1 00:00:08,975 --> 00:00:11,111 WELCOME TO THE CLINICAL CENTER GRAND ROUNDS, 2 00:00:11,177 --> 00:00:14,914 A WEEKLY SERIES OF EDUCATIONAL LECTURES FOR PHYSICIANS AND 3 00:00:14,981 --> 00:00:17,550 HEALTH CARE PROFESSIONALS BROADCAST FROM THE CLINICAL 4 00:00:17,617 --> 00:00:20,520 CENTER AT THE NATIONAL INSTITUTES OF HEALTH IN 5 00:00:20,587 --> 00:00:22,322 BETHESDA, MD. 6 00:00:22,389 --> 00:00:25,859 THE NIH CLINICAL CENTER IS THE WORLD'S LARGEST HOSPITAL TOTALLY 7 00:00:25,925 --> 00:00:29,562 DEDICATED TO INVESTIGATIONAL RESEARCH AND LEADS THE GLOBAL 8 00:00:29,629 --> 00:00:32,499 EFFORT IN TRAINING TODAY'S INVESTIGATORS AND DISCOVERING 9 00:00:32,565 --> 00:00:34,667 TOMORROW'S CURES. 10 00:00:34,734 --> 00:00:43,943 LEARN MORE BY VISITING US ONLINE AT HTTP://CLINICALCENTER.NIH.GOV 11 00:00:44,010 --> 00:00:45,612 GOOD AFTERNOON, AND WELCOME TO 12 00:00:45,678 --> 00:00:46,946 THE CLINICAL CENTER GRAND 13 00:00:47,013 --> 00:00:48,047 ROUNDS. 14 00:00:48,114 --> 00:00:50,450 THE HOPKINS CLOUD CME ACTIVITY 15 00:00:50,517 --> 00:00:53,186 CODE IS 50538. 16 00:00:53,253 --> 00:00:54,721 PLEASE TEXT THIS CODE TO JOHNS 17 00:00:54,788 --> 00:00:56,356 HOPKINS CME PHONE NUMBER ON THE 18 00:00:56,423 --> 00:00:58,525 SLIDE TO RECEIVE CREDIT FOR THIS 19 00:00:58,591 --> 00:00:58,858 LECTURE. 20 00:00:58,925 --> 00:01:00,493 WE KINDLY INVITE YOU TO PROVIDE 21 00:01:00,560 --> 00:01:02,028 FEEDBACK FOR THIS LECTURE. 22 00:01:02,095 --> 00:01:03,129 FORMS ARE AVAILABLE IN THE BACK 23 00:01:03,196 --> 00:01:05,632 TO COMPLETE. 24 00:01:05,698 --> 00:01:09,469 BY VIDEOCAST, THIS LECTURE WILL 25 00:01:09,536 --> 00:01:11,237 BE AVAILABLE ON THE CLINICAL 26 00:01:11,304 --> 00:01:12,005 CENTER GRAND ROUNDS WEBSITE. 27 00:01:12,071 --> 00:01:14,073 FOR THOSE APPLYING FOR CME, WILL 28 00:01:14,140 --> 00:01:15,809 RECEIVE AN EMAIL WITH A FILLABLE 29 00:01:15,875 --> 00:01:17,143 PDF TO COMPLETE AND RETURN. 30 00:01:17,210 --> 00:01:18,578 FOLLOWING THE PRESENTATION, 31 00:01:18,645 --> 00:01:19,779 QUESTIONS FOR THE SPEAKER WILL 32 00:01:19,846 --> 00:01:21,314 BE TAKEN FROM THE MICROPHONES IN 33 00:01:21,381 --> 00:01:23,516 THE AISLES. 34 00:01:23,583 --> 00:01:24,717 ADDITIONALLY, VIDEOCAST VIEWERS 35 00:01:24,784 --> 00:01:25,718 MAY SUBMIT QUESTIONS AT ANY TIME 36 00:01:25,785 --> 00:01:27,187 DURING THE LECTURE BY SCROLLING 37 00:01:27,253 --> 00:01:28,721 DOWN AND CLICKING THE LIVE 38 00:01:28,788 --> 00:01:30,356 FEEDBACK BUTTON LOCATED ON THE 39 00:01:30,423 --> 00:01:31,124 VIDEOCAST WEBSITE. 40 00:01:31,191 --> 00:01:33,426 QUESTIONS WILL BE ANSWERED AS 41 00:01:33,493 --> 00:01:35,061 TIME PERMITS AT THE CONCLUSION 42 00:01:35,128 --> 00:01:37,030 OF THE PRESENTATION. 43 00:01:37,096 --> 00:01:39,566 TODAY I'M VERY HONORED TO 44 00:01:39,632 --> 00:01:41,301 PRESENT TODAY'S SPEAKER, 45 00:01:41,367 --> 00:01:43,136 DR. ERIC C. STRAIN. 46 00:01:43,203 --> 00:01:45,338 DR. STRAIN IS A GEORGE E BIGEOW 47 00:01:45,405 --> 00:01:46,439 PROFESSOR IN THE DEPARTMENT OF 48 00:01:46,506 --> 00:01:47,674 PSYCHIATRY AND BEHAVIORAL 49 00:01:47,740 --> 00:01:49,309 SCIENCES AT JOHNS HOPKINS 50 00:01:49,375 --> 00:01:50,276 UNIVERSITY SCHOOL OF MEDICINE. 51 00:01:50,343 --> 00:01:51,811 THE DIRECTOR OF THE BEHAVIORAL 52 00:01:51,878 --> 00:01:53,880 PHARMACOLOGY RESEARCH UNIT AT 53 00:01:53,947 --> 00:01:55,949 HOPKINS, AND EXECUTIVE VICE 54 00:01:56,015 --> 00:01:57,917 CHAIR FOR PSYCHIATRY AT THE BAY 55 00:01:57,984 --> 00:01:59,452 VIEW MEDICAL CENTER. 56 00:01:59,519 --> 00:02:00,720 DR. STRAIN COMPLETED HIS 57 00:02:00,787 --> 00:02:02,188 BACHELOR OF ARTS AT AMHURST 58 00:02:02,255 --> 00:02:03,623 COLLEGE IN MASSACHUSETTS AND 59 00:02:03,690 --> 00:02:06,459 EARNED HIS MEDICAL DEGREE AT THE 60 00:02:06,526 --> 00:02:07,894 OHIO STATE UNIVERSITY COLLEGE OF 61 00:02:07,961 --> 00:02:08,228 MEDICINE. 62 00:02:08,294 --> 00:02:10,630 HE COMPLETED HIS INTERNSHIP IN 63 00:02:10,697 --> 00:02:13,032 MEDICINE AND PSYCHIATRY AT THE 64 00:02:13,099 --> 00:02:15,535 FRANCIS SCOTT KEY MEDICAL 65 00:02:15,602 --> 00:02:17,070 CENTER, PSYCHIATRY AT THE JOHNS 66 00:02:17,136 --> 00:02:18,271 HOPKINS HOSPITAL. 67 00:02:18,338 --> 00:02:20,440 FOLLOWING SERVICE AS CHIEF 68 00:02:20,507 --> 00:02:21,341 RESIDENT, HE COMPLETED A 69 00:02:21,407 --> 00:02:24,177 FELLOWSHIP IN A BEHAVIORAL 70 00:02:24,244 --> 00:02:25,912 FELLOWSHIP PHARMACOLOGY RESEARCH 71 00:02:25,979 --> 00:02:28,348 UNIT AT HOPKINS, NOW DIRECTOR. 72 00:02:28,414 --> 00:02:30,750 DR. STRAIN IS A PROLIFIC 73 00:02:30,817 --> 00:02:32,619 PHYSICIAN SCIENTIST IN SUBSTANCE 74 00:02:32,685 --> 00:02:34,587 USE RELATED ISSUE, PROVIDING 75 00:02:34,654 --> 00:02:37,790 CLINICAL CARE TO PATIENTS, TEA 76 00:02:37,857 --> 00:02:39,058 TEACHING TO RESIDENTS AND 77 00:02:39,125 --> 00:02:40,360 FELLOWS, AND DEVELOPING NEW 78 00:02:40,426 --> 00:02:41,694 SUBSTANCE USE DISORDER 79 00:02:41,761 --> 00:02:44,130 INITIATIVES AT HOPKINS. 80 00:02:44,197 --> 00:02:46,799 DR. STRAIN'S AREAS OF RESEARCH 81 00:02:46,866 --> 00:02:47,367 INCLUDE INVESTIGATING THE 82 00:02:47,433 --> 00:02:49,602 OPTIMAL MECHANISM FOR TREATING 83 00:02:49,669 --> 00:02:50,870 PATIENTS WITH SUBSTANCE USE 84 00:02:50,937 --> 00:02:52,205 DISORDERS, THE RELATIONSHIP 85 00:02:52,272 --> 00:02:53,373 BETWEEN SUBSTANCE USE AND OTHER 86 00:02:53,439 --> 00:02:54,807 PSYCHIATRIC DISORDERS, THE 87 00:02:54,874 --> 00:03:00,747 ABUTTE LIABABUSELIABILITY OF NOS 88 00:03:00,813 --> 00:03:03,716 AT NEW NOVEL THERAPIES FOR 89 00:03:03,783 --> 00:03:04,617 SUBSTANCE USE TREATMENT. 90 00:03:04,684 --> 00:03:06,719 HIS STUDIES INCLUDE 91 00:03:06,786 --> 00:03:09,889 BUPRENORPHINE, METHADONE, 92 00:03:09,956 --> 00:03:11,758 PHARMACOTHERAPY FOR ALCOHOL 93 00:03:11,824 --> 00:03:13,059 DEPENDENCE, AND 94 00:03:13,126 --> 00:03:14,260 NON-PHARMACOLOGICAL THERAPIES 95 00:03:14,327 --> 00:03:15,828 FOR SUBSTANCE USE DISORDERS. 96 00:03:15,895 --> 00:03:17,230 DR. STRAIN IS A FORMER 97 00:03:17,297 --> 00:03:18,965 EDITOR-IN-CHIEF FOR THE PEER 98 00:03:19,032 --> 00:03:19,966 REVIEWED SCIENTIFIC JOURNAL DRUG 99 00:03:20,033 --> 00:03:21,267 AND ALCOHOL DEPENDENCE. 100 00:03:21,334 --> 00:03:24,137 HE CO-EDITED TEXTBOOKS, 101 00:03:24,203 --> 00:03:26,439 METHADONE TREATMENT FOR OPIOID 102 00:03:26,506 --> 00:03:28,942 DEPENDENCE, THE TREATMENT OF 103 00:03:29,008 --> 00:03:31,578 OPIOID DEPENDENCE AND FIFTH 104 00:03:31,644 --> 00:03:33,513 EDITION OF THE SUBSTANCE USE 105 00:03:33,580 --> 00:03:35,715 COMPREHENSIVE TEXTBOOK. 106 00:03:35,782 --> 00:03:36,816 DR. STRAIN WAS A LEAD IN 107 00:03:36,883 --> 00:03:37,784 DEVELOPING THE FIRST 108 00:03:37,850 --> 00:03:38,751 BUPRENORPHINE CURRICULUM, WHICH 109 00:03:38,818 --> 00:03:40,320 WAS SUBSEQUENTLY USED AS A 110 00:03:40,386 --> 00:03:42,388 PRIMARY SOURCE TO TRAIN 111 00:03:42,455 --> 00:03:43,256 PHYSICIANS IN THE USES OF 112 00:03:43,323 --> 00:03:45,224 MEDICATION FOR TREATMENT OF 113 00:03:45,291 --> 00:03:46,759 OPIOID DEPENDENCE. 114 00:03:46,826 --> 00:03:48,061 DR. STRAIN HAS SERVED AS CHAIR 115 00:03:48,127 --> 00:03:50,797 OF THE FDA'S DRUG ABUSE ADVISORY 116 00:03:50,863 --> 00:03:52,265 COMMITTEE, THE NIH ADDICTION 117 00:03:52,332 --> 00:03:54,067 RISK AND MECHANISM STUDY 118 00:03:54,133 --> 00:03:55,935 SECTION, AND THE AMERICAN 119 00:03:56,002 --> 00:03:57,837 PSYCHIATRIC ASSOCIATION COUNCIL 120 00:03:57,904 --> 00:03:58,571 ON ADDICTION PSYCHIATRY. 121 00:03:58,638 --> 00:04:00,707 HE HAS SERVED AS PAST PRESIDENT 122 00:04:00,773 --> 00:04:02,942 AND A BOARD MEMBER ON THE 123 00:04:03,009 --> 00:04:04,611 COLLEGE ON PROBLEMS OF DRUG 124 00:04:04,677 --> 00:04:05,678 DEPENDENCE AND HAS ALSO SERVED 125 00:04:05,745 --> 00:04:08,047 ON VARIOUS COMMITTEES FOR 126 00:04:08,114 --> 00:04:09,749 NATIONAL INSTITUTE ON DRUG 127 00:04:09,816 --> 00:04:10,350 ABUSE, NATIONAL INSTITUTE ON 128 00:04:10,416 --> 00:04:13,019 ALCOHOL ABUSE AND ALCOHOLISM, 129 00:04:13,086 --> 00:04:14,988 AND FEDERAL TREATMENT SUBSTANCE 130 00:04:15,054 --> 00:04:15,655 USE ATREATMENT. 131 00:04:15,722 --> 00:04:17,824 THE TITLE OF HIS PRESENTATION 132 00:04:17,890 --> 00:04:19,792 TODAY IS OPIOID USE DISORDER. 133 00:04:19,859 --> 00:04:21,194 PLEASE WELCOME -- JOIN ME IN 134 00:04:21,260 --> 00:04:25,698 WELCOMING DR. STRAIN. 135 00:04:25,765 --> 00:04:30,203 [APPLAUSE] 136 00:04:30,269 --> 00:04:31,404 >> THANK YOU. 137 00:04:31,471 --> 00:04:35,775 AND THANKS FOR THAT KIND 138 00:04:35,842 --> 00:04:36,743 INTRODUCTION, AND FOR INVITING 139 00:04:36,809 --> 00:04:41,114 ME HERE TODAY TO TALK TO YOU 140 00:04:41,180 --> 00:04:43,750 ABOUT SUBSTANCE USE, AND IN 141 00:04:43,816 --> 00:04:45,084 PARTICULAR, OPIOID USE DISORDER. 142 00:04:45,151 --> 00:04:49,422 I'VE TITLED THIS TALK, WHERE WE 143 00:04:49,489 --> 00:04:50,957 WERE, WHERE WE ARE, AND WHERE WE 144 00:04:51,024 --> 00:04:52,392 NEED TO GO. 145 00:04:52,458 --> 00:04:54,894 AND I WILL TRY TO MOVE BRISKLY 146 00:04:54,961 --> 00:04:57,630 THROUGH THESE SLIDES. 147 00:04:57,697 --> 00:04:59,399 SO IN THE PAST 24 MONTHS, I'VE 148 00:04:59,465 --> 00:05:01,034 HAD THE FOLLOWING RELATIONSHIPS, 149 00:05:01,100 --> 00:05:10,009 YOU CAN SEE, AND THERE WILL BE A 150 00:05:10,076 --> 00:05:12,178 DISCUSSION OF UNAPPROVED USES OF 151 00:05:12,245 --> 00:05:14,614 MEDICATIONS IN MY TALK TODAY. 152 00:05:14,681 --> 00:05:16,215 AND BY THE END OF THIS 153 00:05:16,282 --> 00:05:17,316 PRESENTATION, YOU SHOULD BE ABLE 154 00:05:17,383 --> 00:05:19,619 TO DISCUSS THE RELATIVELY RECENT 155 00:05:19,686 --> 00:05:20,486 HISTORICAL CIRCUMSTANCES THAT 156 00:05:20,553 --> 00:05:23,790 RESULTED IN INCREASED USE OF 157 00:05:23,856 --> 00:05:24,857 OPIOIDS, IDENTIFY THE CAUSE OF 158 00:05:24,924 --> 00:05:28,027 DIFFERENT WAVES OF OPIOID 159 00:05:28,094 --> 00:05:29,796 OVERDOSE DEATHS AND LIST AT 160 00:05:29,862 --> 00:05:31,330 LEAST THREE FDA-APPROVED 161 00:05:31,397 --> 00:05:33,066 MEDICATIONS USED TO TREAT OPIOID 162 00:05:33,132 --> 00:05:33,399 USE DISORDER. 163 00:05:33,466 --> 00:05:35,468 SO LET'S GET TO IT. 164 00:05:35,535 --> 00:05:38,438 HOW DID WE GET TO THE CURRENT 165 00:05:38,504 --> 00:05:41,374 OPIOID PREDICAMENT? 166 00:05:41,441 --> 00:05:43,009 AND OPIOID DRUGS, JUST TO REMIND 167 00:05:43,076 --> 00:05:46,646 YOU, THEY MOSTLY ARE ANALGESICS, 168 00:05:46,713 --> 00:05:50,283 THEY SUPPRESS COUGH, CONS TI COI 169 00:05:50,349 --> 00:05:52,585 PAIT, THEY GENERAL CAN BE 170 00:05:52,652 --> 00:05:54,754 ABUSED. 171 00:05:54,821 --> 00:06:03,196 OXYCODONE, PERCOCET, TRAMADOL, 172 00:06:03,262 --> 00:06:06,032 HYDROMORPHONE, HEROIN, FENTANYL 173 00:06:06,099 --> 00:06:07,133 IS JUST A PARTIAL LIST OF THE 174 00:06:07,200 --> 00:06:08,668 OPOPIOIDS. 175 00:06:08,735 --> 00:06:10,737 JUST TO REMIND YOU, HEROIN WAS 176 00:06:10,803 --> 00:06:12,605 DEVELOPED BY BAYER 177 00:06:12,672 --> 00:06:14,907 PHARMACEUTICAL PRODUCTS AND WAS 178 00:06:14,974 --> 00:06:16,209 ACTUALLY AN OVER THE COUNTER 179 00:06:16,275 --> 00:06:19,178 MEDICATION AT THE TIME. 180 00:06:19,245 --> 00:06:21,013 AND THEY ARE USEFUL MEDICATIONS 181 00:06:21,080 --> 00:06:23,649 WHEN TAKEN PROPERLY. 182 00:06:23,716 --> 00:06:25,051 SO LET'S NOT THROW OUT THE BABY 183 00:06:25,118 --> 00:06:26,619 WITH THE BATHWATER. 184 00:06:26,686 --> 00:06:28,688 AS WE THICK ABOUT THAT. 185 00:06:28,755 --> 00:06:29,555 THINK ABOUT THAT, THE USE 186 00:06:29,622 --> 00:06:31,190 OF THESE DRUGS. 187 00:06:31,257 --> 00:06:33,493 SO I WANT TO TAKE A LITTLE 188 00:06:33,559 --> 00:06:34,694 TANGENT, THOUGH, WHEN TALKING 189 00:06:34,761 --> 00:06:37,864 ABOUT OPIOIDS, AND TALK A LITTLE 190 00:06:37,930 --> 00:06:41,167 BIT ABOUT WHY DO PEOPLE USE AND 191 00:06:41,234 --> 00:06:43,770 MISUSE DRUGS. 192 00:06:43,836 --> 00:06:44,871 AND IN ORDER TO GET THERE, I 193 00:06:44,937 --> 00:06:47,940 WANT TO THINK ABOUT HOW SOME 194 00:06:48,007 --> 00:06:50,543 PEOPLE BUT NOT ALL, CERTAIN 195 00:06:50,610 --> 00:06:52,945 DRUGS CAN PRODUCE A PLEASURABLE 196 00:06:53,012 --> 00:06:53,279 EFFECT. 197 00:06:53,346 --> 00:06:56,349 SO NOT EVERYBODY FINDS DRUSS 198 00:06:56,415 --> 00:06:57,984 PRESSURABLE AND PARTICULAR DRUGS 199 00:06:58,050 --> 00:06:58,618 PLEASURABLE. 200 00:06:58,684 --> 00:07:01,387 JUST BECAUSE A DRUG PRODUCES A 201 00:07:01,454 --> 00:07:02,355 PLEASURABLE EFFECT DOESN'T MEAN 202 00:07:02,421 --> 00:07:03,256 A PERSON WILL MISUSE IT. 203 00:07:03,322 --> 00:07:06,192 WE USE AND MISUSE DRUGS FOR 204 00:07:06,259 --> 00:07:07,193 COMPLICATED REASONS. 205 00:07:07,260 --> 00:07:09,262 AND I THINK ONE OF THE THINGS WE 206 00:07:09,328 --> 00:07:12,965 STRUGGLE WITH IS THAT WE WANT TO 207 00:07:13,032 --> 00:07:15,168 SIMPLIFY DRUG ABUSE AND WHY 208 00:07:15,234 --> 00:07:16,803 PEOPLE USE DRUGS, BUT IT ISN'T 209 00:07:16,869 --> 00:07:17,370 ALWAYS SIMPLE. 210 00:07:17,436 --> 00:07:19,438 SO AS YOU THINK ABOUT DRUG 211 00:07:19,505 --> 00:07:24,477 ABUSE, THINK ABOUT WHY DO WE 212 00:07:24,544 --> 00:07:25,344 DRINK CAFFEINE? 213 00:07:25,411 --> 00:07:26,646 BECAUSE PROBABLY SOMEWHERE 214 00:07:26,712 --> 00:07:28,614 BETWEEN 70 AND 80% OF YOU USE 215 00:07:28,681 --> 00:07:31,450 CAFFEINE ON A REGULAR BASIS, 216 00:07:31,517 --> 00:07:32,018 RIGHT? 217 00:07:32,084 --> 00:07:34,187 AND YOU KNOW, I USED TO SHOW 218 00:07:34,253 --> 00:07:35,288 THIS SLIDE BECAUSE PEOPLE WOULD 219 00:07:35,354 --> 00:07:37,056 SAY TO ME, I DON'T LIKE TO SEE 220 00:07:37,123 --> 00:07:39,225 THAT LINE IN A METHADONE CLINIC 221 00:07:39,292 --> 00:07:41,861 WHEN PEOPLE LINE UP TO GET THEIR 222 00:07:41,928 --> 00:07:43,162 METHADONE, AND I'D SAY, WELL, 223 00:07:43,229 --> 00:07:45,798 WHAT ABOUT THE LINE AT STARBU 224 00:07:45,865 --> 00:07:46,999 STARBUCKS, TO GET THEIR 225 00:07:47,066 --> 00:07:48,568 STARBUCKS CAFFEINE, RIGHT? 