While most causes of accidental death are on the decline, drug-related deaths are increasing. This is due in part to the increase of deaths caused by prescription pain medication, like Vicodin or OxyContin. A Los Angeles Times investigative series looks at how doctors are contributing to the trend.
Related NPR Stories:
- As Pain Pills Change, Abusers Move To New Drugs
- Florida's Fight Against Prescription Drug Abuse
- Prescription Drug Deaths Major Killer In The U.S.
Copyright NPR. View this article on npr.org.
ARI SHAPIRO, HOST:
This is TALK OF THE NATION. I'm Ari Shapiro. Neal Conan is away. For years, car crashes were the leading cause of accidental death in the United States. Not anymore. Today, drug overdoses hold the top spot. Drug fatalities have doubled in the last 10 years, and prescription painkillers like Vicodin and Oxycontin cause more deaths than cocaine and heroin combined.
This hour, we'll look at the role of doctors and pharmacists in those cases. The L.A. Times studied coroners' reports from four Southern California counties. Almost 4,000 people died of prescription drug overdoses in five years. The L.A. Times found that in nearly half those cases, the person who died had a doctor's prescription for a drug that helped cause his or her death.
We'll talk to one of the reporters behind that series in a moment. But first, doctors and pharmacists, we want to hear from you. Where's the line between treating pain and enabling prescription drug abuse? How do you protect patients who could be a danger to themselves? Tell us your story. Our number is 1-800-989-8255. Our email address is firstname.lastname@example.org. And you can join the conversation at our website. Go to npr.org and click on TALK OF THE NATION.
Later in the program, White House photographers describe what it's like behind the scenes, documenting the president. But first, doctors and prescription drug overdoses. Joining us now from the L.A. Times is investigative reporter Lisa Girion. Along with Scott Glover, she co-reported the L.A. Times series "Dying for Relief."
Lisa, thanks for being here, and congratulations on a very compelling series.
LISA GIRION: Thank you.
SHAPIRO: Why are prescription drug deaths rising so quickly, doubling over the last 10 years?
GIRION: Well, there's no clear answer to that, but what we do know is that the number of prescriptions written for strong painkillers, drugs known as opioids - Oxycontin, Vicodin, those kinds of drugs - have soared at the same time the deaths have increased. So there seems to be a correlation between the number of prescriptions and the number of people using these medications and deaths.
SHAPIRO: And when we talk about prescription drug overdoses, for the most part, is that what we're talking about: painkillers, opioids?
GIRION: Primarily, but there's also a strong component of what are known as benzodiazepines, and they're sold or marketed as Valium, Xanax, drugs like that. And they can work in combination with opioids, because they are all respiratory depressants. So they sort of contribute to the mechanism of death in an overdose.
SHAPIRO: Talk about the people who tend to die in these cases. Are we - are they what we would typically think of as junkies and drug addicts? Or are they people with real, significant, chronic pain problems who just have taken too many pills?
GIRION: Well, that's interesting. That's a really good question, because our analysis of 3,700 prescription drug deaths in Southern California showed that the average age was 47, and our - and they were almost equal between men and women, a little bit more men, but mostly evenly split. But what was really interesting when we dug deeper and really looked at the histories of the people who died, many, many, many of them had been introduced to these drugs through doctors for legitimate injuries and legitimate pain problems.
SHAPIRO: And so they start with a legitimate injury and pain problem, and then what happens? How do they end up in this horrible situation?
GIRION: Well, they'll start post-operatively. You know, they've had some kind of surgery, and they will get these drugs, and they stay on them. And over time, they develop a tolerance to the drugs and oftentimes a dependency that just becomes so gripping and compelling that they can't break free. And, you know, their family members tell us that, you know, they were used to their, you know, mother or their husband, you know, passing out at the dinner table or falling asleep in the La-Z-Boy at night and, you know, or, you know, waking up on the floor, that the drugs really had a deleterious effect on their lives, and yet they couldn't break free and felt very dependent upon them.
SHAPIRO: Your investigation also found that a disproportionate number of the people who die from prescription drugs are getting their drugs from a very small number of doctors.
GIRION: Right, right, so within the 3,700 deaths that we studied, more than 1,700 involved people who got prescriptions from doctors for one or more of the drugs that contributed to their deaths. And within that group, there were 71 doctors - out of the thousands and thousands and thousands of doctors who practice, and many of them prescribed these drugs in Southern California - 71 had three or more of their patients die in this way.
