I WANT TO WELCOME EVERYONE TO THE 133rd MEETING OF THE NATIONAL ADVISORY COUNCIL ON DRUG ABUSE. I'M GOING TO THANK YOU AND SAY GOOD-BYE TO OUR GRADUATING COUNCIL MEMBERS, WHOSE OFFICIAL TIME HAS ENDED. ALTHOUGH WE MAY SAY, I WILL DEFINITELY BELIEVE IT'S NOT THE END FOR INTERACTION WITH NIDA AND WE'LL REACH OUT TO THEM IN THE FUTURE. I WANT TO THANK YOU. WHERE IS WESLEY? I WANT TO SAY THANK YOU VERY MUCH, EVEN KNOW YOU'RE NOT GOING TO BE OFFICIAL REMEMBERS MIGHT NOW WE'LL BE RELYING ON YOU FOR MANY THINGS. FIRST, WESLEY CLARK, WHO IS NOT YET APPEARING, I DO WANT -- >> CAN I SAY SOMETHING WHILE WE'RE WAITING? >> ABSOLUTELY. >> ALSO JUST TO LET YOU KNOW THAT WE REALLY MAY SEE YOU AGAIN BECAUSE WE HAVE A TENDENCY TO ASK PEOPLE TO STAY ON FOR A COUPLE ROUNDS BECAUSE OF THE WAY OF GETTING APPROVAL FOR NEW COUNCIL MEMBERS CAN BE A LENGTHY PROCESS. THAT'S A HEADS UP. YOU DON'T HAVE TO AGREE BUT WE'LL PROBABLY BE IN TOUCH AS WELL. >> WE'RE THANKING YOU AND SAYING GOOD-BYE TO ALL OF YOU BUT IT'S TEMPORARY, AND WE WILL BE REACHING OUT TO YOU. I HOPE THAT YOU KEEP ON YOUR INTERACTIONS DIRECTLY WITH US. SO IT'S ONE, WESLEY CLARK. I ALSO WANT TO THANK AND SAY TEMPORARILY GOOD-BYE TO KARL DEISSEROTH, I THINK YOU'RE ON THE PHONE? I THOUGHT HE WAS ON THE PHONE. OKAY. MARIE? >> SHE WAS RIGHT THERE. >> SHE STEPPED OUT. MARIE DYAK. JAY GIEDD. LISA. AGAIN, YOU KNOW YOU'RE NOT GOING TO BE FREE FROM OUR SOURCE OF ACTIVITIES FROM NIDA BUT IN THE MEANTIME THANKS VERY MUCH. ED, THANKS VERY MUCH. AND FINALLY ROBERT RANCOURT WHO ACTUALLY HAS BEEN A GREAT PLEASURE TO HAVE AT COUNCIL, AND, AGAIN, MARIA, I WAS THANKING YOU AND SAY GOOD-BYE. OFFICIAL TIME AT NIDA COUNCIL ENDED BUT I SAID WE'RE GOING TO BE RELYING ON YOU FOR MANY OTHER THINGS. THANK YOU VERY MUCH. AND -- >> I REALLY DO APPRECIATE -- I DON'T KNOW WHAT OTHERS HAVE SAID ABOUT YOUR THANKS BUT I FEEL LIKE I LEAVE WITH MORE THAN I GIVE. THIS IS JUST REALLY A REMARKABLE EXPERIENCE SO THANK YOU. >> WHAT IS CLEAR IS IT JUST AMPLIFIES THE IMPACT, I THINK THIS IS WHY WE ALL COME TOGETHER IN GROUPS LIKE THIS ONE. I DO WANT TO THANK YOU VERY MUCH. I TAKE ALSO ADVANTAGE OF THE OPPORTUNITY TO WELCOME OUR NEW COUNCIL MEMBERS, AND TO THANK THEM FOR WILLINGNESS TO PARTICIPATE. I WANT TO START WITH DANIEL GOONAN, FIRE CHIEF IN THE CITY OF MANCHESTER, NEW HAMPSHIRE. IN THIS ROLE HE HELPED TO DEVELOP AND IMPLEMENT SAFE FIRST STEP FOR THOSE SEEKING- HELP FROM SUBSTANCE USE DISORDER. DANIEL, WELCOME. >> THANK YOU. >> THEN I WANT TO ASK ALSO WELCOME JESSICA NICKEL, PRESIDENT AND CEO OF THE ADDICTION POLICY FORUM, HELPS FAMILIES AND PATIENTS IN CRISIS, INTEGRATE SUBSTANCE USE DISORDER TREATMENT ACROSS SETTINGS, RAISE AWARENESS ON DISEASE OF ADDICTION, PREVENT ADDICTION, AND ADVOCATE AND EDUCATE ON URGENCY OF ADDICTION. JESSICA, WELCOME. DEVIN REEVES, HE IS THE EXECUTIVE DIRECTOR OF THE PHILADELPHIA. PHRC. SEEKS TO PROMOTE HEALTH, DIGNITY AND HUMAN RIGHTS OF INDIVIDUALS WHO USE DRUGS AND COMMUNITY IMPACTED BY DRUGS. HE HAS WORKED AS COMMUNITY ORGANIZER AND GRADUATE ADVOCACY LEADER EXPANDING ACCESS TO NALOXONE, IMPLEMENTING 911 GOOD SAMARITAN POLICIES, EXPANDING SYSTEMS. WELCOME. SHARON WALSH, PROFESSOR OF PSYCHIATRY AT UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE AND PHARMACY AND DIRECTOR OF U.K. CENTER ON DRUG AND ALCOHOL RESEARCH, CONDUCTING CLINICAL RESEARCH FOR NEARLY 30 YEARS, DR. WALSH IS CURRENT P.I. SHARON, WELCOME. FINALLY DR. PAUL KENNY, PROFESSOR AND CHAIR OF THE DEPARTMENT OF NEUROSCIENCE AT THE ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI, DIRECTOR OF DRUG DISCOVERY INSTITUTE, RESEARCH SEEKS TO UNCOVER NEW SIGNALING ESCAPES IN THE BRAIN OF RODENTS THAT MAY PLAY A ROLE IN ADDICTION-LIKE BEHAVIOR AND TRANSLATION OF THESE INTO MEDICATIONS. PAUL, WELCOME. WE'RE NOW GOING TO HAVE A PHOTO FOR THE GROUP. WE HAVE NEW PHOTOGRAPHER. YOU'RE A MULTI-TASKER. OKAY, GUY, ALL THE NEW MEMBERS COME HERE PLEASE. >> THE GOVERNMENT IN THE SUNSHINE ACT AND FEDERAL ADVISORY COMMITTEE ACT REQUIRES AS MANY ADVISORY COMMITTEE MEETINGS AS POSSIBLE BE OPEN TO THE PUBLIC, THIS INCLUDES MEETINGS OF THE NATIONAL ADVISORY COUNCIL ON DRUG ABUSE. TODAY'S MEETING IS OPEN TO THE PUBLIC AND IS BEING VIDEOCAST AND RECORDED. MINUTES WILL BE AVAILABLE ON THE NIDA HOME PAGE, RECORDINGS OF THE OPEN MEETING ARE NOW POSTED ON THE NIH VIDEOCAST SITE. I AM GOING TO ASK YOU ON CORRECTIONS FOR MINUTES FROM MAY 2019 COUNCIL MEETING. A COPY OF THE MEETING HAS BEEN MADE AVAILABLE TO YOU ON YOUR ELECTRONIC COUNCIL BOOK, UNDER THE NIDA CURRENT COUNCIL TAB. MOTION TO APPROVE ON THE MINUTES? ANYONE IN FAVOR? ANYONE OPPOSED? ABSTAINING? NOW WE'RE GOING TO ANNOUNCE YOUR FUTURE COUNCIL DATES, SO JANUARY 30, 2020. MAY 12, 2020. AND THEN WE HAVE THE NEXT DAY, MAY 13, AND THEN ON SEPTEMBER 10, 2020. AND NOW I'M GOING TO THE NEXT PHASE WHICH IS THE DIRECTOR'S REPORT. AND I WAS ASKING, BECAUSE TODAY WE HAVE A LOT OF INFORMATION THAT I NEED TO PRESENT TO YOU, BUT I ACTUALLY DON'T WANT YOUR MIND WANDERING SO I NEED TO BE VERY STRATEGIC HOW I'M DOING THAT IN A RELATIVELY SHORT PERIOD OF TIME. FIRST, BEFORE I START, I DO WANT YOU TO BE AWARE THAT BECAUSE OF THE OPIOID CRISIS, BECAUSE OF THE EXTRAORDINARY OPPORTUNITY THAT WE HAVE HAD TO BE A MAIN PLAYER ON THE HEAL INITIATIVE, THAT HAS PUT AN ENORMOUS AMOUNT OF EFFORT PLACED ON SHOULDERS OF THE NIDA STAFF AND I WANT YOU TO ACTUALLY, AS I SPEAK OF THE PRESENTATIONS, I AM THE ONE SPEAKING BUT THERE'S A MASSIVE AMOUNT OF CREATIVE THINKING. AND ABILITY TO BRING PEOPLE TOGETHER THAT HAS OCCURRED BEHIND WALLS THAT NOBODY NECESSARILY KNOWS ABOUT THAT IS -- FOR WHICH I'M EXTRAORDINARILY GRATEFUL. PEOPLE GET EXCITED ABOUT THE INITIATIVES OF NIDA, AND THIS AND THAT, BUT THAT IS POSSIBLE BECAUSE I MEAN NIDA IS EXTRAORDINARILY LUCKY TO HAVE AN EXTRAORDINARY GROUP OF PEOPLE BEHIND IT. YOU DON'T NECESSARILY ALWAYS COME TO KNOW THEM, BUT I DO WANT TO RECOGNIZE IT, AND I CERTAINLY AM SOMEONE THAT HAS LEARNED TO APPRECIATE AND VALUE ENORMOUSLY THE SUPPORT THAT I GET FROM NIDA STAFF. ON TOP OF THAT, THERE ARE REALLY WONDERFUL PEOPLE TO INTERACT WITH AND VERY, VERY COMMITTED. SO I'M GOING TO -- AS I GO THROUGH IT, YOU WILL SEE WHY I'M BRINGING THIS UP AT THIS POINT. THIS IS WHERE WE ARE WITH OUR FUNDING, AND YOU SEE THAT CERTAINLY FOR THE 2019 THERE'S BEEN A SIGNIFICANT CHANGE IN THE WAY THAT BUDGETS ARE GIVEN TO NIDA. IT USED TO BE THAT 30% OF OUR BUDGETS WERE FOR AIDS RESEARCH, AND THAT HAS BEEN SLOWLY DECREASING IN PART BECAUSE OF NEW INITIATIVES IDENTIFIED AS PART OF THE HIV/AIDS. SO I WAS MAKING AN ESTIMATE, INSTEAD OF 30% WE'RE NOW 25% OF NIDA'S BUDGETS GOES TO AIDS. OVERALL, WE'RE TOTAL BUDGET THAT IS INDEPENDENT OF HEAL HAS BEEN PREDOMINANTLY INCREASED BECAUSE OF KNOWN AIDS FUNDING. OUR AIDS FUNDING HAS BECOME STABLE BETWEEN 18 AND 19, GOING DOWN ON 2016 AND 2017. AND THEN WE HAVE THE HEAL FUNDS, AND THAT IS ACTUALLY -- I'M SEPARATING IT FROM OUR REST OF OUR BUDGET BECAUSE EVEN THOUGH $250 MILLION HAS BEEN ALLOCATED TO THE NIDA BUDGET, THE OFFICE OF THE DIRECTOR HAS BASICALLY MANAGED DIRECTLY A LOT OF THE ACTIVITIES, I MEAN IN TERMS OF DECISION OF WHAT GETS FUNDED OR NOT FUNDED. AND SO AS A RESULT THERE'S A DIFFERENT TYPE OF STRUCTURE FOR THE OVERSIGHT, AND I WILL BE PRESENTING IT DIFFERENTLY. THIS IS OUR PORTFOLIO, AND IN TERMS OF TRYING TO DIVIDE THE AREAS OF SCIENCE IT'S ARBITRARY IN TERMS OF, SAY, WHAT IS BASIC SCIENCE VERSUS DIFFERENTLY FROM EPIDEMIOLOGY OR CLINICAL TRIALS BECAUSE OBVIOUSLY WHAT WE'RE TRYING TO DO IS INTEGRATE ACROSS THE DIVISIONS, BUT IT'S A PRACTICAL WAY OF PRESENTING IT THAT DOES REFLECT THE PORTFOLIOS THAT END UP IN THE DIVISIONS, THAT DOES NOT MEAN IN ANY WAY BETWEEN THEM AND AS YOU KNOW NOT PRESENTED IN HERE. I WAS ACTUALLY REALIZING IT, IS OUR TRANSLATIONAL PORTFOLIO THAT IS DRIVEN BY THE SBIR AND STTR. I DON'T THINK IT'S THERE BUT WE SHOULD ADD IT, IN ANY CASE. I WANT TO START, I HAD WANTED TO START THIS ON OUR LAST COUNCIL, BUT THE DATA FROM THE SURVEY HAS NOT BEEN RELEASED. I WAS TOLD YOU CANNOT PRESENT THIS IN OPEN COUNCIL BUT IT WAS VERY NOTABLE, YOU'LL SEE WHY I WANTED TO EMPHASIZE. IT IS IMPORTANT FOR US TO BE AWARE BECAUSE IT GIVES US A POLL OF WHAT'S HAPPENING IN PATTERNS OF DRUG USE IN OUR COUNTRY. THE NSDUH IS A YEARLY SURVEY THAT REPRESENTS THE POPULATION, A SURVEY THAT GOES FROM 20 TO OLDER, 20 OVER, OVER 12 YEARS OF AGE, DIFFERENT FROM THE MONITORING THE FUTURE WHICH WE DO, BASICALLY HIGH SCHOOL STUDENTS. IT'S A GOOD PERSPECTIVE TO COMPARE PATTERNS REPORTED BY NSDUH FROM MONITORING THE FUTURE. SPEAKING ABOUT MONITORING THE FUTURE, ONE OF THE THINGS THAT HAS BEEN SURPRISING ALL ALONG IS THAT DRUG USE AMONG TEENAGERS HAS BEEN GOING DOWN FOR EVERYTHING, LEGAL AND ILLEGAL, EXCEPT FOR MARIJUANA, BUT WHAT'S INTERESTING IS WE'RE NOT SEEING AN INCREASE THAT WE WOULD HAVE EXPECTED FROM LEGALIZATION FOR MEDICAL, RECREATIONAL PURPOSES. THAT'S NOT WHAT'S HAPPENING IN THE REST OF THE POPULATION. THE SURVEY SHOWS, THIS IS ACTUALLY SIGNIFICANT IN MARIJUANA YOU THE UTILIZATION, WHEN YOU TAKE THE POPULATION, 12 OR OLDER ACROSS THE UNITED STATES, INDIVIDUALS, THE USE OF MARIJUANA FOR THE PAST YEAR INCREASED BY 150%. THINK ABOUT ONE YEAR, YOU SEE A SIGNIFICANT JUMP IN THE INCREASE OF USE OF MARATHON. IT BEHOOVES US IN TERMS OF IMPLICATION. GOOD NEWS, WE SEE SIGNIFICANT DECREASE FROM 2017? PSYCHOTHERAPEUTIC DRUGS, NOT JUST PRESCRIPTION OPIOIDS AND STIMULANTS, BENZODIAZEPINES AND BARBITURATES, DRIVEN BY PRESCRIPTION OPIOIDS, SOMETHING WE'VE SEEN IN THE ADOLESCENTS, HIGH SCHOOLS, MONITORING THE FUTURE, DECREASE IN UTILIZATION OF USE OF PRESCRIPTION OPIOIDS. I'M PRESENTING OTHER NUMBERS. WE ARE FACED WITH THEM IN TERMS OF BEING PROBLEMATIC, SEEING SIGNIFICANT INCREASES IN WHAT APPEARS TO BE USE OF COCAINE, AND THIS IS NOT SIGNIFICANT FROM 2017, BUT AS YOU LOOK AT LONGER TRENDS YOU CAN START TO SEE THAT IS GOING UP. THE OTHER AREA THAT HAS GENERATED ENORMOUS AMOUNT OF CONCERN IS THAT OF METHAMPHETAMINE USE, NOT SIGNIFICANTLY DIFFERENT FROM 2017 BUT YOU SEE THE UPTICK. LOOK AT THIS NUMBER. THIS HAS BEEN BOTHERING MY BRAIN. HEROIN USE, .3% OF THE POPULATION IN THE UNITED STATES. YOU'RE SEEING -- YET WE'RE SEEING SIGNIFICANT INCREASE IN MORTALITY FOR HEROIN. IT HAS STABILIZED FOR THE 2017 AND IT APPEARS TO STABILIZE IN 2018. BUT EXTREMELY HIGH NUMBERS, AND ACTUALLY I DON'T RECALL EXACTLY THE NUMBERS BUT I THINK IT WAS CLOSE TO 14,000 PEOPLE DYING FROM HEROIN EVERY YEAR. AND YET WE ONLY HAVE 800,000. THE NUMBER OF PEOPLE MISUSING PRESCRIPTION DRUGS, THE PEOPLE THAT ARE MAKING THE DIAGNOSIS OF OPIOID USE DISORDER, WHICH IS ALSO ESTIMATED BY NSDUH, 2.1 MILLION PEOPLE HASN'T CHANGED VERY MUCH YET WE'RE SEEING A HIGH RATE OF MORTALITY. IN MY BRAIN IT'S LIKE THE EQUATION DOES NOT COMPUTE TOTALLY. THE RATE OF DEATHS ARE MUCH GREATER THAN THE NUMBERS THAT WE'RE GETTING IN TERMS OF PEOPLE AFFLICTED BY HEROIN, OR BY PRESCRIPTION OPIOID USE DISORDER, OR NOW SYNTHETICS LIKE FENTANYL. I SAID I NEED TO ASK SAMHSA WHERE DO THEY INCLUDE FENTANYL? YOU CAN CALL THEM -- THEY HAVE A MEDICAL PURPOSE BUT THESE ARE ILLICITLY MANUFACTURED, MANY FENTANYLS DON'T HAVE A MEDICAL PURPOSE, I DON'T KNOW WHERE THEY COME. I RAISE IT FOR TWO THINGS. NUMBER ONE, BY FAR THE GREATEST NUMBER OF PEOPLE EXPOSED TO ILLICIT DRUGS IS MARIJUANA, AND IT IS GROWING. IF MARIJUANA INFLUENCES OTHER PATTERNS OF DRUG USE IT'S SOMETHING WE HAVE TO KEEP OUR EYES ON AS WELL AS NEGATIVE EFFECTS. BUT I ALSO BRING IT UP TO ACTUALLY THAT TO THROW YOU THAT WORRY IN MY BRAIN, I DON'T WANT TO BE ALONE IN THIS WORRY, THE CONCEPT OF THE HIGH, HIGH RATES OF MORTALITY AND YET RELATIVELY STABLE AND LOW LEVELS, RELATIVELY LOW LEVELS OF OPIOID USE DISORDERS ESTIMATED AS I SAY $2.1 MILLION. I'M PUTTING THE DATA JUST FOR MARIJUANA, OVER 4 YEARS, NOW PAST MONTH, PAST YEAR, PAST MONTH, OVER 4 YEARS THE NUMBER ONE GROUP HIGH RISK FOR TAKING DRUGS, WE'VE KNOWN THIS ALL ALONG, ARE YOUNG ADULTS, 18 TO 25, ACCOUNT FOR MAJORITY, THAT'S THE AGE OF GREATEST RISK. THIS IS ONLY 7 YEARS OF AGE. WHEN YOU TAKE IT IN 26 OR OLDER, THAT'S MANY, MANY YEARS OF AGE, EVEN THOUGH IT'S MUCH LOWER IN ABSOLUTE NUMBERS OF COURSE THIS VERY LARGE COHORT IS GOING TO ACCOUNT FOR SIGNIFICANT PORTION OF PEOPLE THAT ARE USING MARIJUANA. SO HERE WE SEE APPROXIMATELY WHAT APPEARS TO BE A 10% INCREASE IN 4 YEARS. HERE YOU SEE MORE LIKE 25 OR ACTUALLY TRYING TO SEE MORE THAN THAT. 30% PERHAPS OF INCREASES IN MARIJUANA USE. SO, THIS IS THE CRUCIAL CONSEQUENCE OF WHERE WE'RE GOING TO SEE THE NEGATIVE EFFECTS OF THE LEGALIZATION OF MARIJUANA. KEEP IT IN THE BACK OF YOUR BRAIN TO SERVE YOU AS A LATE MOTIF IN TERMS OF WHAT WE'RE GOING TO BE PRESENTING THAT SHOCKED ME WHEN I SAW IT FROM THE NSDUH. THIS IS WHAT SHOCKED ME. IT RELATES TO THE 10-YEAR FOLLOW-UP ON THE SERIAL MENTAL ILLNESS IN ADULTS, ALL AGES DIVIDED BY THOSE 18 TO 25 WHERE WE SEE HIGHEST RATES OF DRUG USE, AS I MENTIONED, THOSE 26 TO 49 THAT INTERMEDIATE, AND THOSE THAT ARE MORE THAN 50, LOWEST RATES OF DRUG USE. AND SEE EVEN THOUGH IN 2008 UNTIL 2014 SAW HIGHER LEVELS IN OLDER GROUP, 26 TO 49, THAT IN THE YOUNGEST, 18 TO 25, THAT CHANGES IN 2014. SOMETHING IS HAPPENING THAT IS LEADING TO A VERY STEEP INCREASE IN SERIOUS MENTAL ILLNESS, THIS IS NOT ADHD. THIS IS SERIOUS MENTAL ILLNESS. THE QUESTION THAT FOLLOWS IS WHAT DRIVES THIS PRECIPITOUS INCREASE IN SERIOUS MENTAL ILLNESS? I'M SHOWING YOU THE SLIDE BECAUSE, AGAIN, IT HIGHLIGHTS WHAT WE ALREADY KNOW, THAT INDIVIDUALS WITH MENTAL ILLNESS, MODERATE OR SERIOUS MENTAL ILLNESS, ARE AT GREATER RISK OF TAKING DRUGS. BECAUSE THE DRUGS ARE MOST WIDELY UTILIZED IS MARIJUANA, THAT'S WHERE YOU'RE GOING TO HAVE THE LARGEST ABSOLUTE NUMBERS OF PEOPLE BEING ACTUALLY AFFECTED BY IT. LET'S LOOK AT MARIJUANA. YOU CAN SEE THAT BASICALLY THE RATE OF MARIJUANA USE IN TERMS OF THESE -- IN PEOPLE THAT HAVE SERIOUS MENTAL ILLNESS IS 80% HIGHER THAN THOSE WITHOUT IT. IT'S MUCH, MUCH HIGHER THAN THAT. IN FACT IT'S THREE TIMES HIGHER. I'M JUST LOOKING AT 13% IN THOSE THAT DO NOT HAVE MENTAL ILLNESS, VERSUS 39% OF THOSE WITH A SEVERE MENTAL ILLNESS. THREE-FOLD HIGHER. AS WE THINK ABOUT THE ISSUE OF THE LEGALIZATION OF MARIJUANA FOR MEDICAL OR RECREATIONAL PURPOSES, THE ONES MOST VULNERABLE ARE THOSE WITH MENTAL ILLNESS. ALSO, I THINK THAT IT BEHOOVES THE QUESTION IN TERMS OF TO WHAT EXTENT OF THE EXPANSION OF ACCESS TO DRUGS, EXPANSION ON THE USE OF MARIJUANA BY 18 TO 25 MAY NOT JUST BE AN EFFECT OF -- THIS EXPANSION IN THE SERIOUS MENTAL ILLNESS MAY NOT BE JUST WHAT EXPLAINS MORE USE BUT THE MORE USE OF MARIJUANA AMONG 18 TO 25 IS IT IN ANY WAY CONTRIBUTING TO THIS INCREASE IN THE SERIOUS MENTAL ILLNESS, AND PLANTING THIS IN YOUR BRAIN BECAUSE I'M JUST BASICALLY -- WHEN WE HAVE SUCH FAST CHANGES IN THE PREVALENCE OF SERIOUS MENTAL ILLNESS, WE NEED TO QUESTION WHAT HAS CHANGED IN THAT PERIOD. AND ACTUALLY THIS ALSO IS VERY, VERY SALIENT WHEN YOU LOOK AT THESE NUMBERS, BLEW MY MIND, FROM 2008 TO 2018. I DON'T HAVE AGE RANGES WHICH WOULD HAVE BEEN VALUABLE TO SEE BUT WHAT YOU SEE IS, AGAIN, INDIVIDUALS THAT BASICALLY BETWEEN THESE TEN YEARS THERE'S WILL BE A SIGNIFICANT ALMOST DOUBLING ON THE NUMBER OF SUICIDAL THOUGHTS, ATTEMPTED SUICIDE. THIS IS, AGAIN, HAS BEEN HIGHLIGHTED ALL ALONG AS ONE OF THE FACTORS THAT IS CONTRIBUTING TO DECREASING LIFE SURVIVAL AMONG AMERICANS. YES, WESLEY? >> I HATE TO INTERRUPT YOU, BUT ONE OF THE THINGS THAT YOU DIDN'T MENTION ABOUT THE NSDUH SORT THAT ANY MENTAL ILLNESS INCREASED SUBSTANTIALLY, 26.3%, OF YOUNG ADULTS 18 TO 25 MET CRITERIA FOR ANY MENTAL ILLNESS. SUICIDALITY, ANY ILLNESS HAS INCREASED OVER THE PAST THREE YEARS, SUBSTANTIALLY AND DRAMATICALLY, SO THAT'S ONE OF THE THINGS I, I THINK WE'VE GOT SOMETHING GOING ON IN THE CULTURE, NOT JUST DRUGS. IF 26% OF THE 18 TO 25-YEAR-OLDS ACCORDING TO THE SURVEY ARE EXPRESSING SYMPTOMS OF ANY MENTAL ILLNESS, NOT JUST SERIOUS. >> I HIGHLIGHTED SERIOUS BECAUSE I HAVE TO HIGHLIGHT THINGS. >> I UNDERSTAND. >> I ONLY HAVE 45 MINUTES TO SPEAK. >> ANY MENTAL ILLNESS -- THINK ABOUT IT. OVER A QUARTER OF YOUR 18 TO 25 YEAR OLS ARE SUFFERING OR EXPRESSING SYMPTOMSES OF ANY MENTAL ILLNESS. THAT'S A LOT. >> THAT'S WHY I'M PRESENTING THE DATA. I REALIZE IT'S NOT JUST DRUGS BUT WE CANNOT IGNORE THE POTENTIAL NEGATIVE EFFECTS THAT DRUG USE IS, PARTICULARLY BASICALLY MARIJUANA, SO WIDELY AVAILABLE AND BASICALLY TOUTED AS SAFE, MAY HAVE CONTRIBUTING TO THESE NUMBERS. >> IT'S INCREASED A LITTLE FROM -- >> IT'S 10%. >> (INAUDIBLE) IT WENT UP DRAMATICALLY. >> NO, MARIJUANA USE INCREASED 10% OVER 4 YEARS, DID NOT INCREASE BETWEEN 2017 AND 2018, I SUSPECT IS ALSO ERROR BARS. 10% IS NOT NEGLIGIBLE. >> OLDER PEOPLE ARE USING