226 00:07:48,634 --> 00:07:50,269 WE USE KA FEEP FOR COMPLICATED 227 00:07:50,336 --> 00:07:51,504 REASONS. 228 00:07:51,571 --> 00:07:55,308 AND I'M AS GUILTY AS ANYBODY FOR 229 00:07:55,374 --> 00:07:55,875 USING CAFFEINE. 230 00:07:55,942 --> 00:07:57,510 SO WHY DO WE DRINK CAFFEINE? 231 00:07:57,577 --> 00:08:02,181 WHY DO WE USE A PSYCHOACTIVE 232 00:08:02,248 --> 00:08:03,416 SUBSTANCE REGULARLY? 233 00:08:03,482 --> 00:08:06,452 WELL, TAKING A SUBSTANCE AND 234 00:08:06,519 --> 00:08:09,388 ENGAGING IN AN ACTIVITY HAS 235 00:08:09,455 --> 00:08:10,556 ASPECTS OUTSIDE US AND INSIDE US 236 00:08:10,623 --> 00:08:13,693 THAT CAN INFLUENCE USE. 237 00:08:13,759 --> 00:08:15,728 AND I WANT TO TALK FIRST ABOUT 238 00:08:15,795 --> 00:08:18,831 WHAT'S OUTSIDE US, AND WHAT'S 239 00:08:18,898 --> 00:08:20,900 INSIDE US THEN THAT CAN 240 00:08:20,967 --> 00:08:21,434 INFLUENCE USE. 241 00:08:21,500 --> 00:08:23,069 I'M GOING TO TALK ABOUT ONE OF 242 00:08:23,135 --> 00:08:26,038 MY FAVORITE ACTIVITIES AS AN 243 00:08:26,105 --> 00:08:27,106 EXAMPLE OF THIS. 244 00:08:27,173 --> 00:08:30,509 WHICH IS, EATING PIE. 245 00:08:30,576 --> 00:08:31,377 OKAY? 246 00:08:31,444 --> 00:08:33,579 I LIKE PIE. 247 00:08:33,646 --> 00:08:37,183 AND I LIKE APPLE PIE, THIS IS AN 248 00:08:37,250 --> 00:08:43,422 APPLE PIE, AND THIS IS -- THIS 249 00:08:43,489 --> 00:08:44,957 LATTICE WORK KIND OF PIE IS THE 250 00:08:45,024 --> 00:08:47,226 APPLE PIE MY MOTHER WOULD MAKE 251 00:08:47,293 --> 00:08:48,661 EVERY THANKSGIVING. 252 00:08:48,728 --> 00:08:50,630 AND I LOVED HER PIE. 253 00:08:50,696 --> 00:08:52,164 I DIDN'T JUST LOVE HER APPLE 254 00:08:52,231 --> 00:08:54,367 PIE, I LOVED HER APPLE PIE WITH 255 00:08:54,433 --> 00:08:56,002 VANILLA ICE CREAM AND I WANTED 256 00:08:56,068 --> 00:09:03,309 TWO SCOOPS OF T OF VANILLA ICE . 257 00:09:03,376 --> 00:09:03,776 CREAM. 258 00:09:03,843 --> 00:09:05,211 MY MOTHER WOULD MAKE A GREAT 259 00:09:05,278 --> 00:09:06,412 TURKEY AT THANKSGIVING TIME WITH 260 00:09:06,479 --> 00:09:08,014 DRESSING AND GREEN BEANS AND 261 00:09:08,080 --> 00:09:09,548 SLICED ALMONDS AND ALL THAT GOOD 262 00:09:09,615 --> 00:09:11,651 STUFF, THE SLICED ALMONDS IN THE 263 00:09:11,717 --> 00:09:14,153 GREEN BEANS AND GRAVY, AND I 264 00:09:14,220 --> 00:09:16,555 WOULD EAT THAT STUFF, AND MY 265 00:09:16,622 --> 00:09:18,524 FAMILY WOULD EAT IT, AND THEN MY 266 00:09:18,591 --> 00:09:20,593 MOTHER WOULD BRING OUT -- I'D BE 267 00:09:20,660 --> 00:09:22,361 SATIATED, AND MY MOTHER WOULD 268 00:09:22,428 --> 00:09:24,096 BRING OUT APPLE PIE AND SAY WHO 269 00:09:24,163 --> 00:09:24,864 WANT APPLE PIE? 270 00:09:24,931 --> 00:09:26,732 WHO WANTS APPLE PIE WITH VANILLA 271 00:09:26,799 --> 00:09:27,700 ICE CREAM? 272 00:09:27,767 --> 00:09:29,068 I WOULD SAY I WOULD. 273 00:09:29,135 --> 00:09:29,802 NOW WHY IS THAT? 274 00:09:29,869 --> 00:09:31,971 I WASN'T NEEDING CALORIES. 275 00:09:32,038 --> 00:09:34,273 MY BODY WAS SAYING, YOU'VE GOT 276 00:09:34,340 --> 00:09:35,574 ENOUGH CALORIES, ERIC. 277 00:09:35,641 --> 00:09:37,543 YOU DON'T NEED MORE. 278 00:09:37,610 --> 00:09:39,078 BUT I TOOK IT. 279 00:09:39,145 --> 00:09:41,614 BECAUSE I HAD AN EXTERNAL QUEUE 280 00:09:41,681 --> 00:09:43,149 THAT PROMPTED ME TO WANT TO 281 00:09:43,215 --> 00:09:44,784 ENGAGE IN THE BEHAVIOR OF 282 00:09:44,850 --> 00:09:46,852 EATING, EVEN THOUGH I WASN'T 283 00:09:46,919 --> 00:09:48,621 HUNGRY. 284 00:09:48,688 --> 00:09:49,689 RIGHT? 285 00:09:49,755 --> 00:09:51,324 AND PROBABLY SOME OF YOU SITTING 286 00:09:51,390 --> 00:09:55,161 HERE RIGHT NOW ARE THINKING, I'D 287 00:09:55,227 --> 00:10:00,299 LIKE A SLICE OF PIE, RIGHT? 288 00:10:00,366 --> 00:10:02,835 SO PIE AND ICE CREAM ARE QUEUES 289 00:10:02,902 --> 00:10:04,804 THAT ARE OUTSIDE US THAT PROMPT 290 00:10:04,870 --> 00:10:06,339 US TO WANT TO ENGAGE IN THE 291 00:10:06,405 --> 00:10:11,510 BEHAVIOR OF EATING. 292 00:10:11,577 --> 00:10:13,746 BUT WE ALSO HAVE THINGS INSIDE 293 00:10:13,813 --> 00:10:15,848 US THAT DRIVE US TO EAT, THAT 294 00:10:15,915 --> 00:10:19,585 CAN INFLUENCE USE. 295 00:10:19,652 --> 00:10:20,886 AND YOU PROBABLY KNOW, WELL, 296 00:10:20,953 --> 00:10:23,356 THAT THERE'S BEEN STUDIES THAT 297 00:10:23,422 --> 00:10:27,526 WERE DONE DECADES AGO WHERE 298 00:10:27,593 --> 00:10:30,262 LESIONING THE HYPOTHALAMUS IN 299 00:10:30,329 --> 00:10:32,031 PARTICULAR IN RATS WOULD ENGAGE 300 00:10:32,098 --> 00:10:33,466 THEM TO INCREASE OR DECREASE 301 00:10:33,532 --> 00:10:33,899 EATING BEHAVIOR. 302 00:10:33,966 --> 00:10:37,269 SO LATERAL HYPOTHALAMIC KNEW 303 00:10:37,336 --> 00:10:40,439 CLIE EYE, LESIONING THOSE WOULD 304 00:10:40,506 --> 00:10:43,442 RESULT IN DECREASED EATING. 305 00:10:43,509 --> 00:10:45,244 THE MEDIAL HYPOTHALAMUS WOULD 306 00:10:45,311 --> 00:10:46,345 INCREASE EATING IN RATS. 307 00:10:46,412 --> 00:10:51,117 SO CLEARLY, AND THERE'S BEEN A 308 00:10:51,183 --> 00:10:52,718 LOT OF OTHER STUDIES SINCE THEN 309 00:10:52,785 --> 00:10:54,253 LOOKING AT THE HORMONAL EFFECTS 310 00:10:54,320 --> 00:10:56,322 THAT PRODUCE US TO ENGAGE IN 311 00:10:56,389 --> 00:10:57,990 INCREASED EATING OR DECREASED 312 00:10:58,057 --> 00:11:00,159 EATING AS A BEHAVIOR, REGARDLESS 313 00:11:00,226 --> 00:11:04,096 OF WHAT THE CALORIC NEED IS. 314 00:11:04,163 --> 00:11:07,166 SO EATING, ENGAGING IN A 315 00:11:07,233 --> 00:11:08,367 GOAL-DIRECTED ACTIVITY, CAN 316 00:11:08,434 --> 00:11:11,303 OCCUR BECAUSE OF THINGS GOING ON 317 00:11:11,370 --> 00:11:13,739 INSIDE US, FOR EXAMPLE, OUR BODY 318 00:11:13,806 --> 00:11:15,608 SENDS PHYSIOLOGIC MESSAGES THAT 319 00:11:15,674 --> 00:11:16,675 WE'RE HUNGRY. 320 00:11:16,742 --> 00:11:18,878 AND IT CAN OCCUR BECAUSE OF 321 00:11:18,944 --> 00:11:20,179 THINGS OUTSIDE OF US. 322 00:11:20,246 --> 00:11:22,148 WE AREN'T NECESSARILY HUNGRY, 323 00:11:22,214 --> 00:11:24,450 BUT CUES PROMPT US TO WANT TO 324 00:11:24,517 --> 00:11:24,617 EAT. 325 00:11:24,683 --> 00:11:27,953 AND JUST LIKE EATING, ENGAGING 326 00:11:28,020 --> 00:11:30,356 IN THE BEHAVIOR OF TAKING A 327 00:11:30,423 --> 00:11:31,557 SUBSTANCE LIKEWISE CAN BE 328 00:11:31,624 --> 00:11:33,759 GOVERNED BY THINGS INSIDE US AND 329 00:11:33,826 --> 00:11:35,828 OUTSIDE US. 330 00:11:35,895 --> 00:11:39,865 THE CUES OF SEEING A STARBUCKS 331 00:11:39,932 --> 00:11:43,269 OR WAKING UP IN THE MORNING AND 332 00:11:43,335 --> 00:11:44,370 FEELING LIKE YOU NEED TO GET A 333 00:11:44,437 --> 00:11:48,207 CUP OF COFFEE TO GET STARTED. 334 00:11:48,274 --> 00:11:49,875 SO LIKE EATING, SUBSTANCE USE IS 335 00:11:49,942 --> 00:11:51,043 AN ACTIVITY THAT CAN BE DRIVEN 336 00:11:51,110 --> 00:11:52,912 BY THE THINGS THAT GO ON INSIDE 337 00:11:52,978 --> 00:11:53,979 THE PERSON AND THINGS THAT CAN 338 00:11:54,046 --> 00:11:59,985 GO ON OUTSIDE THAT PERSON. 339 00:12:00,052 --> 00:12:03,055 IN PART, THAT'S WHAT MAKES IT 340 00:12:03,122 --> 00:12:05,257 DIFFICULT AND COMPLICATED TO 341 00:12:05,324 --> 00:12:07,326 TREAT. 342 00:12:07,393 --> 00:12:09,195 PEOPLE WANT SIMPLE SOLUTIONS TO 343 00:12:09,261 --> 00:12:10,529 TREATING A PERSON WITH SUBSTANCE 344 00:12:10,596 --> 00:12:11,897 USE. 345 00:12:11,964 --> 00:12:13,232 WELL, WE'LL COME BACK TO THIS, 346 00:12:13,299 --> 00:12:14,133 LET'S JUST GIVE THEM 347 00:12:14,200 --> 00:12:14,733 BUPRENORPHINE AND EVERYTHING 348 00:12:14,800 --> 00:12:16,068 WILL BE OKAY. 349 00:12:16,135 --> 00:12:19,038 AND SO OFTEN WE FIND THAT GIVING 350 00:12:19,105 --> 00:12:20,873 BUPRENORPHINE OR METHADONE OR 351 00:12:20,940 --> 00:12:23,609 SOME OTHER MEDICINE DOESN'T 352 00:12:23,676 --> 00:12:26,479 SIMPLY SOLVE THE PROBLEM FOR A 353 00:12:26,545 --> 00:12:27,780 PERSON WHO'S STRUGGLING WITH A 354 00:12:27,847 --> 00:12:33,786 SUBSTANCE USE DISORDER. 355 00:12:33,853 --> 00:12:35,321 SO WE CAN UNDERSTAND DRUG MISUSE 356 00:12:35,387 --> 00:12:36,655 WHEN WE APPRECIATE OUR OWN 357 00:12:36,722 --> 00:12:38,524 DRIVEN BEHAVIORS, I WOULD ARGUE. 358 00:12:38,591 --> 00:12:40,226 WE DON'T HAVE TO AGREE WITH IT, 359 00:12:40,292 --> 00:12:42,862 BUT WE CAN BEGIN TO UNDERSTAND 360 00:12:42,928 --> 00:12:43,362 IT. 361 00:12:43,429 --> 00:12:49,802 SO JUST AS WE MIGHT START TO 362 00:12:49,869 --> 00:12:50,870 UNDERSTAND IF YOU TRY GOING 363 00:12:50,936 --> 00:12:52,171 WITHOUT CAFFEINE FOR A WEEK, HOW 364 00:12:52,238 --> 00:12:53,906 DOES THAT GO, OR IF YOU GO 365 00:12:53,973 --> 00:12:56,142 WITHOUT SOMETHING ELSE FOR A 366 00:12:56,208 --> 00:12:58,744 PERIOD OF TIME TO SEE HOW THAT 367 00:12:58,811 --> 00:13:02,014 INFLUENCES YOUR BEHAVIOR. 368 00:13:02,081 --> 00:13:06,385 SO I, FOR EXAMPLE, HAVE THIS 369 00:13:06,452 --> 00:13:07,586 RECURRING NEW YEAR'S RESOLUTION, 370 00:13:07,653 --> 00:13:11,090 WHICH JUST STARTEED 72 HOURS AG, 371 00:13:11,157 --> 00:13:13,159 THAT I WILL NOT EAT SWEETS, 372 00:13:13,225 --> 00:13:14,026 OKAY? 373 00:13:14,093 --> 00:13:15,895 BECAUSE I LOVE SWEETS. 374 00:13:15,961 --> 00:13:17,096 OBVIOUSLY, I LOVE PIE AND ICE 375 00:13:17,163 --> 00:13:18,631 CREAM, YOU'VE ALREADY FOUND THAT 376 00:13:18,697 --> 00:13:19,632 OUT, RIGHT? 377 00:13:19,698 --> 00:13:20,933 SO -- AND IT BECOMES VERY 378 00:13:21,000 --> 00:13:22,568 INTERESTING TO SEE ALL THE CUES 379 00:13:22,635 --> 00:13:24,436 IN THE ENVIRONMENT, ALL THE 380 00:13:24,503 --> 00:13:25,871 THINGS THAT GO ON, AND I'VE 381 00:13:25,938 --> 00:13:27,840 TRIED THIS FOR YEARS. 382 00:13:27,907 --> 00:13:30,009 I USUALLY TRY TO MAKE TO 383 00:13:30,075 --> 00:13:30,676 THANKSGIVING. 384 00:13:30,743 --> 00:13:33,846 AND I DID A ONE-YEAR AND IN THE 385 00:13:33,913 --> 00:13:35,147 SUMMERTIME I WAS GIVING GRAND 386 00:13:35,214 --> 00:13:36,582 ROUNDS IN RICHMOND, AND A FRIEND 387 00:13:36,649 --> 00:13:38,217 TOOK ME TO LUNCH AND HE SAID, 388 00:13:38,284 --> 00:13:39,318 OH, WE'VE GOT TO HAVE ICE CREAM 389 00:13:39,385 --> 00:13:41,987 AT THE END OF LUNCH, THEY'VE GOT 390 00:13:42,054 --> 00:13:42,922 GREAT ICE CREAM HERE. 391 00:13:42,988 --> 00:13:43,889 I SAID I'M OKAY. 392 00:13:43,956 --> 00:13:45,324 HE SAID NO, NO, YOU NEED TO TRY 393 00:13:45,391 --> 00:13:45,524 IT. 394 00:13:45,591 --> 00:13:47,526 I SAID, WELL, I'M OKAY, I 395 00:13:47,593 --> 00:13:49,361 ACTUALLY MADE THIS NEW YEAR'S 396 00:13:49,428 --> 00:13:50,362 RESOLUTION AND I'M TRYING NOT 397 00:13:50,429 --> 00:13:50,729 TO. 398 00:13:50,796 --> 00:13:52,097 THEN HE SAID, JUST HAVE A LITTLE 399 00:13:52,164 --> 00:13:52,531 BIT. 400 00:13:52,598 --> 00:13:54,300 IT WON'T COUNT. 401 00:13:54,366 --> 00:13:55,201 [LAUGHTER] 402 00:13:55,267 --> 00:13:55,601 RIGHT? 403 00:13:55,668 --> 00:13:57,703 THAT SOUNDS JUST LIKE, YOU KNOW, 404 00:13:57,770 --> 00:13:59,872 A DRUG DEALER WITH A DRUG 405 00:13:59,939 --> 00:14:00,839 ABUSER. 406 00:14:00,906 --> 00:14:01,840 JUST -- JUST -- JUST TAKE A 407 00:14:01,907 --> 00:14:02,408 LITTLE BIT. 408 00:14:02,474 --> 00:14:04,677 IT WON'T COUNT, RIGHT? 409 00:14:04,743 --> 00:14:07,546 I DIDN'T TAKE ANY. 410 00:14:07,613 --> 00:14:08,414 OKAY. 411 00:14:08,480 --> 00:14:10,382 AND THEN EVERYONE HAS AN OPINION 412 00:14:10,449 --> 00:14:11,150 ABOUT DRUG ABUSE. 413 00:14:11,217 --> 00:14:12,551 I JUST WANT TO MAKE THAT POINT. 414 00:14:12,618 --> 00:14:14,320 EVERYBODY DOES. 415 00:14:14,386 --> 00:14:16,889 I REMEMBER ONCE YEARS AGO, MY 416 00:14:16,956 --> 00:14:17,823 DENTIST WAS WORKING IN MY MOUTH 417 00:14:17,890 --> 00:14:19,225 AND STARTED GIVING ME HIS 418 00:14:19,291 --> 00:14:20,392 OPINION ABOUT DRUG ABUSE AND HOW 419 00:14:20,459 --> 00:14:22,394 TO SOLVE IT, AND I AGREED WITH 420 00:14:22,461 --> 00:14:23,929 EVERYTHING HE SAID BECAUSE HE 421 00:14:23,996 --> 00:14:25,364 HAD SHARP INSTRUMENTS IN MY 422 00:14:25,431 --> 00:14:25,898 MOUTH. 423 00:14:25,965 --> 00:14:28,200 BUT EVERYBODY'S GOT AN OPINION. 424 00:14:28,267 --> 00:14:29,835 SO HOW DID WE GET HERE WITH 425 00:14:29,902 --> 00:14:30,402 OPIOID USE? 426 00:14:30,469 --> 00:14:31,804 WELL, DOCTORS WERE BEING TOLD 427 00:14:31,870 --> 00:14:33,672 THEY WERE UNDERTREATING PAIN. 428 00:14:33,739 --> 00:14:35,207 WE WERE TOLD WE WERE WORRIED TOO 429 00:14:35,274 --> 00:14:36,141 MUCH ABOUT ADDICTION, THERE WAS 430 00:14:36,208 --> 00:14:37,276 A LOW RISK OF IT. 431 00:14:37,343 --> 00:14:39,812 THERE WAS THIS FAMOUS LETTER TO 432 00:14:39,878 --> 00:14:41,046 THE EDITOR IN THE NEW ENGLAND 433 00:14:41,113 --> 00:14:45,050 JOURNAL OF MEDICINE IN 1980, 434 00:14:45,117 --> 00:14:46,585 PORTER INJEK, IF YOU HAVEN'T 435 00:14:46,652 --> 00:14:47,987 HEARD OF IT, YOU WILL AT SOME 436 00:14:48,053 --> 00:14:49,388 POINT PROBABLY COME ACROSS IT 437 00:14:49,455 --> 00:14:51,824 THAT WAS WIDELY CITED BY THE 438 00:14:51,890 --> 00:14:53,692 PHARMACEUTICAL COMPANY INDUSTRY. 439 00:14:53,759 --> 00:14:56,528 THEY SAID THEY DID THIS REVIEW 440 00:14:56,595 --> 00:14:57,630 WITH 11,882 PATIENTS WHO 441 00:14:57,696 --> 00:14:59,698 RECEIVED AT LEAST ONE NARCOTIC 442 00:14:59,765 --> 00:15:02,434 PREPARATION AND FOUND ONLY FOUR 443 00:15:02,501 --> 00:15:04,570 CASES OF WELL DOCUMENTED 444 00:15:04,637 --> 00:15:05,838 ADDICTION IN PATIENTS WHO HAD NO 445 00:15:05,904 --> 00:15:07,373 HISTORY OF ADDICTION. 446 00:15:07,439 --> 00:15:10,075 AND EVERYBODY SAID, LOOK, GIVE 447 00:15:10,142 --> 00:15:10,743 PEOPLE OPIOIDS. 448 00:15:10,809 --> 00:15:12,611 PEOPLE DON'T GET ADDICTED WITH 449 00:15:12,678 --> 00:15:12,945 OPIOIDS. 450 00:15:13,012 --> 00:15:14,246 SO THEN DOCTORS WERE BEING TOLD 451 00:15:14,313 --> 00:15:16,382 WE WERE UNDERTREATING PAIN AND 452 00:15:16,448 --> 00:15:17,650 WE WERE LETTING PATIENTS SUFFER 453 00:15:17,716 --> 00:15:21,020 WITH PAIN, WAS THE OTHER THING. 