SHAPIRO: Well, that suggests that maybe it's not so difficult for a doctor to prescribe painkillers in a responsible way, that in fact there is a pretty clear line between handling pain medications as they should be handled, and handling them in a way that puts patients at risk.
GIRION: Perhaps. I mean, and there are a lot of guidelines that doctors can use, and certainly many, many people are helped by these drugs, and many doctors are able to prescribe them safely and don't have these kinds of problems.
SHAPIRO: I want to talk about one doctor in particular you write about who had the highest number of patients die in your investigation. He had 16 patients overdose, and his name was Van Vu. When you spoke to him, what was his reaction?
GIRION: Well, he was concerned. He was not aware of all of the deaths.
SHAPIRO: That's amazing to me, that a doctor could be unaware that 16 patients in his care had overdosed and died.
GIRION: I think that's one of the problems. There's not a good, systematic feedback loop for doctors who are treating pain patients with these drugs. If one day a patient stops coming to your practice, you don't know if he lost his job and lost his insurance or found another doctor or died unless you get a call from a coroner's investigator. And that happens frequently, but apparently, not every time.
SHAPIRO: Let's go to a caller. This is Gigi(ph) in Syracuse, Utah. Hi, Gigi.
GIGI: Hi. I'm a doctorally prepared nurse practitioner, and I work in a pain clinic here in Utah.
GIGI: Well, one of my things I'd just like listeners to know is we, as providers for the patients, we really listen to what the patient has to say, but also what family members have to say. So what helps out my clinic is sometimes we'll have a family member or a friend call into the clinic and let us know about what's going on with a patient, especially if there is any aberrant behavior.
SHAPIRO: And then what happens if you get a call like that?
GIGI: Then we have the patient come in. What we do in pain management is we follow the patients really closely. What happens out in - just in general practice is a lot of times, you know, you see a patient who has a problem, even maybe a dentist, and they'll throw 20 or 30 pills at them. But then these patients will go around and actually doctor-shop, because they're in pain, and it's the response to try to make the pain go away.
So if we can help them and control what they're using better and make sure that it's working for them effectively at the best dose for them and at a safe dose and then monitor them closely by checking their urine or their saliva to see where their levels are, then...
SHAPIRO: That's a test you do to see the amount of drug in their system.
GIGI: Yeah, and just to make sure that they're doing what they are supposed to be doing, and that they are actually using the prescriptions that we are getting to them.
SHAPIRO: All right. Well, thanks for the call, Gigi.
GIGI: You're welcome. Thank you.
SHAPIRO: I want to bring Dr. Paul Christo into the conversation. He's a practicing physician and associate professor at the Johns Hopkins Hospital, division of pain medicine. He also hosts the radio talk show "Aches and Gains" on WBAL in Baltimore. He joins us from his office at Johns Hopkins Hospital. Dr. Christo, thanks for being on the program.
PAUL CHRISTO: Thank you very much for having me.
SHAPIRO: Did that sound familiar, what you were just hearing from Gigi about sort of conversations with family to figure out who's using these medicines responsibly and who may have a problem?
CHRISTO: It does. And, I mean, she brings up an excellent point and - because oftentimes, I mean, we do what we can in terms of assessing risk for each patient that we see in whom we're considering opiate therapy, and at the same time, I mean, it's not foolproof. So we do rely on family members and close friends to give us more information, if we need it, with respect to how the patient is using the particular medication.
SHAPIRO: Do you find that a responsible doctor should have a relatively easy time preventing a pain patient from overdosing? Or is there a fine line about how much you prescribe to adequately handle the real problems that a patient may be facing?
CHRISTO: I think that there is a fine line. I think that those - I mean, many years ago, you know, those that prescribed opioids were very specialized physicians. And what's happened over time is that the - I guess, in effect, there's been a liberalization of prescription of opioids. So it's not only pain specialists, if you will, that are prescribing these. It's non-pain specialists now.
And I think, as a result, there's been a lack of education on the part of other practitioners who are prescribing opioids, and that's led, in part, to the problem. And the other problem, of course, is that we need to, I think, better educate people who use them to report to us what their side effects are and to ensure, for example, that they're keeping opioids in their house, in a safe place, so that others don't have access to them.