MARIJUANA. (INAUDIBLE). >> LET'S COME TO DISCUSSION AT THE END. I HAVE A LOT OF THINGS TO PRESENT. I DO WANT TO ALSO COMMENT ON THE NOTION OF THE SUICIDAL THINKING IS ALSO SIGNIFICANTLY ASSOCIATE, MUCH HIGHER IN INDIVIDUALS USING DRUGS. HERE YOU HAVE COCAINE, SUBSTANCE USE DISORDER, AMONG INDIVIDUALS THAT HAVE SUICIDAL THOUGHTS OR PLANS. IN GREEN ARE THOSE THAT HAVE A SUBSTANCE USE DISORDER VERSUS THOSE IN BLUE WITH NO SUBSTANCE USE DISORDER, AND YOU CAN SEE AGAIN IN THIS CASE FOR SERIOUS THOUGHTS MORE THAN A FOUR-FOLD INCREASE AND THE SAME THING, FIVE-FOLD FOR MADE A PLAN AND ATTEMPTED, AND MUCH MORE GIGANTIC WHEN YOU'RE TAKING DRUGS. WHAT IS SORT OF -- AND I AM SHOWING IT HERE BECAUSE. AS WE LOOK AT PRIORITY AREAS OF RESEARCH, I'M NOT EVEN THINKING ABOUT COULD IT BE POTENTIALLY LINKED TO THESE INCREASES OR CONTRIBUTING. LET'S NOT GO THERE. BUT THIS IS SOMETHING WE CANNOT IGNORE IN TERMS OF PRIORITIES WITH RESEARCH BECAUSE THIS IS THE REALITY. PEOPLE THAT ARE TAKING DRUGS ARE BEING ASSOCIATED WITH HIGHER AND MORE SERIOUS MENTAL ILLNESS AND ARE AT GREATER RISK OF SUICIDAL BEHAVIORS. WHERE IS THE DIRECTIONALITY OF THE COMORBIDITY IS PROBABLY BOTH WAYS, PERHAPS, BUT IT NEEDS TO BE ADDRESSED. AND THAT'S WHY I'M PRESENTING THIS HERE. SO, AS YOU KNOW, ONE OF THE THINGS WE'RE MOST INTERESTED IN UNDERSTANDING IS HOW WE GET THERE. WHAT IS IT THAT'S HAPPENING THAT MAKES A PERSON DEVELOP SUBSTANCE USE DISORDER, THAT MAKES A PERSON END UP WITH A MENTAL ILLNESS, WHETHER IT'S SEVERE, MODERATE OR MILD. AND WE DO RECOGNIZE OBVIOUSLY THAT THAT VULNERABILITY IS DRIVEN BY ENVIRONMENTAL FACTORS, DRIVEN BY GENETICS. BUT ULTIMATELY IMPACTS THE BRAIN. THE BRAIN IS BEING AFFECTED BY THE ENVIRONMENT AND GENETICS. SO UNDERSTANDING THAT INTERPLAY, PARTICULARLY DURING ADOLESCENCE AND YOUNG CHILDHOOD, WILL PROVIDE A MEANS TO ACTUALLY UNDERSTAND BETTER HOW THESE FACTORS ARE CONTRIBUTING AND VERY IMPORTANTLY HOW TO BUFFER THEM. AND THAT'S WHAT LED US TO ACTUALLY CREATE THE ABCD STUDY. THE ABCD STUDY STARTED IN 2017, NOW IN ITS BASICALLY THIRD YEAR, IT HAS BEEN VERY, VERY SUCCESSFUL ENDEAVOR. IT HAS RECRUITED, I PRESENTED THIS, CLOSE TO 12,000 CHILDREN THAT ARE BEING FOLLOWED PROSPECTIVELY WITH IMAGING AS WELL AS CAREFUL PHENOTYPIC CHARACTERIZATION. THE DATA AS BEING COLLECTED IS BEING DEPOSITED FOR OPEN ACCESS FOR INVESTIGATORS TO BE ABLE TO TAKE ADVANTAGE OF IT. AND I'M PRESENTING YOU HERE THE SUCCESS THAT WE HAD IN TERMS OF MAKING THESE DATA BASE TO SAY IT'S OPEN ACCESS, BUT FOR PEOPLE TO ACTUALLY TAKE ADVANTAGE OF IT. SO THIS IS A NUMBER OF UNIQUE USERS THAT HAVE DOWNLOADED DIFFERENT COMPONENTS OF THE ABCD, IN TURN EVEN THOUGH IT'S A STUDY THAT'S PROSPECTIVE IS GOING TO GO FOR TEN YEARS HAS RESULTED IN 15 PUBLICATIONS, NINE OF THEM FROM INVESTIGATORS OF THE ABCD, AND IMPORTANTLY SIX OF THEM ACTUALLY FROM INVESTIGATORS THAT ARE NOT PART OF THE ABCD, WHICH IS ULTIMATELY THE VALUE OF THE OPEN DATASETS. THEY ARE SO COMPLEX AND SO RICH WITH INFORMATION THAT THE ONLY WAY THAT THEY CAN BE BASICALLY LOOKED INTO IS MAKING THEM ACCESSIBLE TO AS MANY CREATIVE THINKERS AS POSSIBLE. TO TRY TO ENCOURAGE MORE UTILIZATION WE'RE GOING TO BE HOLDING TUTORIAL AT THE SOCIETY FOR NEUROSCIENCE TO ACTUALLY, AGAIN, TRY TO RECRUIT THE RESEARCHERS INTO TAKING ADVANTAGE OF THESE EXTREMELY RICH DATABASES. AND THAT LEADS ME TO THE SECOND PORTION OF WHAT WE HAVE BEEN SPENDING AN ENORMOUS AMOUNT OF TIME WHICH HAS TO DO WITH THE OPIOID CRISIS. I FEEL A LITTLE EMBARRASSED, WE'RE PRESENTING DATA FROM 2016 BUT I HAVEN'T BEEN ABLE TO GET A GEOGRAPHY OF MAP FOR 2017. WE KNOW IN 2017 THERE WAS 70,000 OVERDOSE DEATHS. 9.6% HIGHER THAN 2016. FOR 2018, THE NUMBERS HAVE APPARENTLY BEEN STABILIZED OR SLIGHTLY DECREASED. AND THAT IS SO OVERALL IT MAY SEEM THAT IT'S NOT GROWING AS FAST. THAT'S WHAT WE KNOW. BUT IT'S STILL HORRIFIC IN TERMS OF THE MORTALITY ASSOCIATED WITH IT. AND THAT IS WHAT LED TO THE HEAL INITIATIVE. THE HEAL INITIATIVE IS INTEGRATION OF THE EFFORTS THAT THE NIH HAS TO ADDRESS THE OPIOID CRISIS. IN SIMPLE TERMS, IT HAS TWO COMPONENTS, ONE RELATED TO WHAT IS IT THAT WE CAN DO TO ADVANCE THE DEVELOPMENT OF TREATMENT AND PREVENTION EFFORTS FOR OPIOID USE DISORDER, ON THE ONE HAND. ON THE OTHER HAND, THE SECOND COMPONENT IS HOW DO WE ADVANCE THE TREATMENT AND MANAGEMENT OF PAIN BECAUSE AFTER ALL, THE OPIOID CRISIS WAS INITIATED BY THE EXCESSIVE UTILIZATION OF OPIOID MEDICATIONS FOR THE MANAGEMENT OF PAIN, BECAUSE PATIENTS ACTUALLY SUFFERING FROM PAIN REQUIRED TREATMENTS AND WE DIDN'T HAVE MANY ALTERNATIVES, PLUS MANY OTHER FACTORS THAT LED& TO ACTUALLY I THINK OVERPRESCRIBING IN MANY INSTANCES. SO, AS I MENTIONED, HALF OF THE MONEY WAS ALLOCATED TO NIDA, HALF OF THE MONEY BY CONGRESS WAS ALLOCATED TO THE NATIONAL INSTITUTE OF NEUROLOGICAL DISEASES AND STROKES. AND THEN THE NIH DIRECTOR'S OFFICE IS BASICALLY TAKING THAT CONCEPT OF THE HEAL TO BRING TOGETHER NOT JUST THESE TWO INSTITUTES BUT OTHER INSTITUTES WHO MAY HAVE EXPERTISE TO HELP ADVANCE PROJECTS THAT COULD -- THAT ARE RELEVANT TO DECREASING THE OPIOID CRISIS. AND THAT INCLUDES NATIONAL INSTITUTE OF CHILD DISEASES AND HEALTH, INCLUDES ALSO NCATS, WHICH IS TRANSLATIONAL INSTITUTE, AND INCLUDES THE INSTITUTE OF NIAMS, WHICH DEALS WITH MUSCULOSKELETAL DISEASES AS WELL AS NATIONAL INSTITUTE OF ALTERNATIVE AND COMPLEMENTARY MEDICINE, BECAUSE OF THE IMPORTANCE -- ITS IMPORTANCE IN TERMS OF MANAGEMENT OF PAIN. WE WERE GIVEN I SAID $500 MILLION IN 2018, TOWARDS THE END OF THE YEAR AND IT WAS DIFFICULT TO ALLOCATE $500 MILLION SO RAPIDLY. BUT CONGRESS GAVE US THE ABILITY TO USE THE DOLLARS INTO 2019, GIVES ENORMOUS AMOUNT OF FLEXIBILITY. AS A RESULT WE FOUND OURSELVES IN 2019 WE HAD $930 MILLION TO SPEND THAT HAD TO BE SPENT IN 2019. THE OFFICE OF THE DIRECTOR, FRANCIS COLLINS, INVITED ALL OF THE I.C.s TO PROPOSE PLANS FOR HEAL , PROPOSE PROJECTS. AND THE OFFICE OF THE DIRECTOR SET RESEARCH PRIORITIES, AND RFAs WERE RELEASED AND REVIEWED IN APPROVED AREAS FROM THE OFFICE OF THE DIRECTORS, AND THESE WERE PRESENTED ON MULTI-DISCIPLINARY WORKING GROUP, THAT WAS CREATED FOR THAT PURPOSE TO OVERSEE AND GET FEEDBACK IN ITEMS OF APPROPRIATENESS OF PRIORITIES BEING SELECTED AND PROPOSED ACTIONS OVER THOSE PRIORITIES, IT INCLUDES EXPERTS ON THE FIELD OF PAIN AND EXPERTS ON THE FIELD OF ADDICTION, FROM THE VERY BASIC TO CLINICAL TO EPIDEMIOLOGICAL TO TRANSLATION. EXTRAORDINARILY DIE DIVERSE GROUP OF PEOPLE IN THE WORKING GROUP. THIS WAS PRESENTED TO THE MULTI-DISCIPLINARY WORKING GROUP, ACTUALLY ALSO HELPS US IDENTIFY AREAS THAT WE MAY HAVE MISSED. IN THE LAST MEETING, FOR EXAMPLE, THAT WE HAD, ONE OF THE AREAS THAT EMERGED AS ONE THAT IS NOT COVERED VERY MUCH BY THE CURRENT PLAN OF PROPOSALS IS THAT OF INDIVIDUALS SUFFERING FROM PAIN THAT ARE ADDICTED TO PAIN MEDICATIONS. AS A RESULT OF THESE RECOMMENDATIONS BY THE MDWG THERE'S A MEETING OF THE EXECUTIV COMMITTEE OF HEAL INCLUDING RELEVANT DIRECTORS INVOLVED WITH THIS PROGRAM, AND THEN FINAL DECISION IS MADE IN DISCUSSION, WITH EXECUTIVE COMMITTEE BY FRANCIS COLLINS. I'M GOING TO BE DISCUSSING ACTUALLY PROJECTS THAT HAVE BEEN APPROVED AND GO THROUGH THIS PROCESS. THAT PERTAIN TO NIDA. I'M NOT GOING TO BE DISCUSSING SUCH PROJECTS THAT PERTAIN TO THE NINDS THROUGH PAIN. BUT IF YOU HAVE QUESTIONS, YOU CAN ASK ME. ALSO KNOW THAT THESE ARE NOT ALL OF THE PROPOSALS THAT NIDA HAS THAT RELATE TO THE HEAL INITIATIVE. LAST TIME IN COUNCIL I PRESENTED HEALING COMMUNITIES AND PRESENTED APPROXIMATELY CLOSE TO $100 MILLION FROM HEAL ARE GOING TO TOWARDS MEDICATION DEVELOPMENT FOR MEDICATIONS THAT CAN HELP US PREVENT AND TREAT OPIOID USE DISORDERS AND OVERDOSES. SO I'M GOING TO ACTUALLY BRING TO YOUR ATTENTION NEW INITIATIVES THAT HAVE NOW BEEN PRESENTED THROUGH THE MDWG AND SUGGESTED AND CONCUR VERY IMPORTANT. THE WAY THAT -- I PRESENTED THIS IN THE PAST, TWO MAJOR CHALLENGES OF COURSE. ONE OF THEM IS WE HAVE MEDICATIONS THAT ARE VERY, VERY USEFUL BUT THEY ARE NOT UTILIZED, NOT UTILIZED BECAUSE THEY ARE STIGMA, NOT YOU UTILIZED BECAUSE THERE'S NOT INFRASTRUCTURE OR RESOURCES OR KNOW-HOW. AND THAT IS THAT LATTER ONE, AN INCREDIBLE OPPORTUNITY FOR US TO CHANGE THAT. THE OTHER ONE WHICH PERTAINS MORE TO MEDICATION DEVELOPMENT IS EVEN WHEN YOU INITIATE THESE MEDICATIONS WE CURRENTLY HAVE AVAILABLE, WHICH ARE VERY EFFECTIVE, 50% OF PATIENTS WILL RELAPSE IN SIX MONTHS. WHICH IS BRINGING US THE NOTION THAT WE HAVE A LOT OF SPACE TO IMPROVE ON WHAT WE CAN DO. AND, AGAIN, THAT -- I'M NOT GOING TO BE PRESENTED THAT PART OF OUR PORTFOLIO ON WHAT ARE PRIORITIES TO MAKE MEDICATIONS TO IMPROVE THE LIKELIHOOD THAT PATIENTS ARE RETAINING TREATMENT FOR LONG PERIODS OF TIME, BECAUSE THEIR OUTCOMES WOULD BE MUCH BETTER. I'M GOING TO CONCENTRATE ON THE FIRST ONE WHICH IS HOW DO WE EXPAND ACCESS TO MEDICATIONS FOR OPIOID USE DISORDER AND PROPER TREATMENT AND INCREASE LIKELIHOOD PEOPLE WILL RECOVER. AND THAT ENDS UP INTO AREAS AND DISCIPLINES WE CALL CLINICAL RESEARCH, RESEARCH TRIALS, CLINICAL TRIALS, IT ALSO GOES INTO IMPLEMENTATION RESEARCH, ALSO GOES INTO SERVICES RESEARCH. AND SO WHAT ARE THE BASICALLY IN THAT SPACE, WHAT ARE THE TWO SPACES WHERE WE'RE MOVING? ONE OF THEM IS HEALTH CARE BECAUSE IT'S SUCH A GIGANTIC INFRASTRUCTURE, AND ADDICTION IS A DISEASE. THE OTHER IS THE JUSTICE SETTINGS. SO HOW CAN WE USE THESE MOMENTUM TO CHANGE PRACTICES AND PROVIDE EVIDENCE THAT THAT RESULTS IN BETTER OUTCOMES? WE'VE BEEN FORTUNATE TO HAVE THE CLINICAL TRIAL NETWORKS. I WANT TO THANK DR. BETTY AND HER TEAM WHO MADE THE STRUCTURE AVAILABLE FOR ALL OF US WORKING ON RESEARCH AND COUNTRY AT THE PERIOD WHERE IT IS HIGHLY NEEDED. WE'VE BEEN EXPANDING THE FUNDING THAT WE HAVE FOR THE CTN, THIS ALLOWED US TO CREATE FIVE NEW NODES THAT COVER SOME AREAS THAT HAVE NOT BEEN REPRESENTED IN OUR CLINICAL TRIALS. IT ALSO HAS ENABLED US AS A RESULT OF THE EXPANDED FUNDS TO ACTUALLY ADDRESS SOME OF THE KEY QUESTIONS THAT HAVE REMAINED UNANSWERED, IN THE FIELD OF THE TREATMENT OF OPIOID ADDICTION. AND WHEN YOU ARE HAVING A LARGE NETWORK, YOU WANT TO MAXIMIZE UTILIZATION IN SUCH A WAY THAT YOU CAN ADDRESS THE VALUE OF HAVING MULTIPLE NODES AT THE SAME TIME WHICH WILL ALLOW YOU TO ACCELERATE THE WAY YOU CAN RECRUIT PATIENTS. AT THE SAME TIME, YOU ALSO WANT TO NOT KEEP ELEMENTS OF THAT NETWORK IDLE AND CREATING PROJECTS THAT CAN BE ADVANCED, SO CREATING TWO LAYERS OF PROJECTS THAT ARE GOING ON TO BASICALLY MAXIMIZE THE LIKELIHOOD THAT YOU'RE PROBABLY UTILIZING RESOURCES. SO, THE MAIN BACKBONE OF THE STORIES THAT ARE GOING TO BE EXPANDED ASK HERE. LARGE MULTI-SIDE OPIOID USE DISORDER STUDIES. AND AGAIN PRIORITIZING CRUCIAL QUESTIONS. OPTIMIZING RETENTION. HOW DO YOU KEEP PATIENTS LONGER THAN SIX MONTHS IN TREATMENT? HOW LONG SHOULD THEY BE STAYING IN TREATMENT? WHEN SHOULD YOU CONSIDER THIS DISCONTINUATION? HOW DO YOU ENSURE WHEN YOU DISCONTINUE THOSE MEDICATIONS FOR OPIOID USE DISORDER THAT PATIENTS DO NOT RELAPSE? BECAUSE THE RISK OF THAT IS VERY HIGH. RIGHT NOW WITH CURRENTLY AVAILABLE DRUGS. SO THIS IS A STUDY THAT IS VERY, VERY COMPLEX THAT AIMS TO DO THAT. ANOTHER VERY IMPORTANT AREA IS DR. DONOFRIO, YOU'RE PART OF COUNCIL WHO CAME UP WITH THAT TRANSFORMATIVE STUDY SHOWING THAT HAVING EMERGENCY DEPARTMENTS ENGAGE IN THE DISPENSING OF BUPRENORPHINE CAN HAVE A TREMENDOUS POTENTIAL IN ENGAGING PEOPLE IN TREATMENT AND IMPROVING THEIR OUTCOMES. AND THAT WAS ONE STUDY. HOW DO YOU EXPAND IT ACROSS DIFFERENT TYPES OF EMERGENCY DEPARTMENTS? THIS FUNDING WOULD ENABLE US TO DO THIS. THE OTHER AREA THAT HAS BECOME VERY RELEVANT IS HOW DO YOU PROVIDE MEDICATIONS FOR OPIOID USE DISORDER IN RURAL COMMUNITIES WHERE YOU MAY NOT HAVE THE CLASSICAL INFRASTRUCTURE THAT YOU HAVE IN A PLACE LIKE NEW YORK CITY OR NEW HAVEN, CONNECTICUT. SO, YOU ACTUALLY -- THE NEED FOR DEVELOPING MODELS THAT ARE GOING TO BE APPLICABLE IN RURAL AREAS IS FUNDAMENTAL BECAUSE A SIGNIFICANT PORTION OF THE CRISIS IS OCCURRING THERE. ANOTHER AREA THAT HAS BEEN DEEMED ACTUALLY VERY, VERY RELEVANT AND IN FACT IT WAS BROUGHT TO MY ATTENTION THE FIRST TIME WHEN I WAS VISITING UNIVERSITY OF KENTUCKY MANY YEARS AGO, HOW MANY PATIENTS ENDED UP WITH SEVERE INFECTIONS, INJECTION PRACTICES, BUT NO ONE WAS TREATING THEM. I HEARD THAT MANY TIMES, WE'RE MISSING AND OPPORTUNITY, YOU'RE HOSPITALIZING SOMEONE AND NOT INITIATING TREATMENT. TWO STUDIES ARE RELEVANT, MEDICATION TREATMENT FOR OPIOID USE DISORDER EXPECTING, WE'VE DONE STUDIES COMPARING METHADONE AND BUPRENORPHINE BUT NOW HAVE NEW MEDICATIONS, EXTENDED RELEASE FORMULATIONS. PARTICULARLY ON BUPRENORPHINE BUT ALSO A LOT OF INTEREST, PHYSICIANS ARE USING VIVITROL FOR TREATMENT OF EXPECTING MOTHERS, A SPACE WE HAVE NOT PROPERLY INVESTIGATED. AND THEN ANOTHER AREA THAT HAS BEEN DEEMED PRIORITY THAT HAS MADE IT IS INITIATION THAT REQUIRES THAT PATIENTS BE DETOXIFIED AND THAT IS ACTUALLY DONE JUST BY VERY FEW CLINICIANS. IS THERE A MODEL THAT WE COULD DEVELOP THAT WOULD MAKE IT MORE ACCESSIBLE TO OTHERS? SO THIS IS THE MAIN BACKBONE. AND THEN PROJECTS, TAKING ADVANTAGE OF RESOURCES AND INFRASTRUCTURE BEING BUILT, TO ADVANCE ON AREAS, CTN HAS BEEN INTERESTED. HOW DO WE ENGAGE PHARMACIES IN THE DISPENSING OF BUPRENORPHINE IN THERE'S NO REASON THEY CAN NOT. THERE'S EVIDENCE THEY CAN DO IT FOR METHAMPHETAMINE AND EVIDENCE THEY CAN DO IT FOR BUPRENORPHINE. HOW DO WE BRING THIS TO AMERICAN INDIANS OR ALASKA NATIVES, INCREASE IN FATALITIES ARE VERY, VERY, VERY HIGH AND THERE'S LIMITED ACCESS TO THESE MEDICATIONS. THE OTHER AREA WE'RE IDENTIFYING, THE IMPORTANCE OF BUILDING UP RESEARCH INFRASTRUCTURE WHICH HAS BEEN VERY LIMITED, DC, AND AN IMPORTANT AREA, ANY ONE OF YOU IN THE SUBSTANCE ABUSE FIELD IS BUILDING UP EVIDENCE FOR HOW TO OPTIMALLY ENGAGE PEER RECOVERY SUPPORT AND COACHES, PEER COACHES. THEY ARE BEING WIDELY UTILIZED BUT THERE'S NOT A SERIES OF STANDARDS ON WHAT COULD IMPROVE THE LIKELIHOOD OF THEIR UTILIZATION, THEIR INVOLVEMENT TO BE MORE SUCCESSFUL. AND THEN ON THE THIRD LAYER ARE EXPANDING STUDIES THAT WILL INCLUDE ECONOMIC PERSPECTIVE OF INTERVENTIONS THAT WE'RE DOING. AND THIS IS EXTREMELY IMPORTANT BECAUSE IF WE BRING UP AN INTERVENTION THAT IS TOO COSTLY, IT'S NOT GOING TO BE SUSTAINABLE. SO TO BE ABLE TO DOCUMENT THAT IN FACT IT IS COST EFFECTIVE WILL INCREASE THE LIKELIHOOD THAT OTHER PAYERS WILL EMBRACE IT. AND THEN DATABASE STUDIES GIVE US AN OPPORTUNITY RIGHT NOW WHERE WE HAVE DATA COLLECTED THAT CAN GIVE US INSIGHT ON QUESTIONS THAT WE DON'T REALLY KNOW COMPLETELY WHAT THE ANSWERS ARE. FOR EXAMPLE, WHAT IS THE DIFFERENCE IN OUTCOMES IN RESIDENTIAL VERSUS OUTPATIENT TREATMENT, AND THIS IS VERY IMPORTANT BECAUSE RESIDENTIAL TREATMENT IS MUCH MORE EXPENSIVE THAN AN OUTPATIENT. SO DO WE HAVE EVIDENCE THERE ARE SIGNIFICANT BENEFITS FOR ONE OTHER THE OTHER, OR WHICH PATIENT CHARACTERISTICS ARE THE ONES THAT WILL BENEFIT THE MOST. THE OTHER QUESTIONS THAT ARE RELEVANT ARE CAN WE BASED ON DATABASES PREDICT WHO IS GOING TO BE DISCONTINUED BUPRENORPHINE SO WE CAN DO INTERVENTION, ALSO IMPORTANCE ON HOW TO ENGAGE 12-STEP MUTUAL HELP GROUPS TO MAXIMIZE LIKELIHOOD THEY CAN INCREASE LIKELIHOOD OF RECOVERY IN PATIENTS. THAT'S ONE LEVEL AS I MENTIONED THAT WE'RE AIMING FOR EXPANDING HEALTH CARE, THAT'S ONE. THIS IS NOT THE ONLY THINGS WE'RE DOING. HIGHLIGHTING PROJECTS THAT ARE RELATED TO THE HEAL INITIATIVE. THE OTHER ONE I MENTIONED TO DO THE JUSTICE SETTING. THE JUSTICE SETTING WE HAVE -- NIDA HAS A LONG, LONG TRADITION OF DOING RESEARCH WITH JUSTICE POPULATIONS AND CREATING NETWORKS. BUT THIS BRINGS IT AT ANOTHER LEVEL. THIS IS AN INITIATIVE THAT HAS BEEN LED BY (INDISCERNIBLE) AND I WANT TO THANK HER FOR HER LEADERSHIP, AND DR. BLANCA'S SUPPORT AND VISION. SO THE CONCEPT IS AS YOU KNOW VERY SIGNIFICANT PORTIONS WITH INDIVIDUALS WITH OPIOID DISORDERS CYCLES THROUGH PRISON AND JAIL, JUSTICE SETTING, A VERY SMALL PORTION OF JAILS OR PRISONS PROVIDE ACCESS TO TREATMENT. I READ DIFFERENT NUMBERS AND TRY TO GET MY HANDS ON NUMBERS THAT MAY BE MORE ACCURATE, BUT I THINK THAT IF I SAY 5% OF THEM ARE ACTUALLY PROVIDING WITH MEDICATIONS, THAT MAY BE A CONSERVATIVE NUMBER. 