data provide us any roadmap to where we may be going?

MR. RICH: Yeah, so the truth is, the best source of data on fentanyl deaths across the country is the CDC, but the latest data that we have for fentanyl deaths is from 2017. So we know that year close to 29,000 people died. But we don't know what happened last year, and we have no idea what's currently going on this year.

But we've been doing a lot of reporting in communities across the country and sort of trying to piece together numbers as to what 2018 looks like in these communities. We know that many of these communities surpassed their 2017 totals nine months into 2018. So we know that 2018, in many of these communities that are already devastated by it, got worse.

And in 2019, it's only slated to continue to get worse unless something major changes. And so we're trying to sort of understand how this is going to spread. But the truth is, because data lags so much, it's very difficult to understand where we currently are in many of these places. And because of that, we may start to see resources poured into areas that are the hardest hit, but they were the hardest hit three years ago. And the places that are now going to be the hardest hit, we won't know that for another two years. And so trying to solve a crisis in which you don't actually know where it is at this current moment is very difficult because you can't get the resources to where they need to be until it's way, way, way too late.

MS. ZEZIMA: So thank you all for coming. So I know we’ve talked about the Obama administration. If you’re wondering what the response from the Trump administration has been on fentanyl, I just have two words for you, which is: stay tuned. We’re working on that and a number of other stories on fentanyl. And I know you’re all very excited to read them. So, if you want to sign up, there’s a link right there: It will be in your inbox when it publishes, that and other stories. And if you have any tips or thoughts for us, please don’t hesitate to reach out on email or Twitter or however you want to get in touch with us.

Thank you all for coming. We really appreciate you being here, and have a great rest of your day.