SHAPIRO: If I may ask, Dr. Christo, in your years practicing pain medicine, have you ever had a patient die from an overdose?
CHRISTO: I haven't. I haven't had a patient die. I mean, I've had patients who have misused them and abused them, and...
SHAPIRO: How do you know when that's happening?
CHRISTO: Well, I usually - patients may report that to me, or, over time, I may notice, based on their behavior, that they're taking too many tablets, and they're telling me, for example, that they are extremely tired during the day. Or they may be taking the medications to sleep, and that's not what they're used for. They're used to help reduce pain.
Or family or friends may report to me that they are misusing them or abusing them, in which case I have patients come in, talk to me about what's going on, and they we decide. I mean, I decide maybe unilaterally, but other times, along with the patient whether we're going to continue this therapy or not.
SHAPIRO: And when you know that somebody is addicted to painkillers and you know that they also have real pain, what is the appropriate course of treatment?
CHRISTO: Well, if the problem of addiction arises - and, you know, my feeling is that it's fairly rare, despite what we're hearing in the media. I think it's - you know, there was a recent study actually out by a reputable organization called the Cochrane Collaboration Group that indicated that fewer than 5 percent of patients prescribe opioids to treat chronic pain became addicted.
So I feel like it's fairly rare, but if it does happen, it should spur a visit with me, and then I refer patients to addiction medicine specialists to get the disease treated.
SHAPIRO: Just briefly, what do you tell your students about how to deal with this?
CHRISTO: That we - that patients should be, you know, offered a variety of therapies, first of all. I mean, we're talking about opioids, but remember, in the context of therapies for chronic pain, there are many. There are nerve blocks. There are implantations that are used. I mean, there are alternative therapies. So this is just one element of therapies for chronic pain patients. But...
SHAPIRO: Stay with us for a moment. We need to take a short break. This is Dr. Paul Christo of the Johns Hopkins Hospital division of pain medicine, and we're also talking with Los Angeles Times investigative reporter Lisa Girion. And doctors and pharmacists, we want to hear from you. The number is 1-800-989-8255. How do you treat pain without enabling prescription drug abuse? I'm Ari Shapiro, and this is TALK OF THE NATION, from NPR News.
(SOUNDBITE OF MUSIC)
SHAPIRO: This is TALK OF THE NATION, from NPR News. I'm Ari Shapiro. Two reporters at the L.A. Times - my guest Lisa Girion and her colleague Scott Glover - are behind the series for the paper called "Dying for Relief." They spoke with patients addicted to painkillers, the families of those who overdosed, pharmacists who fill prescriptions for dangerous drugs and doctors who write those prescriptions, like Dr. Naga Thota and Dr. Doanh Nguyen. Dr. Thota and Dr. Nguyen spoke to the reporters on camera about their patients.
(SOUNDBITE OF INTERVIEW)
DR. NAGA THOTA: We tell them every time when they come for follow-up: This medication can kill you. You know that, right? But I will say it so many times: Be careful with them and use them carefully.
DR. DOANH NGUYEN: That's right. Legitimate pain will become illegitimate if they abuse the pain medication.
SHAPIRO: Coroners' records show that Dr. Thota has lost 15 patients to overdose since 2005. Fourteen of Dr. Nguyen's patients died of overdoses in the same period. Doctors and pharmacists, we want to hear from you. Where's the line between treating pain and enabling abuse of prescription drugs? What do you do to protect patients who you think could be endangering their own lives?
Our number is 1-800-989-8255. Our email address is email@example.com. And you can join the conversation at our website. Go to npr.org and click on TALK OF THE NATION. We have Craig on the line from Tulsa, Oklahoma. Hi, Craig.
CRAIG: Yeah, hey. I just wanted to give you an example of a case I saw of a patient who came in complaining of pain. And they had pain over a joint, and they appeared very middle-class and nicely dressed, and their story seemed quite adequate. So I gave them a few pain pills.
And subsequently, I got a letter from their insurance company saying that they had gotten 1,000 pain pills that month from various providers, and so they were doctor-shopping - not just in my state, but in a number of states.
SHAPIRO: Now, Craig, you're an emergency-room physician, which must present different challenges since you don't generally have an existing relationship with the people who come into your ER.