5%. YET IT'S AN INCREDIBLE OPPORTUNITY TO DO AN INTERVENTION, NOT ONLY ARE PATIENTS CAPTIVE, IF YOU DON'T DO IT THEIR LIKELIHOOD OF OVERDOSING AND DYING IS HIGH, LIKELIHOOD OF RELAPSING IS HIGH. AND LIKELIHOOD OF INCARCERATING IS ALSO VERY, VERY HIGH. SO, HOW DO WE TAKE THE MOMENTUM WE HAVE TO ACTUALLY CHANGE PRACTICES? I THINK IN MANY WAYS THIS IS CHANGING CULTURE BECAUSE IT'S LIKE TWO DIFFERENT WORLDS. HEALTH CARE AND JUSTICE. WELL, IF ADDICTION IS A DISEASE OF THE BRAIN, IF YOU END UP IN JUSTICE SETTING, AGAIN, I REPEAT MYSELF, I DON'T CONDONE CRIMINALIZATION OF A PERSON THAT'S ADDICTED BECAUSE THEY ARE ADISTRICTED. IT'S A DISEASE. YOU DON'T PUT PEOPLE IN PRISON OR JAIL. IF YOU END UP IN PRISON OR JAIL śMEDICAL CONDITIONS.ION TO TREAT YOU DO IT FOR HIV. YOU DO IT FOR HEPATITIS. YOU DO IT FOR ANY INFECTIOUS DISEASE. THE SAME PERTAINS TO ADDICTION. WHY ARE WE NOT DOING IT? MANY TIMES WHAT HAPPENS PEOPLE WHEN THEY DON'T HAVE -- KNOW HOW TO DO IT, DON'T HAVE EXPERIENCE, ARERELUCTANT TO EMBRACE NEW PRACTICES. BY CREATING A NETWORK WHICH IS WHAT THIS PROJECT JCOIN IS DOING, WE'RE ACTUALLY EXPANDING INTERACTIONS BETWEEN RESEARCHERS AND PRACTITIONERS. THROUGH THAT INTERACTION YOU START TO SLOWLY CHANGE CULTURE. IF YOU HAVE ACTUALLY DATA THAT SHOWS LARGE EFFECT SIZES, THEN HOPEFULLY YOU CAN RAPIDLY CHANGE CULTURE SO IT IS EMBRACED. THAT'S WHAT THIS NETWORK IS AIMING TO DO. 12 HUBS, COORDINATIONAL TRANSLATIONAL CENTER, METHODOLOGY, ADVANCED ANALYTIC RESOURCE CENTER LIKE MANY NETWORKS, ACTUALLY FORMED OF 12 HUBS. AND THIS IS THE LOCATION OF THE 12 HUBS, REQUIRED TO HAVE AT LEAST I THINK IT WAS FIVE COMMUNITIES IF THEY WANTED TO BE ABLE TO GET FUNDING, THEY HAVE TO FOLLOW A SCHEDULE OF CARE FOCUS AND THEY HAD TO HAVE A JUSTICE AND TREATMENT DEPARTMENT. THERE WAS INTEREST IN ENSURING THERE WAS DIVERSITY ON JUSTICE SETTINGS, DIVERSITY ON GEOGRAPHY AND DIVERSITY IN THE INTERVENTIONS. SO THE NOVEL STUDIES THAT CAN BE -- THAT ARE GOING TO BE PRIORITIZED ON THIS NETWORK FOLLOW IN ONE, TWO, THREE, FOR SIX CATEGORIES, STATE POLICY ROLLOUTS, HOW DO STATE POLICY AFFECTS ULTIMATELY THE IMPLEMENTATION OF TREATMENT AND FOLLOW-UP OF INDIVIDUALS WHEN THEY ARE RELEASED FROM PRISON. OF COURSE, LEVERAGING TECHNOLOGY, ONE OF THE IMPEDIMENTS FOR INITIATING MEDICATION IN MANY JAIL SYSTEMS IS THEY DON'T HAVE THE SUPPORT OR THE KNOWLEDGE. AND THE SAME THING WHEN RELEASED. SO THE ABILITY NOW TO HAVE MODELS THAT CAN DELIVER mHEALTH TECHNOLOGY FOR EXAMPLE EXPANDS CAPABILITIES ENORMOUSLY. THE PEER NAVIGATION SUPPORT IS ANOTHER ONE WHERE, AGAIN, JUST LIKE IN THE HEALTHCARE SYSTEM YOU HAVE COACHES, PROVIDING EVIDENCE ABOUT HOW TO OPTIMALLY CREATE MODELS THAT ENGAGE -- HELP ENGAGE PATIENTS USING PEER NAVIGATION SYSTEMS IS GOING TO BE VERY IMPORTANT. INTERORGANIZATIONAL LINKAGES IS NOT JUST ABOUT JAIL. IT'S ABOUT PAROLE, DRUG COURT. HOW DO THEY INTERACT WITH ONE ANOTHER. EXTREMELY IMPORTANTLY, THE INTERACTION BETWEEN THE JUSTICE SETTING AND HEALTHCARE, HOW DO YOU CREATE THOSE BRIDGES BECAUSE ONCE THEY ARE RELEASED FROM PRISON YOU WANT TO ENGAGE THEM IN HEALTH CARE. AND THEN THERE IS A STUDY THAT IS GOING TO BE EVALUATING COMPARATIVE EFFECTIVENESS OF EXTENDED RELEASE NALOXONE VERSUS COMPARATIVE EFFECTIVENESS OF EXTENDED RELEASE BUPRENORPHINE. AND IF YOU THINK ABOUT IT, ONE OF THE REASONS THAT IS VOICE IS WHY THERE IS NOT ACCEPTANC AGONIST MEDICATION IN JAIL OR PRISONS THE FEAR THEY ARE DIVERTED. IF THEY ARE INJECTED, THAT CONCERN IS BASICALLY MINIMIZED OR DISAPPEARS. AND SIMILARLY ANOTHER CONCERN IS IF YOU HAVE TO GIVE MEDICAIONS ON A DAILY BASIS MEDICAL SUPPORT THAT YOU REQUIRE FOR THAT IS ACTUALLY NOT AVAILABLE IN MANY PLACES, SO THE EXTENDED RELEASE FORMULATIONS WILL ALLOW US TO DO THAT. AND, AGAIN, THE IDEA IS NOT TO JUST NECESSARILY SAY, WELL, WHICH MEDICATION IS BETTER THAN THE OTHER, BECAUSE IT'S LIKELY THAT ONE MEDICATION WILL BE BETTER FOR ONE PATIENT WITH CERTAIN CHARACTERISTICS, THE OTHER WILL BE BETTER FOR ANOTHER ONE. BUT WE NEED TO UNDERSTAND THAT. IT MAY ALSO BE THAT THERE MAY BE A STAGING PROCESS WHERE YOU WANT TO START WITH ONE MEDICATION AND GO TO THE OTHER. WE NEED TO UNDERSTAND HOW THAT WORKS. THAT'S WHAT THE JCOIN WILL BE DOING. THEN THE THIRD INITIATIVE, SO TWO INITIATIVES IN TERMS OF HOW DO WE EXPAND ACCESS TO MEDICATIONS, HEALTH CARE, JUSTICE SETTINGS AND TREATMENT. AND THEN THE OTHER, THIRD INITIATIVE THAT I WANT TO PRESENT IS PREVENTION. AND THIS BECOMES VERY, VERY RELEVANT BECAUSE IN THE PREVENTION FOR OPIOID USE DISORDER, AND IN THE HEAL INITIATIVE, IN MANY OF THE INTERVENTIONS THAT HAVE BEEN PUT FORWARD THAT ARE VERY, VERY IMPORTANT, THE MAIN EMPHASIS HAS BEEN OF CHANGING PRESCRIPTION PRACTICES FOR OPIOIDS. BECAUSE IF YOU CHANGE THEM, YOU BASICALLY ARE GOING TO DECREASE LIKELIHOOD OF EXPOSING PEOPLE TO OPIOIDS WHEN THEY DON'T NEED THEM, OR EVEN IF THEY NEED THEM FOR SHORTER PERIOD OF TIME THAT IT'S NECESSARY TO AVOID THEM HAVING THE CHRONIC EXPOSURE THAT PUTS THEM AT RISK FOR ADDICTION. THAT'S EXTREMELY IMPORTANT. BUT AS IMPORTANT IS THE EARLY INITIATION ON JUST PREVENTION FOR SUBSTANCE USE DISORDR. AND IF YOU THINK ABOUT PREVENTION OF SUBSTANCE USE DISORDER, YOU DON'T DO A PREVENTION PER SE, OKAY, I'M GOING TO DO PREVENTION ONLY OF MARIJUANA OR ONLY OF OPIOID USE DISORDER. THESE ARE UNIVERSAL PREVENTION. YOU HAVE TO CREATE A SYSTEM TO DECREASE LIKELIHOOD OF THE PERSON, USUALLY PUT A LOT OF 'EM EMPHASIS IN CHILDREN AND ADOLESCENTS WILL NOT HAVE VULNERABILITIES THAT LEADS THEM TO TAKE DRUGS. HERE WE'RE FACED WITH SLIGHTLY DIFFERENT NARRATIVE FROM WHAT HAS HAPPENED IN THE PAST. IN THE PAST, A LOT OF OUR EFFORT FOR PREVENTION WAS ON CHILDREN ANDED A ADOLESCENTS. THE RATE OF USING IN ADOLESCENTS IS LOW IN OUR COUNTRY, GOING DOWN. WHEN THEY TRANSITION FROM ADOLESCENTS TO YOUNG ADULTHOOD, WE BECAME AWARE AND PRESENTED THIS IN THE PAST, THAT WE NEED TO BUILD UP EVIDENCE OF PREVENTION INTERVENTIONS THAT CAN BE DONE INTO LATE ADOLESCENCE, YOUNG ADULTHOOD BECAUSE THAT'S EXACTLY THE PERIOD OF GREATEST RISK. UNFORTUNATELY WE HAVE LIMITED RESEARCH THAT HAS GONE INTO THAT SPACE, AS AN INSTITUTE THIS. PREVENTION EFFORTS AIMS TO CHANGE THAT. I'M VERY THANK FOLLOW FOR DR. JACQUELINE LLOYD WHO BROUGHT IN A SERIES OF SCIENTIFIC EXPERTS TO HELP US THINK THROUGH WHAT COULD BE THE OPTIMAL WAY OF ADDRESSING SUCH AN INITIATIVE. THE LEADERSHIP OF DR. CARLOS BLANCO, WHEN YOU HAVE LIMITED RESOURCES AND WHICH ARE THE MOST IMPORTANT IMPACTFUL AREAS WHERE IF YOU DEVELOP EVIDENCE YOU CAN CHANGE, AND AGAIN AS A RESULT OF THESE MEETINGS AND DELIBERATIONS THERE WERE THREE MAIN AREAS IDENTIFIED FOR THE PREVENTION EFFORTS IN THIS TRANSITION. VULNERABLE POPULATIONS, WE KNOW, AGAIN, THAT INDIVIDUALS WITH CERTAIN CHARACTERISTICS ARE AT GREATER RISK. AND PARTICULARLY HIGH RISK, SO THIS IS THE FIVE AREAS THAT ARE GOING TO BE FUNDED THAT PERTAIN TO VULNERABLE POPULATIONS. THE AMERICAN INDIANS, ALASKA NATIVES, WHETHER URBAN, DIFFERENT CHALLENGES. HOMELESS YOUTH, ONE OF THE HARDEST GROUPS TO REACH OUT AND ALSO ONE OF THE HIGHEST RISK. CHILD WELFARE INVOLVED FAMILIES. AGAIN, WE KNOW FOR MANY YEARS THAT THESE ARE ACTUALLY CHILDREN GROWING UP IN A WELFARE SYSTEM, MUCH GREATER RISK OF SUBSTANCE USE DISORDER, ALSO FOROID USE DIS-- OPIOID USE DISORDER. AND CONSTRUCTION WORKERS, THOSE THAT GET HURT. IF YOU GET TRAUMA AS A YOUNG PERSON, EXPOSED TO OPIOIDS FOR TREATMENT, THAT INCREASES YOUR RISK. THERE WAS A LOT OF DISCUSSION IN TERMS OF HEALTHCARE SYSTEM, COULD THIS BE A GOOD OPPORTUNITY FOR DOING PREVENTION. AND THE DISCUSSIONS WENT AROUND TO SAY JUST IN GENERAL IN HEALTHCARE SYSTEMS YOUR LIKELIHOOD IT WILL BE VALUABLE BUT YOUR LIKELIHOOD OF POSITIVES IS GOING TO BE LOWER SO TAILOR IT. WHAT THE RECOMMENDATIONS AND THIS IS WHERE WE'RE GOING, EMERGENCY DEPARTMENTS BECAUSE, AGAIN, THERE YOU'RE GOING TO BE SEEING INDIVIDUALS THAT ARE LIKELY TO BE AT HIGH RISK BECAUSE THEY ARE ON TRAUMA OR BECAUSE THEY HAVE COMORBIDITIES THAT ENDED UP THERE. THEN SCHOOL-BASED HEALTH CENTERS, AND THERE'S A PROJECT THAT IS GOING TO BE WORKING ON VIDEO GAME INTERACTION DELIVERED THROUGH THESE CENTERS. IMPORTANTLY, PSYCHOPATHOLOGY. I SHOWED YOU THE DATA IN TERMS OF HOW FREQUENTLY THE COMORBIDITY IS, AIMS TO INVESTIGATE HOW INTERVENING ON A SUBSTANCE USE DISORDER AMONG ADOLESCENTS CAN SERVE AS A PREVENTION FOR OPIOID USE DISORDERS. TOO, I MEAN, TAKING ADVANTAGE OF POLICIES THAT ARE BEING MADE AT THE STATE TO TRY TO SEE HOW THAT MAY BE ABLE TO MINIMIZE THAT TRANSITIONING INTO OPIOID USE DISORDERS. AGAIN, THIS PERTAINS TO PRESCRIPTION PRACTICES. AND THEN THE THIRD ONE, AGAIN, EMPHASIZING VERY MUCH IN LINE WITH IMPORTANCE OF THE JUSTICE SETTING THAT I WAS DISCUSSING WITH JCOIN PEOPLE THAT END UP IN JUSTICE SETTING ARE AT HIGH RISK FOR SUBSTANCE USE DISORDER INCLUDING OPIOID USE DISORDER AND FOR MORTALITY IF YOU HAVE OPIOID USE DISORDER. THERE'S EMPHASIS ON TWO PROJECTS EMPHASIZING ADOLESCENTS. THIS IS THE SITES THAT WILL BE CARRYING THESE PROJECTS. THERE IS A COORDINATION CENTER AND DATA CENTER TO INTEGRATE THESE EFFORTS. AND THEN THE FINAL PROJECT I WANT TO BRING TO YOUR ATTENTION THAT I HAD MENTIONED IN THE PAST, WE'RE NO THE PROCESS OF SELECTING THE GRANTS, HEALING BRAIN AND CHILD DEVELOPMENT. HBCD STUDY. THIS AIMS TO ACTUALLY BASICALLY COVER WHAT ABCD DID NOT DO, WHICH IS TO ACTUALLY INVESTIGATE BRAIN DEVELOPMENT IN INFANTS AND FOLLOW THEM THROUGH CHILDHOOD BECAUSE A LOT OF THE FACTORS IN THE ENVIRONMENT AND ALSO IMPORTANT GENETICS ARE ACTUALLY IMPACTED ON DURING THOSE STAGES OF DEVELOPMENT, SO UNDERSTANDING HOW ADVERSE ENVIRONMENTS OR SUPPORTIVE ENVIRONMENTS, HOW EXPOSURE TO DRUGS ARE DOING FETAL DEVELOPMENT, INFLUENCES RISK, HOW IT INFLUENCES THE BRAIN, AND HOW IT ACTUALLY MAKES SOMEONE VULNERABLE TO SUBSTANCE USE DISORDER OR MENTAL ILLNESS. I THINK THAT WHEN I PRESENTED THE DATA IN TERMS OF THE SHOWING PRECIPITOUS INCREASES IN SERIOUS MENTAL ILLNESS AND NON-SERIOUS MENTAL ILLNESS, MENTAL ILLNESS IN GENERAL, INCREASES IN SUBSTANCE USE DISORDER IN OUR COUNTRY AS IT RELATES TO OPIOIDS, METHAMPHETAMINE, COCAINE, IT'S NOT A PROBLEM JUST IN OPIOID ADDICTION. IT'S A PROBLEM OF ADDICTION. IF WE MANAGE IT, THE ONLY WAY IS BY UNDERSTANDING HOW TO OPTIMALLY DO PREVENTION. OF COURSE, PUTTING RESOURCES INTO IT. SO THE HEAL INITIATIVE WE'VE BASICALLY HAVING HAD EXPERIENCE OF ABCD SAID OKAY, IN MY BRAIN, IT WAS VERY SIMPLISTIC, LET'S BRING EXPERTS AND DISCUSS, TWO SETS OF MEETINGS, ONE FOCUSED ON TECHNICAL ASPECTS, THE OTHER FOCUSED ON COMPLEXITIES OF TRYING TO DO A STUDY THAT IS GOING TO BE OVERSAMPLING OF MOTHERS AT HIGH RISK INCLUDING THOSE TAKING OPIOIDS DURING PREGNANCY. WE RAPIDLY REALIZED FROM THE INPUT THAT WE WERE GETTING FROM THE FIELD THAT IT WASN'T GOING TO BE SO STRAIGHTFORWARD AS IT WAS FOR THE ABCD, NOT THAT IT WAS STRAIGHTFORWARD FOR ABCD, BUT AT LEAST WE HAVE THE RETROSPECTIVE KNOWLEDGE WHAT WORKS AND IT'S BEEN A SUCCESSFUL PROGRAM. NOT STRAIGHTFORWARD FROM THE METHODOLOGY FOR IMAGING BECAUSE OF COURSE THE MOTION ARTIFACTS BECOME EVEN WORSE THAN IN ADOLESCENTS, SO WE HAVE TO ACTUALLY DOCUMENT THAT THE TECHNOLOGY IS OUT THERE TO GET GOOD QUALITY BRAIN IMAGING DATA. AND THEN WHEN WE WERE EXPOSED TO WHAT DOES IT MEAN TO RETAIN -- I MEAN RECRUIT AND RETAIN WE WERE ACTUALLY FACED WITH DIFFICULTIES& OF ENGAGING HIGH RISK WOMEN. IN STATES FOR EXAMPLE WHERE TAKING DRUGS WHILE YOU'RE PREGNANT MAY BE A CAUSE FOR REMOVING THE CHILD FROM THE MOTHER, IMMEDIATELY THE ISSUE OF ETHICAL ASPECTS THAT ARE NECESSARY FOR US TO MANAGE BECAME EVIDENT. WHAT THE TWO GROUPS RECOMMENDED WHICH WE EMBRACED IS THE IDEA WE SHOULD GIVE PILOT PROJECTS, 18 MONTHS PILOT PROJECTS, INVESTIGATORS COMING UP WITH A PROJECT, TO DEMONSTRATE THAT THEY HAVE THE CAPABILITY TO ADDRESS LEGAL AND ETHICAL ISSUES, OR THAT THEY HAVE THE CAPABILITY TO RECRUIT AND RETAIN, OR THAT THEY HAVE THE CAPABILITY OF IMAGING, OR THAT THEY HAVE THE CAPABILITY OF OTHER ASSETS AND METHODOLOGIES. THEY DIDN'T NEED TO INCLUDE ALL FOUR, COULD FOCUS ON ONE AREA. THEY COULD COMBINE THEMSELVES OR COME INTEGRATED IN A NETWORK. AGAIN, THE IDEA IS TO GIVE THEM SUFFICIENT TIME TO ACTUALLY DEMONSTRATE TO US THAT THEY CAN DO THIS. AND THEN AS WITH THE ABCD WE'RE ABLE TO INTEGRATE THE NETWORK. IT WAS A VERY SUCCESSFUL. WE GOT A LOT OF APPLICATIONS. AND VERY DIVERSE SETS. ALL OF THESE AREAS ARE COVERED, ACTUALLY QUITE COMPREHENSIVELY. THIS IS A PROJECT THAT DIFFERENT FROM THE OTHER ONES OF HEAL , BASICALLY FULLY BASICALLY ALMOST FULLY FUNDED BY HEAL , THIS PROJECT WOULD BE 50% HEAL , AND THEN 50% COVERED BY THE OTHER INSTITUTES. I THINK NIMH HAS BEEN AN EXTRAORDINARY PARTNER IN ACTUALLY JUSTIFYING WHY THIS STUDY IS SO VERY IMPORTANT. THINK RECOGNIZING WE STILL KNOW LITTLE ABOUT THE BRAIN DEVELOPMENTAL CHANGES THAT HAPPENS WITH MENTAL ILLNESS, AND THE EXTENT TO WHICH THOSE CAN BE INFLUENCED, THE SAME THING WITH SUBSTANCE USE DISORDER. WE NOW HAVE THAT TECHNOLOGY AND TOOLS TO ACTUALLY EXPLORE IT. I THINK LOOKING AT THOSE NUMBERS, IT'S CERTAINLY FROM THE SCIENTIFIC PERSPECTIVE OF OUR INSTITUTES, NOT JUST NIDA AND NIMH, IT'S ALCOHOL INSTITUTE, NICHD, ENVIRONMENTAL INSTITUTE, OBSSR, WOMEN'S HEALTH INSTITUTES, RECOGNITION THAT THIS IS AN EXTREMELY IMPORTANT AREA OF RESEARCH. SO, THAT LEADS ME TO THE OTHER AREA IF IT WERE NOT COMPLEX ENOUGH, AS WE'RE DEALING AND NAVIGATING THE OPIOID CRISIS WHAT HAS LED TO A LOT OF INTEREST AND ALLOCATION OF RESOURCES HAS BEEN OVERDOSE MORTALITY. OVERDOSE MORTALITY IS THE MOST VISIBLE FACE OF THE EPIDEMIC. BEHIND IT THERE ARE MANY OTHER ADVERSE CONSEQUENCES. AND ONE OF THEM THAT IS VERY RELEVANT FOR THE HEALTH AND FOR CERTAINLY NIDA IS THAT OF INFECTIOUS DISEASES. IN PARTICULAR, OF COURSE, HIV AND HCV. WE'VE KNOWN AND WHAT'S INTERESTING BECAUSE IT WAS THE CDC IN 2011 THAT BROUGHT TO MY ATTENTION INCREASE IN NUMBER OF INJECTION DRUG USERS BECAUSE THEY WERE RECORDING INCREASE IN INCIDENCE OF HCV. AND WE NOW KNOW, WE DON'T EVEN KNOW WHAT IS INCIDENCE OF HCV IN OUR COUNTRY. WE KNOW IT'S INCREASING VERY, VERY ABRUPTLY AND DO KNOW THAT'S DRIVEN BY INJECTION DRUG PRACTICES. HIV HAS BEEN DIFFERENT. WHY? WE'VE SEEN DECREASES IN HIV INCIDENCE AS LOW AS DECREASES IN THE UNITED STATES, WE'VE SEEN SLOW -- ACTUALLY DECREASES IN HIV INCIDENCE ACROSS THE GLOBE. IT'S INTERESTING IF YOU LOOK AT THE DATA ACROSS THE GLOBE, WHAT STRUCK MY EYE IS THAT WHILE THERE'S BEEN DECREASES OF HIV GLOBALLY, THAT'S NOT THE CASE WITH INCIDENCE OF INJECTION DRUG USE. INCIDENCE OF HIV-ONLY DRUG USE HAS BEEN GOING ON. MY QUESTION, WHAT HAPPENS IN OUR COUNTRY? HAS THIS BEEN ASSOCIATED WITH INCREASE IN HIV? I STARTED AND APPROACHED BETH AT SAMHSA. BETH, CAN YOU TABULATE FOR ME CHANGES IN INJECTION DRUG USE ACROSS THE UNITED STATES? AND SHE GENERATED THE TABLE, AND YOU CAN SEE FOR YOURSELF. SIGNIFICANT INCREASES IN INJECTION PRACTICES IN OUR COUNTRY. WHAT ARE THE CONSEQUENCES? THIS IS NOT PUBLISHED DATA. THIS IS ACTUALLY DATA THAT I TOOK FROM BETH. WHAT IS THIS? I TRIED TO GET INFORMATION. IS THERE ANY EVIDENCE THERE'S INCREASE IN HIV IN THE UNITED STATES. SO I CALLED CARLOS BLANCO, CARLOS DEL RIO, I CONFUSED YOUR NAMES, HAS INCIDENCE BEEN INCREASING? NORA, I DON'T KNOW THAT I CAN TELL YOU THAT THERE IS AN INCREASE OR NOT BECAUSE I DON'T THINK THERE IS A COMPREHENSIVE DATABASE. WHAT DO I DO? I GOOGLE. HIV AND INJECTION DRUG USE, AND SORT OF STARTED TO LOOK AT NEWSPAPER ARTICLES. THAT'S WHY I SAY THIS IS NEWSPAPER ARTICLES. I DO NOT ABIDE FOR THEIR SCIENTIFIC ACCURACY. THIS IS NEWSPAPER ARTICLES. CERTAINLY IN THE CENTER OF IT IS SCOTS COUNTY, INDIANA, SCIENTIFIC ARTICLE OUT OF NOWHERE IN 2014-2015, 215 HIV CASES IN A VERY SMALL COMMUNITY. I THINK THAT ALERTED EVERYBODY THAT THERE COULD BE PROBLEM ON DRIVEN BY INJECTION DRUG USE, THAT LED OF COURSE CDC TO THEN MAP IN THE UNITED STATES WHICH WERE THE COUNTIES THAT WERE AT RISK OF HIV AND ALSO HCV OUTBREAKS ON THE BASIS OF THE NUMBER OF INJECTION DRUG USERS, OF COURSE THE ACCESS TO SYRINGE EXCHANGE PROGRAM, IF YOU DON'T HAVE THAT PUTS YOU AT GREATER RISK, AND ACCESS TO TREATMENT. IF YOU DON'T HAVE TREATMENT, YOU'RE MUCH GREATER RISK OF INJECTION PRACTICES. THIS IS WHAT I FOUND. NOW, THEY ARE DISSEMINATED. I DO NOT BELIEVE IT'S COMPLETE BECAUSE I MEAN AFTER ALL, YOU ENTER GOOGLE, ALL OF THIS, YOU GET HUNDREDS. YOU TRY TO ACTUALLY COME UP WITH THOSE THAT ARE MOST SALIENT. BUT THE ONE THAT IS ATTRACTING INTEREST IS CABELL COUNTY, WEST VIRGINIA. SOME SAY 74, SOME SAY 75, SOME 76, I DON'T KNOW THE NUMBER BUT. I APOLOGIZE FOR MY GEOGRAPHY, SLIGHTLY WRONG, THIS IS AN AREA NOT DETECTED AS HIGH RISK AREA BY THE CDC. IT DOES HIGHLIGHT AND MAKES US AWARE THAT THE PROBLEM MAY BE MORE THAN WE ARE CURRENTLY RECORDING. YOU SEE IT IN PENNSYLVANIA. I TRIED TO GET MORE ACCURATE NUMBERS FROM THEM. THEY HAVE NOT BEEN ABLE TO GIVE ME, BUT THERE WERE 59 HIV CASES FROM INJECTION DRUG USE IN 2018. THAT'S 2018. 