454 00:15:21,086 --> 00:15:24,523 AND IF YOU LIVE THROUGH THIS, 455 00:15:24,590 --> 00:15:26,492 YOU KNOW IN 1995, THE MIRN PAIN 456 00:15:26,558 --> 00:15:28,894 SOCIETY PUT OUT PAIN AS A FIFTH 457 00:15:28,961 --> 00:15:29,995 VITAL SIGN. 458 00:15:30,062 --> 00:15:32,298 IN 1998, AND THEN AGAIN IN 2004, 459 00:15:32,364 --> 00:15:35,034 THE FEDERATION OF STATE MEDICAL 460 00:15:35,100 --> 00:15:36,902 BOARDS POLICIES ESSENTIALLY 461 00:15:36,969 --> 00:15:38,404 ENCOURAGED DOCTORS TO PRESCRIBE 462 00:15:38,470 --> 00:15:39,938 OPIOIDS FOR PAIN. 463 00:15:40,005 --> 00:15:41,240 THE JOINT COMMISSION ENCOURAGES 464 00:15:41,307 --> 00:15:42,775 TREAT OF PAIN OF THEY WANT TO 465 00:15:42,841 --> 00:15:44,943 SEE DOCUMENTATION OF THAT FIFTH 466 00:15:45,010 --> 00:15:45,511 VITAL SIGN. 467 00:15:45,577 --> 00:15:47,713 THERE'S JUST A CONFLUENCE COMING 468 00:15:47,780 --> 00:15:49,615 ABOUT WHERE WE'RE NOT TREATING 469 00:15:49,682 --> 00:15:53,552 PAIN ADEQUATELY. 470 00:15:53,619 --> 00:15:54,987 AND, OF COURSE, THERE'S 471 00:15:55,054 --> 00:15:58,023 AGGRESSIVE MARKETING OF OPIOID 472 00:15:58,090 --> 00:15:59,224 ANALGESIC MEDICATIONS, RIGHT? 473 00:15:59,291 --> 00:16:00,626 SO I THINK EVERYBODY AT THIS 474 00:16:00,693 --> 00:16:04,063 POINT HAS HEARD ABOUT OXYCONTIN 475 00:16:04,129 --> 00:16:06,899 AND OXYCODONE IS THE OPIOID IN 476 00:16:06,965 --> 00:16:08,534 OXYCONTIN, IT'S MARKETED BY 477 00:16:08,600 --> 00:16:11,270 PURDUE STARTING IN 1996. 478 00:16:11,337 --> 00:16:12,471 IT'S NOT PARTICULARLY SUPERIOR 479 00:16:12,538 --> 00:16:14,073 TO OTHER ANALGESICS, BUT IT'S 480 00:16:14,139 --> 00:16:15,841 GOT A LONGER DURATION OF ACTION 481 00:16:15,908 --> 00:16:17,609 VERSUS OTHER OXYCODONE PRODUCTS, 482 00:16:17,676 --> 00:16:19,011 IT WORKS FOR 12 HOURS. 483 00:16:19,078 --> 00:16:21,213 THEY DO A MAJOR MARKETING PUSH 484 00:16:21,280 --> 00:16:23,082 BY PURDUE PHARMACEUTICALS, SO 485 00:16:23,148 --> 00:16:24,717 YOU HAVE THINGS LIKE DOCTORS 486 00:16:24,783 --> 00:16:26,151 GETTING THESE CLOCKS SHOWING 487 00:16:26,218 --> 00:16:29,421 THAT IT WORKS FOR 12 HOURS, 488 00:16:29,488 --> 00:16:29,655 HATS. 489 00:16:29,722 --> 00:16:33,559 THERE WAS A CD, GET IN THE SWING 490 00:16:33,625 --> 00:16:35,094 WITH OXYCONTIN, THERE WERE TOYS, 491 00:16:35,160 --> 00:16:36,862 TEDDY BEARS, DINNERS FOR 492 00:16:36,929 --> 00:16:38,831 PHYSICIANS, ALL SORTS OF THINGS 493 00:16:38,897 --> 00:16:41,133 PUSHING TO GET DOCTORS TO 494 00:16:41,200 --> 00:16:43,535 PRESCRIBE MORE OXYCONTIN. 495 00:16:43,602 --> 00:16:45,604 THIS JUST SHOWS OXYCONTIN SALES. 496 00:16:45,671 --> 00:16:52,177 THEY REACHED $3 BILLION IN 2010. 497 00:16:52,244 --> 00:16:53,912 AND CONTINUE TO BE HIGH. 498 00:16:53,979 --> 00:16:56,115 I THINK MOST PEOPLE ARE FAMILIAR 499 00:16:56,181 --> 00:16:59,952 WITH THIS STORY, THE SACHLER 500 00:17:00,018 --> 00:17:01,520 FAMILY, PURDUE FA PHARMACEUTICAS 501 00:17:01,587 --> 00:17:03,555 WAS A PRIVATELY HELD COMPANY, 502 00:17:03,622 --> 00:17:08,494 THE SACHLERS OWNED, AND IT'S A 503 00:17:08,560 --> 00:17:09,661 BLOCKBUSTER DRUG DESPITE THE 504 00:17:09,728 --> 00:17:10,662 BACKLASH THAT OCCURRED. 505 00:17:10,729 --> 00:17:12,197 IT IMPORTANT TO NOTE THAT IT 506 00:17:12,264 --> 00:17:14,933 WASN'T JUST OXYCONTIN. 507 00:17:15,000 --> 00:17:17,002 OXYCONTIN AND OTHER OPIOID 508 00:17:17,069 --> 00:17:19,171 ANALGESICS DON'T WRITE THEIR OWN 509 00:17:19,238 --> 00:17:19,505 PRESCRIPTIONS. 510 00:17:19,571 --> 00:17:21,073 IT WAS A CULTURAL PHENOMENON IN 511 00:17:21,140 --> 00:17:22,141 MEDICINE AND IN THE BROADER 512 00:17:22,207 --> 00:17:23,342 SOCIETY THAT SUGGESTED THAT WE 513 00:17:23,409 --> 00:17:25,511 NEEDED TO BE MORE AGGRESSIVE 514 00:17:25,577 --> 00:17:28,147 ABOUT MARKETING. 515 00:17:28,213 --> 00:17:31,116 OPIOID DRUGS. 516 00:17:31,183 --> 00:17:33,852 SO WHERE ARE WE NOW WITH OPIATE 517 00:17:33,919 --> 00:17:38,090 USE WITH THAT SORT OF BACKGR 518 00:17:38,157 --> 00:17:38,424 BACKGROUND? 519 00:17:38,490 --> 00:17:39,858 SO THESE -- I'M GOING TO HAVE A 520 00:17:39,925 --> 00:17:41,593 FEW SLIDES OF THIS. 521 00:17:41,660 --> 00:17:45,230 THIS SHOWS OPIATE PRESCRIPTIONS 522 00:17:45,297 --> 00:17:47,866 DISPENSED, AND IT SHOWS A 523 00:17:47,933 --> 00:17:49,802 BREAKOUT OF -- THE RED LINE IS 524 00:17:49,868 --> 00:17:52,304 HYDROCODONE, THE GREEN LINE IS 525 00:17:52,371 --> 00:17:52,638 OXYCODONE. 526 00:17:52,704 --> 00:17:56,475 SO YOU SEE HERE, AND YOU SEE 527 00:17:56,542 --> 00:18:01,847 THAT STARTING AROUND 2010 TO 528 00:18:01,914 --> 00:18:03,482 2012 AND INTO 2013, WE START TO 529 00:18:03,549 --> 00:18:05,150 SEE AS THIS BACKLASH OCCURS, WE 530 00:18:05,217 --> 00:18:08,620 START TO SEE A DECREASE, SOME 531 00:18:08,687 --> 00:18:11,490 DECREASE IN PRESCRIBING OF 532 00:18:11,557 --> 00:18:12,691 OPIATE ANALGESICS. 533 00:18:12,758 --> 00:18:14,760 AND THIS IS A DIFFERENT SLIDE 534 00:18:14,827 --> 00:18:18,797 THAT LOOKS AT OPIATE 535 00:18:18,864 --> 00:18:20,332 PRESCRIPTIONS DISPENSED FROM A 536 00:18:20,399 --> 00:18:21,967 DIFFERENT DATASET, AND YOU SEE 537 00:18:22,034 --> 00:18:26,438 THIS GOES TO 2020, AND YOU SEE 538 00:18:26,505 --> 00:18:30,709 CLEARLY THAT PRESCRIPTIONS ARE 539 00:18:30,776 --> 00:18:32,578 DECLINING HERE PRETTY 540 00:18:32,644 --> 00:18:35,747 DRAMATICALLY BY 2020. 541 00:18:35,814 --> 00:18:37,282 SO IT GOES FROM A HIGH OF A 542 00:18:37,349 --> 00:18:40,085 LITTLE OVER 250 MILLION DOWN TO 543 00:18:40,152 --> 00:18:42,521 LESS THAN 150 MILLION IN THE 544 00:18:42,588 --> 00:18:49,094 SPACE OF LESS THAN 10 YEARS. 545 00:18:49,161 --> 00:18:50,395 SO OF COURSE ANOTHER PROBLEM, 546 00:18:50,462 --> 00:18:52,931 THOUGH, NOT JUST IN OPIATE 547 00:18:52,998 --> 00:18:54,233 PRESCRIPTIONS BUT WHAT REALLY 548 00:18:54,299 --> 00:18:57,536 CAPTURES US IS OPIATE OVERDOSE 549 00:18:57,603 --> 00:19:01,340 DEATHS FROM THE USE OF OPIOIDS. 550 00:19:01,406 --> 00:19:03,976 AND I THINK, AGAIN, THIS IS 551 00:19:04,042 --> 00:19:07,479 REAL --THIS HAS REALLY NOW BEENL 552 00:19:07,546 --> 00:19:08,247 DISSEMINATED INTO THE COMMUNITY. 553 00:19:08,313 --> 00:19:10,516 I WANT TO HIGHLIGHT FOR YOU THAT 554 00:19:10,582 --> 00:19:13,485 THERE WERE FOUR OVERLAPPING 555 00:19:13,552 --> 00:19:15,687 WAVES OF OPIATE OVERDOSE DEATHS. 556 00:19:15,754 --> 00:19:17,689 SO THE FIRST WAVE BEGINS, AND 557 00:19:17,756 --> 00:19:19,825 I'LL SHOW THIS TO YOU 558 00:19:19,892 --> 00:19:21,159 GRAPHICALLY IN A MOMENT, IN THE 559 00:19:21,226 --> 00:19:23,095 1990s WITH THE LIBERAL 560 00:19:23,161 --> 00:19:24,963 PRESCRIPTION OF OPIOIDS, SO WHAT 561 00:19:25,030 --> 00:19:26,832 WE JUST TALKED ABOUT WITH 562 00:19:26,899 --> 00:19:30,435 RESPECT TO OXYCONTIN AND OTHER 563 00:19:30,502 --> 00:19:32,070 OPIOIDS AS WELL, THEN AS THOSE 564 00:19:32,137 --> 00:19:35,541 START TO DECREASE, WE SEE A 565 00:19:35,607 --> 00:19:38,210 SHIFT OVER TO HEROIN USE, WHICH 566 00:19:38,277 --> 00:19:40,812 STARTS AROUND 2010, SO AS WE 567 00:19:40,879 --> 00:19:42,414 CONTRACT THE AVAILABILITY OF 568 00:19:42,481 --> 00:19:44,016 PRESCRIPTION OPIOIDS, WE SEE 569 00:19:44,082 --> 00:19:48,720 PEOPLE SHIFTING OVER TO HEROIN. 570 00:19:48,787 --> 00:19:50,822 THEN AROUND 2013, THERE'S A 571 00:19:50,889 --> 00:19:53,091 PRETTY QUICK SHIFT FROM HEROIN 572 00:19:53,158 --> 00:19:55,827 TO FENTANYL AND FENTANYL ANALOGS 573 00:19:55,894 --> 00:19:56,929 LIKE CARFENTANYL. 574 00:19:56,995 --> 00:19:59,565 AND NOW MOST RECENTLY, AROUND 575 00:19:59,631 --> 00:20:02,834 2015, WE SEE THAT IT'S OPIOIDS 576 00:20:02,901 --> 00:20:06,238 WITH OTHER DRUGS AND IN 577 00:20:06,305 --> 00:20:07,739 PARTICULAR STIMULANTS AND 578 00:20:07,806 --> 00:20:08,173 XYLAZINE. 579 00:20:08,240 --> 00:20:09,942 I'M NOT GOING TO TALK A LOT 580 00:20:10,008 --> 00:20:12,010 ABOUT THESE TODAY, BUT I WILL 581 00:20:12,077 --> 00:20:14,413 COME BACK TO STIMULANTS IN 582 00:20:14,479 --> 00:20:17,816 PARTICULAR IN A MINUTE. 583 00:20:17,883 --> 00:20:24,723 BUT THIS IS REALLY -- HAS REALLY 584 00:20:24,790 --> 00:20:27,893 WHERE WE'VE BEEN CURRENTLY. 585 00:20:27,960 --> 00:20:29,628 THIS IS A PAPER THAT ONE OF OUR 586 00:20:29,695 --> 00:20:31,096 FACULTY MEMBERS REVIEWED, SHE 587 00:20:31,163 --> 00:20:32,097 PUBLISHED IN THE AMERICAN 588 00:20:32,164 --> 00:20:33,799 JOURNAL OF PSYCHIATRY, I WAS 589 00:20:33,865 --> 00:20:35,233 GOING TO SAY LAST YEAR BUT IT'S 590 00:20:35,300 --> 00:20:39,271 NOW TWO YEARS AGO. 591 00:20:39,338 --> 00:20:40,272 , OF DRUG 592 00:20:40,339 --> 00:20:43,442 OVERDOSE DEATHS FROM 2016 TO 593 00:20:43,508 --> 00:20:49,114 2021 BY DRUG TOXICOLOGY REPORTS. 594 00:20:49,181 --> 00:20:51,750 WHAT YOU SEE HERE IS FOR ANYBODY 595 00:20:51,817 --> 00:20:53,518 OPIOID OVERDOSE, THERE WERE OVER 596 00:20:53,585 --> 00:20:58,523 80,000 DEATHS IN 2021, LAST YEAR 597 00:20:58,590 --> 00:21:02,794 THAT DATA WERE AVAILABLE. 598 00:21:02,861 --> 00:21:04,663 THAT SYNTHETIC OPIOIDS EXCLUDING 599 00:21:04,730 --> 00:21:06,632 METHADONE, SO THAT'S ESSENTIALLY 600 00:21:06,698 --> 00:21:07,833 FENTANYL AND FENTANYL AN LOGS, 601 00:21:07,899 --> 00:21:10,769 ARE THE OVERWHELMING MAJORITY AS 602 00:21:10,836 --> 00:21:15,040 THIS POINT OF THOSE DEATHS. 603 00:21:15,107 --> 00:21:16,908 YOU SEE, ON THE OTHER HAND, 604 00:21:16,975 --> 00:21:18,777 HEROIN IS A VERY SMALL 605 00:21:18,844 --> 00:21:21,513 PROPORTION, IT'S NOT SOMETHING 606 00:21:21,580 --> 00:21:23,482 THAT SHOULD JUST BE IGNORED BUT 607 00:21:23,548 --> 00:21:24,783 IT'S LESS THAN 10,000 DEATHS. 608 00:21:24,850 --> 00:21:26,418 AND IF YOU LOOK AT THAT, IT'S 609 00:21:26,485 --> 00:21:30,589 REALLY BEEN PRETTY LOW AND FLAT 610 00:21:30,656 --> 00:21:33,325 OVER TIME, THOSE DEATHS FROM 611 00:21:33,392 --> 00:21:36,695 HEROIN. 612 00:21:36,762 --> 00:21:39,665 AND THEN NATURAL SEMI SYNTHETIC 613 00:21:39,731 --> 00:21:43,268 OPIOIDS, THINGS LIKE OXYCODONE, 614 00:21:43,335 --> 00:21:46,538 OXYCONTIN, MORPHONE, THOSE ARE 615 00:21:46,605 --> 00:21:48,073 RELATIVELY FLAT AS WELL AT ABOUT 616 00:21:48,140 --> 00:21:51,476 13,000 DEATHS. 617 00:21:51,543 --> 00:21:53,311 SO REALLY IT'S THESE, YOU 618 00:21:53,378 --> 00:21:57,115 KNOW -- THE BIG THING IS THIS 619 00:21:57,182 --> 00:21:59,451 70,000 THE FENTANYL AND FENTANYL 620 00:21:59,518 --> 00:22:00,419 ANALOGS AT THIS POINT THAT'S 621 00:22:00,485 --> 00:22:05,323 REALLY TAKEN OFF IN THIS FOURTH 622 00:22:05,390 --> 00:22:07,392 WAVE, THIRD TO FOURTH WAVE OF 623 00:22:07,459 --> 00:22:08,060 OVERDOSE DEATHS. 624 00:22:08,126 --> 00:22:10,929 WHILE I'M NOT GOING TO FOCUS ON 625 00:22:10,996 --> 00:22:13,331 IT TODAY, I DO WANT TO HIGHLIGHT 626 00:22:13,398 --> 00:22:14,966 THAT THERE'S INCREASING RATES OF 627 00:22:15,033 --> 00:22:18,370 STIMULANT MISUSE AND ASSOCIATION 628 00:22:18,437 --> 00:22:18,904 WITH OVERDOSE DEATHS. 629 00:22:18,970 --> 00:22:20,572 SO GOING BACK TO THAT FIGURE, 630 00:22:20,639 --> 00:22:23,275 LOOK AT THIS GREEN LINE, WHICH 631 00:22:23,341 --> 00:22:27,546 IS STIMULANTS, WHICH IS 632 00:22:27,612 --> 00:22:28,413 METHAMPHETAMINE, COCAINE, WHICH 633 00:22:28,480 --> 00:22:31,383 IS REALLY -- HAS REALLY BEEN 634 00:22:31,450 --> 00:22:31,917 GOING UPWARDS NOW. 635 00:22:31,983 --> 00:22:35,220 THIS IS TYPICALLY COMBINED WITH 636 00:22:35,287 --> 00:22:37,055 OPIOIDS, BUT STILL IT'S A 637 00:22:37,122 --> 00:22:37,989 PROBLEM AND A CONCERN THAT WE 638 00:22:38,056 --> 00:22:43,528 NEED TO BE AWARE. 639 00:22:43,595 --> 00:22:44,596 THESE ARE -- I THOUGHT ABOUT 640 00:22:44,663 --> 00:22:46,164 TAKING THIS OUT BECAUSE THIS IS 641 00:22:46,231 --> 00:22:49,768 A PAPER THAT CAME OUT IN 2015 BY 642 00:22:49,835 --> 00:22:52,370 CASE AND DEITIN, THERE'S BEEN 643 00:22:52,437 --> 00:22:53,905 SOME PUSHBACK ABOUT WHETHER THE 644 00:22:53,972 --> 00:22:55,674 ANALYSES ARE CORRECT BUT I STILL 645 00:22:55,741 --> 00:22:56,875 THINK IT'S WORTH SHOWING. 646 00:22:56,942 --> 00:23:01,446 THIS IS -- THEY SHOWED U.S. 647 00:23:01,513 --> 00:23:12,090 DEATH RATE - IN 45 TO 45 TO 648 00:23:13,391 --> 00:23:15,127 54-YEAR-OLDS, THESE ARE DEATHS 649 00:23:15,193 --> 00:23:15,994 PER 100,000. 650 00:23:16,061 --> 00:23:16,661 THESE ARE DIFFERENT COUNTRIES 651 00:23:16,728 --> 00:23:19,698 THAT ARE SHOWN, SO YOU CAN SORT 652 00:23:19,765 --> 00:23:20,699 OF FIGURE IT OUT. 653 00:23:20,766 --> 00:23:23,235 THIS IS FRANCE, GERMANY, THE 654 00:23:23,301 --> 00:23:26,738 U.K., CANADA, AUSTRALIA, SWEDEN. 655 00:23:26,805 --> 00:23:28,140 AND WHAT YOU SEE OVERALL IS THAT 656 00:23:28,206 --> 00:23:30,642 THE LINES ARE ALL KIND OF 657 00:23:30,709 --> 00:23:34,379 TRENDING DOWN OVER TIME IN DEATH 658 00:23:34,446 --> 00:23:35,914 RATES, WITH THE EXCEPTION OF 659 00:23:35,981 --> 00:23:39,484 U.S. WHITE NON-HISPANICS. 660 00:23:39,551 --> 00:23:41,052 AND AGAIN, THERE'S BEEN SOME 661 00:23:41,119 --> 00:23:42,420 PUSHBACK ABOUT THESE ANALYSES, 662 00:23:42,487 --> 00:23:44,656 BUT I THINK IT STILL HAS BEEN 663 00:23:44,723 --> 00:23:47,125 SOMETHING THAT'S CAPTURED A LOT 664 00:23:47,192 --> 00:23:48,360 OF ATTENTION BECAUSE IT DOES 665 00:23:48,426 --> 00:23:50,829 SEEM LIKE IT'S A PARTICULAR 666 00:23:50,896 --> 00:23:53,231 POPULATION THAT'S BEEN A 667 00:23:53,298 --> 00:23:53,999 CONCERN. 668 00:23:54,065 --> 00:23:56,067 SO IT'S A RELATIVELY FLAT DEATH 669 00:23:56,134 --> 00:23:59,037 RATE COMPARED TO OTHERS, AND 670 00:23:59,104 --> 00:24:05,577 THIS OBVIOUSLY PRECEDES COVID. 671 00:24:05,644 --> 00:24:06,878 INTERESTINGLY, THAT U.S. H IS 672 00:24:06,945 --> 00:24:08,246 U.S. HISPANICS, AND THAT LINE 673 00:24:08,313 --> 00:24:09,314 HAS STILL BEEN TRENDING DOWN 674 00:24:09,381 --> 00:24:10,415 LIKE OTHER COUNTRIES OVER THIS 675 00:24:10,482 --> 00:24:13,018 TIME PERIOD. 676 00:24:13,084 --> 00:24:17,322 SO IT WASN'T SIMPLY THE WHOLE 677 00:24:17,389 --> 00:24:22,761 POPULATION, THIS HAS REALLY HIT 678 00:24:22,828 --> 00:24:24,296 U.S. WHITES, IT'S BEEN NOTED. 