CRAIG: You're exactly right. So it really takes all your skills to assess people. You know, and earlier, one of your commentators said that people innocently get involved with this. Sometimes that's true, but on the other hand, these chemicals are euphorics, meaning they make people feel good. And so there is that unfortunate issue of euphoria as a side effect of these opioid painkillers. So it's an enjoyable thing.
And so I expect that young lady who had the 1,000 pills, she didn't have that much pain. What did she do with 1,000 pills? Maybe sold them. So I was fooled. I've been practicing well over 30 years. So it's a tricky thing, but I think just to say that people quite innocently get involved just because they had surgery and then had post-op - true, that does happen, and I think that that is a mechanism, but there really is an element of sociopathy that, of course, is, you know, part of addictionology, that there's a denial that the people are actually doing this to get euphoric.
SHAPIRO: Yeah. Well, thanks for the call, Craig.
CRAIG: Yes, sir.
SHAPIRO: And Lisa Girion, investigative reporter for the L.A. Times, clearly, there are good, well-intentioned doctors who get duped by patients, as our last caller was. But then there are doctors who make a lot of money from selling pills to people who want it, no matter what the circumstance is. You profiled one of those doctors in the second part of your series. Tell us a little bit about him.
GIRION: Right. So you are talking about Dr. Carlos Estiandan, who, for a period, was one of the largest prescribers of these painkillers in the country. And he was actually on the radar of the state medical board for several years and under investigation before they finally caught up with him. And he was ultimately arrested and prosecuted for improperly prescribing, and served about half of a five-year sentence.
SHAPIRO: And people were dying while he was being investigated.
GIRION: Exactly, yeah.
SHAPIRO: You write that patients would drive hundreds and hundreds of miles, because they knew they could get pills from him - no questions asked, more or less.
GIRION: Right, right. So the problem is that the medical board was unaware of most of those deaths and - as they were happening. And that's another problem with the various feedback loops: Nobody really has a good sense of what's going on. So, yes, a number of his patients did die before finally his practice was stopped.
SHAPIRO: Lisa, you also write about the role of pharmacists in this entire ecosystem. We have a pharmacist on the line now, Scott from Nashville, Tennessee. Hi, Scott.
SCOTT: Hey, there. How's it going?
SHAPIRO: Good. Tell us your story.
SCOTT: Well, you know, I deal with this a lot, and it actually ends up being a large part of my day, just kind of triaging this. We get doctors that are, you know, for pain clinics that are very legitimate, that are trying to help people, trying to help pain. And then you get other doctors that we call, in the pharmacy world, pill mills, that are just cranking out the same prescription over and over and over.
And it's just something we have to do to be careful to keep those from falling in the wrong hands. They're - oftentimes, they're...
SHAPIRO: And what's your role in those instances? When you see something from a doctor who you think is running a pill mill, what do you do?
SCOTT: Absolutely, absolutely. So first, we'll take the controlled monitoring database that we have in this state to make sure they're not getting it from another pharmacy. We'll notify the board of medicine if we think it's a chronic thing. I have notified the board of medicine about several doctors in my area that write the same, exact prescription for Oxycodone for every single patient they see and have spoke to.
SHAPIRO: And do you know whether the board does anything to stop that? Or...
SCOTT: They do.
SHAPIRO: They do.
SCOTT: They do, and they've gotten back to me. And, you know, my friends - I'm friends with the other pharmacists around here, and we all kind of try to keep them in the loop. But we'll get a letter to say they're working on it. But I know there's a backlog of several weeks before they can often address these situations. It's just very frustrating for us to see that, and - yeah.
SHAPIRO: Well, thanks for the call, Scott.
SCOTT: All right.
SHAPIRO: Dr. Paul Christo, you deal with pain medicine. What role do you expect pharmacists to play? Are they an important backstop in this system?
CHRISTO: They are. So for all patients that I start opioid therapy on, I mean, I contact -or the trainees that I work with - contact the pharmacist. And we actually require that each patient list the pharmacy that he or she is going to go to to pick up the opioid medication so that that dialogue exists, the communication exists, because I think pharmacists are important in terms of giving us more information about the patient that we wouldn't know otherwise.
SHAPIRO: And have you been duped by people? I mean, have you had people pull the wool over your eyes? And how did you find out about it?