60% INCREASE IN 2016. MORE THAN KENTUCKY HAD A TRIPLING IN THE NUMBER OF HIV CASES. MASSACHUSETTS ALSO HAS HAD SIGNIFICANT INCREASE, LOWELL AND LAWRENCE COUNTY, 129 CASES BETWEEN 2015 AND 2018. IN MORE OR LESS BETWEEN 2012 AND 2014 THE WHOLE MASSACHUSETTS HAD ONLY 123. YOU SEE THE NUMBERS FOR YOURSELF. IT BEHOOVES US TO TRY TO FIGURE OUT HOW TO GET A BETTER SENSE OF THE IMPACT THAT THIS INCREASE IN INJECTION DRUG USE IS HAVING FOR HIV. THIS SHOULD NOT BE HAPPENING. WE KNOW HOW TO PREVENT HIV. I MEAN, THAT HAS BEEN SHOWN, SYRINGE EXCHANGE PROGRAMS SHOWN MANY YEARS AGO BASICALLY PREVENT INFECTION FROM HIV. WE ALSO KNOW THAT TREATMENT OF OPIOID USE DISORDER PREVENTS FROM HIV. SO, WE HAVE TOOLS THAT ACTUALLY HAVE SHOWN, WE DON'T NEED TOE DO MORE RESEARCH. THEY HAVE SHOWN TO BE EFFECTIVE IN HIV. WHY ARE WE NOT IMPLEMENTING? AND WHAT TYPE OF RESEARCH DO WE NEED TO DO TO CHANGE THAT BLINDNESS THAT IS LEADING TO THE LACK OF IMPLEMENTATION. THAT'S ULTIMATELY AS WE'RE THINKING IN TERMS OF WHERE WE MOVE WITH OUR HIV PORTFOLIO, YOU'RE GOING TO BE HEARING FROM REDONNA CHANDLER LATER ON SOME OF OUR UPDATED PRIORITIES, WE NEED TO CONCENTRATE ON OUR EFFORTS TO BRING THIS FORWARD AND COME UP WITH INTERVENTIONS AND RESEARCH THAT WILL HELP US. WE HAVE MULTIPLE MECHANISMS THAT WE HAVE CREATED TO FUND RESEARCH THAT RELATES TO THE HIV THAT GOES BEYOND THAT TRADITIONAL R01 MECHANISM TO CREATE MORE INNOVATION, HIGHER RISK, TO ENGAGE RESEARCHERS THAT HAVE NOT BEEN INTERESTED ON SUBSTANCE USE DISORDER, THAT HAVE BEEN WORKING ON HIV TO COME INTO STUDY THE INTERACTIONS, AND AGAIN REDONNA WILL BE SPEAKING ABOUT IT LATER TODAY. I DO WANT TO BRAG AND THANK DR. RITA VALENTINO FOR LEADERSHIP IN LEADING OUR NEUROSCIENCE ALONG WITH HER TEAM WHICH HAS BEEN JUST FANTASTIC, A PLEASURE TO WORK WITH. THIS YEAR WE GOT THREE EARLY CAREER AWARDEES, THIS IS ONE OF THE MOST PRESTIGIOUS AWARDS THAT YOU CAN GET AS A YOUNG INVESTIGATOR, HIGHLY COMPETITIVE, TO GET THREE NIDA, I THINK THIS IS ONE OF OUR RECORDS. AMY JANES FROM HARVARD, DONNA CALU FROM UNIVERSITY OF MARYLAND, AND IAN MAZE FROM MOUNT SINAI. SINCE I LIKE DIVERSITY I WAS DELIGHTED TO SEE EVEN THOUGH IT'S THREE, NOT A SAMPLE SIZE, IT IS DIVERSE. SO I DO WANT TO THANK VERY MUCH DNB FOR LEADERSHIP AND EFFORT TO MAKE THIS FACILITATE THE CAREERS OF THESE VERY TALENTED INVESTIGATORS. AND SPEAKING OF THE DNB, I WANT TO USE THIS OPPORTUNITY TO ADVERTISE ONE OF OUR KEY EVENTS IN TERMS OF MEETINGS, WHICH IS SYMPOSIUM WE HOLD THE DAY BEFORE THE SOCIETY OF NEUROSCIENCES FOR THE PAST FOUR OR FIVE YEARS WE'VE BEEN DOING IT IN PARTNERSHIP WITH ALCOHOL INSTITUTE. IT'S AN OPPORTUNITY TO HIGHLIGHT SOME OF THE CUTTING-EDGE RESEARCH AREAS IN NEUROSCIENCE THAT ARE RELEVANT TO THE PROBLEM OF SUBSTANCE USE DISORDER. SO ROGER HAS BEEN TAKING RESPONSIBILITY FOR MANY YEARS, THEY HAVE TO STRUGGLE WHAT TO SELECT AMONG THE PANOPLY OF INTERESTING ADVANCES. AND SO IT'S ALWAYS FASCINATING. THE THREE SESSIONS THAT THEY SELECTED THIS YEAR ARE SENSING NEW OPPORTUNITIES FOR ADDICTION NEUROSCIENCE, EXPANDED BECAUSE OF ALL OF THE TOOLS THAT HAVE BEEN DEVELOPED AS A FUNCTION OF BRAIN . WE WANT TO ENSURE TECHNOLOGIES AND TOOLS ARE APPLIED. THE OTHER ONE IS NOVEL TECHNOLOGIES AND APPROACHES FOR TRANSLATIONAL RESEARCH TARGETING SUBSTANCE USE DISORDERS. WE'RE AWARE THAT, AGAIN, KNOWLEDGE IS EXTRAORDINARILY IMPORTANT, IT'S WHAT LEADS US TO ADVANCE, WE'RE ALSO AWARE SOMETIMES SOME OF THAT KNOWLEDGE THAT COULD HAVE AN OPPORTUNITY FOR TRANSLATION IS NOT TAKING THE NEXT STEP. HOW WE AS AN INSTITUTE CAN BE MORE PRO-ACTIVE TO FACILITATE THE LIKELIHOOD THAT KNOWLEDGE THAT IS TRANSLATABLE WOULD HAPPEN. AND THEN FINALLY THE EXTREMELY EXCITING AREA OF SCIENCE THAT IS BROUGHT BY CRISPR AND HOW DO WE USE THIS TECHNOLOGY TO HELP ADVANCE OUR UNDERSTANDING FOR SUBSTANCE USE DISORDER AND PSYCHIATRIC DISORDER RESEARCH. WITH THAT, I WANT TO THANK YOU FOR YOUR ATTENTION. I'LL BE HAPPY TO ANSWER ANY QUESTIONS THAT YOU MAY HAVE. [APPLAUSE] >> SO, THANK YOU FOR THAT REPORT. I THINK I HAVE TWO QUESTIONS AND FIRST OF ALL, WHEN YOU TALK ABOUT SCHOOL AGE KIDS AND OPIOID USE, SCHOOL AGE KIDS, IT STRIKES ME AT LEAST FROM WHAT I'VE SEEN IN MANY CASES THERE ARE TWO ISSUES THAT ARE REALLY IMPORTANT. ONE IS SPORTS INJURIES THAT LEAD TO OPIOID PRESCRIPTIONS, AS ENTRY POINT. AND THE SECOND IS DENTISTS. A FRIEND CALLED ME THIS WEEK TO SAY, YOU KNOW, THE DEALER IN THE SCHOOL TOLD MY SON I KNOW YOU'RE GETTING YOUR WISDOM TEETH REMOVED, YOU'RE GOING TO GET A BOTTLE OF PILLS, BRING THEM OVER AND I'LL BUY THEM FROM YOU. IT'S AMAZING HOW PEOPLE KNOW IF YOU GO TO THE DENTIST YOU'RE GOING TO GET A PRESCRIPTION. WHAT KIND OF RESEARCH AND STUDIES COULD BE DONE IN THOSE SETTINGS ARE THINGS I'M WONDERING ABOUT. THE SECOND, EVEN THOUGH I'M AN HIV RESEARCHER I'M STRUCK BY SOMETHING I HEARD THE OTHER DAY, IT'S TRUE, THE MOST -- IN THE CURRENT OPIOID EPIDEMIC, INJECTION DRUG USE EPIDEMIC, THE MOST SERIOUS INFECTIONS ARE NO LONGER HIV AND HEPATITIS C BUT ARE BACTERIAL INFECTIONS, STAPH ENDOCARDITIS, ENDOCARDITIS, STAPH INFECTION, IS THERE ANYTHING NIDA IS DOING TO ADDRESS THAT ISSUE BECAUSE I CAN TELL YOU THE NUMBER OF PEOPLE WITH ENDOCARDITIS WHO GET ADMITTED AND TREATED AND NOT TREATED FOR SUBSTANCE ABUSE IS APPALLING AND REALLY MALPRACTICE, AS FAR AS I'M CONCERNED. WHAT CAN WE DO TO IMPROVE OUTCOMES OF PEOPLE THAT HAVE ENDOCARDITIS AND INFECTIOUS DISEASES ASSOCIATED WITH OPIOID EPIDEMIC NON-HIV AND HCV. >> I WAS COMMENTING I'VE BEEN ALERTED TO THE ISSUE AT THE UNIVERSITY OF KENTUCKY, THEY WERE COMMENTING ABOUT THE HIGH -- INCREASE IN CASES OF ENDOCARDITIS THEY WERE GETTING. THEY WERE TELLING OF A CASE THAT HAD TWO OR THREE SURGERIES DONE IN ONE YEAR. AND THAT THESE PATIENTS WERE NOT BEING TREATED, EXACTLY. THAT'S ONE OF THE REASONS WHY ONE OF THE PROJECTS THAT WE'RE LAUNCHING IS PART OF THE HEAL INITIATIVE, INITIATION OF OPIOID USE DISORDER MEDICATIONS WHILE IN THE HOSPITAL, THAT'S GOING TO BE ONE OF OUR PRIORITY PROTOCOLS THAT'S GOING TO BE DONE IN THE CLINICAL TRIALS NETWORK. WITH RESPECT TO THE OTHER TWO POPULATIONS THAT ACTUALLY PUTS THE -- THOSE ARE EXACTLY THE TWO SETUPS WHERE TEENAGERS ARE LIKELY TO BE GIVEN AN OPIOID IN TERMS OF ABSOLUTE NUMBERS, DENTISTS AND TRAUMA. AND SO WE IMMEDIATELY AT THE BEGINNING, HIGHEST NUMBER WAS DENTIST. SO WE HAVE PARTNERED WITH DENTAL SOCIETY, I DON'T KNOW WHAT IS THE NAME. >> AMERICAN DENTAL ASSOCIATION. >> THE DENTAL INSTITUTE WAS IMMEDIATELY WENT TO LARRY TABAK, DIRECTOR THERE. I TOLD THE STORY MANY TIMES. NORA, DENTISTS DO NOT USE OPIOIDS. THAT'S NOT THE PRESCRIPTION PRACTICE. NO, NO, NO, IT'S THE ISSUE WHAT YOU RECOMMEND. YOU MAY HAVE PRACTICES AND GUIDELINES, NOT NECESSARILY THE WAY THAT CLINICIANS ARE GOING TO BEHAVE AND TREAT THEIR PATIENTS NECESSARILY. WE HAVE HAD A VERY, VERY STRONG AND VERY PRO-ACTIVE RESPONSE FROM THAT ASSOCIATION. IN FACT, THEY HAVE BEEN THE MOST AGGRESSIVE IN TERMS OF EDUCATING AND TRAINING DENTISTS SO THEY DON'T PRESCRIBE OPIOIDS. IN PARTICULARLY ADOLESCENTS. AND YOU CAN SEE IT. IT'S NOT JUST BLABBER. YOU CAN SEE DECREASE IN NUMBER OF PRESCRIPTIONS OF OPIOIDS BY DENTISTS. THAT'S BEEN PRECIPITOUSLY DECLINING, A SPECIALLY WITH THE MOST PRECIPITOUS DECLINE. WITH TRAUMA, THAT IS PERHAPS DIFFERENT. THAT IS ONE OF THE AREAS THAT WE'RE GOING TO BE ACTUALLY TRYING TO GET EVIDENCE OF WHAT TYPE OF INTERVENTIONS YOU CAN DO WHEN YOU HAVE A TEENAGER SUFFERING FROM TRAUMA WITH SEVERE PAIN. HOW DO YOU OPTIMALLY MANAGE THEM. AND THIS TYPE OF CIRCUMSTANCE ACTUALLY IS ONE OF THE ONES THAT CERTAINLY ALERTED ME THAT WE NEEDED MEDICATIONS FOR PAIN NOT JUST FOR CHRONIC PAIN WHICH HAD BEEN MY NARRATIVE FOR MANY YEARS, I SAID, NO, NORA, MEDICATIONS FOR ACUTE PAIN TO ADDRESS SEVERE ACUTE PAIN COULD BE VERY VALUABLE. IF YOU CAN ACTUALLY DEVELOP THEM, BECAUSE YOU'RE GOING TO HAVE TO TREAT. A KID THAT HAS A FRACTURE, YOU HAVE TO TREAT. SO THERE ARE -- WE'RE GOING TO BE FUNDING RESEARCH THAT RELATES TO YOUNG PEOPLE THAT HAVE TRAUMA FOR -- BECAUSE OF CONSTRUCTION, AND THROUGH THE HEAL INITIATIVE ON THE OTHER SIDE OF THE PAIN SIDE THERE IS EMPHASIS ON DEVELOPING PAIN MEDICATIONS, AND, AGAIN, ONE OF THE AREAS THAT THE MWG RECOGNIZES IS UNDERREPRESENTED IS THAT COMBINATION OF PEOPLE THAT HAVE OPIOID USE DISORDER AND PAIN AND PERHAPS THE WAY THAT I'M REWORDING IT WHICH HAS NOT BEEN REPRESENTED PROPERLY IS HOW DO YOU TREAT PAIN ON SOMEONE AT HIGH RISK FOR OPIOID USE DISORDER. THEY DON'T HAVE IT BUT THEY ARE AT HIGH RISK, HOW DO YOU DO IT. >> (INAUDIBLE). >> IF YOU'RE IN REMISSION AND NEED SURGERY, BASICALLY -- >> THAT'S THE BIGGEST FEAR OF PEOPLE IN RECOVERY. HOW DO I DEAL WITH PAIN. >> YEAH. >> I'M ON. CARLOS POINTED OUT, VERY GOOD OVERVIEW, VERY GOOD PRESENTATION. I STILL LIKE TO POINT OUT THAT WE'RE DEALING WITH STRANGE PERIOD IN HISTORY. IF YOU LOOK AT DEPRESSIVE DISORDERS IN YOUNG ADULTS, 18 TO 25, AND 2013, 8.7 MET CRITERIA, BY 2018, 13%. IT'S GOING UP. WE'RE NOT JUST DEALING WITH SUBSTANCE ABUSE. WE'RE ALSO DEALING WITH GROWING ANXIETY AND TENSION AMONG YOUNG ADULTS. IT STARTS TO DROP OFF AFTER 30. BUT 18 TO 25-YEAR-OLD CATEGORY FOR PAST THREE YEARS THE DATA ARE KIND OF FRIGHTENING. WITH THAT, YOU SHOULD ALSO -- GIVEN YOU'RE DOING THE HEAL INITIATIVE, I WANT TO POINT OUT PROPOSED CHANGES TO 42 CFR PART 2 WHICH MAY INTERFERE WITH YOUR HEAL INITIATIVE AND OTHER THINGS THAT YOU'RE ATTEMPTING TO DO. EVEN NOW IN 2015, THERE WERE 669,000 YOUNG ADULTS RECEIVING SOME FORM OF SUBSTANCE ABUSE TREATMENT. BY 2018 THAT NUMBER DROPPED TO 547,000. WE'RE SEEING FEWER PEOPLE ENTERING TREATMENT. WE'RE ALSO SEEING FEWER PEOPLE PERCEIVING THE NEED FOR TREATMENT WHICH MIGHT ACCOUNT FOR SOME OF THESE OTHER EVENTS YOU'RE SEEING. SO I WOULD ENCOURAGE YOU TO LOOK AT HOW PEOPLE PERCEIVE GOING TO TREATMENT OR WELCOMED IN TREATMENT, THE 42 CFR PART 2 CURRENT PROPOSAL IS TO TO CHANGE IN PURSUIT OF DRUG TRAFFICKING, SPECIFICALLY STATES NOT JUST THE PATIENT'S RECORD BUT THE PATIENT PROVIDER RECORDS, OR SOMEONE THAT THE PATIENT KNOWS. SO WE'RE DOING FOR THE FIRST TIME SINCE 1987, CHANGING THE INTERPRETATION OF 263A 2 FROM SERIOUS CRIMES COMMITTED BY PATIENT OR CHILD ABUSE TO INCLUDE DRUG TRAFFICKING. THE PREAMBLE OF THAT PARTICULAR DOESN'T DEFINE DRUG TRAFFICKING AN MOST PATIENTS WHO USE ILLEGAL DRUGS HAVE BARTERED ILLEGAL DRUGS, IN ORDER TO GET IT, YOU GOT TO GET IT FROM SOMEBODY. YOU MAY HAVE BEEN ENGAGED IN DRUG TRAFFICKING. AND SO THIS TURNS CONFIDENTIAL REGULATIONS AROUND, THE PATIENT BECOMES THE SNITCH ON THEMSELF, SELF INCRIMINATION, ON THE PROVIDER, OTHER WAYS TO GET TO THE PROVIDER, AND ON THE PATIENT'S FRIENDS AND FAMILY WHICH MAKES YOU A SNITCH WHICH DOESN'T GO OVER TOO WELL IN THE COMMUNITY. SUBSTANCE USE TREATMENT SHOULD NOT BE HOSTILE. I WANT TO ENCOURAGE WHOEVER IS DOING POLICY RESEARCH TO TAKE THAT AND KEEP THAT IN MIND BECAUSE FEWER PEOPLE PERCEIVING NEED FOR TREATMENT ACCORDING TO NISDA AND FEWER PEOPLE GOING INTO TREATMENT. >> THIS IS OF COURSE -- COULD HAVE DIRECT IMPLICATIONS IN TERMS OF OUR -- NOT JUST ABILITY TO DO RESEARCH BUT AS YOU SAY FOR PATIENTS GETTING THE TREATMENT THAT THEY NEED, SO WE'LL LOOK INTO THIS. >> FOLLOWING UP WITH BUPRENORPHINE, THE PEOPLE WHO USE BUPRENORPHINE, MISUSE BUPRENORPHINE. AT ONE POINT IT WAS THOUGHT THEY WERE EXCHANGING BECAUSE THEY DIDN'T HAVE ACCESS. OTHERS SUGGEST THEY MAY BE BUYING BUPRENORPHINE BECAUSE THEY DON'T WANT TO BE IN FORMAL TREATMENT. IF YOU'RE IN FORMAL TREATMENT YOU GO INTO ELECTRONIC HEALTH RECORDS, PDMPs, INTO THE SYSTEM. IF YOU BUY YOUR BUPRENORPHINE OFF THE STREET, YOU DON'T GO INTO THE SYSTEM. >> WESLEY, THAT'S AN IMPORTANT STATEMENT. NOT IN MY RADAR. WE DEFINITELY WILL SLOBBING TO -- WILL LOOK TO GET A SENSE HOW RELEVANT THIS IS. IT COULD INTERFERE WITH EFFORTS TO MAKE ACCESS TO MEDICATION. SEVERAL PEOPLE ARE RAISING QUESTIONS. ALBERT AND PAUL, I'M TRYING TO KEEP SEQUENCE AND THEN WE HAVE GAIL. OKAY, YES. >> I'LL SPEAK UP. IT'S NOT WORKING. THERE WE GO. NORA, A COUPLE THINGS WESLEY BROUGHT UP, IN MY WORLD, THE JUSTICE WORLD, WHEN YOU TALK ABOUT 18 TO 25 YEAR OLD, 25% WITH MENTAL ILLNESS, THAT'S A SIGNIFICANT NUMBER. WE SEE THEM MUCH EARLIER THAN THAT. WE START SEEING THE JUVENILE SYSTEM 14, 15, 16, 17 YEARS OF AGE. UNTREATED. A LOT OF THEM ARE JUVENILE PETTY OFFENDERS, MEANING OUR JURISDICTION IS LIMITED AS FAR AS HOW LONG WE CAN KEEP THEM IN THE SYSTEM. UP TO SIX MONTHS. A LOT OF THEM WILL BE REFERRED TO TREATMENT AT. A LOT OF TREATMENT PROVIDERS REALLY ARE UNEQUIPPED TO HANDLE THAT POPULATION. IF THEY ACT UP, WE'VE HAD PEOPLE DISCHARGED FROM TREATMENT, ADOLESCENTS, BECAUSE THEY ACTED UP IN TREATMENT. THINK OF THAT. I MEAN WHEN YOU LOOK AT A POSSIBLE CHANGE, THAT'S ONE OF THEM. THEN WHEN WE GET THEM TO 18 TO 25-YEAR-OLD POPULATION, I WAS TALKING TO ED ABOUT THIS EARLIER, IT'S REALLY CRUSHING FOR A JUDGE QUITE FRANKLY TO SEE THAT POPULATION COME BEFORE US WHEN YOU'VE HAD UNTREATED ADOLESCENTS. NOW IN ADULT CRIMINAL SYSTEM WITH PRESUMPTIVE SENTENCING AND GUIDELINES THAT CAN SEND THEM TO PRISON. NOW, LEGISLATION HAS CHANGED WHICH IS A GOOD THING ON SOME DRUG CASES, THEY ARE NOT PRESUMPTIVE COMMITS TO PERSON BUT A LOT OF JUDGES ARE SETSING SETS -- SENTENCING UP TO A YEAR IN JAIL. A LOT OF URBAN COURTS AND JAILS, PARTICULARLY JAILS, HAVE A MENTAL HEALTH ACCESS AS WELL AS CHEMICAL HEALTH RESOURCES WITHIN THE JAILS. RURAL POPULATIONS DON'T HAVE THAT LUXURY. WHAT YOU'RE DOING IS HOUSING AN UNTREATED ADDICT POSSIBLY WITH MENTAL ILLNESS FOR UP TO A YEAR WITHOUT ASSISTANCE TO ADDRESS THE UNDERLYING MENTAL ILLNESS OR ADDICTION. THEY ARE COMING OUT AFTER A YEAR UNTREATED. GUESS WHAT HAPPENS. WE KNOW THE STATISTICS. THEY COME BACK. THEY ARE BEFORE THE COURT AGAIN, NOW A SUBSEQUENT CONVICTION, THEY CAN GO TO PRISON. THAT DOESN'T MAKE SENSE TO ME. WHEN YOU LOOK AT THIS IT'S SOMETHING TO TAKE INTO CONSIDERATION, HOW IN THE JUSTICE SYSTEM WHEN YOU CONNECT WHAT YOU'RE TALKING ABOUT, THE SCIENCE, WITH THE CULTURE OF THE JUSTICE SYSTEM. HOW DO YOU DO THAT? A LOT OF JAIL, PARTICULARLY IN RURAL COMMUNITY, THEIR JOB IS TO HOUSE THESE PEOPLE IN A SAFE WAY SO THEY ARE NOT HURT IN THE JAIL. THEY ARE NOT LOOKING AT TREATMENT MODALITY. WE'VE BEEN DOING IN SOME OF OUR RURAL COMMUNITIES, I THINK THROUGHOUT THE COUNTRY, REFERRING A LOT OF THOSE PEOPLE OR FURLOUGH THEM INTO TREATMENT. EVEN THOUGH THEY ARE IN THE CUSTODY OF THE COURT THROUGH PROBATION. WE'RE DOING FURLOUGHS INTO TREATMENT. AND THAT'S BEEN SUCCESSFUL AS FAR AS GETTING IN TREATMENT. IF THEY DO WELL IN TREATMENT WE CAN DISCHARGE THEM FROM FURTHER JAIL TIME TO COMPLETE SENTENCE SO THEY HAVE INCENTIVE. >> THANK YOU VERY MUCH FOR BRINGING THAT TO OUR ATTENTION. CERTAINLY WE'VE REACHED OUT TO NIMH TO HIGHLIGHT IMPORTANCE OF ACTUALLY DOING PROJECTS TOGETHER HAVING AN INFRASTRUCTURE. I DO KNOW DR. JOSH GORDON IS VERY, VERY SUPPORTIVE AND INTERESTED. SO I THINK THAT ONCE THE STRUCTURE IS CREATED, HOPEFULLY THAT WILL EXPAND THE TYPE OF SCIENTIFIC QUESTIONS WE CAN ASK AND GET EVIDENCE. THANKS A LOT. YOU'VE BEEN RAISING YOUR HAND FOR A WHILE. >> SO THIS IS RELATED ACTUALLY. SO IN SAN DIEGO, IN THE PROCESS OF ANALYZING 130,000 OF A DEPRESSION SCREEN, BASED ON ANSWERS, THIS IS FOR HEALTHY SEVENTH AND 8th GRADERS IN THE SCHOOL. ONE IN SEVEN 13 TO 19-YEAR-OLDS EXPERIENCE SEVERE DEPRESSION DURING THAT TIME. ONLY ONE IN SEVEN OF THOSE WILL HAVE ANY FORM OF TREATMENT. INCLUDING TALKING TO THE SCHOOL COUNSELOR. WE FIND PEOPLE WHO DO GET TREATMENT FOR DEPRESSION, WHEN DID THIS START, RIGHT? 