679 00:24:24,362 --> 00:24:25,397 IF YOU'RE INTERESTED IN READING 680 00:24:25,463 --> 00:24:31,403 ABOUT THIS, THERE'S TALK ABOUT 681 00:24:31,469 --> 00:24:34,372 SAM KIONE'S BOOKS, IN 682 00:24:34,439 --> 00:24:35,807 PARTICULAR, DREAMLAND AND THE 683 00:24:35,874 --> 00:24:37,642 LEAST OF US, I WOULD RECOMMEND. 684 00:24:37,709 --> 00:24:40,378 I THINK -- THE LEAST OF US, I 685 00:24:40,445 --> 00:24:43,014 HOPE SAM ISN'T LISTENING IN, BUT 686 00:24:43,081 --> 00:24:44,416 I THINK THE LEAST OF US IS A 687 00:24:44,482 --> 00:24:46,184 BETTER VERSION OF DREAMLAND. 688 00:24:46,251 --> 00:24:47,719 IT'S KIND OF LIKE HE WROTE THE 689 00:24:47,786 --> 00:24:49,020 SAME BOOK TWICE AND HE GOT A 690 00:24:49,087 --> 00:24:50,422 LITTLE BIT BETTER THE SECOND 691 00:24:50,488 --> 00:24:51,857 TIME. 692 00:24:51,923 --> 00:24:56,361 BUT THEY'RE BOTH GOOD BOOKS. 693 00:24:56,428 --> 00:24:58,330 TALKING ABOUT SORT OF THE 694 00:24:58,396 --> 00:24:59,831 EPIDEMIOLOGY OF OPIOID ABUSE, I 695 00:24:59,898 --> 00:25:00,799 THOUGHT THIS WAS AN INTERESTING 696 00:25:00,866 --> 00:25:02,234 PAPER I WANT TO HIGHLIGHT ABOUT 697 00:25:02,300 --> 00:25:05,637 WHERE DO PEOPLE GET OPIOIDS AND 698 00:25:05,704 --> 00:25:07,706 ESPECIALLY PRESCRIPTION OPIOIDS. 699 00:25:07,772 --> 00:25:10,442 THESE DATA ARE OLD NOW, ALMOST 700 00:25:10,508 --> 00:25:13,645 10 YEARS OLD. 701 00:25:13,712 --> 00:25:14,613 BUT I THINK THEY'RE INTERESTING. 702 00:25:14,679 --> 00:25:15,814 IT VARIES AS A FUNCTION OF 703 00:25:15,881 --> 00:25:17,515 WHETHER THEY HAVE PROBLEMATIC 704 00:25:17,582 --> 00:25:18,650 USE OF PRESCRIPTION OPIOIDS. 705 00:25:18,717 --> 00:25:21,386 SO THIS IS A PAPER THAT WAS 706 00:25:21,453 --> 00:25:23,588 PUBLISHED NOW ABOUT SEVEN YEARS 707 00:25:23,655 --> 00:25:25,490 AGO BY HANN, ET AL. IN THE 708 00:25:25,557 --> 00:25:26,858 ANNALS OF INTERNAL MEDICINE. 709 00:25:26,925 --> 00:25:29,427 THEY USED NSDA DATA, THE 710 00:25:29,494 --> 00:25:31,229 NATIONAL SURVEY ON DRUG USE AND 711 00:25:31,296 --> 00:25:32,764 HEALTH FROM 2015, AND THIS WAS, 712 00:25:32,831 --> 00:25:34,633 I THOUGHT, A VERY INTERESTING 713 00:25:34,699 --> 00:25:35,166 PAPER. 714 00:25:35,233 --> 00:25:37,369 THEY SHOWED ADULTS WHO WERE 715 00:25:37,435 --> 00:25:38,904 REPORTING MISUSE WITHOUT A USE 716 00:25:38,970 --> 00:25:41,740 DISORDER, SO THESE ARE PEOPLE 717 00:25:41,806 --> 00:25:43,742 WHO ARE SORT OF SPORADICALLY 718 00:25:43,808 --> 00:25:45,377 USING BUT THEN NOT DEVELOPING 719 00:25:45,443 --> 00:25:48,513 PROBLEMATIC USE, AND COMPARED 720 00:25:48,580 --> 00:25:51,016 THAT TO ADULTS REPORTING A USE 721 00:25:51,082 --> 00:25:52,484 DISORDER, SO BASICALLY WHAT WE 722 00:25:52,550 --> 00:25:55,553 USED TO CALL DEPENDENCE OR ABUSE 723 00:25:55,620 --> 00:25:55,987 ON OPIOIDS. 724 00:25:56,054 --> 00:25:56,922 WHAT YOU SEE IS THAT IF YOU 725 00:25:56,988 --> 00:26:00,992 DIDN'T HAVE A USE DISORDER, 726 00:26:01,059 --> 00:26:05,497 YOU'D OBTAINED OPIOIDS FOR FREE 727 00:26:05,563 --> 00:26:07,098 FROM A FRIEND OR RELATIVE, MORE 728 00:26:07,165 --> 00:26:07,365 COMMONLY. 729 00:26:07,432 --> 00:26:10,402 SO THIS IS SORT OF -- I GO CLEAN 730 00:26:10,468 --> 00:26:11,836 MY GUTTERS, I M COULD IN, MY 731 00:26:11,903 --> 00:26:14,472 BACK HURTS, I ASK MY WIFE IF SHE 732 00:26:14,539 --> 00:26:19,311 STILL HAS, YOU KNOW, A DILAUDID 733 00:26:19,377 --> 00:26:20,679 FROM WHEN SHE HAD HER TOOTH 734 00:26:20,745 --> 00:26:21,680 TAKEN OUT AND I TAKE IT. 735 00:26:21,746 --> 00:26:23,648 IT'S THAT SORT OF THING. 736 00:26:23,715 --> 00:26:28,019 AND I DON'T -- I'VE NEVER DONE 737 00:26:28,086 --> 00:26:29,120 THAT, BY THE WAY, FOR THE 738 00:26:29,187 --> 00:26:29,354 RECORD. 739 00:26:29,421 --> 00:26:30,522 IS THIS BEING RECORDED? 740 00:26:30,588 --> 00:26:31,723 YEAH, I'VE NEVER DONE THAT, BUT 741 00:26:31,790 --> 00:26:33,391 THAT WOULD BE AN EXAMPLE OF WHAT 742 00:26:33,458 --> 00:26:33,625 HAPPENS. 743 00:26:33,692 --> 00:26:34,326 ON THE OTHER HAND, FOR PEOPLE 744 00:26:34,392 --> 00:26:36,995 WHO HAVE A USE DISORDER, THEY'RE 745 00:26:37,062 --> 00:26:38,964 BUYING THEM FROM A FRIEND OR 746 00:26:39,030 --> 00:26:39,931 RELATIVE, MORE COMMONLY, SO 747 00:26:39,998 --> 00:26:43,435 THEY'RE BUYING THEM, OR THEY'RE 748 00:26:43,501 --> 00:26:45,270 BUYING THEM FROM OTHERS, FROM A 749 00:26:45,337 --> 00:26:50,342 DRUG DEALER OR A STRANGER. 750 00:26:50,408 --> 00:26:52,410 OKAY. 751 00:26:52,477 --> 00:26:56,348 SO WHERE ARE WE NOW WITH OPIATE 752 00:26:56,414 --> 00:26:56,781 ABUSE? 753 00:26:56,848 --> 00:26:58,249 TO SUMMARIZE, IT'S A CHANGING 754 00:26:58,316 --> 00:26:58,550 LANDSCAPE. 755 00:26:58,616 --> 00:27:00,618 WHERE WE ARE NOW IS NOT WHERE WE 756 00:27:00,685 --> 00:27:05,323 WERE JUST A FEW YEARS AGO. 757 00:27:05,390 --> 00:27:06,858 WE'RE SEEING A CLEAR DECREASE IN 758 00:27:06,925 --> 00:27:09,027 THE PRESCRIBING OF OPIOIDS, SO 759 00:27:09,094 --> 00:27:12,197 PHYSICIANS HAVE GOT THE MESSAGE 760 00:27:12,263 --> 00:27:13,565 THEY WERE OVERPRESCRIBING 761 00:27:13,631 --> 00:27:14,933 OPIOIDS, THEY WERE TOO LIBERAL, 762 00:27:15,000 --> 00:27:16,201 THERE'S BEEN A LOT OF PUSHBACK 763 00:27:16,267 --> 00:27:16,701 ON THAT. 764 00:27:16,768 --> 00:27:19,170 THERE'S BEEN A LOT OF WORK WITH 765 00:27:19,237 --> 00:27:19,971 ELECTRONIC MEDICAL RECORDS AND 766 00:27:20,038 --> 00:27:24,242 THINGS LIKE THAT TO GET 767 00:27:24,309 --> 00:27:26,544 PHYSICIANS TO DECREASE THEIR 768 00:27:26,611 --> 00:27:27,512 PRESCRIBING OF OPIOIDS. 769 00:27:27,579 --> 00:27:33,752 HEAR WIN USHEROIN USE IS LEVELIR 770 00:27:33,818 --> 00:27:35,487 DECREASING, THAT IS HEROIN, NOT 771 00:27:35,553 --> 00:27:35,754 FENTANYL. 772 00:27:35,820 --> 00:27:37,489 AND LET ME SAY THERE, IT'S 773 00:27:37,555 --> 00:27:38,523 INTERESTING BECAUSE WHEN I TALK 774 00:27:38,590 --> 00:27:40,859 TO PEOPLE ABOUT WHAT THEY'RE 775 00:27:40,925 --> 00:27:42,160 USING, THEY'LL SAY, WELL, I'M 776 00:27:42,227 --> 00:27:43,061 USING HEROIN. 777 00:27:43,128 --> 00:27:44,896 AND THEN WE'LL TEST THEIR URINE, 778 00:27:44,963 --> 00:27:46,865 AND IT DOESN'T HAVE ANYTHING 779 00:27:46,931 --> 00:27:47,966 EVIDENCE OF MORPHINE IN IT, 780 00:27:48,033 --> 00:27:49,601 WHICH IS THE METABOLITE FROM 781 00:27:49,667 --> 00:27:50,568 HEROIN. 782 00:27:50,635 --> 00:27:52,337 BUT IT HAS FENTANYL IN IT. 783 00:27:52,404 --> 00:27:54,005 AND I'LL TELL THEM, YOU DIDN'T 784 00:27:54,072 --> 00:27:54,873 USE HEROIN. 785 00:27:54,939 --> 00:27:56,174 YOU USED FENTANYL. 786 00:27:56,241 --> 00:27:58,243 AND THEY'LL SAY NO, NO, I 787 00:27:58,309 --> 00:27:58,476 DIDN'T. 788 00:27:58,543 --> 00:28:00,011 I BOUGHT HEROIN ON THE STREET. 789 00:28:00,078 --> 00:28:02,180 I'M NOT USING FENTANYL. 790 00:28:02,247 --> 00:28:03,615 SO EVEN THOUGH PEOPLE MAY BE 791 00:28:03,681 --> 00:28:05,683 SAYING THEY'RE USING HEROIN, 792 00:28:05,750 --> 00:28:06,918 WHAT THEY'RE REALLY USING IS 793 00:28:06,985 --> 00:28:08,420 FENTANYL AT THIS POINT. 794 00:28:08,486 --> 00:28:11,389 SO THERE'S INCREASING FENTANYL 795 00:28:11,456 --> 00:28:12,791 MISUSE, AND WE'RE SEEING THE 796 00:28:12,857 --> 00:28:18,596 ADDITION NOW OF SI XYLAZINE TO E 797 00:28:18,663 --> 00:28:19,798 SUPPLY. 798 00:28:19,864 --> 00:28:21,232 THERE'S INTERESTING STUFF COMING 799 00:28:21,299 --> 00:28:22,767 OUT, IF YOU'RE NOT FAMILIAR WITH 800 00:28:22,834 --> 00:28:27,472 XYLAZINE, THE STREET NAME IS 801 00:28:27,539 --> 00:28:28,006 TRA NC. 802 00:28:28,073 --> 00:28:29,207 WE'RE STARTING TO GO BACK AND 803 00:28:29,274 --> 00:28:31,609 LOOK AT URINE SAMPLES IN TESTS 804 00:28:31,676 --> 00:28:33,044 AND WE'RE SEEING THAT THERE'S 805 00:28:33,111 --> 00:28:35,213 RAMPANT USE -- THERE'S 806 00:28:35,280 --> 00:28:37,315 FREQUENTLY URINE SAMPLES 807 00:28:37,382 --> 00:28:38,817 POSITIVE FOR FENTANYL AND 808 00:28:38,883 --> 00:28:41,553 XYLAZINE. 809 00:28:41,619 --> 00:28:44,089 WHICH IS PROBLEMATIC, WE'RE 810 00:28:44,155 --> 00:28:45,190 FINDING. 811 00:28:45,256 --> 00:28:46,925 AND I WANT TO SAY, WE MAY BE 812 00:28:46,991 --> 00:28:48,460 PLAYING WHACK MOLE HERE. 813 00:28:48,526 --> 00:28:50,261 WE ADDRESS ONE PROBLEM, 814 00:28:50,328 --> 00:28:52,063 PRESCRIPTION OPIATE USE, 815 00:28:52,130 --> 00:28:54,032 AANOTHER POPS UP, LIKE FENTANYL. 816 00:28:54,099 --> 00:28:55,567 SO I THINK THAT WE NEED TO BE 817 00:28:55,633 --> 00:28:58,870 CAREFUL THERE. 818 00:28:58,937 --> 00:28:59,504 AS WE THINK ABOUT 819 00:28:59,571 --> 00:29:00,939 THIS AND SAY GEE, WE DON'T HAVE 820 00:29:01,005 --> 00:29:04,776 THE OPIOID PROBLEM UNDER CONTROL 821 00:29:04,843 --> 00:29:06,177 BECAUSE WE GOT PRESCRIPTION 822 00:29:06,244 --> 00:29:07,712 OPIATE USE DECREASING BUT WE'RE 823 00:29:07,779 --> 00:29:08,980 JUST SHIFTING OVER TO SOMETHING 824 00:29:09,047 --> 00:29:13,585 THAT'S ACTUALLY MORE PROBLEM 825 00:29:13,651 --> 00:29:13,885 PROBLEMATIC. 826 00:29:13,952 --> 00:29:14,819 SO NEXT I WANT TO TURN TO WHAT 827 00:29:14,886 --> 00:29:16,788 CAN WE DO. 828 00:29:16,855 --> 00:29:18,189 AND I'M GOING TO MAKE SOME 829 00:29:18,256 --> 00:29:19,724 GENERAL POINTS ABOUT WHAT WE CAN 830 00:29:19,791 --> 00:29:21,259 DO, THEN I'M GOING TO TALK ABOUT 831 00:29:21,326 --> 00:29:24,195 CURRENT MODALITIES OF TREATMENT, 832 00:29:24,262 --> 00:29:25,530 I'M GOING TO TALK A LITTLE ABOUT 833 00:29:25,597 --> 00:29:30,435 FUTURE OR NEW TREATMENTS, AND 834 00:29:30,502 --> 00:29:33,738 I'LL TAKE A MOMENT TO TALK ABOUT 835 00:29:33,805 --> 00:29:34,639 CREATING INTEGRATED SYSTEMS OF 836 00:29:34,706 --> 00:29:34,939 CARE. 837 00:29:35,006 --> 00:29:36,341 I'VE BEEN THINKING ABOUT THAT A 838 00:29:36,407 --> 00:29:38,209 LITTLE BIT IN TERMS OF SYSTEMS 839 00:29:38,276 --> 00:29:39,077 RATHER THAN SIMPLY AT THE 840 00:29:39,144 --> 00:29:44,315 PATIENT LEVEL. 841 00:29:44,382 --> 00:29:44,782 OKAY. 842 00:29:44,849 --> 00:29:47,485 SO LET'S TALK FIRST ABOUT SOME 843 00:29:47,552 --> 00:29:49,053 GENERAL POINTS. 844 00:29:49,120 --> 00:29:50,121 THE FIRST GENERAL POINT I WANT 845 00:29:50,188 --> 00:29:51,890 TO MAKE IS, THE PROBLEM IS EASY 846 00:29:51,956 --> 00:29:53,191 TO DEVELOP, BUT 847 00:29:53,258 --> 00:29:57,195 OVERNITRIFICATIOOVERNIGHT FIXES. 848 00:29:57,262 --> 00:29:59,430 I THINK THIS IS -- HOPEFULLY I'M 849 00:29:59,497 --> 00:30:01,232 IN SHOUTING DISTANCE OF CONGRESS 850 00:30:01,299 --> 00:30:03,334 AND THE WHITE HOUSE AND THINGS 851 00:30:03,401 --> 00:30:06,938 STANDING HERE, BUT YOU KNOW, I 852 00:30:07,005 --> 00:30:08,673 THINK PEOPLE, POLITICIANS, THE 853 00:30:08,740 --> 00:30:10,008 LAY PUBLIC, THEY WANT ANSWERS 854 00:30:10,074 --> 00:30:11,176 AND THEY WANT ANSWERS NOW. 855 00:30:11,242 --> 00:30:13,144 I MET WITH A DONOR ABOUT THREE 856 00:30:13,211 --> 00:30:15,013 OR FOUR YEARS AGO WHO WANTED TO 857 00:30:15,079 --> 00:30:18,183 GIVE SOME MONEY, AND THEY WANTED 858 00:30:18,249 --> 00:30:20,385 TO GO TO SOMETHING THAT WOULD 859 00:30:20,451 --> 00:30:21,819 FIX OPIATE OVERDOSES WITHIN THE 860 00:30:21,886 --> 00:30:24,856 NEXT YEAR. 861 00:30:24,923 --> 00:30:25,623 YEAH. 862 00:30:25,690 --> 00:30:31,996 YOU KNOW, AND I'VE MET WITH 863 00:30:32,063 --> 00:30:34,265 LEADERSHIP OR HEALTH SYSTEMS AT 864 00:30:34,332 --> 00:30:36,901 TIMES WHO WILL SAY WE WANT TO 865 00:30:36,968 --> 00:30:38,436 DECREASE OPIATE OVERDOSE DEATHS 866 00:30:38,503 --> 00:30:40,505 IN EAST BALTIMORE BY SOMETHING 867 00:30:40,572 --> 00:30:43,041 LIKE 50% WITHIN THE NEXT YEAR. 868 00:30:43,107 --> 00:30:46,411 IT'S SORT OF -- YOU KNOW, AND 869 00:30:46,477 --> 00:30:52,417 IT'S JUST PORTRAYING THE NAIVETY 870 00:30:52,483 --> 00:30:53,851 ABOUT HOW COMPLICATED THIS 871 00:30:53,918 --> 00:30:54,953 DISORDER IS AND HOW DIFFICULT IT 872 00:30:55,019 --> 00:30:55,720 IS TO TREAT IT. 873 00:30:55,787 --> 00:30:56,921 AND THERE AREN'T 874 00:30:56,988 --> 00:30:57,555 OVERNITRIFICATIONS. 875 00:30:57,622 --> 00:31:04,028 OVER --OVERNIGHT FIXES. 876 00:31:04,095 --> 00:31:05,763 OVERNIGHT FIXES ARE RARELY 877 00:31:05,830 --> 00:31:07,632 AVAILABLE. 878 00:31:07,699 --> 00:31:13,972 PEOPLE LOOK FOR MIRACLE CURES. 879 00:31:14,038 --> 00:31:16,808 CANNABIS, HEROIN, PSYCHEDELICS. 880 00:31:16,874 --> 00:31:17,909 THERE'S A FLAVOR THAT COMES 881 00:31:17,976 --> 00:31:20,211 AROUND EVERY FIVE OR 10 YEARS. 882 00:31:20,278 --> 00:31:24,682 I MEAN, RIGHT NOW IT'S SORT OF 883 00:31:24,749 --> 00:31:25,850 KRATOM AND PSYCHEDELICS ARE THE 884 00:31:25,917 --> 00:31:27,218 TWO BIGGIES. 885 00:31:27,285 --> 00:31:28,519 PSYCHEDELICS ARE GOING TO CURE 886 00:31:28,586 --> 00:31:30,054 EVERYTHING, TREATMENT-RESISTANT. 887 00:31:30,121 --> 00:31:32,123 AND WE'RE A BIG RESEARCH SITE 888 00:31:32,190 --> 00:31:34,859 FOR PSYCHEDELICS, OUR RESEARCH 889 00:31:34,926 --> 00:31:43,134 GROUP. 890 00:31:43,201 --> 00:31:47,038 DEPRESSION, PTSD, CANNABIS USE 891 00:31:47,105 --> 00:31:49,140 DISORDER, LYME DISEASE, 892 00:31:49,207 --> 00:31:49,407 ANOREXIA. 893 00:31:49,474 --> 00:31:52,176 YOU KNOW, YOU CAN NAME SOMETHING 894 00:31:52,243 --> 00:31:54,445 AND WE'LL TRY PSYCHEDELICS FOR 895 00:31:54,512 --> 00:31:54,712 IT. 896 00:31:54,779 --> 00:31:57,915 I THINK THEY CAN BE USEFUL, BUT 897 00:31:57,982 --> 00:32:07,392 I THINK THEY'RE ANYWAY. 898 00:32:07,458 --> 00:32:08,393 QUALITY TREATMENT WORKS. 899 00:32:08,459 --> 00:32:10,361 WE NEED TO RECOGNIZE THE 900 00:32:10,428 --> 00:32:11,996 COMPLEXITY OF DRUG USE, THE 901 00:32:12,063 --> 00:32:13,398 PHYSICAL AS WELL AS THE 902 00:32:13,464 --> 00:32:14,065 ENVIRONMENTAL CIRCUMSTANCES THAT 903 00:32:14,132 --> 00:32:15,600 DRIVE USE, THOSE THINGS INSIDE 904 00:32:15,667 --> 00:32:17,135 US, OUTSIDE US, QUALITY 905 00:32:17,201 --> 00:32:17,769 TREATMENT WORKS. 906 00:32:17,835 --> 00:32:21,506 QUALITY TREATMENT IS NOT 907 00:32:21,572 --> 00:32:23,574 INEXPENSIVE. 