CHRISTO: Sure, sure. I mean, I have. And, you know, one example is that I had an older adult patient who was, I think, in her 70s, maybe she was 75. And she - I was giving her long-acting morphine to help control chronic pain. And I had been giving it to her for months. I was doing what I thought was reasonable in terms of year-end monitoring and pill counts, and so on.
And I noticed, though, over the course of a couple of months, that her pain never improved. And at one point, you know, I asked her whether she was even taking the medication. And I'd asked her this before, and she said yes, yes, yes, yes, yes. I'm taking it. And finally - but the problem is when she said that before to me, her son was in the room.
And two months later, I asked her again when no relatives were in the room, and she admitted to me that she wasn't taking them. In fact, she was giving the medication to her son, because her son told her that he was in pain. And I found out later that the son was diverting the opioid. And so that duped me. And, you know, I learned from that experience.
SHAPIRO: Wow. What did you learn? I mean, how do you avoid something like that in the future? Here's an innocuous-looking, 75-year-old woman.
CHRISTO: You're right. You're right. I mean, I can't - I'm not a soothsayer, see, so I can't 100 percent protect myself and patients. But I do the best I can. And, you know, I tell them up front now. I mean, I tell all patients up front: These are the guidelines for use. And, you know, you need to take them yourself. You cannot give them to anybody else.
I mean, she didn't know. You know, she just wasn't educated. I failed in educating her that you cannot give this to anybody else, regardless of whether they ask you for it or whether they're in pain. This is for you. And if anyone asks you for it, then you need to tell me about it.
So, I mean, it's those educational steps that made the big difference for me and for her.
SHAPIRO: We have Ed on the line from Denver, Colorado. Hi, Ed.
ED: Hi. Well, my perspective on this is I'm put in a position where I'll have to do surgery on someone for a variety of reasons - sometimes emergent, sometimes not - who already has been taking narcotics for a long period of time. And unfortunately - not in my personal experience - but I've had partners who've had patients die of overdoses in that situation. And...
SHAPIRO: Because on top of the painkillers they're already taking, you have to give...
ED: Well, the way I explain it to a patient is when they've - on narcotics for a long period of time, they've built up a resistance to the medication. And therefore to control their postoperative pain, we're forced to give them higher and higher doses of medication, and those doses become far more risky, and it's far more difficult to predict, to titrate the amount of medication given.
SHAPIRO: So what do you do?
ED: And so - well, basically, what I've done and what's difficult because about five years ago, I remember there was a big hoopla in the press about how doctors were under-treating pain, and people remember that...
ED: ...you know? I basically tell these people, I'm not going to be able to control your pain as well postoperatively. I basically - I just - I'm just upfront with them, and I tell them exactly what I think, and that's that their use of opioids, long term, puts them at much higher risk of dying of a drug overdose, and therefore, as a responsible physician, I have to err on the side of safety. And a lot of people don't like that, but I'm not going to have a patient die on me, and I've seen it happen, you know? And...
SHAPIRO: Wow. OK. Ed, thanks for the call.
SHAPIRO: And Lisa Girion of the LA Times, you document how much this problem has grown in the last 10 years. What is in store for the next 10 years? Is this problem just going to continue to explode?
GIRION: Well, that's a very good question, and I think that at a lot of levels now, people are becoming aware of what's going on - the general public, the physician community, as Dr. Christo alluded to, the primary care community, regulators, law enforcement, you know, public health officials. People are really struggling with how to, you know, reduce the deaths associated with these drugs.
SHAPIRO: But, Dr. Christo, do you fear that the pendulum could swing too far in the opposite direction and, as the previous caller mentioned, people could be under-medicated for legitimate pain?
CHRISTO: Sure, I do. I mean, that is a concern. And, you know, don't forget, I think the previous physician mentioned that we do have an epidemic of uncontrolled pain in the United States and, in fact, the world. I mean, about a third of the population in the United States suffers from uncontrolled pain. That's huge.
So, you know, at the same time, we've got an epidemic of pain. We do have a rise in the number of people who, unfortunately, are dying from opioid prescription overdoses. So, you know, I'm concerned that the pendulum is going to swing to the point where we're - we don't have opioids as an option anymore because that's sad. I mean, I do have plenty of patients who do well, use the medications responsibly, who work, who have a high quality of life.
SHAPIRO: Let's go to another call. This is Leslie(ph) in Salt Lake City, Utah. Hi, Leslie. You're on the air.