10.8 YEARS IS THE AVERAGE TIME FROM ONSET OF THE SYMPTOMS TO ANY FORM OF TREATMENT AT ANY FORM. OH, YOU BROKE UP WITH YOUR GIRLFRIEND? NO, I WAS GOING TO END IT ALL. IT'S NOT LIKE EVERYONE IS SAD. IT'S LIFE-THREATENING. IT'S SHAMEFUL. WE'RE COMPLETELY MISSING IT. IT'S THERE, IT'S RIGHT IN FRONT OF US, TREATABLE, AND WE MISS IT LEFT AND RIGHT. WE JUST GOT BUY-IN FROM HIGH SCHOOL COACHES IN CALIFORNIA, TO ADMINISTER THE QUESTIONS AS WELL. AND HIGH SCHOOL COACHES ARE OFTEN -- SOMETIMES THEY KNOW THE KIDS BETTER THAN THE PARENTS, THE TEACHERS, IT'S AN INTIMATE -- IT'S SCARY TIMES HOW MUCH INFLUENCE. WE HAD HIGH PROFILE SUICIDE AMONGST PEOPLE WHO SAY YOU'RE KIDDING. IT SOMETIMES TAKES THESE PUBLIC EVENTS AND STUFF TO DRAW ATTENTION, LIKE THE GUN STUFF AND THEN PEOPLE ARE OUTRAGED FOR TWO WEEKS AND IT'S BACK TO BUSINESS AS USUAL. WE'RE HOPING TO GET SOME MOMENTUM HERE IN TERMS OF THIS VERY LONG LAG TIME FOR OBSESSIVE COMPULSIVE DISORDERS, OVER 10 YEARS, ANXIETY DISORDERS OVER 8. TIME BETWEEN HAVING THE ILLNESS AND RECOGNIZING TREATING IT, IT'S LITERALLY SHAMEFUL. I FEEL MY PROFESSION OF ADOLESCENT PSYCHIATRY, HOW CAN WE DO BETTER WITH TECHNOLOGIES, I MEAN THE SUICIDE NUMBERS, YOU KNOW, REELING. I COULD FILL UP MY PRIUS WITH CYBER NEUROSCIENCE ABSTRACTS FROM THE 30 YEARS OF DOING THIS. WE'VE LEARNED SO MUCH ABOUT BRAIN BEHAVIOR, WE'RE GOING BACKWARDS. THESE ARE NUMBERS THAT WORSE THAN WHEN I STARTED. WE LEARNED SO MUCH ABOUT THE BRAIN AND BEHAVIOR, AND WE'RE GOING BACKWARDS. IT'S REALLY HUMBLING. AND THE SUICIDE NUMBERS, EVERYONE IS WATCHING THEM, IS IT SOCIAL MEDIA, IS IT SUBSTANCE ABUSE? NOTHING IS SORT OF OBVIOUS IN TERMS OF WHY IT'S THE SECOND LEADING CAUSE OF DEATH AFTER CAR ACCIDENTS AND ACCIDENTS. ALL THE THINGS, YOU KNOW, IT'S LIKE THE NUMBER ONE. JUST ONE LAST THING, I WAS GOING TO PUT IN A PLUG FOR -- YOU WERE TALKING ABOUT INFECTIONS, STEPHANIE JUST FINISHED ROTATING OFF OF THIS COUNCIL, RIVETTING, FASCINATING BOOK, THE PERFECT PREDATOR, HER AN HER HUSBAND'S EXPERIENCE TREATING SUPER BUGS THAT ARE GIVEN TO THE POINT ANTIBIOTICS WON'T BE USEFUL, THE NEW FORM OF THERAPY WE HAVE VIRUSES THAT KILL THE BACTERIA, BUT IT'S A GREAT READ IF PEOPLE WANT TO LEARN MORE ABOUT THE CURRENT STATE OF SUPER BUGS AND EPIC BATTLE BETWEEN SCIENTISTS AND BACTERIA. >> I AGREE. I THINK THE QUESTION THAT WE COULD SOLVE IS WHAT'S GOING ON IT'S AN IMPORTANT QUESTION, SORT OF HOPEFULLY TRUE STORIES LIKE THE HBCD OR ABCD WILL HAVE MORE KNOWLEDGE. WE DON'T HAVE THE LUXURY OF TIME INTERVENTIONS. DEVIN? >> ALL RIGHT. THERE WE GO. I GUESS THE FIRST THING I WANT TO SAY, I FEEL LIKE I WENT TO THE MASTER'S CLASS, WHICH IS EXCITING TO BE AT THE TABLE WITH EVERYBODY HERE, A FAN BOY MOMENT. SO, I GUESS, AGAIN, I'M THE GUY THAT I SEE MYSELF ON THE GROUND, IMPLEMENTING THINGS. IN PENNSYLVANIA WE LIVE IN A STATE WHERE THE STATE HAS SAID THROUGH LEADERSHIP OF JOHN WETZEL, SECRETARY WETZEL, ALL THE STATE PRISONS WILL OFFER M.A.T. IN JAILS BUT THAT'S KIND OF -- DOESN'T MEAN AS MUCH BECAUSE PEOPLE GO TO COUNTY JAIL FIRST, AND THEY WILL BE DO A HARD DETOX THERE WITHOUT ANY HELP AND THEY ARE NOT GOING TO IMPLEMENT OUD AT THE STATE LEVEL, SO I GUESS MY QUESTION IS, YOU KNOW, HOW DOES THE POLITICAL LANDSCAPE WHERE PEOPLE DID IT THEMSELVES, WE DON'T WANT TO HELP THEM, LAW ENFORCEMENT'S CONCERN ABOUT DIVERSION AND SUBOXONE AND UNWILLINGNESS TO TREAT WITH NALOXONE UNLESS THEY ARE PREGNANT HINDER RESEARCH OR HOW DO WE OVERCOME THAT. WHAT WE'RE DOING IS TRAINING COPS AND SHERIFFS TO TALK TO WARDENS, TRYING TO RAISE MONEY OUT OF THE LEGISLATURE, I SEE THE DISCONNECT WHERE LIKE I SHOW THEM THE RESEARCH ABOUT PEOPLE DYING, THEY ARE LIKE WE DON'T CARE. OUR PROBLEMS ARE DIVERSION, DIVERSION, DIVERSION. AND WE'RE SLOWLY TRYING TO BUILD MOMENTUM IN OUR STATE AND GET MORE COUNTIES ON BOARD BECAUSE IT BECOMES A 67-COUNTY FIGHT. THAT'S HOW MANY COUNTIES ARE IN PENNSYLVANIA. SECOND THING I WANT TO SAY, WHILE YOU POINT OUT THE 220 COUNTIES MOST AT RISK OF OVERDOSE, ONLY HALF OF THOSE COUNTIES HAVE SYRINGE SERVICE PROGRAMS, AND, AGAIN, HOW DO WE ADDRESS THAT WHEN THE POLICY ISSUES ARE OUR PROBLEM. I MEAN, EVEN SECRETARY OF HEALTH IS NOW SAYING YOU WOULDN'T EXPECT REPUBLICAN HEALTH SECRETARY TO SUPPORT THE PROGRAMS BUT I DO, HOW CAN NIDA PUSH THAT FORWARD? I LIVE IN A STATE WHERE SYRINGE SERVICE PROGRAMS ARE AM BIG HOUSE UNDER THE -- AMBIGUOUS UNDER THE LAW. WE'RE THE STATE WITH THE MOST OVERDOSES. I'VE NEVER BROUGHT A RESEARCH STUDY TO ANY LEGISLATOR, THERE'S 30 YEARS OF RESEARCH, YOU'VE GOT A PROBLEM IN YOUR COUNTY, POTENTIAL OUTBREAK OF HIV AND AIDS, IT'S JUST A GUESSTIMATION. WE NEED SURVEILLANCE. OTHER STATES NEED SURVEILLANCE. AND THERE HAS TO BE ECONOMIC TO THAT. IF YOU DON'T DO THIS IT'S GOING TO COST A MILLION DOLLARS, $10 MILLION. AS SOMEBODY DOING IMPLEMENTING I NEED SOMETHING THAT WORKS WITH PEOPLE THAT GOT THE JUICE. >> WHAT YOU'RE POINTING IS EXACTLY THE BIG CHALLENGE THAT WE HAVE. WE DON'T NEED MORE EVIDENCE TO SHOW SYRINGE EXCHANGE PROGRAMS WORK. WE NEED DATA OR STRATEGIES THAT WILL CHANGE THE ETIOLOGY AND STIGMA. BECAUSE WE'RE A SCIENCE ORGANIZATION, OUR TOOLS ARE SCIENCE AND KNOWLEDGE. HOW IS THE MOST ELOQUENT WAY OF PRESENTING DATA THAT CANNOT BE IGNORED. AS SELECTING THE PRIORITY, THIS WAS ON TOP OF OUR BRAIN. WHAT IS IT WE CAN PROVIDE. WE ALSO BROUGHT IN THE ECONOMIC EMPHASIS IN MANY PROPOSALS BECAUSE IT DOES TURN AROUND A LOT IN TERMS OF HOW MUCH IT COSTS. SO IF YOU CAN SHOW THAT IT DECREASES COST, THAT MAKES A BIG IMPACT, IF YOU CAN SHOW YOU'RE DECREASING MORTALITY, DECREASING INFECTION, DECREASING CRIMINAL BEHAVIOR, I MEAN, IN WAYS THAT ARE -- I MEAN THESE EFFECT SIZES ARE LARGE, IT'S NOT LIKE 10% CHANGE. WE'RE SEEING HUGE CHANGES BUT NEED TO DOCUMENT IN A WAY THAT IS REPRESENTATIVE AND THAT, AGAIN, SOMEONE CANNOT IGNORE, JUST BECAUSE I DON'T BELIEVE. THIS IS WHAT HAPPENS. WHY DO WE NOT HAVE SYRINGE EXCHANGE PROGRAMS? PEOPLE BELIEVE YOU PROMOTE DRUG USE BY THOSE PATTERNS, YOU SHOULDN'T BE GIVING NALOXONE BECAUSE YOU'RE CREATING AN OPPORTUNITY FOR PEOPLE TO DO MORE RISKY BEHAVIOR. THAT IS THE TYPE OF FACTORS THAT ENTER. HOW DO WE CHANGE IT? AND I'M VERY AWARE, ONE OF THE REASONS WHY WE VALUE AL YOUR PERSPECTIVES BECAUSE YOU CAN GET US AN INSIGHT OF WHAT TYPE OF INFORMATION MAY BE MOST VALUABLE FOR YOU TO BE ABLE TO GO TO THE POLICYMAKERS, TO YOUR STATE LEGISLATORS, TO CHANGE PRACTICE SO WE CAN -- THAT'S WHERE WE NEED TO BE. LET ME DO MARYANN AND YOU. THERE WAS GAIL. MARIA, GAIL, I'M TRYING TO. >> THANK YOU. I APPRECIATE IT. GOING BACK TO WESLEY'S INITIAL COMMENT ABOUT THE CULTURE, I FEEL LIKE THE NIDA DOES HAVE SO MUCH RESEARCH. WHEN WE LEAVE HERE, I FEEL SOMEWHAT EMPOWERED. THE FIRST PERSON I RUN INTO I WANT TO TELL ABOUT THIS. IT'S VERY CONVINCING. THE PUBLIC I DON'T THINK HAS VERY MUCH OF AWARENESS. IF WE DID A PUBLIC SURVEY OF BASIC DEFINITIONS, HARM REDUCTION IS A HISTORY THAT KEEPS SOME PEOPLE AWAY. AND OTHERS GRAVITATE. I THINK THAT'S AN ISSUE. IT'S EVEN MORE BASIC THAN THAT. WE HAVE A CULTURE WHERE WE HAVE TRUSTED IN MEDICATION, AND NOW WE'RE SUING THE MANUFACTURERS OF THIS MEDICATION SO WHERE IS THE TRUST, DO I TRUST ONE DOCTOR WHO PRESCRIBED, ANOTHER DOCTOR WHO IS PRESCRIBING SOMEBODY TO GET ME OFF? WHERE IS THAT CONFIDENCE, WHERE IS THAT TRUST IN MEDICAL DELIVERY? I THINK THE SCIENCE THAT NIDA PRODUCES WILL HELP US TURN THAT AROUND BUT I THINK THAT'S AN ISSUE OF TRUST, INTEGRATING MENTAL HEALTH IN THIS CONVERSATION IS A GOD SEND FRANKLY. ONE FAMILY IN PARTICULAR, SON COMPLETED DRUG TREATMENT, COMING HOME, WORKING, THIS AND THAT. THEN THE SUICIDE NOTE BASICALLY SAID I'M NOT NORMAL. I DON'T FEEL NORMAL. I NEVER WILL. WHAT WAS GOING ON THAT WAS NOT RECOGNIZED EARLIER THAT SENSE OF BASIC FEELING OF NORMAL? WHEN WE START TALKING ABOUT PEOPLE USING MEDICATION TO SELF MEDICATE, CARLOS, YOUR COMMENT ABOUT IF YOU'RE GOING TO THE DENTIST I'LL PAY YOU FOR WHATEVER. EVEN IF YOU DON'T WANT TO USE THEM YOURSELF, A KID THAT AGE MIGHT SAY, WHY NOT? I THINK THERE ARE A LOT OF CULTURAL ISSUES THAT DEAL WITH TRUST AND UNDERSTANDING, NOT JUST OF OUR MEDICAL PROFESSIONALS BUT THE SCIENCE BEHIND IT. WE CAN USE SCIENCE TO TURN THAT AROUND. BECAUSE IT DOESN'T -- THIS SOUNDS CRASS BUT IT DOESN'T FOLLOW THE MONEY. PEOPLE CAN EXPLAIN ABOUT DOCTORS, THIS AND THAT BUT WHEN THEY TALK ABOUT SCIENCE IT'S PRETTY HARD TO REFUTE IT. ESPECIALLY WHEN IT'S INTEGRATED WITH THESE OTHER INSTITUTES THAT ALL PLAY AN IMPORTANT ROLE. >> GAIL? >> THANK YOU. A COUPLE THINGS. ONE I CAN CONFIRM BEING ON THE FRONT LINES THAT WE'RE SEEING CONSTANT AMOUNTS OF MENTAL ILLNESS, THE ENTIRE E.D. IS FULL OF IT. WE HAVE NO PIPELINE TO TAKE CARE OF IT. INTERVENTIONS ARE GREAT BUT WE HAVE NO ONE TO DO IT. THAT'S OUR BIG ISSUE. WE NEED TO THINK ABOUT THAT. I WANT TO GO BACK TO YOUR FENTANYL ISSUE, NORA, YOU SAID YOU WERE WORRIED ABOUT EPIDEMIOLOGY DATA, FENTANYL NOT HEROIN. MOST E.D.s DO NOT MEASURE FENTANYL SO ALL OF YOUR NON-FATAL OVERDOSES ARE NEVER KNOWN WHAT IT IS. WE IN MY HOSPITAL CAN BUT WE'RE ONE OF VERY, VERY FEW. MOST PLACES CAN'T MEASURE IT. SO MOST EVEN PEOPLE AND INDIVIDUALS ARE USING DON'T EVEN KNOW. SOME KNOW IT'S FENTANYL, MANY DON'T. THEY MAY NOT KNOW WHAT THEY ARE USING, JUST USING WHITE POWDER. IT'S CLEAR FENTANYL IS GOING UP. I THINK UNFORTUNATELY WE'RE GOING TO SEE EVERYTHING IS A YEAR BEHIND, BUT WHAT WE'RE SEEING NOW IN CONNECTICUT JUST NOW WE HAVE A -- LOOKS LIKE IN 2019, A 7% INCREASE IN OVERDOSE DEATHS. THOSE ARE ALL, YOU KNOW, MORE THAN 60% OF THEM HAVE FENTANYL IN THEM. M.E.s CAN MEASURE FOR THAT. WE SAW THIS KIND OF LEVELING OUT LAST YEAR, BUT YOU'RE GOING TO SEE MORE INCREASE IN EVERYTHING. AND, YOU KNOW, JUST IN THE LAST MONTH MY DOCTORS GIVE OUT 34 PRESCRIPTIONS FOR BUPRENORPHINE. THAT'S UNHEARD OF IN WHAT WE DO BUT IT'S MORE AND MORE PEOPLE WHO ARE COMING IN. WE'RE GOING TO SEE THAT AND THE WORRY I HAVE IS WE DON'T HAVE THE WORKFORCE. WE HAVE TO THINK HOW TO CREATE THE SCIENCE THAT WILL HELP CREATE THE WORKFORCE. SO WE TALK ABOUT ENDOCARDITIS, ALL OF THIS, WHY ISN'T IT TREATED. IT'S BECAUSE WE DON'T HAVE DOCTORS IN HOUSE THAT KNOW HOW TO TREAT IT. SO WE HAVE ABOUT 54 RESIDENCIES IN ADDICTION MEDICINE, WE NEED AT LEAST 125 TO WHAT WE PROJECT, WE NEED AT LEAST 7500 PHYSICIANS WHO KNOW SOMETHING ABOUT ADDICTION MEDICINE, BY 2025, TO DO THIS. WE ONLY HAVE 54 RESIDENCIES, WE NEED -- OR FELLOWSHIPS. WE NEED THE GOVERNMENT TO PAY THE HOSPITALS TO CREATE THOSE FELLOWSHIPS, JUST A YEAR FELLOWSHIP. WE TALK IN ENDOCARDITIS WE'RE SEEING TONS IN MY HOSPITAL. LUCKILY AGAIN AFTER YEARS OF FIGHTING WE HAVE ONE ADDICTION PERSON AND OF THAT WE GOT TO HIRE. AND IT'S 1500-BED HOSPITAL, IT'S HARD TO GO EVERYWHERE AND TEACH EVERYBODY, SO THE SCIENCE AND SEEING, YES, THIS WILL WORK IS GOOD. WE ALSO NEED SOMETHING AROUND THE WORKFORCE LIKE SOMETHING ABOUT TRAINING AND ABILITY TO TRAIN MORE PEOPLE AND HOW TO PUT THEM OUT THERE. >> (INAUDIBLE) A SERIES OF INITIATIVES TO ADDRESS THE CRISIS. WE'RE SCIENCE. THERE ARE INITIATIVES THAT IDENTIFY IMPORTANCE OF TRAINING. NOT JUST PHYSICIANS BUT ALSO COACHES AND NURSE PRACTITIONERS AND SO THERE IS MAJOR EFFORT OF HHS NOW, WHAT I DO NOT KNOW IS EXACTLY IN TERMS OF THE DISTRIBUTION AND WHAT ARE THE TIMELINES. BUT WE ALWAYS FROM THE PERSPECTIVE OF SCIENCE, WAIT I TURN THESE THINGS AROUND IS IF YOU CAN DOCUMENT FOR EXAMPLE YOU SAID, WELL, WE DON'T HAVE SUFFICIENT PERSONNEL ON THE EMERGENCY DEPARTMENT TO TAKE CARE OF MENTAL ILLNESS, THAT IS LIKELY TO BE A HIGH RISK FOR SUBSTANCE USE DISORDER, BUT WHAT MODEL WOULD WORK? AND SO WHAT IS IT, HOW DO WE CHANGE OUR VISION OF EMERGENCY DEPARTMENT, IN THAT MEETING THAT YOU ATTENDED WHERE ONE OF THE THINGS THAT WAS SAID COULD THERE BE INTERMEDIATE WAITING AREA WHERE YOU COULD HAVE PATIENTS BE DETOXIFIED, THERE ARE MODELS THAT CAN DETERMINE COST AND HOW DO YOU SUPPORT THEM. PEOPLE LIKE YOU ARE THE ONES THAT HAVE TO GENERATE AND LEAD IN TERMS OF MODELS THAT CAN WORK SO THAT CAN CHANGE. WE CAN HELP OF COURSE FUND THAT AND CREATION OF THE PROGRAM. SHARON, SORRY, I KEPT YOU WAITING. >> SO, I'M GOING TO FOLLOW ON FROM WHAT GAIL AND DEVIN SAID EARLIER, JUST ABOUT THE GAPS BETWEEN WHAT WE KNOW WORKS AND WHAT ACTUALLY HAPPENS, HOW DO WE FILL THAT GAP IN BECAUSE WE'VE BEEN TALKING ABOUT THIS FOR A LONG TIME. AND JUST AS EXAMPLE, EVIDENCE THAT SOME MEDICATIONS WE HAVE AVAILABLE HAS BEEN AROUND FOR ALMOST NOW 50 YEARS, THAT'S A REALLY LONG TIME. AND WHILE WE HAVE HAD A LOT OF TROUBLE GETTING TRACTION, BOTH BECAUSE OF SYSTEM BARRIERS AND STIGMA, A FAILURE TO UNDERSTAND THE NATURE AT LEAST AROUND OPIOID USE DISORDER, I DO WANT TO SAY THAT I REMAIN OPTIMISTIC, SINCE THE CRISIS STARTED, I WAS INVOLVED IN RESEARCH STARTED THAT MY JOB BECAME ABOUT CHANGING HEARTS AND MINDS RATHER THAN TRYING TO GET DOWN TO NITTY-GRITTY. WHEN YOU TALK TO PEOPLE NOT IN SCIENCE, SOMETIMES IT GETS LOST IN THE TRANSLATION. AND ONE OF THE MOST IMPORTANT THINGS NIDA IS DOING AND SHOULD CONTINUE TO THINK HOW TO EXPAND THIS IS THE NETWORKS. THE REASON I SAY THAT IS LIKE GAYLE IS A CHAMPION IN HER EMERGENCY DEPARTMENT, AND I'VE SEEN A LOT OF CHANGESIN OUR HEALTH CARE LOCAL SYSTEM BECAUSE WE HAVE CHAMPIONS. SOMETIMES IT TAKES ONE PERSON AND SO A JUDGE TALKING TO ANOTHER JUDGE OR JAILER TALKING TO ANOTHER JAILER THAT HAS HAD SOME POSITIVE EXPERIENCE CAN BE SO MUCH MORE POWERFUL THAN, YOU KNOW, PRESENTING 30 STUDIES TO SOMEBODY. AND SO I THINK TRYING TO THINK ABOUT HOW TO ACTUALLY LEVERAGE THE NETWORKS THAT YOU'RE SETTING UP SO THAT YOU CAN CREATE CHAMPIONS OUTSIDE SCIENTIFIC FIELD WHO CAN THEN HELP BE AN AGENT OF CHANGE ELSEWHERE IN THE COMMUNITY IS SOMETHING THAT I DON'T THINK WE'RE LEVERAGING IN A VERY ORGANIZED FASHION, BUT IT'S AN OPPORTUNITY TO DO THAT. AND I SEE THAT HERE WITH JCOIN BECAUSE I MEAN I CAN TELL YOU THAT THE CONTEXT OF HOW JUDGES ARE DEALING WITH PEOPLE IN FAMILY COURT HAS CHANGED. I KNOW THE BUREAU OF PRISONS, YOU AND I HAD AN E-MAIL EXCHANGE ABOUT THAT COMING DOWN FROM HHS, NOW IT'S GOING TO BE A MANDATE THEY HAVE TO PROVIDE MEDICATIONS FOR OPIOID USE DISORDER. AND THEY'VE GOT TO ROLL THAT OUT PRETTY SOON. IT'S NICE WHEN IT'S FORCED ON PEOPLE, IT'S ALSO NICE WHEN IT BUBBLES UP. I THINK THINKING ABOUT HOW TO REALLY CREATE THOSE NETWORKS >> I LIKE THE WAY THAT YOU PHRASED IT. I THINK WE WILL EXPLICITLY SEE HOW TO OPTIMALLY USE THE NETWORKS THAT WE HAVE AND TO MAXIMIZE THAT FROM HAPPENING. WE'LL DO SOME BRAINSTORMING. >> I WANTED TO FOLLOW UP ON A COMMENT THAT JAY MADE ABOUT THE GAP, WHEN WE RECEIVE MENTAL ILLNESS AND ADOLESCENT AND TREAT THE GAP, ADDICTION POLICY WE'RE SEEING THE SAME IN FTD SPACE, WE KNOW THIS IS AN ADOLESCENT BRAIN MOSTLY ADULT-CENTERED TREATMENT SYSTEM. WE CREATED A DATABASE TO FOR OUR HELP LINE, 24/7 HELP LINE, CREATED A DATABASE. SOME STATES HAVE 20% OF PROVIDERS WILL SEE ADOLESCENT, SOME STATES IT'S AS LOW AS 5, RIGHT? SO WHEN WE'RE SEEING THIS -- WE'LL HELP YOU IF YOU COME BACK, MUCH SICKER WHEN YOU'RE 22, BUT THE PARENT CALLING WITH THE 14 OR 15 YEAR OLD, THE AGE OF INITIATION WE'RE DEALING WITH, A LOT OF ALCOHOL, MARIJUANA, AND COMBINATION OPIOIDS ADDING AFTER THAT, IT'S A REAL CONCERN ABOUT HOW DO WE HELP FAMILIES WHEN THERE'S A DESERT THERE FOR WHEN THIS REALLY HITS THAT PATIENT THAT NEEDS HELP. SO IT'S AN ISSUE. I WANT TO FOLLOW UP ON ONE OTHER ITEM ABOUT SORT OF UTILIZATION OF DIVERTED BUPRENORPHINE LIKE SELF TREATING. WE SEE THAT SO MUCH BECAUSE YOU CAN FIND IT ON THE STREET, YOU CAN FIND OTHER STUFF, IT'S RETICENCE TO BE ENTERED INTO THE SYSTEM FROM FEAR. I WISH WE LIVED IN A WORLD WHERE WE DIDN'T NEED 42 CFR PART 2, WE DON'T LIVE IN THAT WORLD. THE CONSEQUENCES FROM CHILD CUSTODY, COURT, DIVORCE, LEGAL RAMIFICATIONS, JOBS, ARE JUST SO PROFOUND. BUT ALSO OTHER THINGS, WE FIND FOLKS ARE SELF TREATING AND FINDING MEDS OUTSIDE THE HEALTHCARE SYSTEM OR SKIPPING MEDS AND GOING THROUGH 12 STEPS AND PEER SYSTEMS, FRIENDLIER PLACES FOR THEM. SO MUCH OF HEALTH CARE HAS SO MUCH STIGMA. ALL OF THE TESTIMONIALS AND SOME INFO THAT WE'VE COLLECTED IN SURVEYS OF PATIENTS AND FAMILIES, YOU GO IN, YOU'RE AN E.D. OR PRIMARY CARE, YOU GO TO SEE SOMEONE, IT'S SO TERRIBLE THAT YOU LEAVE AND GO INTO ANOTHER HEALTH CARE PROVIDER AND OMIT ANY MENTION OF YOUR SUD HISTORY OR CURRENT USE. AND YOUR TREATMENT IN BOTH SETTINGS IS SO DIFFERENT. I THINK WE NEED TO WORK WITH PROVIDERS AND ALL DIFFERENT SUBSPECIALITIES IN HEALTH CARE TO REALLY SORT OF, AS SHARON WAS SAYING, IT'S THE HEARTS AND MIND PIECES WE NEED TO DO. WE'RE SEEING LACK OF UTILIZATION OF REAL TREATMENT IN MEDICINES THAT ARE AVAILABLE, BECAUSE OUR SYSTEMS AREN'T SUPER PATIENT FRIENDLY RIGHT NOW. >> I'VE BEEN LISTENING, IT'S AN HONOR TO BE HERE BECAUSE THIS IS CERTAINLY LISTENING TO PEOPLE THAT ARE SO FREAKING SMART I CAN'T KEEP UP. SINCE I STARTEDTO TALK TO YOU FOLKS AND SINCE YOU VISITED MY PROGRAM IN MANCHESTER, AN HONOR ALSO, WE -- IT'S SO FRUSTRATING. I'LL BE PUSHING THE MEDICAL ASSISTED TREATED PART OF THIS, AND I GUESS THE BIGGEST THING WE'RE SEEING, IN MANCHESTER WE'RE SEEING A PERFECT STORM OF ISSUES HAPPENING. EVERY TIME SOMETHING'S BROUGHT UP HERE, FOR INSTANCE POLY USE, METHAMPHETAMINES, WHAT WE'RE SEEING ON THE STREET IS OVERWHELMING. MENTAL HEALTH IS ABSOLUTELY OUT OF CONTROL. THE WHOLELESS POPULATION IS OUT OF CONTROL IN MANCHESTER. PEOPLE ARE BEING DRIVEN INTO THE COMMUNITY JUST BECAUSE OF THE LACK OF SERVICES AROUND THE STATE. SO, WE TURNED INTO THE CATCHMENT AREA FOR THE ENTIR STATE OF NEW HAMPSHIRE. AND MY NUMBERS ARE GOING WAY UP. ONE OF THE BIG THINGS THAT WE'RE FIGHTING IN THE STATE OF NEW HAMPSHIRE, IT'S OUR OWN BUREAUCRACY. WE'RE GETTING SO MUCH MONEY, FOR SO MANY DIFFERENT THINGS. BUT TO TRICKLE DOWN TO WHERE I'M AT THERE'S REALLY NOTHING. NOT ONLY THAT, THERE'S NO COMMUNICATION. WHAT I'M CONSTANTLY FIGHTING IS POLITICS OF THE WHOLE THING. WHICH IS OVERWHELMING FOR A FIRE CHIEF CERTAINLY AND, YOU KNOW, IT'S -- WE GET THE CITY OF MANCHESTER, BIGGEST CITY IN NEW HAMPSHIRE, AND WE'RE LOOKING TO POSSIBLY SET UP A PROCESS IN MANCHESTER THAT IS LIKE AN EMERGENCY MANAGEMENT PROCESS TO DEAL WITH THIS BECAUSE WE'RE ABSOLUTELY OVERWHELMED. WE HAVE $44 MILLION COMING INTO THE STATE. NO ONE ASKED US WHAT TO DO WITH IT. IT GOES RIGHT INTO THE STATE GOVERNMENT. AND IT'S FARMED OUT THE WAY THEY SEE FIT WITHOUT ASKING ANYBODY ELSE. IT TURNS INTO A MASSIVE POLITICAL ISSUE. SO, IF ANYTHING'S GOING TO KILL PEOPLE, THE POLITICS OF THIS. IT'S JUST ABSOLUTELY FRUSTRATING TO BATTLE THAT WHEN YOU SHOULD BE ON THE BACKS OF PEOPLE THAT ARE SUFFERING. IT'S REALLY TERRIBLE. I COULD TALK ABOUT THAT ALL DAY BECAUSE IT'S SUCH A BIG PART OF WHAT I'M DOING NOW. IT'S LIKE YOU TRY TO STAY IN YOUR LANE. I'M ON A SUPERHIGHWAY NOW AND DON'T KNOW, IT'S DIFFICULT TO DEAL WITH. THE STIGMA IS THE STIGMA FROM THE -- FROM ALL THE ABOVE, YOU KNOW, EVEN IN THE E.D.s, IT'S DIFFICULT TO MANEUVER. WE'RE TRYING TO MAKE THOSE CONNECTIONS. WE HAD A PRETTY GOOD INFRASTRUCTURE WITH THE PROGRAM, A LOT OF PEOPLE BOUGHT INTO IT, BUT IT'S JUST BECOMING OVERWHELMING. I DON'T KNOW WHAT MY SPECIFIC POINT IS. I GUESS IT'S JUST THAT TO MANEUVER AROUND THE POLITICS OF THIS IS REALLY TROUBLING. >> (INAUDIBLE) WHICH IS HOW DO YOU DO THE RIGHT THING WHEN THE RIGHT THING, THERE IS EVIDENCE IT WORKS MUCH BETTER, BUT BECAUSE OF CONFLICTING ETIOLOGY OR LACK OF KNOWLEDGE IS NOT PRIORITIZED. AGAIN, I REPEAT MYSELF. WHAT IS IT THAT SCIENCE -- HOW DO WE GENERATE THAT EVIDENCE IN A WAY THAT IT CANNOT BE IGNORED. AGAIN, THE SAME QUESTION THAT I ASKED, WHAT IS IT THAT IF WE HAD KNOWLEDGE ON WOULD MAKE YOUR JOB EASIER TO DO, TO IMPLEMENT WHERE WE KNOW WILL RESULT IN BETTER OUTCOME. AGAIN, THAT'S THE ESSENCE OF HOW -- BECAUSE IT'S CHANGING A CULTURE, CHANGING A WAY OF DOING THINGS. SCIENTIFIC PAPER HERE, IT'S NOT GOING TO MAKE IT. >> YOU TALKED ABOUT IT SEEMED TO BE COMING VERY MUCH FROM LIKE YOU SAID, OH, WE SEE PEOPLE RELAPSE IN THE FIRST SIX MONTHS. I THINK THAT'S IMPORTANT, REOCCURENCE OF USE COULD EQUAL DEATH, BUT IS THEIR QUALITY OF LIFE BETTER, REOCCURENCE LESS DANGEROUS, USE STERILE SYRINGES, TEST YOUR DRUGS, I HEAR YOU SAYING THAT SCIENCE IS WHAT WE DO. WE GIVE PEOPLE LIKE ME TOOLS TO FIGHT. RESEARCH OUT OF HOPKINS AND BROWN IS PRE-FENTANYL, EVERYWHERE. 