908 00:32:23,641 --> 00:32:25,109 WE NEED TO DECREASE THE NUMBER 909 00:32:25,176 --> 00:32:25,877 DEVELOPING THE PROBLEM AND 910 00:32:25,943 --> 00:32:28,846 PROVIDE TREATMENT TO THOSE WHO 911 00:32:28,913 --> 00:32:29,280 HAVE IT. 912 00:32:29,347 --> 00:32:31,649 SO WE NEED TO BOTH DECREASE -- 913 00:32:31,716 --> 00:32:32,884 TURN DOWN THE WATER THAT'S 914 00:32:32,950 --> 00:32:34,552 COMING IN TO THE BATHTUB, WHILE 915 00:32:34,619 --> 00:32:36,054 WE ALSO ADDRESS THE WATER THAT'S 916 00:32:36,120 --> 00:32:38,122 IN THE BATHTUB AS WELL. 917 00:32:38,189 --> 00:32:39,891 AND IF WE AREN'T DOING BOTH OF 918 00:32:39,957 --> 00:32:41,092 THOSE THINGS, THEN WE'RE JUST 919 00:32:41,159 --> 00:32:42,493 GOING TO CONTINUE TO BE IN THE 920 00:32:42,560 --> 00:32:44,462 SAME SITUATION. 921 00:32:44,529 --> 00:32:45,897 AND TREATMENT MAY TAKE TIME TO 922 00:32:45,963 --> 00:32:48,299 WORK FOR SOMEONE. 923 00:32:48,366 --> 00:32:48,733 THAT'S IMPORTANT. 924 00:32:48,800 --> 00:32:50,268 SO THIS IS A SLIDE, A FIGURE 925 00:32:50,335 --> 00:32:55,340 FROM A PAPER THAT SHUR PUBLISHED 926 00:32:55,406 --> 00:32:56,607 15 OR MORE YEARS AGO NOW. 927 00:32:56,674 --> 00:32:57,942 THIS IS KIND OF INTERESTING. 928 00:32:58,009 --> 00:33:00,244 THEY LOOKED BACK AT THE LIFE 929 00:33:00,311 --> 00:33:03,948 COURSE, THEY HAD DATA ON OVER 33 930 00:33:04,015 --> 00:33:06,551 YEARS OF 471 MALE HEROIN USERS 931 00:33:06,617 --> 00:33:08,853 IN THE CALIFORNIA AREA, AND WHAT 932 00:33:08,920 --> 00:33:11,155 THEY FOUND, THIS IS DAYS USED, 933 00:33:11,222 --> 00:33:12,123 AND THEY FOUND THAT PEOPLE SORT 934 00:33:12,190 --> 00:33:14,892 OF FELL INTO THREE CATEGORIES. 935 00:33:14,959 --> 00:33:18,296 SOME PEOPLE WITHIN A FEW YEARS 936 00:33:18,363 --> 00:33:19,364 REALLY DECREASED AND THEN 937 00:33:19,430 --> 00:33:22,100 STOPPED THEIR USE. 938 00:33:22,166 --> 00:33:25,803 SOME PEOPLE, IT TOOK TIME, ABOUT 939 00:33:25,870 --> 00:33:28,439 A THIRD, AND SOME PEOPLE JUST 940 00:33:28,506 --> 00:33:30,408 KEPT USING. 941 00:33:30,475 --> 00:33:31,943 BUT WE CAN'T GIVE UP, I THINK IS 942 00:33:32,009 --> 00:33:32,443 THE POINT. 943 00:33:32,510 --> 00:33:34,679 BECAUSE WE DON'T KNOW A YEAR 944 00:33:34,746 --> 00:33:36,514 INTO IT WHICH OF THESE THREE 945 00:33:36,581 --> 00:33:38,282 GROUPS SOMEBODY FALLS INTO, AND 946 00:33:38,349 --> 00:33:40,151 WHO KNOWS, MAYBE THIS GROUP OF 947 00:33:40,218 --> 00:33:41,686 YELLOW WILL START TO TREND DOWN. 948 00:33:41,753 --> 00:33:44,422 SO WE CAN'T GIVE UP. 949 00:33:44,489 --> 00:33:46,391 AND TREATMENT TAKES MULTIPLE 950 00:33:46,457 --> 00:33:48,025 TRIALS OFTEN WITH OPIATE USE 951 00:33:48,092 --> 00:33:52,497 DISORDER TO HAVE AN EFFECT. 952 00:33:52,563 --> 00:33:54,165 SO TREATMENT VARIES. 953 00:33:54,232 --> 00:33:57,201 THERE ARE SOME FOR WHOM IT'S 954 00:33:57,268 --> 00:33:59,837 RELATIVELY EASY, BUT THERE IS A 955 00:33:59,904 --> 00:34:00,805 POPULATION THAT'S MUCH MORE 956 00:34:00,872 --> 00:34:01,172 PROBLEMATIC. 957 00:34:01,239 --> 00:34:02,340 SO I'M GOING TO TALK ABOUT 958 00:34:02,407 --> 00:34:04,108 BUPRENORPHINE IN A MINUTE 959 00:34:04,175 --> 00:34:05,076 BRIEFLY, BUT I WANT TO 960 00:34:05,143 --> 00:34:08,679 ACKNOWLEDGE, THERE ARE SOME 961 00:34:08,746 --> 00:34:09,781 PEOPLE PRESCRIPTION OPIOID USERS 962 00:34:09,847 --> 00:34:11,115 GOT PUT ON BUPRENORPHINE, THEY 963 00:34:11,182 --> 00:34:12,550 HAD RELATIVELY STABLE LIVES, 964 00:34:12,617 --> 00:34:15,153 THEY WORKED, THEY HAVE SOCIAL 965 00:34:15,219 --> 00:34:16,120 SUPPORTS, THEY HAD GOOD 966 00:34:16,187 --> 00:34:17,221 INSURANCE AND THEY'VE GONE ON 967 00:34:17,288 --> 00:34:18,022 WITH THEIR LIVES AND THAT'S 968 00:34:18,089 --> 00:34:18,956 GREAT. 969 00:34:19,023 --> 00:34:22,927 BUT THERE ARE SOME PEOPLE WHO 970 00:34:22,994 --> 00:34:24,228 DON'T -- YOU KNOW, IT'S MUCH 971 00:34:24,295 --> 00:34:25,663 MORE COMPLICATED. 972 00:34:25,730 --> 00:34:29,267 WHEN YOU LOOK AT THE DATA ON 973 00:34:29,333 --> 00:34:30,468 BUPRENORPHINE AND PEOPLE GETTING 974 00:34:30,535 --> 00:34:33,538 PLACED ON BUPRENORPHINE, 975 00:34:33,604 --> 00:34:36,040 GENERALLY, THE OVERWHELMING 976 00:34:36,107 --> 00:34:38,342 MAJORITY, SOMETHING LIKE 50% OR 977 00:34:38,409 --> 00:34:40,011 MORE, DEPENDING UPON THE STUDY, 978 00:34:40,077 --> 00:34:43,147 DROP OUT OF TREATMENT. 979 00:34:43,214 --> 00:34:45,216 SO WE'VE GOT TO FIGURE OUT WHY 980 00:34:45,283 --> 00:34:47,518 IS THAT, AND WHAT CAN WE DO TO 981 00:34:47,585 --> 00:34:48,853 KEEP PEOPLE ENGAGED IN 982 00:34:48,920 --> 00:34:49,854 TREATMENT. 983 00:34:49,921 --> 00:34:51,689 BECAUSE SOME PEOPLE, IT JUST 984 00:34:51,756 --> 00:34:53,791 DOESN'T TAKE RIGHT AWAY. 985 00:34:53,858 --> 00:34:55,426 SO LET'S TALK ABOUT CURRENT 986 00:34:55,493 --> 00:34:56,527 MODALITIES OF TREATMENT, 987 00:34:56,594 --> 00:34:59,030 THINKING BROADLY. 988 00:34:59,096 --> 00:35:02,867 SO MEDICATIONS, THERE ARE THREE 989 00:35:02,934 --> 00:35:04,235 FDA-APPROVED MEDICATIONS FOR 990 00:35:04,302 --> 00:35:06,137 WHAT WOULD BE CALLED 991 00:35:06,204 --> 00:35:08,005 MEDICATION-ASSISTED TREATMENT, 992 00:35:08,072 --> 00:35:08,439 MAT. 993 00:35:08,506 --> 00:35:09,740 BUPRENORPHINE, METHADONE AND 994 00:35:09,807 --> 00:35:10,408 NALTREXONE. 995 00:35:10,475 --> 00:35:11,843 I'M JUST GOING TO TOUCH ON EACH 996 00:35:11,909 --> 00:35:15,012 OF THESE. 997 00:35:15,079 --> 00:35:16,747 BUPRENORPHINE, IT'S MARKETED AS 998 00:35:16,814 --> 00:35:20,151 A TRANS MUCOSAL, SUBLINGUAL 999 00:35:20,218 --> 00:35:21,252 TABLETS OR FILMS. 1000 00:35:21,319 --> 00:35:22,553 THERE'S ALSO LONG-ACTING 1001 00:35:22,620 --> 00:35:23,855 INJECTIONS THAT CAN BE GIVEN 1002 00:35:23,921 --> 00:35:25,823 EITHER WEEKLY OR MONTHLY. 1003 00:35:25,890 --> 00:35:28,893 THERE WAS A SIX-MONTH ROD THAT 1004 00:35:28,960 --> 00:35:31,095 WAS PUT UNDER THE SKIN, KIND OF 1005 00:35:31,162 --> 00:35:32,930 LIKE NORPLANT. 1006 00:35:32,997 --> 00:35:37,802 IT'S NOW OFF THE MARKET, BUT IT 1007 00:35:37,869 --> 00:35:42,573 WAS DEVELOPED AND WAS EFFECTIVE. 1008 00:35:42,640 --> 00:35:44,542 IT JUST DIDN'T GET MUCH UPTAKE. 1009 00:35:44,609 --> 00:35:46,077 BUPRENORPHINE IS EFFECTIVE, IT'S 1010 00:35:46,143 --> 00:35:47,845 AVAILABLE AS AN OFFICE-BASED 1011 00:35:47,912 --> 00:35:50,348 OPIOID TREATMENT OR THE ACRONYM 1012 00:35:50,414 --> 00:35:57,321 OFTEN USED IS OBOT. 1013 00:35:57,388 --> 00:35:59,857 THEY HAD TO GET A SPECIAL X 1014 00:35:59,924 --> 00:36:00,191 NUMBER. 1015 00:36:00,258 --> 00:36:02,593 YOU NO LONGER NEED TO GET AN X 1016 00:36:02,660 --> 00:36:04,462 NUMBER, A SPECIAL DEA NUMBER TO 1017 00:36:04,529 --> 00:36:05,329 PRESCRIBE IT. 1018 00:36:05,396 --> 00:36:07,064 IT'S PRETTY EASY TO PRESCRIBE 1019 00:36:07,131 --> 00:36:11,435 NOW IN MOST OF THE COUNTRY. 1020 00:36:11,502 --> 00:36:12,003 NEXT, METHADONE. 1021 00:36:12,069 --> 00:36:14,939 THIS IS AN ORAL DAILY DOSING 1022 00:36:15,006 --> 00:36:15,506 MEDICATION. 1023 00:36:15,573 --> 00:36:17,775 IT'S EFFECTIVE, IT'S GENERALLY A 1024 00:36:17,842 --> 00:36:19,977 MEDICATION THAT INCLUDES 1025 00:36:20,044 --> 00:36:21,312 NON-PHARMACOLOGIC TREATMENT, 1026 00:36:21,379 --> 00:36:23,581 COUNSELING SERVICES, GROUPS, 1027 00:36:23,648 --> 00:36:26,217 CONTINGENCY MANAGEMENT. 1028 00:36:26,284 --> 00:36:27,184 I'LL COME BACK TO SOME OF THOSE 1029 00:36:27,251 --> 00:36:28,719 IN A MINUTE. 1030 00:36:28,786 --> 00:36:30,321 IT'S ESSENTIALLY ONLY AVAILABLE 1031 00:36:30,388 --> 00:36:33,124 THROUGH A SPECIALIZED CLINIC 1032 00:36:33,190 --> 00:36:35,960 TREATMENT, OPIOID TREATMENT 1033 00:36:36,027 --> 00:36:37,495 PROGRAMS, OTPs IS THE FEDERAL 1034 00:36:37,562 --> 00:36:38,029 TERM FOR THAT. 1035 00:36:38,095 --> 00:36:39,463 THERE IS DISCUSSION ABOUT MOVING 1036 00:36:39,530 --> 00:36:41,198 METHADONE INTO OFFICE-BASED 1037 00:36:41,265 --> 00:36:42,099 PRACTICE LIKE BUPRENORPHINE IS 1038 00:36:42,166 --> 00:36:43,501 AND ALLOWING PEOPLE TO PRESCRIBE 1039 00:36:43,568 --> 00:36:45,803 IT. 1040 00:36:45,870 --> 00:36:50,408 AND THEN THE THIRD MEDICATION IS 1041 00:36:50,474 --> 00:36:51,842 NALTREXONE. 1042 00:36:51,909 --> 00:36:53,144 IT HAS ORAL DOSING. 1043 00:36:53,210 --> 00:36:56,113 IT CAN BE GIVEN EITHER DAILY OR 1044 00:36:56,180 --> 00:36:57,415 THRICE WEEKLY. 1045 00:36:57,481 --> 00:37:02,219 THERE ALSO IS A LONG-ACTING 1046 00:37:02,286 --> 00:37:03,421 INJECTABLE GIVEN ONCE A MONTH. 1047 00:37:03,487 --> 00:37:05,056 THERE CAN BE SOME DIFFICULTY TO 1048 00:37:05,122 --> 00:37:07,158 TRANSITION ONTO IT, BUT THE 1049 00:37:07,224 --> 00:37:08,726 EVIDENCE OF -- THERE IS EVIDENCE 1050 00:37:08,793 --> 00:37:10,528 OF GOOD EFFICACY WHEN YOU GET A 1051 00:37:10,595 --> 00:37:13,164 PATIENT ON NALTREXONE. 1052 00:37:13,230 --> 00:37:13,831 NIDA'S CLINICAL TRIALS NETWORK 1053 00:37:13,898 --> 00:37:15,032 PUBLISHED A NICE MULTI-SITE 1054 00:37:15,099 --> 00:37:17,201 STUDY OF THAT A FEW YEARS AGO. 1055 00:37:17,268 --> 00:37:20,171 THAT SHOWED THAT NALTREXONE 1056 00:37:20,237 --> 00:37:21,272 COULD BE QUITE EFFECTIVE ONCE 1057 00:37:21,339 --> 00:37:22,373 YOU GOT THROUGH THAT TRANSITION 1058 00:37:22,440 --> 00:37:27,078 PERIOD. 1059 00:37:27,144 --> 00:37:28,579 IN ADDITION TO MEDICATIONS, 1060 00:37:28,646 --> 00:37:29,780 THERE'S OBVIOUSLY 1061 00:37:29,847 --> 00:37:30,781 NON-PHARMACOLOGIC TREATMENTS, 1062 00:37:30,848 --> 00:37:31,882 AND THERE'S THINGS LIKE 1063 00:37:31,949 --> 00:37:34,051 INPATIENT SERVICES, RESIDENTIAL 1064 00:37:34,118 --> 00:37:37,021 PROGRAMS, OUTPATIENT COUNSELING, 1065 00:37:37,088 --> 00:37:38,789 SELF-HELP GROUPS SUCH AS 1066 00:37:38,856 --> 00:37:39,423 NARCOTICS ANONYMOUS. 1067 00:37:39,490 --> 00:37:44,028 THESE CAN ALL BE VERY HELPFUL. 1068 00:37:44,095 --> 00:37:45,796 AND THERE'S ALSO MODALITIES SUCH 1069 00:37:45,863 --> 00:37:47,164 AS CONTINGENCY MANAGEMENT, 1070 00:37:47,231 --> 00:37:49,834 SOMETIMES REFERRED TO AS CM, 1071 00:37:49,900 --> 00:37:51,569 MOTIVATIONAL INTERVIEWING AND 1072 00:37:51,636 --> 00:37:53,037 12-STEP FACILITATION. 1073 00:37:53,104 --> 00:37:55,873 I POINT OUT THAT MULTIPLE 1074 00:37:55,940 --> 00:37:58,709 REVIEWS HAVE SHOWN CON TINGE Z. 1075 00:37:58,776 --> 00:38:00,177 MANAGEMENT AS A HIGHLY EFFECTIVE 1076 00:38:00,244 --> 00:38:04,415 TREATMENT INTERVENTION. 1077 00:38:04,482 --> 00:38:05,716 AND I WANT TO JUST ACKNOWLEDGE 1078 00:38:05,783 --> 00:38:06,951 THERE ARE THINGS LIKE 1079 00:38:07,018 --> 00:38:08,252 PRESCRIPTION DRUG MONITORING 1080 00:38:08,319 --> 00:38:09,553 PROGRAMS WHICH HAVE BEEN VERY 1081 00:38:09,620 --> 00:38:10,655 USEFUL, I THINK, IN TERMS OF 1082 00:38:10,721 --> 00:38:12,623 GETTING CONTROL OF PRESCRIPTION 1083 00:38:12,690 --> 00:38:13,190 OPIOID USE. 1084 00:38:13,257 --> 00:38:16,027 THOSE REALLY HAVE COME ONLINE 1085 00:38:16,093 --> 00:38:16,994 NATIONALLY OVER THE LAST FEW 1086 00:38:17,061 --> 00:38:21,065 YEARS AND REALLY ARE ROBUST 1087 00:38:21,132 --> 00:38:21,399 SYSTEMS. 1088 00:38:21,465 --> 00:38:22,967 THERE ARE ALSO THINGS LIKE 1089 00:38:23,034 --> 00:38:25,136 OPIOID TREATMENT COMMUNITIES AND 1090 00:38:25,202 --> 00:38:26,570 HEALTH SYSTEMS THAT HAVE COME 1091 00:38:26,637 --> 00:38:29,540 TOGETHER TO FIGURE OUT HOW TO 1092 00:38:29,607 --> 00:38:31,275 BETTER MANAGE OPIATE USE 1093 00:38:31,342 --> 00:38:33,444 DISORDER, AND USE OF ELECTRONIC 1094 00:38:33,511 --> 00:38:35,780 MEDICAL RECORDS, EMRs, HAS 1095 00:38:35,846 --> 00:38:37,348 BEEN A HELPFUL STEP FORWARD AS 1096 00:38:37,415 --> 00:38:40,584 WELL TO GET CONTROL OF, 1097 00:38:40,651 --> 00:38:41,218 ESPECIALLY, AGAIN, PRESCRIPTION 1098 00:38:41,285 --> 00:38:41,919 OPIOID USE. 1099 00:38:41,986 --> 00:38:43,888 CURRENT TREATMENTS CAN WORK WELL 1100 00:38:43,954 --> 00:38:46,390 WHEN COMBINING MEDICATION WITH 1101 00:38:46,457 --> 00:38:47,925 NON-PHARMACOLOGIC TREATMENT, 1102 00:38:47,992 --> 00:38:50,461 ESPECIALLY CONTINGENCY 1103 00:38:50,528 --> 00:38:51,562 MANAGEMENT. 1104 00:38:51,629 --> 00:38:52,763 SO LET ME MOVE ON TO TALK A 1105 00:38:52,830 --> 00:38:54,498 LITTLE BIT ABOUT SOME KIND OF 1106 00:38:54,565 --> 00:38:56,701 FUTURE TREATMENTS OR THINGS TO 1107 00:38:56,767 --> 00:38:58,135 THINK ABOUT IN TERMS OF 1108 00:38:58,202 --> 00:39:02,073 TREATMENTS GOING FORWARD. 1109 00:39:02,139 --> 00:39:05,142 KIND OF -- WE'VE BEEN LOOKING 1110 00:39:05,209 --> 00:39:06,343 OUR SHOULDER WHAT'S AVAILABLE 1111 00:39:06,410 --> 00:39:07,645 OUT THERE, NOW LET'S LOOK AHEAD 1112 00:39:07,712 --> 00:39:08,546 TO THINK ABOUT WHAT'S AVAILABLE. 1113 00:39:08,612 --> 00:39:10,715 SO I WANT TO TALK ABOUT 1114 00:39:10,781 --> 00:39:13,784 MEDICATIONS AND DEVICES, AND I'M 1115 00:39:13,851 --> 00:39:15,219 GOING TO GO INTO A LITTLE BIT OF 1116 00:39:15,286 --> 00:39:16,854 DETAIL ON A COUPLE OF THESE. 1117 00:39:16,921 --> 00:39:21,125 THERE HAVE BEEN FURTHER DEVEL 1118 00:39:21,192 --> 00:39:22,993 DEVELOPMENT OF WAYS -- THAT'S A 1119 00:39:23,060 --> 00:39:24,395 TYPO, IT SHOULD SAY WAYS TO 1120 00:39:24,462 --> 00:39:27,598 OPTIMIZE USE OF LONG-ACTING 1121 00:39:27,665 --> 00:39:28,365 INJECTABLES LIKE BUPRENORPHINE 1122 00:39:28,432 --> 00:39:29,467 AND THE WEEKLY AND MONTHLY 1123 00:39:29,533 --> 00:39:30,000 PRESCRIBING OF THAT. 1124 00:39:30,067 --> 00:39:33,771 I THINK THAT THAT'S SOMETHING 1125 00:39:33,838 --> 00:39:37,374 THAT WE CAN BE THINKING ABOUT 1126 00:39:37,441 --> 00:39:39,777 FURTHER BECAUSE YOU CAN PUT 1127 00:39:39,844 --> 00:39:43,247 SOMEBODY ON WEEKLY LONG-ACTING 1128 00:39:43,314 --> 00:39:43,848 INJECTABLE BUPRENORPHINE RIGHT 1129 00:39:43,914 --> 00:39:44,148 AWAY. 1130 00:39:44,215 --> 00:39:46,016 YOU DON'T HAVE TO PUT THEM ON 1131 00:39:46,083 --> 00:39:47,985 SUBLINGUAL OR TRANS MUCOSAL 1132 00:39:48,052 --> 00:39:49,553 FIRST, SO THAT OPENS UP 1133 00:39:49,620 --> 00:39:52,089 OPPORTUNITIES TO THINK ABOUT 1134 00:39:52,156 --> 00:39:55,659 STARTING PEOPLE ON MEDICATIONS N 1135 00:39:55,726 --> 00:39:57,128 NOVEL SETTINGS, LIKE EMERGENCY 1136 00:39:57,194 --> 00:39:57,461 DEPARTMENTS. 