LESLIE: Hi. I'm a physician in Utah, and I had an experience where I fired a patient from my practice because I did feel he was using narcotics inappropriately, multiple providers. And then I got a call that he had forged a prescription for narcotics in my name. And I'm very...
SHAPIRO: A call from the pharmacist?
LESLIE: Yeah, a call from our hospital pharmacy. They had had an alert, and they saw that the prescription I had written looked suspicious. It was a Flexeril prescription that he had converted into Percocet. But I was really discouraged that it was really hard for me to report the issue, and the police looked like they never did anything about it. And a few months later when I checked our drug registry, he was still getting narcotics from other providers.
SHAPIRO: Wow. We're talking about prescription drug overdoses, and you're listening to TALK OF THE NATION, from NPR News. And, Leslie, you say you had a hard time figuring out how to report this guy to somebody who could deal with the problem. How did that ultimately get resolved? Was he ever held to account?
LESLIE: I never got any follow-up. And when I originally called our drug database, they told me that they were there to deal with allegations against physicians, but not against patients. So it was hard for me to figure out who I was even supposed to call.
Our pharmacy ended up calling the police, and I followed up with a patient of mine who was a police officer. And so she told me someone within the police department to contact, but it wasn't a very easy process at all for me as a physician.
And I was also frustrated when I called another physician before I fired him from my practice to say, you know, I'm looking at his drug registry, and I see things that are very suspicious.
LESLIE: The other providers seemed very hesitant to even take it seriously, and it - the whole process of communicating when we do have these patients of concern is really difficult.
And the other thing I want to mention is that Utah providers, we have a Medicaid system which gives people primary care only and not specialty benefits. So when your pain specialist say, oh, you could get an alternate therapy and physical therapy, a lot of our Medicaid population, they can only get pills, maybe even four prescriptions a month. So doctors seem to be pressed to give pain prescriptions...
LESLIE: ...because they can't give them a physical therapy prescription or even send them to a pain clinic.
SHAPIRO: Well, thanks for the call, Leslie. And, Lisa, in your investigative work for the LA Times, you looked into what kind of oversight there is for people who are abusing prescription drugs and providing prescription drugs to abusers. Is there an easy answer for where to go when you become aware of something like this?
GIRION: No is the short answer. When it comes to physicians, if you believe there's a problem with a physician, you can contact the medical board. But when it comes to doctor-shopping patients, I assume that would be a local police issue.
We did find - what's interesting is when we looked at about 300 of the deaths that belong to the doctors with three or more deaths, many, many of those patients had warning signs, a history that would have suggested they were at very high risk of overdose such as prior overdoses, prior suicides, mental illness issues and things like that. So there are things that doctors can look for to be, you know, to notify them that they need to take extreme caution with those kinds of patients. Doctor shopping would be another thing that they could look for.
SHAPIRO: Dr. Paul Christo, briefly, one hope for the future seems to be that there might someday be painkiller drugs that people don't want to take for pleasure, for euphoria. They're not addictive. Any hope for that in the future?
CHRISTO: You know, I think there is a lot of hope. There is hope that we will understand better the genetics of how opioids work in our bodies, and that work is being done now. And I think what we'll find in the future is that we'll be able to genetically test me, for example, if I need opioid medications to determine which of the several that are available are the most effective in me, which are going to produce the most pain relief with the fewest side effects.
SHAPIRO: Well, let's hope. Lisa Girion is an investigative reporter for the Los Angeles Times, and along with Scott Glover, she co-reported the L.A. Times series "Dying for Relief." She joined us from the L.A. Times offices. Lisa, thanks for being with us.
GIRION: Thank you.
SHAPIRO: And Dr. Paul Christo is a practicing physician and associate professor at the Johns Hopkins Hospital Division of Pain Medicine. He also hosts the radio talk show "Aches and Gains" on WBAL in Baltimore. He joined us from his office at Johns Hopkins Hospital. Dr. Christo, thanks to you for being with us.
CHRISTO: My pleasure.
SHAPIRO: And when we come back in just a moment, we'll talk with two of the people who have had the best access of anyone to 1600 Pennsylvania Avenue. Former White House photographers Robert McNeely and Eric Draper, they'll join us after a short break. So stay with us. I'm Ari Shapiro, and it's TALK OF THE NATION from NPR News. Transcript provided by NPR, Copyright NPR.