80 TO 90% OF HEROIN IN PENNSYLVANIA, IN PHILADELPHIA, HAS FENTANYL IN IT. PLACES LIKE BOSTON THERE IS NO HEROIN, IT'S JUST FENTANYL. ENGAGING IN HARM REDUCTION STRATEGIES, MORE RESEARCH FOR THAT, THAT'S A WILDLY CRAZY IDEA, MASS SPECS EXPENSIVE TO BUY BUT SYRINGE PROGRAMS ARE GOOD. ANYBODY WHO USES DRUGS SHOULD TEST THEM, AS LONG AS WE HAVE PROHIBITION MARKET, THE NEED FOR BLACK MARKET DRUGS IS THERE. >> GROWING DIFFICULTY, I HEAR THIS IN WEST VIRGINIA, COMBINATIONS, GABAPENTIN, A WHOLE MESH OF THINGS GOING ON. WHICH MAKES THE WHOLE PROCESS SO MUCH HARDER. HAVING WAYS OF PROPERLY MEASURING THE PERSON SEEKING HELP IN THE EMERGENCY DEPARTMENT IS FUNDAMENTAL. WITHOUT IT, EVEN MORE LAW ENFORCEMENT, WITHOUT UNDERSTANDING DYNAMICS, MAY NOT BE SEEING THERE'S AN INCREASE IN THE CERTAIN DELIVERY OF A DRUG. WE'RE INTERESTED IN DEVELOPING THROUGH SMALL BUSINESS PROGRAM. >> (INAUDIBLE). >> ANOTHER AREA, I'LL HAVE TO ASK CARLOS AND HIS TEAM IF WE HAVE RESEARCH THAT TAKES ADVANTAGE OF SYRINGE EXCHANGE PROGRAMS, PLACES WHERE WE CAN DO INTERVENTIONS TO TRY TO ENGAGE PEOPLE IN TREATMENT. SO IT'S ANOTHER -- THIS IS THE LAST ONE, BECAUSE YOU HAVE TO GO EAT SOMETHING. >> I WOULD LIKE TO COME BACK BRIEFLY TO THE TROUBLING MARIJUANA DATA YOU PRESENTED EARLIER, BECAUSE I BELIEVE THAT THERE MIGHT BE SIGNIFICANTLY MORE RAMIFICATIONS THAN WE THINK INCLUDING SERIOUS MENTAL ILLNESSES. I SEEM TO REMEMBER THAT IN THE PREVIOUS MEETING YOU PRESENT DATA SHOWING THE POTENCY OF THC INCREASED BY FACTOR OF FOUR OVER THE LAST 20 YEARS, INCIDENTALLY THERE WAS A PAPER PUBLISHED EARLIER THIS YEAR IN "THE LANCET" PSYCHIATRY SHOWING ASSOCIATION BETWEEN FREQUENCY OF USE, THC POTENCY, AND THE OCCURRENCE OF PSYCHOTIC EPISODES. I WAS WONDERING, I THINK IT'S GOING TO BE CRITICAL TO REALLY UNDERSTAND THE ROOT CAUSE BETWEEN -- BEHIND DATA YOU PRESENTED THIS MORNING. I WAS WONDERING IF SAMHSA COULD PERHAPS TAKE DEEPER DIVE INTO THE DATA THAT YOU PRESENTED THIS MORNING, TRYING TO UNDERSTAND IF INDEED MAYBE WHAT WE SEE IN TERMS OF SERIOUS MENTAL ILLNESS IS SOMEHOW ASSOCIATED WITH FREQUENCY OF USE, AND THC POTENCY IN MARIJUANA-BASED PRODUCTS. >> I KNOW BECAUSE I'VE DISCUSSED THIS WITH DR. MECAN, SHE'S INTERESTED AND WORRIED, HAS BEEN LOOKING AT DATA FROM THE STATE JUST TO UNDERSTAND THE TRENDS, EVEN THOUGH THE DATA IS NOT PUBLISHED BY STATES, AND ON THE BASIS OF THE PREVALENCE OF USE OF MARIJUANA AND RECREATIONAL LOSS, IT IS VERY CONCERNING. I THINK WE DON'T -- WE CANNOT SAY THIS IS A CONTRIBUTING FACTOR BUT IT IS LIKELY THAT IT MAY BE PLAYING A ROLE, AND, AGAIN, I AM NOT SPEAKING OF THE DIRECTIONALITY BECAUSE WE DON'T HAVE SUFFICIENT SCIENCE TO SAY CLEARLY, BUT I THINK WE HAVE SUFFICIENT SCIENCE TO ACTUALLY RECOGNIZE THAT FIRST OF ALL THIS INCREASES IN MARIJUANA AND I HAVE NO TROUBLE STATING IT, ARE GOING TO BE MAKING PEOPLE WITH MENTAL ILLNESS MORE VULNERABLE. I HAVE NO PROBLEM STATING THIS, WE KNOW IF YOU HAVE AS A VULNERABILITY FOR PSYCHOSIS, IT'S EASIER TO GET MARIJUANA IN YOUR PLACE, HIGHER THC, IT'S GOING TO EXACERBATE. I WITH PSYCHOSIS THE DATA IS CONSISTENT BUT AN AREA WE DON'T HAVE SUFFICIENT DATA EVEN THOUGH IT'S STARTING TO EMERGE IS ASSOCIATION WITH SUICIDAL BEHAVIOR. I DON'T THINK WE UNDERSTAND IT WELL. I'M BEING TENTATIVE, BUT IT DOES COME INTO YOUR POINT, IT DOES HIGHLIGHT THE IMPORTANCE FOR US TO KEEP OUR EYES ON WHAT IS GOING ON AND EVALUATING IT BECAUSE IF WE DON'T SCREEN AND IF WE DON'T EVALUATE, IT MAY BE WE'LL NEVER SEE OR RECOGNIZE IT. I SPECIFICALLY AM EXPLICITLY PRESENTED THE DATA ON SERIOUS MENTAL ILLNESS AND SUICIDE FOLLOWING THE INCREASES IN MARIJUANA, SOMETHING WE HAVE TO KEEP -- I'M NOT SAYING CAUSALITY BUT SUFFICIENTLY WORRISOME WE CANNOT IGNORE IT. WE CANNOT IGNORE IT. I THINK THE TIME HAS COME TO HAVE BREAK FOR LUNCH, RIGHT, SUSAN? I PASS TO YOU. >> WE'RE A LITTLE BIT LATE BUT I THINK DO YOU THINK AN HOUR WILL BE ENOUGH? WE SHOULD START BACK UP AGAIN AT 1:30. SEE YOU IN LITTLE LESS THAN AN HOUR >> IT IS A PLEASURE FOR ME TO INTRODUCE DR. REDONNA CHANDLER WHO DIRECTS THE AIDS STRATEGIC PLAN. SHE WILL GIVE UPDATE ON HIV AIDS PRIORITIES FOR NIDA. >> THERE WAS A POINTER HERE. IS THAT NORA'S? CAN I BORROW IT? IT DISAPPEARED. OH, THIS ONE. OKAY. THANK YOU. GOOD AFTERNOON, EVERYONE. AND THANK YOU FOR THIS OPPORTUNITY TO BE HERE. THIS IS MY FIRST TIME TO PRESENT TO COUNCIL AS THE NIDA DIRECTOR FOR THE AIDS RESEARCH PROGRAM. AND I KNOW THAT ON YOUR AGENDA, IT SAYS THAT I'M GOING TO TALK ABOUT A STRATEGIC PLAN BUT I WANT TO MAKE A CLARIFICATION WHICH IS THAT NIDA HAS A SINGLE STRATEGIC PLAN FOR THE ENTIRE INSTITUTE. THAT STRATEGIC PLAN WILL BE REVISED THE NEXT FISCAL YEAR SO WHAT I'M GOING TO TALK ABOUT TODAY THAT WILL BE REFLECTED IN THE STRATEGIC PLAN WHEN UPDATED. BUT YOU ALL WERE INTRODUCED TO MY ASSOCIATE DIRECTOR THIS MORNING. AND SO CAVI AND I BEING NEW IN THE RESEARCH PROGRAM DECIDED WE WANTED TO EXAMINE THE SCIENCE THAT HAD BEEN CONDUCT AND DEVELOP HIGH PRIORITY RESEARCH AREAS AND SO WE GET OUR BOX CHECKED FOR THE STRATEGIC PLAN EARLY. SO I WANT TO REMIND EVERYONE THAT NIDA IS THE SECOND LARGEST FUNDER AT THE NIH FOR RESEARCH IN THE AREA OF HIV WITH AN ANNUAL BUDGET OF APPROXIMATELY $264 MILLION. OUR SCIENCE ADDRESSES THE INTERSECTION OF DRUG USE AND HIV AND CUTS ACROSS THE SCIENTIFIC SPECTRUM. IT'S EMBEDDED IN EVERY DIVISION AND CENTER INCLUDING IRP, CTNND OTP AND IT ENCOMPASSES DIVERSE POPULATIONS INCLUDING ADOLESCENCE AND PREGNANT WOMEN AND UNIQUE SETTINGS LIKE JUSTICE SETTINGS, AND INFECTIOUS DISEASE PRACTICES. SO WE EMBARKED ON A SERIES OF ACTIVITIES THAT BEGAN A YEAR AGO TO DEVELOP THE RESEARCH PRIORITIES THAT YOU WILL SEE LATER. WE HELD A SERIES OF SCIENTIFIC MEETINGSTHAT TOOK PLACE IN FALL OF 2018. WE ISSUE AD REQUEST FOR INFORMATION TO SOLICIT FEEDBACK FROM STAKEHOLDERS AS WELL AS INVESTIGATORS IN JANUARY. FRSES AND WE TALKED WITH COLLEAGUES ACROSS THE NIH AND NIDA AND ENSURED THAT OUR RESEARCH PRIORITIES WERE ALIGNED WITH THE NIH PRIORITIES FOR HIV AND HIV RELATED RESEARCH. IF YOU ARE INTERESTED IN THE MEETING SUMMARIES OR IN THE FEEDBACK THAT WE SOLICITED FROM THE RFI, THOSE ARE AVAILABLE ON THE NIDA WEBSITE. WE KNOW HIV AND DRUG ABUSE ARE RELATED, BUT I'M GOING TO WALK THROUGH SOME RECENT DATA THAT REFLECTS THIS REALITY. THIS IS NEW DATA FROM UNAs AND IT LOOKS AT THE RELATIVE RISK FOR CONTRACTING HIV AND COMPARING GROUPS OF INDIVIDUALS AND RELATIVE RISK AMONG INJECTION DRUG USERS IS EQUAL TO MEN WHO HAVE SEX WITH MEN AND EQUAL TO THAT OF SEX WORKERS. GLOBALLY THERE ARE AN ESTIMATED 13 MILLION PEOPLE WHO INJECT DRUGS OF WHOM 1.7 MILLION ARE HIV POSITIVE. THOSE ARE THOUGHT TO BE UNDERITSELF MATES ACTUALLY IN THE AREA OF HIV AND WE KNOW THAT BOTH INCIDENCE AS WELL AS PREVALENCE OF HIV HAVE INCREASED BETWEEN 2011 AND 2016 P. AS NORA INDICATED EARLIER TODAY, WHILE IT'S BELIEVED THAT AROUND THE WORLD THE TOTAL POPULATION OF NEW INCIDENCES OF HIV CASES HAS BEEN DECLINING, THAT WITH PEOPLE WHO INJECT DRUGS, THAT HAS INCREASED. NORA ALSO SHOWED THIS SLIDE AND TALKED ABOUT THE FACT THAT THERE ARE MANY GRAVE CONSEQUENCES TO OUR DOMESTIC OPIOID EPIDEMIC INCLUDING OVERDOSE FATALITIES BUT WE ARE ALSO SEEING AN INCREASE IN INJECTION DRUG USE AND THIS AGAIN IS UNPUBLISHED DATA BY SAMSMA THAT SHOWS SIGNIFICANT INCREASE IN THE PAST 15 YEARS AND PREVALENCE OF INJECTION DRUG USE. SO THE IMPLICATIONS FOR INFECTIOUS DISEASE ARE STARK, WE KNOW THAT HIV CAN SPREAD RAPIDLY AMONG INDIVIDUALS WHO INJECT DRUGS AND AGAIN, NORA CAULKED ABOUT THIS DATA BUT I WILL MAKE ONE ADDITIONAL POINT WHICH IS THAT OUR SURVEILLANCE DATA IN THIS COUNTRY THAT THE TIME HORIZON IS FAR TOO LONG FOR US TO BE ABLE TO CONDUCT RESEARCH AND TO BE ABLE TO HAVE ACTIONABLE DATA. SO WE REALLY NEED TO DECREASE THE LAG TIME SIGNIFCANTLY FOR SURVEILLANCE DATA RELATED TO HIV. AS PEOPLE HAVE BEEN ABLE TO LIVE WITH HIV WITH ADVENT OF EFFECTIVE ANTI-RETROVIRAL THERAPY THERE'S BEEN AN E MER JEJ OF CO-MORBID MEDICAL CONDITIONS, AND DR. DELL RIO MENTIONED THIS MORNING SPECIFIC CO-MORBIDITIES THAT ARE COMMON AMONG PEOPLE WHO USE DRUGS AND LIVING WITH HIV. WHILE THIS REVIEW PAPER IS FAIRLY DATAD, IT'S STILL REMAINING ONE OF THE MOST COMPREHENSIVE REVIEW PAPERS THAT LOOKS SPECIFICALLY AD PEOPLE WHO USE DRUGS AND HIV POSITIVE AND CO-MORBID CONDITIONS IN AREAS LIKE CNS AND HAND WHICH WE CARE VERY MUCH ABOUT BUT ALSO ENDOCARDITIS AS WELL AS SKIN AND SOFT TISSUE DISORDERS MENTIONED EARLIER THIS MORNING. AND SEVERE MENTAL HEALTH CONDITIONS INCLUDING DEPRESSION AND ANXIETY THAT ARE REALLY IN ADDRESSING THOSE EFFECT TESTIFILY AS CRITICAL RESEARCH GAPS. SO I WILL TALK ABOUT RESEARCH AND FEATURE STUDIES LOOKING AT INTERSECTION OF HIV AND DRUGS. NIDA HAS ASSISTED IN THE DEVELOPMENT OF MANY EFFECTIVE INTERVENTIONS TO ADDRESS DRUG ABUSE, PARTICULARLY MEDICATIONS FOR OPIOID USE DISORDER, AND OUR RESEARCH HAS DEMONSTRATED THAT NOT ONLY IS THERE BENEFIT THAT RELATES SPECIFICALLY TO THE DRUG USE AND PSYCHOSOCIAL BENEFITS BUT ALSO IN THE AREA OF HIV AS WELL. SO THIS PARTICULAR PAPER NOTED THAT THERE ARE DECREASES IN HIV AND HCV TRANSMISSION, INCREASES IN RETENTION OF PEOPLE IN HIV TREATMENT, IMPROVEMENTS IN HIV OUTCOMES, AND THAT OVERALL THE RISK FOR CONTRACTING HIV WAS REDUCE BID 54% AMONG PEOPLE WHO WERE ON MEDICATION FOR OPIOID USE DISORDER. THIS IS ANOTHER META ANALYSIS THAT LOOKED AT THE IMPACT OF MEDICATION FOR OPIOID USE DISORDER. ON ART OUTCOMES FOR PEOPLE LIVING WITH HIV AND IT SHOWS THAT THE USE OF MEDICATION FOR OPIOID USE DISORDER HAS MANY IMPORTANT BENEFITS INCLUDING A 69% INCREASE IN RECRUITMENT TO ART. WHICH IS PRETTY PHENOMENAL. A TWOFOLD INCREASE IN ART ADHERENCE, 23% DECREASE IN ODDS OF ATTRITION AND 45% INCREASE IN THE ODDS OF VIRAL PLASMA SUPPRESSION. SO THIS SLIDE SHOWS DATA FROM THE NIDA SEEK TEST TREAT AND RETAIN COLLABORATIVE WHERE MANY PEOPLE CAME TOGETHER TO POOL THEIR DATA FOR ANALYSES. THIS INCLUDES DATA FROM 27 HIV CLINICS IN THE NIAID FUNDED SCENICS NETWORK AS WELL AS NIDA SUPPORTED CRIMINAL JUSTICE STTR STUDIES. AND IT USES JOINT LONGITUDINAL AND SURVIVAL MODELS TO EXAMINE THE IMPACT OF DECREASING DRUG OF THE DRUGS THAT YOU SEE. INCLUDING OPIOID, METHAMPHETAMINE, COCAINE AND MARIJUANA ON VIRAL SUPPRESSION. THE NAIL SEIZE WERE REFEETED USING -- REPEATED TO EXAMINE ASSOCIATIONS BETWEEN CHANGE IN FREQUENCY OF DRUG USE AND VIRAL LOAD. A STUDY FOUND THAT ABSTINENCE WAS ASSOCIATED WITH HIGHER ODDS OF VIRAL SUPPRESSION AND LOWER VIRAL LOAD FOR ALL FOUR DRUG CATEGORIES BUT IMPORTANTLY REDUCING THE FREQUENCY OF ELICIT OPIOID AND METHAMPHETAMINE USE WITHOUT ABSTINENCE WAS ASSOCIATED WITH VIRAL SUPPRESSION. THIS REALLY IMPACTS THE IMPORTANCE OF HELPING PATIENTS TO BE ABLE TO REDUCE RISK EVEN IF THEY ARE NOT ABLE TO ACHIEVE ABSTINENCE AND IMPORTANCE THIS CAN HAVE ON HIV OUTCOMES. THIS STUDY WHILE A BIT OLD NOW DOES DEMONSTRATE THAT NIDA SUPPORTED RESEARCH THAT LOOKS AT PUBLIC HEALTH IMPACT OF ADDRESSING HIV AND SUBSTANCE ABUSE. THIS IS WORK THAT WAS DONE IN BRITISH COLUMBIA THAT SHOWED THAT ACROSS A CERTAIN REGION AS YOU INCREASED HEART AVAILABILITY YOU DECREASED INCIDENCE OF HIV EVEN AMONG INJECTION DRUG USERS AND THAT KEY TO BEING SUCCESSFUL WAS WIDE AVAILABILITY OF SYRINGE SERVICE PROGRAMS AND EXTENSIVE USE OF MEDICATION FOR OPIOID USE DISORDER. IN SPITE OF THE FACT WE KNOW ANTI-RETROVIRAL THERAPY IS EFFECTIVE AND MEDICATION FOR OPIOID USE DISRD OARS ARE EFFECTIVE, THERE IS A TREATMENT GAP, MEDICATION FORS OUD ARE UNDERUTILIZED, ALL ACROSS THE WORLD AS ARE MEDICATIONS FOR HIV CARE, UNFORTUNATELY PROVIDERS STIGMA PLAY AS REALLY IMPORTANT ROLE, THIS IS A SLIDE WITH DATA FROM TWO SEPARATE SURVEYS THAT WERE CONDUCTED WITH INFECTIOUS DISEASE PHYSICIANS, THE ONE OF YOUR LEFT WAS IN THE UNITED STATES, THE ONE ON YOUR RIGHT WAS WITHIN MALAYSIA. WHAT YOU CAN SEE IS PHYSICIANS REPORTED THEY WOULD DELAY THE INITIATION OF ART FOR PATIENTS WHO WERE ACTIVELY INJECTING DRUGS EVEN WHEN THEY HAD SEVERELY LOW CD4 CELL COUNTS AND WERE VERY ILL. SO THIS IMPACTS THE LIFE AND WELL BEING OF THE INDIVIDUAL PATIENT BUT ALSO KEEPS US FROM BEING ABLE TO FULLY REALIZE THE BENEFITS OF A TREATMENT AS PREVENTION PARADIGM. SO AS YOU KNOW, NIDA ALSO SUPPORTS REALLY EXCITING BASIC SCIENCE AND I'M GOING TO QUICKLY GO THROUGH A COUPLE OF BASIC SCIENCE STUDIES RECENTLY. THE ELIMINATION OF HIV-1 REQUIRES REMOVAL OF INTEGRATED PROVIRAL DNA FROM INFECTED CELLS AND TISSUES. WHILE ART ENABLES PATIENTS TO LIVE LONG AND PRODUCTIVE LIVES IT FAILS TO ELIMINATE COPIES OF THE HIV PROVIRAL DNA FROM THE HOST GENOME. AND THUS IT'S NOT A CURE. SO THIS STUDY FOCUSED ON DEVELOPING AN APPROACH TO ELIMINATE THE PRESENCE OF HIV-1. THIS IS A CARTOON ILLUSTRATION HERE, OF HUMANIZED MICE THAT WERE INFECTED WITH HIV-1 AND THEY WERE ASSIGNED TO ONE OF FOUR GROUPS, ON YOUR FAR LEFT, A NO TREATMENT GROUP, THE NEXT GROUP WAS TREATED WITH CHRIS PER CAS 9 INJECTION. THE THIRD GROUP TREATED WITH LASER ART WHICH WAS A FACILITATED SUSTAINED INHIBITION OF VIRAL REPLICATION WITH ANTI-RETROVIRAL NANOPARTICLES. AND THEN THE FINAL GROUP WAS TREATED WITH LASER ART AND CHRIS PER CAS. WHAT THEY FOUND WAS THAT THERE WAS AN OBSERVED RESTRICTION OF VIRAL INFECTION IN THE MICE THAT WERE TREATED WITH LASER ART. BUT THERE WAS AN INABILITY TO ACHIEVE ELIMINATION OF THE VIRUS BY CHRIS PER CAS TREATMENT ALONE. HOWEVER WHEN YOU SEQUENCED THE TRUE TREATMENTS TOGETHER, A CERTAIN PERCENTAGE OF ANIMALS IN THAT TREATMENT GROUP WERE ABLE TO ACHIEVE COMPLETE ELIMINATION AND ESSENTIALLY CURE. SO THIS IS VERY EXCITING AND PROMISING RESEARCH, IT'S A LONG WAY PROBABLY FROM BEING A TREATMENT THAT WILL ACTUALLY GO INTO HUMANS BUT IT DOES DEMON INVESTIGATE THE VIABLE OF THIS PARTICULAR MODEL. LIKEWISE, WE KNOW PRIMATE LABS PLAY A CRITICAL ROLE IN MODELING HIV-1 DISEASE AND TRANSMISSION. WHAT THIS RESEARCHER IS SEEKING TO DO IS TO BUILD A BETTER PRIMATE MODEL AND REALLY MAXIMIZE OUR USE OF NON-HUMAN PRIMATES IN HIV RESEARCH IN PARTICULARLY IN PURSUING VACCINE RESEARCH. SO THIS STUDY SOUGHT TO EVALUATE THE ABILITY OF PRIMATE CD4 PROTEINS TO FUNCTION AS RECEPTORS FOR VARIOUS CLASSES OF HIV-1 WITH A PRIMARY INTEREST IN HIV ISOLATES THAT ARE DERIVED FROM BLOOD OF PEOPLE WHO ARE NEWLY INFECTED. THAT'S BECAUSE OF A NEW APPRECIATION FOR PROPERTIES FROM INDIVIDUAL WHOSE ARE NEWLY INFECTED THAT RELATE TO TRANSMISSION. SO YOU SEE HERE THAT THIS STUDY EXPANDED AND INCLUDED 15 PRIMATE SPECIES, AND THAT RESULTS INDICATE THAT WHEN CHALLENGED WITH HIV-1 CD4 RECEPTORS, IN THE SIX SPECIES IN PURPLE BEHAVED SIMILARLY TO HUMAN CD4, THAT A SECOND CLASS OF SPECIES IN THE GRAY BARS ENCO-ED CD4 RECEPTORS THAT SUPPORTED ENTRY OF THE VIRUS BUT AT LEVEL APPROXIMATELY TWOFOLD LOWER THAN HUMANS CD4. THEN A THIRD CLASS OF SPECIES ENCODED CD4 RECEPTORS AND SUPPORTED ENTRY BUT AT A LEVEL OF 25 FOLD OR GREATER REDUCED TO THAT OF HUMAN CD4. SO IT'S THESE COMPARATIVE KINDS OF STUDIES