1137 00:39:57,528 --> 00:40:00,197 THERE'S ALSO WITHDRAWAL 1138 00:40:00,264 --> 00:40:06,771 MEDICATIONS ON PARTICULAR 1139 00:40:06,837 --> 00:40:09,373 LOFEXIDINE, IT'S LIKE CLONIDINE 1140 00:40:09,440 --> 00:40:12,810 THAT CAN BE USED FOR WITHDRAWAL 1141 00:40:12,877 --> 00:40:15,880 OFF OF OPIOIDS AND IS RELATIVELY 1142 00:40:15,946 --> 00:40:16,647 UNDERUTILIZED, I THINK, AT THE 1143 00:40:16,714 --> 00:40:17,181 MOMENT. 1144 00:40:17,248 --> 00:40:18,616 THEN AS I MENTIONED A MOMENT 1145 00:40:18,682 --> 00:40:20,818 AGO, METHADONE THROUGH OFFICE 1146 00:40:20,885 --> 00:40:22,486 BASED OPIOID TREATMENT, THERE'S 1147 00:40:22,553 --> 00:40:23,654 BEEN NOT SOME, THERE'S BEEN A 1148 00:40:23,721 --> 00:40:25,956 LOT OF INTEREST IN TRYING TO 1149 00:40:26,023 --> 00:40:27,825 MOVE METHADONE OUT OF THE OPIOID 1150 00:40:27,892 --> 00:40:30,027 TREATMENT PROGRAMS OR THE OLD 1151 00:40:30,094 --> 00:40:31,562 WHAT WE CALL METHADONE CLINICS, 1152 00:40:31,629 --> 00:40:33,531 AND ALLOWING PHYSICIANS AND 1153 00:40:33,597 --> 00:40:36,934 OTHER PROVIDERS TO PRESCRIBE 1154 00:40:37,001 --> 00:40:38,669 METHADONE FOR OPIOID DEPENDENCE 1155 00:40:38,736 --> 00:40:46,043 OUT OF OFFICE-BASED PRACTICES. 1156 00:40:46,110 --> 00:40:47,478 ONE OF THE THINGS WE'VE GOTTEN 1157 00:40:47,545 --> 00:40:49,313 INTERESTED IN IS WITHDRAWAL 1158 00:40:49,380 --> 00:40:49,547 DEVICE. 1159 00:40:49,613 --> 00:40:50,114 THERE ARE TWO. 1160 00:40:50,181 --> 00:40:51,415 ONE IS CALLED THE BRIDGE DEVICE 1161 00:40:51,482 --> 00:40:54,385 AND THERE'S ANOTHER CALLED THE 1162 00:40:54,451 --> 00:40:56,587 SPARROW ASCENT. 1163 00:40:56,654 --> 00:40:57,788 THESE ARE KIND OF INTERESTING 1164 00:40:57,855 --> 00:40:58,222 DEVICES. 1165 00:40:58,289 --> 00:41:03,260 I CONFESS I WAS NOT REALLY AWARE 1166 00:41:03,327 --> 00:41:04,895 OF DEVICES AND THE FDA APPROACH 1167 00:41:04,962 --> 00:41:06,730 TO DEVICES AS MUCH AS I PROBABLY 1168 00:41:06,797 --> 00:41:07,865 SHOULD HAVE BEEN BEFORE THIS. 1169 00:41:07,932 --> 00:41:09,166 THE BRIDGE DEVICE, AND HERE'S A 1170 00:41:09,233 --> 00:41:14,305 PICTURE OF IT, IS WORN FOUR TO 1171 00:41:14,371 --> 00:41:19,910 FIVE DAYS, IT STIMULATES CRANIAL 1172 00:41:19,977 --> 00:41:21,111 NERVES WITH ENDINGS IN THE EAR. 1173 00:41:21,178 --> 00:41:22,446 THERE'S NO REAL RISKS TO IT. 1174 00:41:22,513 --> 00:41:27,151 IT COSTS ABOUT $500 TO USE. 1175 00:41:27,218 --> 00:41:29,019 IT'S FDA-CLEARED FOR USE. 1176 00:41:29,086 --> 00:41:33,057 THERE'S NEVER BEEN A WELL 1177 00:41:33,123 --> 00:41:33,924 CONTROLLED, PLACEBO CONTROLLED 1178 00:41:33,991 --> 00:41:34,825 TRIAL OF IT. 1179 00:41:34,892 --> 00:41:38,762 WE'VE BEEN TRYING TO DO ONE 1180 00:41:38,829 --> 00:41:42,166 UNDER A NIDA GRANT, AND WE GOT 1181 00:41:42,233 --> 00:41:43,801 THE GOOD LUCK OF GETTING THE 1182 00:41:43,868 --> 00:41:45,536 GRANT JUST AS COVID HIT, WHICH 1183 00:41:45,603 --> 00:41:48,873 SORT OF MADE IT COMPLICATED TO 1184 00:41:48,939 --> 00:41:50,074 DO THE STUDY. 1185 00:41:50,140 --> 00:41:55,312 BUT IT'S AN INTERESTING DEVICE, 1186 00:41:55,379 --> 00:41:56,280 AND IT'S OUT THERE ON THE 1187 00:41:56,347 --> 00:41:59,149 MARKET. 1188 00:41:59,216 --> 00:42:01,452 ANOTHER SORT OF IN THE REALM OF 1189 00:42:01,518 --> 00:42:03,754 DEVICES I JUST WANT TO TOUCH ON 1190 00:42:03,821 --> 00:42:04,955 IS ELECTRONIC PILL BOXES. 1191 00:42:05,022 --> 00:42:06,290 WE'VE, AGAIN, GOTTEN INTERESTED 1192 00:42:06,357 --> 00:42:07,358 IN THESE DURING COVID. 1193 00:42:07,424 --> 00:42:09,326 SO THERE ARE THESE BOXES, SOME 1194 00:42:09,393 --> 00:42:12,630 OF THEM ARE BLUETOOTH-ENABLED, 1195 00:42:12,696 --> 00:42:13,831 SO YOU CAN LOAD THEM WITH THE 1196 00:42:13,898 --> 00:42:16,901 MEDICINE FOR 30 DAYS, AND WHEN 1197 00:42:16,967 --> 00:42:19,536 COVID HIT, WE WERE USING ONE OF 1198 00:42:19,603 --> 00:42:21,405 THESE WITH METHADONE PATIENTS. 1199 00:42:21,472 --> 00:42:22,072 THEY'RE LOCKED. 1200 00:42:22,139 --> 00:42:26,977 THE CELLS ARE LOCKED SO -- THESE 1201 00:42:27,044 --> 00:42:28,545 CELLS ARE LOCKED, THEY ONLY WILL 1202 00:42:28,612 --> 00:42:29,546 POP OPEN ON THE DAY THE PERSON 1203 00:42:29,613 --> 00:42:30,714 IS TO GET THE MEDICINE. 1204 00:42:30,781 --> 00:42:34,985 IF THERE'S A PROBLEM AND THEY'RE 1205 00:42:35,052 --> 00:42:36,320 BLUETOOTH-ENABLED, YOU CAN POP 1206 00:42:36,387 --> 00:42:40,257 OPEN AN EMERGENCY ONE IF YOU 1207 00:42:40,324 --> 00:42:41,792 NEED TO. 1208 00:42:41,859 --> 00:42:44,295 SO THAT SOMEBODY DOESN'T 1209 00:42:44,361 --> 00:42:45,629 NECESSARILY DOUBLE UP THEIR 1210 00:42:45,696 --> 00:42:48,032 METHADONE DOSE BUT STILL DOESN'T 1211 00:42:48,098 --> 00:42:49,566 HAVE TO COME IN TO THE CLINIC ON 1212 00:42:49,633 --> 00:42:51,435 A DAILY BASIS TO USE THEM. 1213 00:42:51,502 --> 00:42:54,505 SO THIS OPENS UP SOME 1214 00:42:54,571 --> 00:42:57,341 INTERESTING POSSIBILITIES FOR 1215 00:42:57,408 --> 00:42:59,543 USE. 1216 00:42:59,610 --> 00:43:00,744 AND WE'VE HAD A COUPLE OF 1217 00:43:00,811 --> 00:43:04,248 STUDIES SHOWING THEY'RE USEFUL, 1218 00:43:04,315 --> 00:43:06,450 THEY CAN BE USED IF PEOPLE DON'T 1219 00:43:06,517 --> 00:43:07,518 SMASH THEM AGAINST THE GROUND 1220 00:43:07,584 --> 00:43:08,085 AND THINGS LIKE THAT. 1221 00:43:08,152 --> 00:43:09,954 THEY ARE EXPENSIVE. 1222 00:43:10,020 --> 00:43:11,155 AND THE THIRD THING THAT WE'VE 1223 00:43:11,221 --> 00:43:13,123 GOTTEN KIND OF INTERESTED IN IS 1224 00:43:13,190 --> 00:43:15,326 PRESCRIPTION DIGITAL 1225 00:43:15,392 --> 00:43:20,130 THERAPEUTICS, SUCH AS RESET O. 1226 00:43:20,197 --> 00:43:21,999 I DON'T HAVE A SLIDE OF THIS, 1227 00:43:22,066 --> 00:43:25,536 BUT RESET O WAS MARKETED BY PARA 1228 00:43:25,602 --> 00:43:27,705 THERAPEUTICS WHICH UNFORTUNATELY 1229 00:43:27,771 --> 00:43:30,140 HAS GONE BANKRUPT, BUT THIS IS 1230 00:43:30,207 --> 00:43:31,241 AN INTERESTING PRODUCT. 1231 00:43:31,308 --> 00:43:32,676 IT'S A PRESCRIPTION DIGITAL 1232 00:43:32,743 --> 00:43:33,110 THERAPEUTIC. 1233 00:43:33,177 --> 00:43:35,145 SO YOU WOULD GO IN TO THE 1234 00:43:35,212 --> 00:43:36,280 MEDICAL ELECTRONIC MEDICAL 1235 00:43:36,347 --> 00:43:36,714 RECORD AND ORDER IT. 1236 00:43:36,780 --> 00:43:38,515 IT'S NOT A MEDICATION, IT'S A 1237 00:43:38,582 --> 00:43:40,684 THERAPEUTIC THAT'S ON A 1238 00:43:40,751 --> 00:43:41,919 SMARTPHONE. 1239 00:43:41,986 --> 00:43:43,654 THIS WAS TIED TO USE OF 1240 00:43:43,721 --> 00:43:45,656 CONTINGENCY MANAGEMENT AND IT 1241 00:43:45,723 --> 00:43:49,026 WAS A KIND OF CLEVER PROGRAM, 1242 00:43:49,093 --> 00:43:51,996 AND PARA DEVELOPED RESET, 1243 00:43:52,062 --> 00:43:52,963 RESET-O. 1244 00:43:53,030 --> 00:43:55,265 THEY ALSO DEVELOPED ONE FOR 1245 00:43:55,332 --> 00:43:55,599 INSOMNIA. 1246 00:43:55,666 --> 00:43:57,034 THESE WERE ALL PRESCRIPTION 1247 00:43:57,101 --> 00:43:58,569 DIGITAL THERAPEUTICS THAT REALLY 1248 00:43:58,635 --> 00:44:02,072 DIDN'T GET TAKEN UP SUFFICIENTLY 1249 00:44:02,139 --> 00:44:02,840 TO SUSTAIN THEM. 1250 00:44:02,906 --> 00:44:04,708 I THINK PROBABLY THEY SUFFERED 1251 00:44:04,775 --> 00:44:05,776 BECAUSE THEY WERE THE FIRST OUT 1252 00:44:05,843 --> 00:44:08,112 OF THE GATE WITH ONE OF THESE. 1253 00:44:08,178 --> 00:44:10,748 THERE'S ANOTHER ONE BEING 1254 00:44:10,814 --> 00:44:17,454 DEVELOPED PRETTY FAR ALONG BY 1255 00:44:17,521 --> 00:44:17,855 DYNAMACARE. 1256 00:44:17,921 --> 00:44:19,189 I THINK WE'LL PROBABLY SEE ONE 1257 00:44:19,256 --> 00:44:21,125 OF THOSE GET OUT THERE AND MAKE 1258 00:44:21,191 --> 00:44:24,461 A GO OF IT EVENTUALLY, IS MY 1259 00:44:24,528 --> 00:44:25,129 SENSE OF IT. 1260 00:44:25,195 --> 00:44:27,998 I JUST THINK PDTs ARE STILL 1261 00:44:28,065 --> 00:44:30,267 KIND OF A FOREIGN IDEA TO THE 1262 00:44:30,334 --> 00:44:31,802 PROVIDER COMMUNITY. 1263 00:44:31,869 --> 00:44:33,237 WE GET PRESCRIBING A MEDICINE, 1264 00:44:33,303 --> 00:44:37,074 WE DON'T THINK OF PRESCRIBING A 1265 00:44:37,141 --> 00:44:38,475 DIGITAL THERAPEUTIC IN THE SAME 1266 00:44:38,542 --> 00:44:38,942 WAY. 1267 00:44:39,009 --> 00:44:40,711 AND THEN NOVEL MEDICATIONS. 1268 00:44:40,778 --> 00:44:48,285 I'M GOING TO TALK ABOUT SE 1269 00:44:48,352 --> 00:44:48,952 SUVAREXIN. 1270 00:44:49,019 --> 00:44:49,586 THERE'S OTHERS AS WELL. 1271 00:44:49,653 --> 00:44:51,221 WE'VE GOTTEN INTERESTED IN ARE 1272 00:44:51,288 --> 00:44:52,356 THERE THINGS THAT CAN BE GIVEN 1273 00:44:52,423 --> 00:44:54,324 WITH A MEDICINE LIKE 1274 00:44:54,391 --> 00:44:55,759 BUPRENORPHINE OR METHADONE MAYBE 1275 00:44:55,826 --> 00:45:00,030 TO ADDRESS ANXIETY OR SLEEP OR 1276 00:45:00,097 --> 00:45:07,771 SOME OTHER PROBLEM TO EN ENHANCR 1277 00:45:07,838 --> 00:45:09,339 IMPROVE THE MAIN MEDICATION 1278 00:45:09,406 --> 00:45:09,840 BEING USED. 1279 00:45:09,907 --> 00:45:13,577 THIS IS A STUDY DONE BY ANDREW 1280 00:45:13,644 --> 00:45:16,513 HUNE IN OUR GROUP AND REALLY HAS 1281 00:45:16,580 --> 00:45:19,283 DEVELOPED A NICE LINE OF 1282 00:45:19,349 --> 00:45:23,020 RESEARCH LOOKING AT ANTAGONISTS. 1283 00:45:23,087 --> 00:45:25,222 HE DID THIS DOUBLE BLIND PLACEBO 1284 00:45:25,289 --> 00:45:25,622 CONTROLLED TRIAL. 1285 00:45:25,689 --> 00:45:27,424 IT WAS A RESIDENTIAL STUDY IN 1286 00:45:27,491 --> 00:45:29,393 WHICH PEOPLE HAD A BUPRENORPHINE 1287 00:45:29,460 --> 00:45:31,662 TAPER FOR OPIATE-DEPENDENT 1288 00:45:31,728 --> 00:45:32,129 PERSONS. 1289 00:45:32,196 --> 00:45:35,732 THEY GOT SUVOREXANT, 20 OR 1290 00:45:35,799 --> 00:45:36,900 40 MILLIGRAMS VERSUS PLACEBO. 1291 00:45:36,967 --> 00:45:38,035 THIS WAS THE FIRST STUDY THAT 1292 00:45:38,102 --> 00:45:40,804 CAME OUT OF THIS. 1293 00:45:40,871 --> 00:45:42,873 HE WAS LOOKING TO SEE IF YOU 1294 00:45:42,940 --> 00:45:47,711 COULD IMPROVE PEOPLE'S SLEEP 1295 00:45:47,778 --> 00:45:49,780 WHILE THEY WERE GETTING OPIOID 1296 00:45:49,847 --> 00:45:50,247 TAPERS. 1297 00:45:50,314 --> 00:45:52,850 THE SLEEP TIME WAS BETTER DURING 1298 00:45:52,916 --> 00:45:55,586 SUVO, THE GREY LINES, DURING THE 1299 00:45:55,652 --> 00:45:58,021 TAPER. 1300 00:45:58,088 --> 00:45:59,323 , WHEN IT WAS COMBINED WITH 1301 00:45:59,389 --> 00:46:00,757 BUPRENORPHINE AND THAT PERSISTED 1302 00:46:00,824 --> 00:46:04,027 SLIGHTLY BETTER DURING THE POST 1303 00:46:04,094 --> 00:46:06,563 TAPER TIME, WHICH WAS NICE TO 1304 00:46:06,630 --> 00:46:11,535 SEE. 1305 00:46:11,602 --> 00:46:13,303 SO THEN IF YOU LOOK AT 1306 00:46:13,370 --> 00:46:15,339 SELF-REPORTED WITHDRAWAL, 1307 00:46:15,405 --> 00:46:16,473 INTERESTINGLY SELF-REPORTED 1308 00:46:16,540 --> 00:46:17,474 WITHDRAWAL WAS ALSO BETTER WITH 1309 00:46:17,541 --> 00:46:18,142 LOWER RATINGS. 1310 00:46:18,208 --> 00:46:20,310 THIS WAS SORT OF UNEXPECTED, 1311 00:46:20,377 --> 00:46:22,312 REALLY DIDN'T EXPECT TO SEE 1312 00:46:22,379 --> 00:46:25,916 THAT. 1313 00:46:25,983 --> 00:46:26,583 AND THEN THIS WAS HOW MUCH DO 1314 00:46:26,650 --> 00:46:30,754 YOU WANT TO AVOID OPIOIDS RIGHT 1315 00:46:30,821 --> 00:46:32,389 NOW, A VISUAL ANALOG SCALE. 1316 00:46:32,456 --> 00:46:35,459 AND WHAT YOU SEE IS, THIS IS THE 1317 00:46:35,526 --> 00:46:37,294 THREE CONDITIONS, PLACEBO, 20 1318 00:46:37,361 --> 00:46:40,063 AND 40 MILLIGRAMS OF SUVO, AND 1319 00:46:40,130 --> 00:46:43,467 THIS IS THE TAPER AND THE 1320 00:46:43,534 --> 00:46:45,569 POST-TAPER PERIOD, AND THERE'S A 1321 00:46:45,636 --> 00:46:49,173 PRETTY ROBUST DIFFERENCE BETWEEN 1322 00:46:49,239 --> 00:46:54,111 THE PLACEBO GROUP AND THE SUVO 1323 00:46:54,178 --> 00:46:56,747 GROUP WHEN TREATED WITH 1324 00:46:56,813 --> 00:46:57,080 SUVOREXANT. 1325 00:46:57,147 --> 00:46:58,615 THAT'S REALLY GOTTEN A LOT OF 1326 00:46:58,682 --> 00:46:59,483 ATTENTION ACTUALLY. 1327 00:46:59,550 --> 00:47:05,556 SO PEOPLE WHO'VE GOT AREXIN 1328 00:47:05,622 --> 00:47:06,323 ANTAGONISTS ARE INTERESTED IN 1329 00:47:06,390 --> 00:47:06,723 THIS. 1330 00:47:06,790 --> 00:47:08,292 ANDREW IS DOING SOME FOLLOW-UP 1331 00:47:08,358 --> 00:47:09,059 STUDIES AS WELL. 1332 00:47:09,126 --> 00:47:11,795 THIS WAS A RELATIVELY SMALL 1333 00:47:11,862 --> 00:47:16,233 STUDY BUT MOVING FORWARD WITH 1334 00:47:16,300 --> 00:47:19,903 IT. 1335 00:47:19,970 --> 00:47:21,238 FINALLY I WANT TO TAKE A COUPLE 1336 00:47:21,305 --> 00:47:22,239 MINUTES TO TALK ABOUT, I THINK 1337 00:47:22,306 --> 00:47:23,440 AS WE THINK ABOUT THIS, I'VE 1338 00:47:23,507 --> 00:47:27,144 ALSO BEEN THINKING MORE AND MORE 1339 00:47:27,211 --> 00:47:28,612 ABOUT THINGS LIKE HOUSING FIRST 1340 00:47:28,679 --> 00:47:31,682 MODELS FOR THE HOMELESS. 1341 00:47:31,748 --> 00:47:33,850 I'VE BEEN SORT OF -- MY SON, 1342 00:47:33,917 --> 00:47:36,086 WHO'S IN HIS EARLY 30s, 1343 00:47:36,153 --> 00:47:37,721 ACTUALLY WORKS WITH THE HOMELESS 1344 00:47:37,788 --> 00:47:40,791 IN L.A., AND HE'S REALLY GOT ME 1345 00:47:40,857 --> 00:47:41,892 THINKING, WE'VE HAD A LOT OF 1346 00:47:41,959 --> 00:47:43,327 GOOD DISCUSSIONS ABOUT THE 1347 00:47:43,393 --> 00:47:43,994 HOUSING FIRST MODEL FOR 1348 00:47:44,061 --> 00:47:44,428 HOMELESS. 1349 00:47:44,494 --> 00:47:48,799 I JUST FINISHED A BOOK, I THINK 1350 00:47:48,865 --> 00:47:52,436 THE LAST NAME IS DUGAN, 1351 00:47:52,502 --> 00:47:53,403 HOMELESSNESS IS A HOUSING 1352 00:47:53,470 --> 00:47:56,907 PROBLEM, WHICH IS A REALLY 1353 00:47:56,974 --> 00:47:57,908 INTERESTING BOOK. 1354 00:47:57,975 --> 00:48:00,077 I HEARD HIM GIVE A TALK ON IT, 1355 00:48:00,143 --> 00:48:02,379 AND IT'S AN IMPRESSIVE SET OF 1356 00:48:02,446 --> 00:48:07,551 ANALYSES LOOKING AT TRYING TO 1357 00:48:07,618 --> 00:48:08,952 UNDERSTAND HOMELESSNESS, AND IS 1358 00:48:09,019 --> 00:48:10,153 HOMELESSNESS BECAUSE OF DRUG USE 1359 00:48:10,220 --> 00:48:11,521 OR MENTAL HEALTH OR WHATNOT, AND 1360 00:48:11,588 --> 00:48:13,056 HE MAKES A PRETTY COGENT 1361 00:48:13,123 --> 00:48:14,791 ARGUMENT THAT IT'S BECAUSE WE'RE 1362 00:48:14,858 --> 00:48:18,428 JUST NOT PRODUCING THE HOUSING. 