THAT WILL HELP TO REALLY MAXIMIZE OUR USE OF NON-HUMAN PRIMATES AS WE ADVANCE FORWARD IN DEVELOPING ANIMAL MODELS ABOUT THE BIOLOGY OF HIV, TRANSMISSION OF HIV AND THE DEVELOPMENT OF EFFECTIVE VACCINES. SO NIDA HAS ALSO SUPPORTED REAL INNOVATORS AND BOUNDARY SPAN NERS IN THE AREA OF SCIENCE. WE HAVE TWO PARTICULAR MECHANISMS WE ARE VERY PROUD OF, THE AVANT-GARDE AND THE AVENIR, THAT PROVIDES US WITH AN OPPORTUNITY TO SUPPORT BOTH WELL ESTABLISHED INVESTIGATORS AS WELL AS EARLY CAREER RESEARCHERS THAT ARE INTERESTED IN CONDUCTING VERY INNOVATIVE AND GROUND BREAKING AND REALLY AS NORA LIKES TO SAY, SHE WANTS PARADIGM SHIFTERS IN THIS PARTICULAR AREA. SO THESE TWO PROGRAMS CONTINUE TO PROVIDE US A WAY TO SUPPORT HIGH RISK HIGH REWARD RESEARCH AS WELL AS NEW RISING STARS IN THE FIELD OF DRUG ABUSE AND HIV RESEARCH. AND YOU SEE THREE EXAMPLES, JULIO MONTOYA WHO WORKED FROM BRITISH COLUMBIA I HIGHLIGHTED EARLIER Y. SARA SAWYER, DEVELOPING THE NON-HUMAN PRIMATE MODEL AND THEN SUNIL SOLOMON IS A RECENT AVENIR RECIPIENT AND HE'S FOCUSED TO FIND WAYS TO SEEK OUT INDIVIDUALS THAT ARE EXTRAORDINARILY DIFFICULT TO REACH THAT HAVE INJECTION DRUG USE AND CO-INFECTION WITH HIV AND HEPC AND HIS WORK IS BEING CONDUCTED IN INDIA. SO NOW I'M GOING TO MOVE AFTER HAVING DONE A TOUR DEFORCE ABOUT OUR FINDINGS TO TALK ABOUT RESEARCH PROI YOURTY AREAS. PRIORITY AREAS. AREA ONE IS PREVENTION OF NEW INFECTIONS AND TRANSMISSION OF HIV. WE WANT TO FOCUS ON SCIENCE IN THE AREA OF PRIMARY PREVENTION TO PREVENT ACQUISITION OF HIV IN PEOPLE WHO ARE USING DRUGS. AND IN THIS AREA WE HAVE A HUGE GAP AROUND PREP. THE PREP TRIALS DID NOT INCLUDE PEOPLE WITH SUBSTANCE USE DISORDERS IN TESTING THE EFFECTIVENESS OF PREP. SO WE KNOW VERY LITTLE EVEN AT A BIOLOGICAL LEVEL ABOUT HOW -- WHAT THE IMPACT OF DRUGS OF ABUSE WOULD HAVE ON PREP. WE KNOW ALMOST NOTHING ABOUT THE AVAILABILITY OF PREP, THE ACCEPTABILITY OR THE USE OF PREP AMONG SUBSTANCE USERS. SO WE HAVE A CURRENT RFA OUT ON THE STREET RIGHT NOW. SOLICITING APPLICATIONS IN THE AREA OF PREP FOR SUBSTANCE USERS. WHO ARE AT RISK FOR HIV BUT WE KNOW THIS WILL BE A RESEARCH PRIORITY FOR SOMETIME TO COME. IN THE AREA OF SECONDARY PREVENTION, PREVENTING TRANSMISSION FROM PEOPLE WHO ARE LIVING WITH HIV AND MISUSE DRUGS, TO OTHERS, THAT'S REALLY ABOUT TRYING TO ENHANCE THAT TREATMENT CASCADE AND ENSURING THAT PEOPLE WITH SUBSTANCE USE DISORDERS ARE PROVIDED ALL THE TYPES OF TREATMENT THAT WOULD BE NECESSARY INCLUDING THAT INTEGRATED CARE WHERE YOU ARE ADDRESSING BOTH SUBSTANCE USE DISORDER AS WELL AS HIV. FINALLY STRUCTURAL BARRIERS REALLY HAVE TO BE ADDRESSED. SO THAT WE DO MORE THAN JUST DESCRIBE PROVIDERS STIGMA BUT HOW TO CHANGE PHYSICIAN BEHAVIOR AND HOW DO YOU ACTUALLY ADDRESS PROVIDERS SIGNATURE STIGNA MANY AN -- STIGMA IN AN EFFECTIVE WAY. PRIORITY AREA 2 IS UNDERSTANDING PATHOGENIUS SPREAD, THAT INCLUDES ASSESSING ROLE OF DRUG USE AND HIV INFECTION AND PATHOLOGY IN THE CNS. DETERMINING HOW DRUG USE OR SUBSTANCE USE THERAPIES INTERACT WITH HIV AND HEART. ELUCIDATING THE MECHANISMS BY WHICH DRUG USE AFFECTS HIV LAY -- LATENT SI AND OTHER THERAPEUTIC TRAT JIS. AREA THREE IS ADDRESS GZ CO-MORBIDITIES PANNED IMPROVING HEALTH OUTCOMES AMONG PEOPLE USING DRUGS AND HAVING HIV. WE GET FOCUSED ON ABSTINENCE AND VIRAL LOAD THAT WE FORGET WE WANT TO ENSURE THAT WE ARE SUPPORTING RESEARCH THAT IMPROVES THE LIVES OF THESE INDIVIDUALS AS WELL. SO LOOKING AT IDENTIFYING COMMON UNDERLYING MECHANISTIC SUBSTRATES FOR NEUROLOGICAL CO-MORBIDITIES. INCLUDING SUBSTANCE USE, MENTAL HEALTH, HAND, UNDERSTANDING THE INTERACTIONS OF DRUG USE, HIV AIDS, HCV AND MEDICATIONS USED TO TREAT THESE SPECIFIC CNDITIONS AND ELICIT DRUGS BEING USED. ELUCIDATING MECHANISMS WHICH DRUG USE AFFECTS CLINICAL OUTCOMES INCLUDING HIV PROGRESSION AND MORTALITY. AND REALLY IMPORTANTLY, DEVELOPING INTEGRATED MODELS OF CARE TO ADDRESS SUDs, HIV, HCV AND OTHER CO-MORBIDITIES THAT CAN BE EFFECTIVELY LAUNCHED AND SUSTAINED IN MULTIPLE HEALTHCARE AND COMMUNITY SETTINGS. PRIORITY AREA FOUR IS REALLY TRYING TO ACCELERATE SCIENTIFIC DISCOVERY IN THE AREA OF HIV AIDS AND SUBSTANCE USE RESEARCH. ENHANCING THE DEVELOPMENT OF TOOLS AND TECHNOLOGIES THAT WILL INCREASE THE PACE AND THE PRODUCTIVITY OF RESEARCH, FINDING WAYS TO SUPPORT TEAM SCIENCE AND CURRENT TENURE OF THE INDIVIDUAL PI AND TENURE SYSTEM. LEVERAGING BIG DATA TO ADDRESS UNIQUE QUESTIONS THAT WE HAVE AND THEN ENSURING THAT WE TRAIN AND MAINTAIN A STRONG GROUP OF BASIC AND CLINICAL SCIENTISTS AND PRACTITIONERS TO MOVE FORWARD IN THE FUTURE. WE HAVE A LOT OF TOOLS TO ADDRESS SUBSTANCE USE DISORDER AND WE HAVE MANY TOOLS TO EFFECTIVELY ADDRESS HIV. AND YET WE KNOW WE CAN DO BETTER IN SCIENCE -- AND SCIENCE WILL PLAY AN IMPORTANT ROLE NOT ONLY IN IMPLEMENTATION BUT DEVELOPING NEW THERAPEUTICS. WE LOOK FORWARD TO BEING ABLE TO JOIN OUR COLLEAGUES ACROSS THE NIH AND ACROSS THE RESEARCH COMMUNITY IN ORDER TO ACCOMPLISH THIS GOAL. THE ADMINISTRATION HAS SET AN AMBITIOUS GOAL IN ORDER TO END THE HIV EPIDEMIC DOMESTICALLY AND WE REALIZE THAT ACCOMPLISHING THIS GOAL WILL REQUIRE CONTINUED AND ONGOING EFFORTS TO SUPPORT RESEARCH THAT'S AT THE INTERSECTION OF SUBSTANCE USE AND HIV. BEFORE I END I WANT TO THANK MY COLLEAGUES AT NIDA FOR THEIR TIRELESS WORK IN HIV AND SUBSTANCE USE. WE IN THE AIDS RESEARCH PROGRAM COORDINATE THESE ACTIVITIES BUT IT IS THE PROGRAM OFFICIALS AND DIVISION DIRECTORS WORKING WITH THE SCIENTISTS AND PAGHTS ANALYSTLY -- PASSIONATELY HELPING IN DEVELOPMENT OF RESEARCH SO WE APPRECIATE ALL YOUR EFFORTS. LIKEWISE, WE COLLABORATE WITH MANY PEOPLE ACROSS THE NIH ON REALLY IMPORTANT SCIENTIFIC ENDEAVORS. SO WE APPRECIATE THE OPPORTUNITY TO WORK WITH THEM AND HAVE THEIR INPUT. AS WELL. SO THANK YOU. AND I THINK WE HAVE SOME TIME, SUSAN. >> THEARKS SO MUCH, TERRIFIC PRESENTATION AND SET OF PRIORITY AREAS. CURIOUS WHAT NORA SAID EARLIER HOW THE AIDS BUDGET CHANGED AT NIDA. CAN YOU SPEAK HOW THIS IS STRUCTURED WITHIN NIDA. DOES THE BUDGET FOR THESE ACTIVITIES YOU OUTLINED SPAN ACROSS ALL THE DIFFERENT DIVISIONS NOW? OR HOW HAS THAT CHANGED? >> SO THE CHANGES IN THE BUDGET REALLY HAD TO DO WITH THE FACT THAT NIH SHIFT AND DEVELOPED A SET OF RESEARCH PRIORITIES. WE HAVE BEEN WORKING TO ALIGN THE SCIENCE THAT WE SUPPORT WITH THOSE RESEARCH PRIORITIES. THE FUNDING IS DIVIDED BETWEEN THE DIFFERENT DIVISIONS. THE NIDA BUDGETS REALLY IN NORA'S OFFICE, IT'S THE NIDA BUDGET SO IT'S NOT LIKE WE HAVE A SET BUDGET FOR EACH OF THE DIVISIONS FOR HIV. WE LOOK ALL THE RESEARCH TO DETERMINE WHAT'S THE MORE SCIENTIFICICALLY MERITORIOUS AND WHAT IS THE PROGRAM MA TICK GAPS AN WORK WITH COLLEAGUES TO ENSURING IT ALIGNS WITH THE NIH HIV PRIORITIES AS WELL MAKE FUNDING DECISIONS. >> THANK YOU, REDONNA, REALLY DPOOD SUMMARY AND GREAT -- GOOD SUMMARY. COUPLE OF ISSUES THAT ARE REALLY CRITICAL, I THINK CLEARLY THERE'S A MAJOR HIV EPIDEMIC INITIATIVE. AND WHILE WE HAVE TYPICALLY I THINK SUBSTANCE ABECAUSE HAS BEEN THOUGHT ABOUT AT RISK FOR GETTING HIV VERY FEW -- PEOPLE ARE NOW BEGINNING TO REALIZE THAT HIV AND SUBSTANCE ABUSE ARE MORE INTEGRATED THAN JUST OH A RISK FACTOR. THERE IS A REASON PEOPLE ARE NOT IN CARE OR ON THERAPY, IT'S REASON FOR SO MANY THINGS. SO I THINK THERE'S OOH SO MANY OPPORTUNITIES FOR RESEARCH FROM VERY BASIC RESEARCH TO REALLY GOOD IMPLEMENTATION SCIENCE REA RESEARCH TO SEE THE BEST MODEL FORS ADDRESSING THIS -- IMPROVING SUBSTANCE ABUSE CARE FOR PEOPLE WHO HAVE HIV, AS A WAY TO IMPROVING THEIR HIV OUTCOMES BECAUSE IF WE DON'T GET PEOPLE WHO ARE USING DRUGS AND THAT'S CRACK COCAINE, METH, OPIOIDS, ET CETERA, BETTER CONTROL OF SUBSTANCE APEWS AND MENTAL HEALTH ISSUES WE ARE NOT GOING TO GET HIV CONTROL AND SOME HOW WE CANNOT JUST HAVE THEM TWO SEPARATE ISSUES THEY NEED TO BE INTEGRATED AS ONE ISSUE. I WOULD LOVE TO SEE AS PART OF THE END THE EPIDEMIC INITIATIVE, I SAID THIS LAST TIME WHEN BRENT WAS HERE, WE NEED NIDA TO BE PART OF THAT, IT'S NOT JUST NAID INITIATIVE, IT'S NOT SIMPLY GETTING PILLS TO PEOPLE. >> WE AGREE. YOU WILL SEE AFTER MANY I PRESENTATION YOU WILL SEE SOME CONCEPTS COMING FORWARD FOR COUNCIL ACCORDANCE THAT FOCUS ON AREAS YOU MENTIONED. WE HAVE BEEN WORKING HARD WITH OUR COLLEAGUES AT NIAID AS WELL AS AT OAR TO TALK ABOUT THE IMPORTANCE OF ADDRESSING SUBSTANCE USE DISORDERS AND THEY ARE NOT GOING TO BE ABLE TO ACHIEVE THE GOALS THEY WANT WITHIN ENDING THE EPIDEMIC UNLESS THEY DO. >> WE NEED TO FIGURE HOW WE -- FOR EXAMPLE GET OAR TO UNDERSTAND THAT WHEN THEY WANT HIV OUTCOMES, HIV END POINTS, VIRAL SUPPRESSION IS A ONE THAT REALLY COUNTS. IF THAT'S THE END POINT THAT SHOULD BE A GOOD END POINT, NOT JUST UPS DENSE AND OTHER THINGS THEY ARE LOOKING FOR WHEN THEY THINK ABOUT SUBSTANCE ABUSE. >> THANKS VERY MUCH. >> NOW WE'RE GOING TO GO TO THE NEXT STAGE OF THE AGENERAL DA, A CONCEPT CLEARANCE FROM NIDA. THE FIRST CONCEPT CLEAR IS GIVEN BY VASUNDHARA VARTHAKAVI, WHO ACTUALLY CO-LEADS WITH REDONNA PROGRAMS ON HIV AND SHE WILL SPEAK TO YOU ALSO ABOUT THE AVENIR WORK PROGRAM FOR RESEARCH ON SUBSTANCE ABUSE AND HIV. >> THANK YOU. I'M HERE TO REQUEST COUNCIL APPROVAL FOR REISSUE OF RFA 1804, AVENIR AWARD PROGRAM FOR RESEARCH ON SUBSTANCE ABUSE AND HIV AIDS. THIS PROGRAM JUICING DP 2 OTHERWISE NIH DIRECTORS NEW INNOVATOR AWARD SERIES WHICH AT THE AGENCY LEVEL WAS CREATED TO ACCELERATE THE PACE OF BIOMEDICAL BEHAVIORAL AND SOCIAL SCIENCE DISCOVERIES BY SUPPORTING CREATIVE SCIENTISTS WITH HIGHLY INNOVATIVE RESEARCH IDEAS. THIS AVENIR IS JUST OF THIS NIH LEVEL EFFORT. SO AVENIR IS A FRERCHL -- FRENCH WORD MEANING FUTURE. AS YOU CAN SEE, HERE -- SORRY. NIDA ENSURE A ROBUST RESEARCH PLATFORM THAT HAS THE POTENTIAL FOR HEALING DISCOVERIES WITH HIGHEST IMPACT ON PEOPLE LIVING WITH HIV AND USE DRUGS. IT IS DESIGNED TO FILL TWO GAPS. THE FIRST GAP IS THERE IS A CRITICAL NEED TO ENSURE GOOD SOLID MINE OF EARLY STAGE INVESTIGATORS WITH HIGHLY IB INVESTIGATIVE RESEARCH IDEAS WITH A FOCUS ON HIV IN CONTEXT OF SUBSTANCE USE DISORDERS EXISTS. THE SECOND GAP IS TO ENSURE THAT TRANSFORMATIVE RESEARCH TO IMPROVE TREATMENT PREVENTION AND ERADICATION OF HIV AND SUBSTACE USING POPULATIONS AND WHY IS THAT? DRUG EPIDEME AND HIV EPIDEMICS ARE CHANGING CONSTANTLY AND WE STILL HAVE LONG STANDING QUESTIONS THAT REMAIN SURROUNDING HIV CARE TREATMENT AND PREVENTIONMENT ALONG WITH THAT WE HAVE TO DEAL WITH CHALLENGE OF ACHIEVING THESE GOALS IN THE REALITY OF LIMITED RESOURCES SO ALL THESE CHALLENGES CANNOT BE DEALT WITH IF YOU DON'T HAVE OUT OF THE BOX THINKING, TRANSFORMATIVE WAY OF APPROACHING THIS PROBLEM. SO WE FEEL THAT THIS AWARD REALLY ADDRESS KEY GAP AREA SO OPPORTUNITIES OF COURSE ARE TO INVEST IN CAREERS OF EARLY STAGE INVESTIGATORS. REWARD RESEARCH AS NEXUS OF HIV AND SUD. SO INITIATIVE GOALS ARE SUPPORT CREATIVE EARLY CAREER INVESTIGATORS WHO PROPOSE INNOVATIVE HIGH IMPACT RESEARCH PROJECTS, ADDRESSING NIH HIV AIDS RESEARCH PRIORITIES. AND THROUGH THIS AWARD WE SUPPORT A BROAD SPECTRUM OF RESEARCH ANYWHERE FROM PAY -- BASIC CLINICAL TRANSLATIONAL RESEARCH TO HAS POTENTIAL TO BENEFIT SUBSTANCE USING POPULATIONS WHO ARE AT RISK FOR HIV AIDS, BUT ABUSING INCIDENTS, IMPROVING THERAPIES FOR HIV AND REDUCING IMPACT OF CO-MORBID CONDITIONS AND ERADICATING HIV. THE SIGNIFICANCE IS TWOFOLD. OF COURSE WE ARE ABLE TO ENGAGE EARLY STAGE INVESTIGATORS AS DEFINED BY THE NIH. AS PEOPLE WHO HAVE -- WHO ARE WITHIN THE TEN YEARS OF COMPLETION OF THEIR TERMINAL DEGREE WHICH IS Ph.D. OR DOCTORAL DEGREE. AND WHO HAVE THIS YOU KNOW INVESTIGATIVE IDEAS TO U ADDRESS HIV IN SUBSTANCE USING POPULATIONS. AND WHAT'S UNIQUE ABOUT MECHANISM AND AWARD IS THAT IT ENCOURAGES INVESTIGATORS TO SUBMIT THEIR CREATIVE RESEARCH IDEAS IN ABSENCE OF PRELIMINARY DATA, NO REQUIREMENT FOR PRELIMINARY DATA. AS YOU KNOW, MANY OTHER GRANT MECHANISMS IF YOU HAVE AN OUTSTANDING IDEA, CANNOT GO IN TO SUBMIT AN RO1 WITHOUT HAVING SOLID PRELIMINARY DATA. SO THIS CIRCUMVENTS THE NEED. I GUESS THAT'S IT. I'M HERE TO ANSWER ANY QUESTIONS. >> THANK YOU. [APPLAUSE] (OFF MIC) >> ONE THING. I'M THINKING MAYBE IN THE FUTURE NOT NOW BUT FUTURE SOME COMMUNICATION BE NICE TO SEE OVER THE -- TO DEVELOP YOUNG INVESTIGATORS. NICE TO SEE WHAT THE IMPACT HAS BEEN, IN OTHER WORDS SEE PEOPLE FUNDED THREE FOUR FIVE YEARS AGO WHAT ARE THEY DOING NOW, HOW DOES THIS HELP THEIR CAREERS? WILL BE HELPFUL FOR PEOPLE TO SEE. >> WE WERE THINKING ABOUT THAT AS WE WERE GOING THROUGH STARTING A YEAR AGO OF DOING A PORTFOLIO ANALYSIS AND LOOKING SOME OF THE THINGS. BUT THIS IS THE FIRST TIME THE MECHANISM HAS BEEN RENEWED. SOME FOLKS HAVE ONLY HAD THEIR AWARDS FOR FOUR YEARS BUT YOU ARE RIGHT WE WANT TO AND INTEND TO FOLLOW THEM AND SEE WHAT HAPPENS IN WITH THEM AND PRODUCTIVITY AND THINGS LIKE THAT IN A SIMILAR FASHION THAT WE HAVE DONE WITH AVANT-GARDE. I WOULD LIKE TO INTRODUCE TWO HIV CONCEPTS WITHIN THE SCOPE OF ADDICTION TREATMENT AND SERVICES. FIRST IS IMPLEMENTING THE HIV SERVICE CASCADE FOR JUSTICE INVOLVED POPULATIONS. THE JUSTICE SYSTEM IS A CRITICAL CATCHMENT AREA FOR HIV PREVENTION AND TREATMENT, GIVEN THAT A QUARTER OF PEOPLE WITH HIV PASS TRUE THE JUSTICE SYSTEM EACH YEAR AND PEOPLE WHO INJECT DRUGS ARE ELEVATED RISK FOR HIV. WITHIN THESE ELEVATED RISKS, PERSONS WHO INJECT DRUGS ARE INVOLVED IN -- THAT ARE INVOLVED IN THE JUSTICE SYSTEM, SHOULD BE PRIORITIZED FOR RECEIPT OF THE FULL SPECTRUM OF HIV SERVICES COMMUNITY REENTRY FROM INCARCERATION IS A PERIOD OF HEIGHTENED RISK FOR OPIOID RELAPSE, MORTALITY, HIV RISK BEHAVIORS AND NON-COMPLIANCE IN HIV TREATMENT. INTEGRATED HIV AND OUD MODELS OF CARE THAT ADDRESS BARRIERS TO ACCESS AND UTILIZATION, CAN REDUCE HIV TRANSMISSION, ENHANCE VIRAL SUPPRESSION AND REDUCE RELAPSE AND RECIDIVISM. THE GOAL OF THIS INITIATIVE IS TO SUPPORT A MULTISITE IMPLEMENTATION EFFECTIVENESS TRIAL WITH EMPHASIS ON DELIVERY OF FULL CONTINUUM OF INTEGRATED SERVICES TO ADDRESS HIV AND OPIOID USE DURING THE PERIOD OF COMMUNITY REENTRY FROM PRISON OR JAIL SPHVMENT OF JAILS. CONSIDERING HIV TREATMENT AND PREVENTION, OUD AND ADDRESS BARRIERS TO ACCESS VIA MOBILE VAN SPECIFICALLY AND PATIENT NAVIGATORS. WE HAVE A UNIQUE OPPORTUNITY HERE TO LEVERAGE THE JUSTICE COMMUNITY OPIOID INNOVATION NETWORK OR J COIN, TO PROVIDE SUPPORTIVE INFRASTRUCTURE AND NOVEL APPROACHES FOR COLLABORATION. AND THIS INITIATIVE ALSO ALIGNS WITH THE END OF THE AIDS EPIDEMIC AND APPLICATIONS WOULD BE LIMITED TO THE CDC LIST OF VULNERABLE COMMUNITIES AND JURISDICTIONS. ANY QUESTIONS? YES. >> NL EARLIER PRESENTATIONS WE HEARD ABOUT OTHER HEALTH CONDITIONS THAT SEEM LIKE THEY COULD BE MAYBE INCLUDED IN THIS -- NEAR FUTURE WITH YOUR GOALS. I DON'T REMEMBER THE SPECIFIC HEALTH CONDITIONS BUT THEY WERE CONDITIONS RELATED TO IV DRUG USE. AND IT MIGHT BE GOOD WHILE ESTABLISHING THIS TO CERTAINLY BE INCLUDE THOSE SINCE THEY HAVE ALREADY BEEN IDENTIFIED. >> CERTAINLY, THAT'S DEFINITELY SOMETHING TO CONSIDER AS WE FURTHER FORMULATE THE CONCEPT. THANK YOU. >> PROBABLY APPLIES TO THE WHOLE PORTFOLIO, I KNOW SAMSA HAS A SUBSTANTIAL AMOUNT OF MONEY FOR HIV RELATED ACTIVITIES AND WE KEEP HEARING OVER AND OVER AGAIN HIV AND SUBSTANCE USE. IT WOULD BE NICE TO KNOW THAT FROM A TRANSLATIONAL PROCESS THAT SOME OF WHAT'S BEING DEVELOPED WITH THE NIDA PORTFOLIO IS BEING ADOPTED BY BOTH SAMSA AND HRSA. SO I WOULD ENCOURAGE COLLABORATION ALONG THOSE LINES AS THEY THINK ABOUT WHAT DO THEY DO WITH HIV SPECIFIC PORTFOLIO. >> THANKS FOR THAT SUGGESTION. I AGREE. >> I WAS WONDERING, A LOT OF TIMES WE TALK HIV IN PENNSYLVANIA AND HEPATITIS C KIND OF IN THE SAME BREATH. BUT HERE IT SEEMS LIKE THEY ARE SPLIT UP, IS THAT A FUNDING THING OR IS IT A -- HEPATITIS C LIVES SOMEPLACE ELSE? SOMETIMES WITH OPIOID MONEY IF SOMEBODY DOESN'T USE OPIOIDS AND CAN'T QUALIFY FOR SERVICES, I DON'T KNOW DOES THIS CREEP UP HERE LIKE IF SOMEBODY HAS HEPATITIS C HIGH RISK DRUG USER, LIKE OH NO YOU DON'T FIT BECAUSE YOU KNOW WHAT I MEAN? DOES THAT CREEP UP HERE? I DON'T KNOW. >> IT DOES CREEP UP HERE. ABSOLUTELY. ONE OF THE ISSUES THAT -- I MEAN CERTAINLY IT PLAYS -- IS THE WAY THAT WE ARE REPRESENTING IS THAT WE ARE ALLOCATED FUNDING SPECIFICALLY FOR HIV, IT HAS TO BE APPROVED BY OFFICE OF AIDS RESEARCH, ON THE BASIS OF WHETHER THEY CONSIDER IT IN THEIR TOP PRIORITIES. SO IF YOU STATE FOR EXAMPLE THAT MAJORITY INCIDENCE GREATER RATE FOR HPC THAN HIV, IF YOU EMPHASIZE THAT COMPONENT YOU END UP STATING THIS IS NOT HIV, NOT A PROVEN HIV, IT'S APPROVED FOR HCV SO THEREFORE YOU CANNOT USE RESOURCES FOR THAT OF THEY SAY YOU ONLY BE USE 50%. BUT THERYIALITY IS THAT HCV IS A MAJOR PROBLEM AND IT IS BEING DISSEMINATED VERY RAPIDL. SO WE CANNOT IGNORE IT. NOW, THE COUNTER ARGUMENT AND AGAIN WHEN WESLEY WAS SAYING THE INCREDIBLE OPPORTUNITIES