1363 00:48:18,495 --> 00:48:20,197 AND THE HOUSING FIRST MODEL FOR 1364 00:48:20,264 --> 00:48:21,064 HOMELESSNESS IS A WAY TO MAYBE 1365 00:48:21,131 --> 00:48:23,400 START TO THINK ABOUT THAT. 1366 00:48:23,467 --> 00:48:24,935 THE BETTER INTEGRATION OF 1367 00:48:25,002 --> 00:48:27,004 SERVICES, AND ESPECIALLY BRIDGE 1368 00:48:27,070 --> 00:48:28,905 SERVICES, AND RAPID INTAKES TO 1369 00:48:28,972 --> 00:48:30,340 TREATMENT, SUCH AS STARTING 1370 00:48:30,407 --> 00:48:31,241 BUPRENORPHINE IN THE EMERGENCY 1371 00:48:31,308 --> 00:48:32,643 DEPARTMENT, WHICH I MENTIONED 1372 00:48:32,709 --> 00:48:33,076 BEFORE. 1373 00:48:33,143 --> 00:48:34,311 I THINK THESE ARE ALL THINGS TO 1374 00:48:34,378 --> 00:48:35,946 BE THINKING ABOUT. 1375 00:48:36,013 --> 00:48:41,318 THERE'S ALSO -- I DON'T WANT TO 1376 00:48:41,385 --> 00:48:43,620 OVERLOOK WHAT SO CALLED HARM 1377 00:48:43,687 --> 00:48:45,188 REDUCTION APPROACHES, WHICH I 1378 00:48:45,255 --> 00:48:46,790 WOULD NOTE, METHADONE AND 1379 00:48:46,857 --> 00:48:48,225 BUPRENORPHINE ARE HARM REDUCTION 1380 00:48:48,292 --> 00:48:49,793 APPROACH, BUT OTHER ONES, NEEDLE 1381 00:48:49,860 --> 00:48:51,995 EXCHANGE SERVICES, FENTANYL TEST 1382 00:48:52,062 --> 00:48:53,397 STRIPS, SAFE INJECTION 1383 00:48:53,463 --> 00:48:56,800 FACILITIES, AND HE HEROIN 1384 00:48:56,867 --> 00:48:57,701 TREATMENT. 1385 00:48:57,768 --> 00:48:59,903 I'VE GOT THOUGHTS ABOUT EACH OF 1386 00:48:59,970 --> 00:49:03,173 THESE, AND WHERE THEY FIT IN THE 1387 00:49:03,240 --> 00:49:04,174 CONTINUUM OF CARE AND HOW BEST 1388 00:49:04,241 --> 00:49:06,710 TO APPROACH THEM. 1389 00:49:06,777 --> 00:49:08,412 AND THEIR COST-BENEFIT ANALYSIS 1390 00:49:08,478 --> 00:49:11,415 OF THEM. 1391 00:49:11,481 --> 00:49:13,817 I THINK SOMETIMES WE MAY BE 1392 00:49:13,884 --> 00:49:16,820 LOOKING FOR FAST SOLUTIONS, SUCH 1393 00:49:16,887 --> 00:49:18,789 AS HEROIN TREATMENT, RATHER THAN 1394 00:49:18,855 --> 00:49:21,958 THINKING ABOUT WHETHER IT REALLY 1395 00:49:22,025 --> 00:49:23,827 PROVIDING TREATMENT TO HELP 1396 00:49:23,894 --> 00:49:26,697 PEOPLE WHO MAY BE 1397 00:49:26,763 --> 00:49:28,131 DISENFRANCHISED AND IN NEED OF 1398 00:49:28,198 --> 00:49:30,534 OTHER KINDS OF SERVICES, BUT 1399 00:49:30,600 --> 00:49:31,635 GLAD TO TALK ABOUT THAT FURTHER. 1400 00:49:31,702 --> 00:49:34,171 AND THEN JUST A MOMENT ABOUT 1401 00:49:34,237 --> 00:49:36,039 CREATING INTEGRATED SYSTEMS OF 1402 00:49:36,106 --> 00:49:37,174 CARE, THAT WE NEED TO BE 1403 00:49:37,240 --> 00:49:39,242 THINKING ABOUT INTEGRATING 1404 00:49:39,309 --> 00:49:41,211 PROGRAMS ACROSS LEVELS OF 1405 00:49:41,278 --> 00:49:43,080 SERVICE, MAKING SURE PEOPLE 1406 00:49:43,146 --> 00:49:44,414 ENTER AT THE APPROPRIATE LEVEL 1407 00:49:44,481 --> 00:49:46,083 OF SERVICE, AND IMPROVE 1408 00:49:46,149 --> 00:49:47,584 TRANSITION ACROSS LEVEL OF 1409 00:49:47,651 --> 00:49:47,918 SERVICES. 1410 00:49:47,984 --> 00:49:51,855 AND I'LL JUST SAY THAT WE NEED 1411 00:49:51,922 --> 00:49:53,890 TO THINK ABOUT MOVING BETWEEN 1412 00:49:53,957 --> 00:49:56,193 INPATIENT RESIDENTIAL 1413 00:49:56,259 --> 00:49:56,927 OUTPATIENT, THE EMERGENCY 1414 00:49:56,993 --> 00:49:59,229 DEPARTMENT APPROACHES, EACH OF 1415 00:49:59,296 --> 00:50:02,766 THEE ANDTHESE, AND HOW DO WE BER 1416 00:50:02,833 --> 00:50:03,967 INTEGRATE WHAT ARE SOMETIMES 1417 00:50:04,034 --> 00:50:05,669 DISPARATE LEVELS OR -- NOT 1418 00:50:05,736 --> 00:50:07,637 DISPARATE BUT NOT FULLY ENGAGED 1419 00:50:07,704 --> 00:50:12,976 LEVELS OF SERVICE. 1420 00:50:13,043 --> 00:50:14,177 AND WE NEED TO THINK ABOUT 1421 00:50:14,244 --> 00:50:15,312 LONGER TERM TREATMENT. 1422 00:50:15,379 --> 00:50:16,747 AS I'VE ALLUDED TO BEFORE THE 1423 00:50:16,813 --> 00:50:17,714 IMPORTANCE OF HOUSING. 1424 00:50:17,781 --> 00:50:19,916 TREATMENT OF THE WHOLE PERSON 1425 00:50:19,983 --> 00:50:21,718 AND THE SOCIAL ASPECTS, 1426 00:50:21,785 --> 00:50:23,120 PARTNERSHIPS WITH THE COMMUNITY 1427 00:50:23,186 --> 00:50:25,288 AND TURNING DOWN THE INFLOW, AS 1428 00:50:25,355 --> 00:50:28,158 I MENTIONED BEFORE. 1429 00:50:28,225 --> 00:50:29,793 SOME OF THIS, I WANT TO 1430 00:50:29,860 --> 00:50:33,196 ACKNOWLEDGE, I THINK IT'S 1431 00:50:33,263 --> 00:50:36,199 INTERESTING, NORA NORA VOLKOW,E 1432 00:50:36,266 --> 00:50:38,068 HEAD OF NIDA, HAS STARTED 1433 00:50:38,135 --> 00:50:39,236 SHOWING A SLIDE I'VE SEEN IN 1434 00:50:39,302 --> 00:50:40,537 SEVERAL OF HER TALKS OF WHAT 1435 00:50:40,604 --> 00:50:41,938 APPEARS TO BE A HOMELESS PERSON 1436 00:50:42,005 --> 00:50:43,440 UNDER A BRIDGE AND TALKING ABOUT 1437 00:50:43,507 --> 00:50:45,675 THE SOCIAL ASPECTS OF DRUG USE 1438 00:50:45,742 --> 00:50:46,910 AND NEEDING TO ACKNOWLEDGE THOSE 1439 00:50:46,977 --> 00:50:50,614 AS WE THINK ABOUT THIS. 1440 00:50:50,680 --> 00:50:52,716 DURING MY LAST YEAR OF EDITING 1441 00:50:52,783 --> 00:50:54,818 DRUG AND ALCOHOL DEPENDENCE, I 1442 00:50:54,885 --> 00:50:56,787 PUBLISHED A COMMENTARY ABOUT 1443 00:50:56,853 --> 00:51:01,024 NEEDING TO ADDRESS MEANING AND 1444 00:51:01,091 --> 00:51:03,059 PURPOSE IN THE OPIATE EPIDEMIC. 1445 00:51:03,126 --> 00:51:04,261 IT'S INTERESTING, IN ALL MY 1446 00:51:04,327 --> 00:51:05,228 PAPERS, IT'S THE ONE THAT I GOT 1447 00:51:05,295 --> 00:51:08,031 THE MOST, I THINK, EMAILS FROM 1448 00:51:08,098 --> 00:51:09,366 PROVIDERS AND THE COMMUNITY 1449 00:51:09,433 --> 00:51:10,233 SAYING, ABSOLUTELY, THIS IS WHAT 1450 00:51:10,300 --> 00:51:11,802 WE NEED TO BE THINKING ABOUT, 1451 00:51:11,868 --> 00:51:13,336 NOT JUST HOW DO WE STOP PEOPLE 1452 00:51:13,403 --> 00:51:14,538 FROM OVERDOSING. 1453 00:51:14,604 --> 00:51:15,939 WE NEED TO THINK ABOUT THAT, BUT 1454 00:51:16,006 --> 00:51:17,741 WE ALSO NEED TO THINK ABOUT HOW 1455 00:51:17,808 --> 00:51:19,543 DO WE ENSURE THAT WE'RE 1456 00:51:19,609 --> 00:51:20,343 ADDRESSING MEANING AND PURPOSE 1457 00:51:20,410 --> 00:51:22,779 IN PEOPLE'S LIVES. 1458 00:51:22,846 --> 00:51:25,015 SO LET ME SUMMARIZE SOME FINAL 1459 00:51:25,081 --> 00:51:27,184 THOUGHTS, SEE IF THERE'S ANY 1460 00:51:27,250 --> 00:51:27,517 QUESTIONS. 1461 00:51:27,584 --> 00:51:29,219 WE CONTINUE TO STRUGGLE WITH THE 1462 00:51:29,286 --> 00:51:30,287 OPIOID PROBLEM. 1463 00:51:30,353 --> 00:51:32,389 WE'VE BEEN DOING IT FOR YEARS 1464 00:51:32,456 --> 00:51:32,689 NOW. 1465 00:51:32,756 --> 00:51:34,224 I WOULD SAY WE DON'T HAVE AN 1466 00:51:34,291 --> 00:51:35,826 OPIOID PROBLEM, WE HAVE A 1467 00:51:35,892 --> 00:51:37,561 SUBSTANCE USE PROBLEM, AND IF WE 1468 00:51:37,627 --> 00:51:39,429 KEEP FOCUSING ON OPIOIDS, WE'LL 1469 00:51:39,496 --> 00:51:43,300 SIMPLY HAVE A METHAMPHETAMINE 1470 00:51:43,366 --> 00:51:46,236 PROBLEM OR A XYLAZINE PROBLEM OR 1471 00:51:46,303 --> 00:51:48,538 A BENZO PROBLEM OR AN ALCOHOL 1472 00:51:48,605 --> 00:51:50,006 PROBLEM IN A FEW YEARS, IF WE 1473 00:51:50,073 --> 00:51:50,874 DON'T ALREADY. 1474 00:51:50,941 --> 00:51:52,075 ADDRESSING THE PROBLEM FROM 1475 00:51:52,142 --> 00:51:53,944 HEALTH SYSTEM PERSPECTIVES 1476 00:51:54,010 --> 00:51:55,245 REQUIRES ENDURING COMMITMENT, 1477 00:51:55,312 --> 00:51:56,413 AND WE HAVE NOT BEEN GOOD ABOUT 1478 00:51:56,480 --> 00:51:58,682 THIS. 1479 00:51:58,748 --> 00:52:01,318 I THINK WE TEND TO -- I THINK WE 1480 00:52:01,384 --> 00:52:05,856 TEND TO SAY, OKAY, WE'VE GOT THE 1481 00:52:05,922 --> 00:52:07,357 CURVE GOING DOWN, WE CAN SHIFT 1482 00:52:07,424 --> 00:52:11,194 OUR FOCUS TO SOMETHING ELSE. 1483 00:52:11,261 --> 00:52:12,329 ALZHEIMER'S DISEASE, LYME 1484 00:52:12,395 --> 00:52:12,562 DISEASE. 1485 00:52:12,629 --> 00:52:14,331 THOSE ARE IMPORTANT THINGS, 1486 00:52:14,397 --> 00:52:15,065 ABSOLUTELY, BUT AS SOON AS WE 1487 00:52:15,131 --> 00:52:18,034 FEEL LIKE WE'VE GOT SOMETHING 1488 00:52:18,101 --> 00:52:19,202 UNDER CONTROL, WE TEND TO MOVE 1489 00:52:19,269 --> 00:52:22,138 ON TO THE NEXT THING. 1490 00:52:22,205 --> 00:52:23,340 WE HAVE APPROACHES THAT WORK 1491 00:52:23,406 --> 00:52:26,843 THAT ARE EVIDENCE-BASED. 1492 00:52:26,910 --> 00:52:31,147 WE JUST DON'T DO THEM. 1493 00:52:31,214 --> 00:52:33,783 , IS THE PROBLEM. 1494 00:52:33,850 --> 00:52:34,751 THERE ARE GREAT OPPORTUNITIES 1495 00:52:34,818 --> 00:52:35,852 FOR ALL TYPES OF RESEARCH IN THE 1496 00:52:35,919 --> 00:52:38,388 AREA OF ADDICTIVE DISORDERS. 1497 00:52:38,455 --> 00:52:39,723 I THINK -- YOU KNOW, MY CAREER 1498 00:52:39,789 --> 00:52:41,024 HAS BEEN IN THIS, IT'S BEEN 1499 00:52:41,091 --> 00:52:44,895 REALLY GRATIFYING AND 1500 00:52:44,961 --> 00:52:45,662 INTERESTING, INTELLECTUALLY 1501 00:52:45,729 --> 00:52:45,996 STIMULATING. 1502 00:52:46,062 --> 00:52:47,097 I TELL MEDICAL STUDENTS, IF 1503 00:52:47,163 --> 00:52:48,732 YOU'RE INTERESTED IN 1504 00:52:48,798 --> 00:52:49,833 UNDERSTANDING HOW RAISING TAXES 1505 00:52:49,900 --> 00:52:53,870 ON TOBACCO CAN DECREASE SMOKING, 1506 00:52:53,937 --> 00:52:54,571 THE SUBSTANCE ABUSE FIELD IS 1507 00:52:54,638 --> 00:52:55,105 OPEN TO YOU. 1508 00:52:55,171 --> 00:52:56,339 IF YOU'RE INTERESTED IN LOOKING 1509 00:52:56,406 --> 00:53:02,445 AT HOW DOPAMINE IN THE NUCLEUS 1510 00:53:02,512 --> 00:53:03,246 ACCUMBENS AFFECTS DRUG USE, 1511 00:53:03,313 --> 00:53:04,548 WE'RE THERE, WE'VE GOT IT ALL 1512 00:53:04,614 --> 00:53:05,715 FROM SOUP TO NUTS. 1513 00:53:05,782 --> 00:53:07,217 I CAN'T SEE WHY ANYTHING GOES 1514 00:53:07,284 --> 00:53:10,820 INTO ANYTHING ELSE, FOR THOSE IN 1515 00:53:10,887 --> 00:53:13,056 PEDIATRIC ONCOLOGY AND THINGS 1516 00:53:13,123 --> 00:53:13,490 LIKE THAT. 1517 00:53:13,557 --> 00:53:16,660 I THINK IT'S FASCINATING, EXCUSE 1518 00:53:16,726 --> 00:53:18,428 ME, AND REALLY INTERESTING. 1519 00:53:18,495 --> 00:53:21,064 AND THIS CAN BE EXTREMELY 1520 00:53:21,131 --> 00:53:22,599 GRATIFYING AS AN AREA OF 1521 00:53:22,666 --> 00:53:23,934 MEDICINE, IN WHICH TO WORK 1522 00:53:24,000 --> 00:53:24,634 CLINICALLY. 1523 00:53:24,701 --> 00:53:28,004 PATIENTS GET BETTER, AND THEN 1524 00:53:28,071 --> 00:53:29,973 OFTEN SOME OF THE MOST 1525 00:53:30,040 --> 00:53:30,941 APPRECIATIVE PEOPLE -- I CAN'T 1526 00:53:31,007 --> 00:53:32,375 TELL YOU HOW MANY PEOPLE I'VE 1527 00:53:32,442 --> 00:53:33,810 MET WHO SAY I DON'T CARE ABOUT 1528 00:53:33,877 --> 00:53:35,779 WHAT KIND OF TENNIS SHOES I 1529 00:53:35,845 --> 00:53:37,113 WEAR, I DON'T CARE WHAT KIND OF 1530 00:53:37,180 --> 00:53:37,981 CAR I DRIVE. 1531 00:53:38,048 --> 00:53:40,984 I'M WORKING MY PROGRAM, I'M 1532 00:53:41,051 --> 00:53:43,987 STAYING SOBER, I'M NOT USING, 1533 00:53:44,054 --> 00:53:45,255 AND I'M TRYING TO HELP OTHER 1534 00:53:45,322 --> 00:53:46,122 PEOPLE AS WELL. 1535 00:53:46,189 --> 00:53:48,124 AND THAT'S REALLY FUN AND 1536 00:53:48,191 --> 00:53:49,125 EXCITING TO SEE. 1537 00:53:49,192 --> 00:53:51,194 SO THANK YOU, AND WE'VE GOT A 1538 00:53:51,261 --> 00:53:52,195 FEW MINUTES FOR SOME QUESTIONS. 1539 00:53:52,262 --> 00:53:58,969 [APPLAUSE] 1540 00:53:59,035 --> 00:54:01,738 >> FIRST OF ALL, I THINK I'M 1541 00:54:01,805 --> 00:54:02,606 SPEAKING FOR EVERYBODY, THAT WE 1542 00:54:02,672 --> 00:54:05,609 REALLY ENJOYED YOUR WONDERFUL 1543 00:54:05,675 --> 00:54:06,376 PRESENTATION HERE, GIVING US 1544 00:54:06,443 --> 00:54:07,577 DEEP INSIGHTS, A LOT TO THINK 1545 00:54:07,644 --> 00:54:08,111 ABOUT. 1546 00:54:08,178 --> 00:54:10,680 SHOWING US IT'S NOT JUST A 1547 00:54:10,747 --> 00:54:11,881 BIOLOGICAL MEDICAL AND HEALTH 1548 00:54:11,948 --> 00:54:13,083 ISSUE, BUT OBVIOUSLY A SOCIAL 1549 00:54:13,149 --> 00:54:15,819 ISSUE AS WELL. 1550 00:54:15,885 --> 00:54:18,655 SO I GUESS PEOPLE HAVE 1551 00:54:18,722 --> 00:54:19,589 QUESTIONS. 1552 00:54:19,656 --> 00:54:20,790 I DO WANT TO KIND OF START WITH 1553 00:54:20,857 --> 00:54:21,992 MORE OF A COMMENT THAN ANYTHING. 1554 00:54:22,058 --> 00:54:27,297 IT ALWAY ALWAYS IRRITATED ME, WS 1555 00:54:27,364 --> 00:54:28,832 THE ROLE YOU -- YOU TALKED ABOUT 1556 00:54:28,898 --> 00:54:30,233 IT IN THE BEGINNING, THE ROLE OF 1557 00:54:30,300 --> 00:54:33,036 THE STATE LICENSURES AND JOINT 1558 00:54:33,103 --> 00:54:34,137 COMMISSION HAD IN ACTUALLY 1559 00:54:34,204 --> 00:54:35,171 ENCOURAGING OR ADVOCATING FOR 1560 00:54:35,238 --> 00:54:37,574 THE USE OF OPIOIDS TO TREAT 1561 00:54:37,641 --> 00:54:37,907 PAIN. 1562 00:54:37,974 --> 00:54:39,309 AND AT THAT TIME, WHEN THIS ALL 1563 00:54:39,376 --> 00:54:41,277 CAME OUT, LET'S SAY THAT IT 1564 00:54:41,344 --> 00:54:42,879 REALLY RUBBED ME THE WRONG WAY, 1565 00:54:42,946 --> 00:54:44,514 AND I WAS GETTING THOSE EMAILS 1566 00:54:44,581 --> 00:54:45,915 SAYING I'M NOT BEING AGGRESSIVE 1567 00:54:45,982 --> 00:54:47,517 ENOUGH IN TREATMENT OF PAIN. 1568 00:54:47,584 --> 00:54:48,585 NOW THAT WE'VE KIND OF 1569 00:54:48,652 --> 00:54:49,919 RECOGNIZED THAT, WHAT IS THE 1570 00:54:49,986 --> 00:54:51,688 ROLE OF THESE SAME ORGANIZATIONS 1571 00:54:51,755 --> 00:54:54,691 TO KIND OF TURN THAT AROUND? 1572 00:54:54,758 --> 00:54:57,293 >> YEAH, NO, SHOULD I REPEAT 1573 00:54:57,360 --> 00:54:58,995 QUESTIONS OR ARE THEY BEING -- 1574 00:54:59,062 --> 00:55:01,097 >> THEY'RE BEING PICKED UP. 1575 00:55:01,164 --> 00:55:02,265 >> GREAT. 1576 00:55:02,332 --> 00:55:02,932 GREAT QUESTION. 1577 00:55:02,999 --> 00:55:04,134 YEAH, YOU KNOW, IT'S VERY 1578 00:55:04,200 --> 00:55:05,802 INTERESTING, BECAUSE I DID A LOT 1579 00:55:05,869 --> 00:55:06,436 OF -- NOT A LOT. 1580 00:55:06,503 --> 00:55:08,872 I DID SOME DIGGING LIKE ON THE 1581 00:55:08,938 --> 00:55:11,975 FEDERATION STATE MEDICAL BOARDS, 1582 00:55:12,042 --> 00:55:13,043 WEBSITES, THE JOINT COMMISSION 1583 00:55:13,109 --> 00:55:14,177 AND THINGS LIKE THAT AT ONE 1584 00:55:14,244 --> 00:55:15,712 POINT A FEW YEARS BACK, AND THEY 1585 00:55:15,779 --> 00:55:18,348 ALL HAVE LIKE BACKED OFF 1586 00:55:18,415 --> 00:55:19,582 TREMENDOUSLY IN SAYING OH, WE 1587 00:55:19,649 --> 00:55:20,784 NEVER REALLY SAID PEOPLE SHOULD 1588 00:55:20,850 --> 00:55:24,320 BE, YOU KNOW, DOING THIS. 1589 00:55:24,387 --> 00:55:27,724 AND I THINK THEY'RE PROBABLY 1590 00:55:27,791 --> 00:55:29,225 SCARED SOMEWHAT ABOUT THE 1591 00:55:29,292 --> 00:55:34,264 LIABILITY TO SOME OF THIS. 1592 00:55:34,330 --> 00:55:35,965 SO I THINK THAT WHERE THEY COME 1593 00:55:36,032 --> 00:55:40,336 DOWN NOW IS, YOU KNOW, IN 1594 00:55:40,403 --> 00:55:40,870 DOCUMENTATION, ELECTRONIC 1595 00:55:40,937 --> 00:55:41,805 MEDICAL RECORDS, THINGS LIKE 1596 00:55:41,871 --> 00:55:45,742 THAT, THEY'RE PUSHING TRYING TO 1597 00:55:45,809 --> 00:55:47,711 GET DECREASED PRESCRIBING OF 1598 00:55:47,777 --> 00:55:48,912 ANALGESICS. 1599 00:55:48,978 --> 00:55:51,781 BUT ACCEPTING ANY 1600 00:55:51,848 --> 00:55:52,415 RESPONSIBILITY, I HAVEN'T SEEN 1601 00:55:52,482 --> 00:55:52,782 THAT. 1602 00:55:52,849 --> 00:55:56,152 THE AMERICAN PAIN SOCIETY, I 1603 00:55:56,219 --> 00:55:58,521 THINK -- I'M LIKE 95% CERTAIN, I 1604 00:55:58,588 --> 00:55:59,723 THINK THEY WENT BANKRUPT. 1605 00:55:59,789 --> 00:56:03,460 I THINK THEY WERE SUED BY THE 1606 00:56:03,526 --> 00:56:05,562 STATES AND I THINK THEY WENT 1607 00:56:05,628 --> 00:56:06,229 BELLY-UP. 1608 00:56:06,296 --> 00:56:09,833 YOU KNOW, AS PART OF THE WHOLE 1609 00:56:09,899 --> 00:56:11,634 FIASCO. 1610 00:56:11,701 --> 00:56:13,203 >> THANK YOU. 1611 00:56:13,269 --> 00:56:14,704 >> HI. 1612 00:56:14,771 --> 00:56:16,673 LAUREN ATLAS, I'M A PAIN NURSE 1613 00:56:16,740 --> 00:56:19,275 SCIENTIST, SO I CAN CONFIRM APS 1614 00:56:19,342 --> 00:56:19,709 DID SHUT DOWN. 1615 00:56:19,776 --> 00:56:20,076 >> YEP. 1616 00:56:20,143 --> 00:56:21,511 >> THE U.S. ASSOCIATION FOR THE 1617 00:56:21,578 --> 00:56:24,013 STUDY OF PAIN HAS BEEN FORMED, 1618 00:56:24,080 --> 00:56:25,882 FOCUSING JUST ON RESEARCH ABOUT 1619 00:56:25,949 --> 00:56:29,319 PAIN, KIND OF, AND NO 1620 00:56:29,385 --> 00:56:29,853 PHARMACEUTICAL SUPPORT AND 1621 00:56:29,919 --> 00:56:30,053 STUFF. 1622 00:56:30,120 --> 00:56:31,087 I GUESS THE QUESTION THAT WAS 1623 00:56:31,154 --> 00:56:33,323 JUST ASKED SORT OF SETS ME UP 1624 00:56:33,389 --> 00:56:33,523 WELL. 1625 00:56:33,590 --> 00:56:35,525 AT THE END, YOU CONCLUDED WITH, 1626 00:56:35,592 --> 00:56:39,696 YOU KNOW, THIS IS AN OPIOID 1627 00:56:39,763 --> 00:56:40,630 PROBLEM, THIS IS A SUBSTANCE USE 1628 00:56:40,697 --> 00:56:41,831 PROBLEM, BUT I WAS CURIOUS ABOUT 1629 00:56:41,898 --> 00:56:43,133 WHAT YOU THOUGHT PAIN 1630 00:56:43,199 --> 00:56:44,334 RESEARCHERS CAN DO, GIVEN THAT 1631 00:56:44,400 --> 00:56:46,903 WE DID PLAY A ROLE AT THE 1632 00:56:46,970 --> 00:56:48,338 BEGINNING SO, YOU KNOW, YOU 1633 00:56:48,404 --> 00:56:50,173 MIGHT WANT TO ELABORATE? 1634 00:56:50,240 --> 00:56:52,108 >> SO IT WAS YOU? 1635 00:56:52,175 --> 00:56:52,976 [LAUGHTER] 1636 00:56:53,042 --> 00:56:55,178 >> I WASN'T AROUND THEN, BUT 1637 00:56:55,245 --> 00:56:56,679 YEAH, I AM CURIOUS TO HEAR WHAT 1638 00:56:56,746 --> 00:56:57,847 YOU THINK THE FIELD OF PAIN 1639 00:56:57,914 --> 00:56:58,815 RESEARCH COULD BE DOING NOW, 1640 00:56:58,882 --> 00:57:00,917 BECAUSE I THINK -- YEAH, I 1641 00:57:00,984 --> 00:57:02,385 GUESS -- I GUESS PART OF YOUR 1642 00:57:02,452 --> 00:57:04,354 DATA SORT OF SHOWED ME ACTUALLY 1643 00:57:04,420 --> 00:57:05,989 THAT OXYCONTIN IS SUCH A SMALL 1644 00:57:06,055 --> 00:57:08,491 PROPORTION RELATIVE TO THE 1645 00:57:08,558 --> 00:57:09,993 OVERALL OVERDOSES HAPPENING AS A 1646 00:57:10,059 --> 00:57:11,127 RESULT OF FENTANYL AND STUFF, 1647 00:57:11,194 --> 00:57:13,163 BUT DO YOU STILL SEE A PLACE 1648 00:57:13,229 --> 00:57:15,098 THAT PAIN SCIENCE SHOULD BE 1649 00:57:15,165 --> 00:57:15,965 REALLY THINKING HARD ABOUT THIS 1650 00:57:16,032 --> 00:57:19,435 AND HOW WE COULD AMELIORATE THE 1651 00:57:19,502 --> 00:57:19,636 ISSUE? 1652 00:57:19,702 --> 00:57:22,272 >> ABSOLUTELY, NO, I DO. 1653 00:57:22,338 --> 00:57:24,440 AND YOU KNOW, EVERYBODY'S SAID 1654 00:57:24,507 --> 00:57:26,042 THIS OR WRITTEN THIS, THE HOLY 1655 00:57:26,109 --> 00:57:27,710 GRAIL, OF COURSE, IS AN 1656 00:57:27,777 --> 00:57:29,012 EFFECTIVE ANALGESIC THAT'S 1657 00:57:29,078 --> 00:57:30,547 EQUIVALENT TO MORPHINE BUT NOT 1658 00:57:30,613 --> 00:57:31,981 WITH THE ABUSE PROFILE. 1659 00:57:32,048 --> 00:57:36,052 YOU KNOW, THE COLLEGE ON 1660 00:57:36,119 --> 00:57:37,320 PROBLEMS WITH DRUG DEPENDENCE, 1661 00:57:37,387 --> 00:57:38,655 WHICH USED TO BE THE COMMITTEE 1662 00:57:38,721 --> 00:57:40,056 ON DRUG DEPENDENCE, IT'S BEEN 1663 00:57:40,123 --> 00:57:42,125 AROUND SINCE THE 1920s AS A 1664 00:57:42,192 --> 00:57:43,760 COMMITTEE. 1665 00:57:43,827 --> 00:57:46,062 AND THEY WERE WORKING ON THAT 1666 00:57:46,129 --> 00:57:49,732 BACK FROM THEIR INCEPTION 1667 00:57:49,799 --> 00:57:51,201 SAYING, OH, WE'VE GOT TO FIND -- 1668 00:57:51,267 --> 00:57:52,902 THEY KEPT THINKING THEY WOULD 1669 00:57:52,969 --> 00:57:57,040 FIND IT, MALBUFENE AND THINGS 1670 00:57:57,106 --> 00:57:58,208 LIKE THAT, WHERE THEY THOUGHT 1671 00:57:58,274 --> 00:58:01,444 THEY COULD FIND SOMETHING. 1672 00:58:01,511 --> 00:58:04,614 I THINK THERE STILL IS A ROLE, 1673 00:58:04,681 --> 00:58:07,217 ABSOLUTELY, AND ESPECIALLY FOR 1674 00:58:07,283 --> 00:58:11,921 ACUTE PAIN CONTROL. 1675 00:58:11,988 --> 00:58:12,722 AND WE NEED IT. 1676 00:58:12,789 --> 00:58:16,559 I MEAN, I JUST HAD -- NOT TO 1677 00:58:16,626 --> 00:58:20,396 PERSONALIZE THIS, BUT I JUST HAD 1678 00:58:20,463 --> 00:58:21,731 INGUINAL HERNIA SURGERY A COUPLE 1679 00:58:21,798 --> 00:58:22,432 MONTHS AGO. 1680 00:58:22,498 --> 00:58:23,433 IT WAS VERY INTERESTING GOING 1681 00:58:23,499 --> 00:58:25,935 INTO IT, BECAUSE I SAID, I DON'T 1682 00:58:26,002 --> 00:58:26,703 WANT ANY OPIOIDS. 1683 00:58:26,769 --> 00:58:30,940 THEY GAVE ME LIKE FIVE 1684 00:58:31,007 --> 00:58:32,008 HYDROMORPHONES, I THINK, OR 1685 00:58:32,075 --> 00:58:32,809 SOMETHING, TO TAKE. 1686 00:58:32,876 --> 00:58:34,444 AND IT WAS VERY FUNNY, BECAUSE 1687 00:58:34,510 --> 00:58:35,578 THE NURSE DIDN'T KNOW I WORKED 1688 00:58:35,645 --> 00:58:37,347 IN THE SUBSTANCE USE AREA AND 1689 00:58:37,413 --> 00:58:39,015 SHE GAVE ME THIS BIG LECTURE 1690 00:58:39,082 --> 00:58:41,751 ABOUT THE ABUSE POTENTIAL OF THE 1691 00:58:41,818 --> 00:58:43,319 OPIOIDS AND TAKE THEM TO THE 1692 00:58:43,386 --> 00:58:45,021 POLICE STATION TO GET RID OF 1693 00:58:45,088 --> 00:58:46,389 THEM IF I DON'T USE THEM AND ALL 1694 00:58:46,456 --> 00:58:47,257 THIS STUFF. 1695 00:58:47,323 --> 00:58:49,058 BUT I WAS STRUCK BY THE FACT 1696 00:58:49,125 --> 00:58:50,059 THAT I DIDN'T USE ANY. 1697 00:58:50,126 --> 00:58:51,060 I DIDN'T USE ANY. 1698 00:58:51,127 --> 00:58:52,428 YOU KNOW, I WANTED TO GET RID OF 1699 00:58:52,495 --> 00:58:52,762 THEM. 1700 00:58:52,829 --> 00:58:54,397 I SAID NO, WE'VE GOT TO PUT THEM 1701 00:58:54,464 --> 00:58:55,832 IN THE BOXY KEEP ALL THE 1702 00:58:55,899 --> 00:58:57,400 MEDICINES IN, IN CASE SOCIETY 1703 00:58:57,467 --> 00:59:01,037 BREAKS DOWN AND WE NEED THEM. 1704 00:59:01,104 --> 00:59:04,207 BUT I THINK -- YEAH, SO I THINK 1705 00:59:04,274 --> 00:59:05,775 STUDYING OTHER ALTERNATIVE 1706 00:59:05,842 --> 00:59:07,977 ANALGESICS. 1707 00:59:08,044 --> 00:59:09,512 I THINK THE OTHER THING, THOUGH, 1708 00:59:09,579 --> 00:59:11,214 IS, AND I COULD -- I WANT TO BE 1709 00:59:11,281 --> 00:59:15,151 CAREFUL ABOUT TIME, BUT YOU 1710 00:59:15,218 --> 00:59:17,720 KNOW, WE USED TO RUN INTEGRATED 1711 00:59:17,787 --> 00:59:21,224 PAIN TREATMENT PROGRAMS IN THIS 1712 00:59:21,291 --> 00:59:21,658 COUNTRY. 1713 00:59:21,724 --> 00:59:24,060 THEY CAME OUT OF THE UNIVERSITY 1714 00:59:24,127 --> 00:59:24,727 OF WASHINGTON-SEATTLE AS THE 1715 00:59:24,794 --> 00:59:25,528 MODEL. 1716 00:59:25,595 --> 00:59:27,096 THOSE WERE GREAT PROGRAMS, AND 1717 00:59:27,163 --> 00:59:28,164 THEY REALLY WERE EFFECTIVE. 1718 00:59:28,231 --> 00:59:33,536 WHEN I WAS A RESIDENT, THE ONE 1719 00:59:33,603 --> 00:59:34,904 IN HOPKINS RAN ON PSYCHOLOGY, 1720 00:59:34,971 --> 00:59:36,773 BUT IT RAN ON NEUROSURGERY, 1721 00:59:36,839 --> 00:59:37,307 ORTHOPEDICS. 1722 00:59:37,373 --> 00:59:38,574 WE'VE LOST THOSE AND THOSE WERE 1723 00:59:38,641 --> 00:59:40,009 GREAT PROGRAMS. 1724 00:59:40,076 --> 00:59:43,279 YOU THINK STUDYING THAT ON THE 1725 00:59:43,346 --> 00:59:46,616 CLINICAL SIDE AS WELL. 1726 00:59:46,683 --> 00:59:48,084 >> I THINK YOU HAVE TIME FOR ONE 1727 00:59:48,151 --> 00:59:50,453 MORE QUESTION, BUT WE CAN 1728 00:59:50,520 --> 00:59:51,988 TAKE -- DR. STRAIN WILL TAKE 1729 00:59:52,055 --> 00:59:52,889 QUESTIONS AFTERWARDS, AFTER THIS 1730 00:59:52,956 --> 00:59:54,457 IS OVER TOO. 1731 00:59:54,524 --> 00:59:54,924 >> I'LL STICK AROUND. 1732 00:59:54,991 --> 00:59:55,591 >> HELLO. 1733 00:59:55,658 --> 00:59:58,294 MY NAME IS RUTH, ACTUALLY FROM 1734 00:59:58,361 --> 01:00:03,166 ONE FELLOW AMHURST TO ANOTHER I 1735 01:00:03,232 --> 01:00:03,733 SAY HELLO. 1736 01:00:03,800 --> 01:00:05,802 SO MY QUESTION BOUNCES OFF OF 1737 01:00:05,868 --> 01:00:06,569 LAUREN'S. 1738 01:00:06,636 --> 01:00:08,071 BUT MORE FROM THE MEDICAL 1739 01:00:08,137 --> 01:00:09,572 PERSPECTIVE OR HEALTHCARE 1740 01:00:09,639 --> 01:00:10,073 PERSPECTIVE. 1741 01:00:10,139 --> 01:00:11,874 SO I UNDERSTAND THAT THE GOAL 1742 01:00:11,941 --> 01:00:13,242 OBVIOUSLY IN A PERFECT WORLD 1743 01:00:13,309 --> 01:00:17,480 WOULD BE TO CUT OPIATE OR 1744 01:00:17,547 --> 01:00:22,285 SUBSTANCESUBSTANCE ABUSE TO ZERT 1745 01:00:22,352 --> 01:00:24,587 WHAT WOULD BE THE GOAL FOR 1746 01:00:24,654 --> 01:00:26,990 DOCTORS IN REALTIME FOR 1747 01:00:27,056 --> 01:00:28,291 SUBSTANCE USE? 1748 01:00:28,358 --> 01:00:33,730 >> WELL, I WAS TALKING TO RITA 1749 01:00:33,796 --> 01:00:34,831 STEVENS ABOUT THIS WALKING OVER, 1750 01:00:34,897 --> 01:00:36,032 BECAUSE YOU KNOW, IF YOU LOOK IN 1751 01:00:36,099 --> 01:00:37,233 THE OLD TESTAMENT OF THE BIBLE, 1752 01:00:37,300 --> 01:00:40,370 YOU CAN FIND PASSAGES ABOUT 1753 01:00:40,436 --> 01:00:43,206 ALCOHOL AND HOW BAD ALCOHOL IS, 1754 01:00:43,272 --> 01:00:46,909 AND IT'S REALLY VIVID, ABOUT HOW 1755 01:00:46,976 --> 01:00:49,278 LIKE AT THE TOP OF THE MAST OF A 1756 01:00:49,345 --> 01:00:50,913 SAILING SHIP BUFFETED BY THE 1757 01:00:50,980 --> 01:00:52,115 WINDS, AND THE NEXT DAY I WANT 1758 01:00:52,181 --> 01:00:52,782 MORE ALCOHOL. 1759 01:00:52,849 --> 01:00:56,119 SO WE'VE HAD SUBSTANCE ABUSE FOR 1760 01:00:56,185 --> 01:00:57,353 THOUSANDS OF YEARS. 1761 01:00:57,420 --> 01:00:59,756 I DON'T THINK WE'RE GOING TONESS 1762 01:00:59,822 --> 01:01:01,157 NECESSARILY GET RID OF IT. 1763 01:01:01,224 --> 01:01:05,194 BUT I THINK WE CAN MAKE A KRA 1764 01:01:05,261 --> 01:01:05,928 DRAMATIC DECREASE IN USE. 1765 01:01:05,995 --> 01:01:07,463 I THINK, YOU KNOW, WE CAN DO A 1766 01:01:07,530 --> 01:01:08,865 BETTER JOB IN EXPLAINING TO 1767 01:01:08,931 --> 01:01:12,101 PEOPLE EARLY ON ABOUT THOSE 1768 01:01:12,168 --> 01:01:14,303 RISKS, THE RISKS OF EVEN 1769 01:01:14,370 --> 01:01:16,372 MODERATE ALCOHOL USE, THE RISKS 1770 01:01:16,439 --> 01:01:19,008 OF THE PRESCRIPTION OPIOID 1771 01:01:19,075 --> 01:01:19,409 YOU'RE GIVEN. 1772 01:01:19,475 --> 01:01:21,944 I MEAN, WE HAVEN'T EVEN TOUCHED 1773 01:01:22,011 --> 01:01:22,245 ON CANNABIS. 1774 01:01:22,311 --> 01:01:24,547 YOU KNOW, WE'RE IN THIS GRAND 1775 01:01:24,614 --> 01:01:26,682 SOCIAL EXPERIMENT OF MAKING 1776 01:01:26,749 --> 01:01:27,784 CANNABIS AVAILABLE, AND WE 1777 01:01:27,850 --> 01:01:28,785 REALLY DON'T KNOW WHAT THE 1778 01:01:28,851 --> 01:01:29,852 CONSEQUENCES OF THAT ARE. 1779 01:01:29,919 --> 01:01:31,921 I THINK WE NEED TO DO A BETTER 1780 01:01:31,988 --> 01:01:34,624 JOB AS HEALTHCARE PROFESSIONALS 1781 01:01:34,690 --> 01:01:36,392 ABOUT INOCULATING PEOPLE ABOUT 1782 01:01:36,459 --> 01:01:39,862 WHAT THOSE RISKS ARE FOR DRUGS. 1783 01:01:39,929 --> 01:01:42,465 >> SORRY, I MEANT TO ALSO 1784 01:01:42,532 --> 01:01:43,466 CLARIFY, SPECIFICALLY RELATING 1785 01:01:43,533 --> 01:01:45,568 TO THOSE WITH CHRONIC PAIN. 1786 01:01:45,635 --> 01:01:46,602 >> OH, OH! 1787 01:01:46,669 --> 01:01:47,136 >> YEAH. 1788 01:01:47,203 --> 01:01:48,671 >> I THINK -- SO I THINK WE LOOK 1789 01:01:48,738 --> 01:01:50,039 AT OTHER TREATMENT MODALITIES 1790 01:01:50,106 --> 01:01:52,675 FOR CHRONIC PAIN, LIKE THOSE OLD 1791 01:01:52,742 --> 01:01:53,976 UNIVERSITY OF WASHINGTON, YOU 1792 01:01:54,043 --> 01:01:56,746 KNOW, PROGRAMS WHERE YOU GIVE 1793 01:01:56,813 --> 01:01:59,415 PEOPLE A VARIETY OF TREATMENTS 1794 01:01:59,482 --> 01:02:01,284 BEYOND SIMPLY SAYING, WELL, 1795 01:02:01,350 --> 01:02:03,886 HERE'S AN OXYCONTIN 1796 01:02:03,953 --> 01:02:04,454 PRESCRIPTION. 1797 01:02:04,520 --> 01:02:04,687 THANKS. 1798 01:02:04,754 --> 01:02:06,923 >> THANK YOU. 1799 01:02:06,989 --> 01:02:07,757 >> DR. STRAIN, THANK YOU VERY 1800 01:02:07,824 --> 01:02:08,024 MUCH. 1801 01:02:08,091 --> 01:02:09,325 I WANT TO THANK THE AUDIENCE FOR 1802 01:02:09,392 --> 01:02:11,427 THEIR QUESTIONS, AND THIS GIVES 1803 01:02:11,494 --> 01:02:13,029 US A LOT TO THINK ABOUT. 1804 01:02:13,096 --> 01:02:15,565 SO ENJOY YOUR AFTERNOON AND FOR 1805 01:02:15,631 --> 01:02:17,300 SOME REASON I HAVE A VERY ODD 1806 01:02:17,366 --> 01:02:18,701 CRAVING FOR APPLE PIE AT THIS 1807 01:02:18,768 --> 01:02:19,469 MOMENT. 1808 01:02:19,535 --> 01:02:19,902 ANYWAY, THANK YOU. 1809 01:02:19,969 >> THANK YOU.