THAT WE HAVE BY CREATING THE PARTNERSHIP WITH JUSTICE SETTINGS IS THAT IF YOU MAKE A DIAGNOSIS, SO HOW MANY OF THE JAIL SYSTEMS ARE DOING SCREENING FOR HEPATITIS C? I DON'T THINK THAT MANY. IF IT IS POSITIVE THERE MAY BE OBLIGED TO TREAT THAT PERSON THAT'S VERY EXPENSIVE. SO THAT ISSUE IS WHAT ARE THE POLICY BEHIND IT AND HOW DO WE MOVE THAT TO BE IMPLEMENTED. IT WILL BE WONDERFUL. SO WE HAVE BEEN DISCUSSING IN TERMS OF WHEN WE WERE SPEAKING ABOUT DOING ASSESSMENT OF ACTUALLY IN PRIOR STORY TRY TO DETERMINE IN THE JAIL SYSTEMS HOW MANY OF THEM WERE SCREENING TO GET AN IDEA OF THE LANDSCAPE. IT WAS NOT VERY GOOD, FOR HEPATITIS IS THE SAME. SO I THINK YOU DON'T SEE IT FOR THAT REASON BUT IT IS IN OUR RADAR AND I GUESS THAT WHAT YOU PERHAPS ARE IMPLYING BY YOUR COMMENT IS THAT THESE TWO THINGS SHOULD BE LOOKED -- >> THAT IS WHAT I'M TRYING TO SAY. >> JUST SAID IT. YES. AND WE -- I MEAN, AGAIN, TRYING TO IDENTIFY WAYS WE HAVE BEEN VERY SENSITIVE ABOUT THE ISSUE OF HCV. PATIENTSTHAT ARE HCV POSITIVE, MOST ARE FROM INJECTION PRACTICES. ARE NOT BEING GIVEN MEDICATIONS. I THINK LIKE 3%. SO IT'S FRUSTRATING. IT'S A MATTER OF -- SO IT'S A MATTER OF VERY COSTLY SO WE ARE CREATING PARTNERSHIPS AND IN FACT WE HAVE A PARTNERSHIP WE ARE DOING WITH THE NATIONAL CANCER INSTITUTE TO DEPLOY A PILOT STUDY WHERE WE ACTUALLY PARTNER WITH GILL YARD WHO WILL BE GIVING MEDICATIONS TO TREAT ABSOLUTELY IN KENTUCKY EVERY PERSON THAT IS POSITIVE. TO TRY TO SEE THE COST AND SUSTAINABILITY OF A MODEL LIKE THAT. WE ARE IN DISCUSSION WITH CDC FOR ANOTHER PROJECT PERHAPS IN LOUISIANA. SO THERE IS A AN ISSUE OF FUNDING MIND ALL THIS. (OFF MIC) FUNDING BEHIND ALL OF THIS. (OFF MIC) >> NO, IT'S A FANTASTIC PREVENTION FOR CANCER. (OFF MIC) >> BUT THANKS FOR BRINGING THAT UP, THAT IS YOUR TASK. WE HAVE TO FIGURE OUT HOW TO GET THESE THINGS DONE. >> ANY OTHER QUESTIONS, COMMENTS? THANKS VERY MUCH. >> NUMBER TWO. NUMBER TWO. THE NEXT INITIATIVE IS ENDING THE EM EPIDEME U NEW MODELS OF HIV IDZ ADDICTION -- CO-MORBIDITIES ARE COMMON AMONG PERSONS WITH HIV AND AIDS THOSE SUFFERING FROM ADDICTION AND OTHER MENTAL BEHAVIORAL AND PHYSICAL HEALTH CONDITIONS AND CHALLENGES. DISJOINTED UNCOORDINATED CARE CONTRIBUTES TO SUBOPTIMAL OUTCOMES AND NEW INNOVATIVE MODELS OF CARE THAT INTEGRATE COMPREHENSIVE SERVICES THAT ADDRESS THE SPECTRUM OF PREVENTION TO TREATMENT SERVICES FOR HIV AND ADDICTION WITHIN PRIMARY CARE SERVICES COULD TRANSFORM TOTAL PERSON CARE. THAT SAID, THE GOAL OF THIS INITIATIVE WOULD BE TO DEVELOP AND TEST ORGANIZATIONAL COMPREHENSIVE INTEGRATED INTERVENTIONS TO IMPROVE THE HEALTH OF OUTCOMES RELATED TO HIV AND SUD. WE ARE REALLY FOCUSED ON IMPLEMENTATION SCIENCE AND FORMED APPROACHES WITHIN THE EMPHASIS ON SCALABILITY, REPLICABILITY AND QUALITY MEASUREMENT. OF COURSE SUSTAINABILITY AND COST EFFECTIVENESS. THIS ALSO ALIGNS WITH THE END OF THE AIDS EPIDEMIC AND AGAIN WOULD BE RESTRICTED TO THE CDC LIST OF VULNERABLE COUNTIES AND JURISDICTIONS. QUESTIONS? >> JUST AS A POINT OF CLARIFICATION, DOES CDC UPDATE THAT LIST? WITH NEW REGULARITY? >> I DON'T KNOW THE FREQUENCY WITH WHICH THEY UPDATE THAT LIST BUT I CAN PROBABLY RESEARCH THAT AND GET BACK WITH YOU ON THAT. (OFF MIC) >> SO AFTER THEY HAD THE OUTBREAK IN INDIANA, THEY DID THEIR COUNTY BY COUNTY ASSESSMENT AND SEVERAL MORE COUNTIES POPPED AS SUPER HIGH RISK. WOULD THOSE BE ELIGIBLE OR ONLY THE CDC IDENTIFIED FROM 2016 WHICH IS NOW SUPER ANCIENT DATA? >> THAT'S A GOOD QUESTION, SOMETHING WE PROBABY HAVE TO HAVE A DISCUSSION ABOUT INTERNALLY TO FLESH THAT OUT. I DN'T KNOW HOW FIRM WE ARE WITH THIS SPECIFIC RESTRICTION AT THIS PARTICULAR JUNCTURE. >> AS ADVOCATES NATIONWIDE WE ARE ASKING STATES TO DO STATEWIDE ASSESSMENT COUNTY BY COUNTY AND THEN USING THAT AS AMMO TO GET MORE RESOURCES INTO OUR COMMUNITY. SO THAT WAS VIABLE TO US, THAT WOULD BE GOOD FOR US. >> THANK YOU. >> ANY OTHER QUESTIONS? >> THANK YOU. [APPLAUSE] >> THE NEXT PRESENTATION IS BY DR. JENNIFER WENZEL. INVESTIGATING THE ROLES OF BIOMOLECULAR CONJUGATES IN SUBSTANCE USE DISORDER. SOFERRY, AMY. I'M PLOKING YOU. THE NEXT PRESENTATION IS AMY GOLDSTEIN ON REDUCING STIGMA RELATED TO DRUG USE IN HUMAN SERVICE SETTINGS. AMY. >> THANK YOU. >> FIRST TIME IN COUNCIL, RIGHT? DISPL IT IS MY FIRST PRESENTATION TO COUNCIL. NICE TO BE HERE. I DO WANT TO SAY I'M PRESENTING ON BEHALF OF RICH JENKINS SO ON THE FACE OF THIS CONCEPT FOR TODAY BUT HE'S THE BRAINS BEHIND IT. BUT RICH COULDN'T BE HERE TODAY HE'S ATTENDING A MEETING OF THE RURAL APPROXIMATE LAY SHAN COMMITTEE IN RURAL NORTH CAROLINA BY WAY OF CONTEXT NIDA PARTICIPATES IN A CROSS INSTITUTE WORK GROUP ON SIGNATURE STIGMA THAT DEVELOPED OUT OF MEETINGS ORGANIZED BY THE FOGARTY INTERNATIONAL CENTER AND THESE GREW FROM THE TRANSIC MEETINGS SO I'M BRINGING THIS UP BECAUSE WE HOPE INSTITUTES AND CENTERS WILL BE INTERESTEDDED IN THIS CONCEPT MOVING FORWARD. I WANT TO START WITH TWO QUICK DEFINITIONS SO WE'RE ON THE SAME PAGE. WE ARE TALKING IDENTITY MARKED BY DISGRACE OR SHAME WHICH LEADS TO DISCRIMINATORY TREATMENT BY OTHERS. FOR THIS CONCEPT WE ARE INTERESTED IN STIGMA IN HUMAN SERVICE SETTINGS, DEFINED BROADLY THINKING ABOUT HEALTHCARE SETTINGS, SOCIAL SERVICE SETTINGS AND WITHIN PUBLIC HEALTH SYSTEMS. A PLOT OF THIS CAME UP IN DISCUSSIONS EARLIER TODAY, STIGMA RELATED TO SUBSTANCE USE IS PERVASIVE. AND STIGMA CAN RESULT IN AN INDIVIDUAL NOT SEEKING SERVICES TO ADDRESS THEIR OWN SUBSTANCE USE WHICH CAN THEN ALSO LIMIT ENGAGEMENT AND OTHER PREVENTIVE SERVICES. WHEN WE THINK ABOUT STIGMA YOU CAN THINK ABOUT IT OCCURRING AT MULTIPLE LEVELS. THERE COULD BE ORGANIZATIONAL OR STRUCTURAL STIGMA AT LEVEL OF PROVIDER OR THE SETTING. THERE COULD BE INDIVIDUAL LEVEL INTERNALIZED SELF STIGMA ONE'S OWN BEHAVIOR AND THERE COULD BE STIGMA WITH PROVIDED SERVICES TO INDIVIDUALS WHO USE SUBSTANCES SO A PROVIDER WHO WANTS TO BE DELIVERING BUP NORPHENE OR MA MA LOCK ZONE STIGMAS HAVING DEVELOPED IMPLEMENTED WIDE SCALE BUT THE GAP IDENTIFIED IS ONE MENTIONED EARLIER IS LACK OF STIGMA REDUCTION INTERVENTIONS SPECIFICALLY TARGETED TO INDIVIDUAL WHOSE USE SUBSTANCES SO WITH THIS INITIATIVE WE WANT TO BUILD OFF AN EXISTING LITERATURE ON STIGMA AND OTHER CONDITIONS SUCH AS CANCER AND MENTAL ILLNESS WHICH SPEEDS INTERVENTIONS ADDRESSING STIGMA IN INDIVIDUALS WHO USE SUBSTANCES SO THE OVERARCHING GOAL IS TO STIMULATE STIGMA REDUCTION RESEARCH ACROSS A VARIETY OF STIGMAS SETTINGS AND INTERSECTIONAL IDENTITIES. AND BY INTERSECTIONAL IDENTITIES, SUBSTANCE USE OCCURS IN PRESENCE OF OTHER ISSUES PERTAINING TO GENDER, RACE, SEXUAL IDENTITY AND RELIGION SO WE ENCOURAGE RESEARCH THAT ADDRESSES THESE INTERSECTIONAL IDENTITIES AND NOT JUST FOCUS USE BEHAVIOR. WE ENCOURAGE RESEARCH IN A RANGE OF SETTLINGS AS MENTIONED EARLIER THIS MORNING, YOU NEED TO WORK ACROSS ALL LEVELS OF THE HEALTHCARE SYSTEM. THERE ARE WIDE RANGE OF SETTINGS WHERE ENTERVEKS WE NEED TO TAKE PLACE SO NOT LIMITED TO DRUG TREATMENT PROGRAMS OR HIV TREATMENT SETTINGS,THINK ABOUT EMERGENCY DEPARTMENT OR PRIMARY CARE SO AGAIN FOCUSING ON PLACES WHERE INDIVIDUAL WHOSE USE SUBSTANCES MAY SEEK CARE. AND THE RESEARCH PROJECTS THAT CAN DEVELOP NEW INTERVENTIONS OR ADAPT IMPLEMENT AND EVALUATE EXISTING STIGMA REDUCTION STRATEGIES FOR MENTAL HEALTH OR OTHER FIELDS FOR USE AMONG INDIVIDUAL WHOSE USE SUBSTANCES IN THE SETTINGS THAT SERVE THEM WE ENCOURAGE INTERVENTIONS EMBEDDED IN PROFESSIONAL TRAINING PROGRAMS SO YOU ARE DEVELOPING A WORK FORCE TRAINED IN STIGMA REDUCTION STRATEGIES AND THE GOAL WOULD BE TO DEVELOP A DIVERSE SET OF RESEARCH STUDIES ADDRESSING DIFFERING AND MULTIPLE TYPES OF STIGMAS ACROSS A RANGE OF SETTINGS. WELCOME FEEDBACK OR QUESTIONS YOU MIGHT HAVE. >> AS A SENIOR CITIZEN, REALIZING THAT SUBSTANCE USE MAY NOT BE A HIGH PREVALENCE IN THE OVER 65 AGE RANGE BUT I WOULD INCLUDE AGE AS ONE OF THE VARIABLES IN ADDITION TO THE ONES THAT YOU VERY APPROPRIATELY INCLUDED. IF YOU DON'T MIND. >> NOT AT ALL. >> I THINK IT'S A REALLY IMPORTANT TOP INC. AND IT IS -- TOPIC PARTICULARLY RELATEDDED TO A HEALTH PROFESSIONAL AS WELL. SO I THINK THIS IS GREAT. I THINK THOUGH WE OWN PART OF THIS AND THAT'S THAT I KNOW NORA HAS DUB A LOT OF WORK -- DONE A LOT OF WORK IN TERMS OF LANGUAGE MATTERS BUT WE HAVE TO STOP WITH THE MAT WORD SO WE USE IT AND IT COMES OUT IN CERTAIN PUBLICATIONS AND THEY SAY THEY HAVE TO GET RID OF THAT WORD, IT COMES OUT, I HAD A HUGE FIGHT WITH SAMSA ABOUT SOMETHING WE ARE PUBLISHING A ONE OF THEIR -- I DON'T KNOW WHAT YOU CALL IT, MOUD IN EMERGENCY DEPARTMENTS AND I MAD TO FIGHT AND SAY YOU CAN'T USE MY WORK IF YOU'RE GOING BACK TO MAT. SO WE SAY TO EVERYBODY THAT IT IS ASSISTED TREATMENT. WHAT DOES THAT TREATMENT WE ARE ASSIST SOMETHING WE WANT IT TO BE A MENTAL HEALTH BRAIN ISSUE, A BRAIN DISEASE, AND YET NEW YORK CITY WE ARE AFRAID TO WRITE IT DOWN BECAUSE WE ARE AFRAID SOMEONE MIGHT SEE IT, WE ARE AFRAID -- WE ARE COUNTER PRODUCTIVE IN MANY WAYS THAT WE FUNCTION EVEN HERE. SO AND I CAN'T READ ENOUGH STUFF THAT KEEPS TALKING ABOUT THOUGH WE HAVE HAD TONS OF DATA THAT SHOW THAT MEDICATION IS THE TREATMENT AND OF COURSE THERE NEEDS TO BE OTHER THINGS BECAUSE IT'S COMPLICATED. AND MANY PEOPLE HAVE MENTAL HEALTH CO-MORE PIDTIES. SO -- CO-MORBIDITIES SO OF COURSE THERE'S THINGS BUT WE CONTINUE OURSELVES TO PE PET WAIT THIS SO IN THE SCIENCE WORLD WE NEED TO STICK WITH WHAT IT IS AND THAT WHAT WE KNOW AND WE KNOW BASICALLY THAT OPIATE AGONIST TREATMENT WORK, WE HAVE LIMITED KNOWLEDGE THAT REA LITTLENAL TREK ZONE WORKS IN CERTAIN AREAS, DOESN'T REDUCE MORTALITY IN WHAT WE KNOW SO FAR. SWOA STILL NEED THE COIT WITH OUR -- DO IT WITH OUR SCIENCE AND THEN IT WOULD BE GREAT TO GO FORWARD. I REALLY DO BELIEVE THE ANSWER TO MOST OF THIS IS LEADERSHIP AND IT. SO WHEN IT'S INFRASTRUCTURED AND IT JUST IS THE WAY THAT IT IS, AND WE HAVE SEEN THIS IN SOME OF THE THINGS WE ARE DOING IN THE UG 3 TRIAL IS JUST PUT IT ON THE INTERNET, PUT IT ON THE EHR, POPS UP, PEOPLE DO IT AND SHUT UP. SO IS MORE AS YOU CAN THINK OF IT SOLUTIONS IN HERE, AND THINK ABOUT THE TECHNOLOGY OF HOW ONE CHANGES BEHAVIOR, I TELL YOU THAT IN PHYSICIANS IT'S CHANGED BY INFRASTRUCTURE. IF IT'S EASY TO DO AND ON THIS IT AND I'M EXPECTED TO DO IT, I JUST DO IT. I HAVE TO LIKE IT. I JUST DO IT. WE DON'T ASK TO WHAT DO YOU THINK ABOUT GIVING OUT TETANUS THOUGH NONE OF US HAVE SEEN A TETANUS CASE. WHAT DO YOU THINK ABOUT OFFERING THAT? WHAT DO YOU THINK ABOUT OFFERING THIS NEW INSULIN REGIMEN BECAUSE SOMEONE HASN'T BEEN ADHERENT, RIGHT? BUT WE CONSTANTLY THINK THAT WE HAVE TO ADDRESS ALL THIS. SO ANYWAY, I WOULD THINK ABOUT TECHNOLOGY, AS ONE OF THE MOST IMPORTANT WAYS OF DEALING WITH, AT LEAST THROUGH THE HEALTH PROFESSIONS. >> GAIL, I WANT TO POINT OUT THAT PART OF OUR GOAL OF REVIEWING THESE CONCEPTS IS TO ALERT ALL OF YOU AND TO ALERT THE LARGER RESEARCH COMMUNITY OF THESE LIKELY FUNDING ANNOUNCEN'TS COMING OW IN -- OUT IN THE FUTURE SO SOUND LIKE YOU HAVE INTERESTING IMPORTANT RESEARCH IDEAS AND LOOK FORWARD TO SEEING THEM TURN INTO SOMETHING VERY PRACTICAL. >> FIRST JUST A THANK YOU. THIS IS SO IMPORTANT, -- IS THAT BETTER? SORRY. JUST A THANK YOU FROM SORT OF A PATIENT AND FAMILY PERSPECTIVE ADDRESSING THIS IS JUST SO CRITICAL. AND ALL THESE ELEMENTS FROM MAKING SURE, IN DIFFERENT SPACES WHETHER PROVIDERS OR DIFFERENT LOCATIONS BUT ALSO ADDRESSING THE SELF STIGMA, WHEN YOU HAVE STIGMA MANY OTHER SET -- IN OTHER SETTINGS THAT COMPOUND UPON SELF STIGMA WHICH IS PREVALENT WITHIN OUR PATIENT SPACE. THIS IS MUSIC TO OUR EARS AND WE ARE VERY GRATEFUL. BUT ONE LITTLE COMMENT ABOUT SOME OF THE WORK WE DO ON STIGMA IS THAT IT REALLY WE FOUND HAS TO BE NUANCE TO THE AUDIENCE YOU ARE TRYING TO -- IT ISN'T JUST SOME OF THE COMPONENTS YOU WANT TO PLEA AGREEMENT, IT REALLY IS A CULTURE CHANGE AND SEEING THIS IN A DIFFERENT WAY. WE BUILT THIS -- WE BUILT THE TRAINING AND TRYING TO PUT SOME MATERIALS TOGETHER AND ENCOURAGE HEALTHCARE PROVIDERS AND STAFF TO ENGAGE WITH OUR PATIENT POPULATION AND WE DID A FOCUS GROUP AND ONE RURAL OHIO HOSPITAL, WITH OB NURSES, LET ME TELL YOU, NOT EXACTLY THE SAME EXPERIENCE WE HAD SITTING DOWN WITH HEALTHCARE PROFESSIONALS IN D.C . OR NEW HAM SHIR OR BOSTON -- HAMPSHIRE OR BOSTON SO PART OF THE LAST BULLET ABOUT PROFESSIONAL TRAINING THAT IS SPECIFIC, AND REALLY MAKING SURE THAT WE CAN GET OUT TO A BROAD RANGE OF DIFFERENT AUDIENCES, AND BEYOND PHYSICIANS, MAKING SURE WE GOT NURSES AND OTHER HEALTHCARE PROVIDERS ENGAGED IN THAT, IS SO IMPORTANT YOU HAVE TO LISTEN AND SORT OF SIT WITH THE DISCOMFORT OF WORKING WITH OUR POPULATION TO GET TO A PLACE WHERE THEY SEE EYE TO EYE. >> I THINK THE INTENT TO IS NOT JUST PROVIDER BUT ANYBODY WHO CAN COME IN CONTACT WITH THE INDIVIDUAL SO FRONT DESK STAFF, ANYBODY IN THE PROVIDER SPACE IS A TARGET HERE FOR INTERVENTION. >> THE DOCTOR IS AMAZING -- >> BUT THE FRONT OFFICE STAFF IS NOT. >> THAT'S -- SO JUST THANK YOU VERY MUCH, THIS IS TERRIFIC. >> THANK YOU FOR THE COMMENT. >> WHILE I HAVE THE MICROPHONE OPEN. THIS IS REAL IMPORTANT SUBJECT TO US AND WHAT WE SEE AT FIRE HOUSE WITH THE SAFE STATION PROGRAM, WHAT WE HAVE DONE IS KIND OF CREATED A STIGMA-FREE ZONE, LITTLE THRESHOLD FACE TO FACE ENTRY INTO OR ACCESS POINT BUT WHAT WE ARE SEEING IS PEOPLE COMING I THINK ONE OF THE SIX -- ONE OF THE BIG SUCCESSES WITH THIS IS THAT STIGMA-FREE ZONE BECAUSE WE ARE SEEING PEOPLE COME IN AND THIS DON'T WANT TO GO TO THE HOSPITAL SETTING BECAUSE THEY CAN GET THAT FIRST LOW THRESHOLD FACE TO FACE STIGMA FREE ACCESS TO TREATMENT SO IT'S JUST THAT FIRST TREAT SOMEONE WITH HAND SHAKE AND NO JUDGMENT. IT'S REALLY BENEFIT EFFECTIVE AND I THINK IT'S REALLY IMPORTANT ESPECIALLY TO GET INTO THE EDs BECAUSE MY WIFE IS A -- I WAS AN ED NURSE A LONG TIME, CERTAINLY THERE'S STIGMA THERE. >> THANK YOU, >> NOW CORRECT ORDER. DR. JENNIFER WENZEL WILL BE PRESENTING INVESTIGATING THE ROLES OF BIOMOLECULAR CON DEN SATES IN SUBSTANCE USE DISORDER OR HIV INFECTION OR PATHOGENESIS. JENNIFER. >> I'M PRESENTING THIS CONCEPT ON BEHALF OF JOHN SATTERLY WHO DEVELOPED THIS, DEPENDING THE DEPTH OF YOUR QUESTIONS I MAY HAVE TO HAVE JOHN FOLLOW-UP WITH YOU. SO BIOMOLECULAR CON DEN SATES ARE A GROUP OF NON-MEMBRANE BOUND ORGANELLES OR SUB CLASSES THAT CONTAIN PROTEINS RNAs AND OTHER MOLECULES. THEY ARE FORMED BY LIQUID LIQUID PHASE TRANSITIONS OR LIQUID LIQUID PHASE SEPARATIONS. WHERE IN THESE PROTEINS AND RNAs AND MOLECUES CONDENSE OUT OF THE AQ3IOUS FLUID TO A DENSE STATE THAT RESEMBLES A WATER DROPLET. THIS IS SIMILAR TO WHAT WE SEE IN SALAD DRESSING WHEN WE HAVE THIS WELL MIX SALAD DRESSING THAT GOES THROUGH LIQUID LIQUID PHASE SEPARATION INTO TWO LIQUIDS OIL AND VINEGAR. SO THESE BIOMOLECULAR CONTENT SATES OR BMCs ARE LOCATED THROUGHOUT CELLS INCLUDING BRAIN CELLS OR NEURONS. PARTICULARLY GERMANE TO THIS CONCEPT, THERE ARE MANY BMCs LOCATED AT THE CELL MEMBRANE, WHERE THEY ARE INVOLVED IN MEMBRANE SIGNALING. ALSO AT SYNAPTIC DENSITIES THERE ARE NUMBER OF BMCs THAT ARE INVOLVED IN SYNAPTIC FUNCTION AND DENDRITE FORMATION AND DENDRITE SPINES. AND ALSO A NUMBER OF BMCs IN THE NUCLEUS WHERE THEY REGULATE GENE TRANSCRIPTION AND ARE INVOLVED IN NUCLEAR FUNCTION. SO THE GOALS OF THIS CONCEPT ARE TO SUPPORT EXPLORATORY RESEARCH INTO THE ROLE OF BMCs AND BOTH SUBSTANCE USE DISORDER AND HIV. SO THOSE BMCs AT THE MEMBRANE TO LOOK AT HOW THEY ARE INVOLVED IN G PROTEIN COUPLED RECEPTOR SIGNALING INCLUDING THOSE GPCRs WE ARE INTERESTED IN HERE AT NIGH NIDA. HOW ARE THEY SYNAPSES IN DRUG MEDIATED CHANGES TO SYNAPTIC SPINE AND SYNAPTIC FUNCTION AND HOW INVOLVED IN HIV ASSOCIATED NEUROCOGNITIVE DISORDERS. WITH THE BMCs IN THE NUCLEUS HOW ARE THEY INVOLVED IN DRUG MEDIATED CHANGES IN CNS CHROME TIN STRUCTURE OR GENE EXPRESSION AND ALSO IN HIV REPLICATION LAY TAN SI FORMATION OR MAINTENANCE. BECAUSE EVEN THOUGH THEY ARE WIDESPREAD THROUGHOUT THE CELL AND INVOLVED IN MANY IMPORTANT CELLULAR FUNCTION RELATIVELY LITTLE IS KNOWN ABOUT THEIR ROLE IN SUD OR HIF. -- HIV. SO WITH THE WORK FROM THIS CONCEPT WE MIGHT GAIN MECHANISTIC INCITES TO THESE VARIOUS GOALS AND ALSO IDENTIFY NOVEL THERAPEUTIC TARGETS FOR SUBSTANCE USE DISORDER AND HIV. ANY QUESTIONS? >> I BELIEVE SO BUT I CAN ALSO HAVE JOHN FOLLOW-UP WITH YOU TO BE SURE. >> ANY OTHER QUESTIONS? JENNIFER, THANKS VERY MUCH. [APPLAUSE] THE NEXT PRESENTATION IS GIVEN BY DR. WOODY LIN USING HIV IMAGING APPROACHES THE CHARACTERIZE HIV RESERVOIRS IN LYMPHOID TISSUES AND CNS IN CONTEXT OF INJUKS DRUG USE. >> ON BEHALF OF NIDA'S RESEARCH PROGRAM AND DIVISION OF NEUROSCIENCE BEHAVIOR I PRESENT TO YOU THIS F OA CONCEPT USING IMAGE APPROACHES TO CHARACTERIZE HIV RESERVOIRS IN LYMPHOID TISSUES AND CNS IN A CONTEXT OF INJECTION DRUG USE. THE CONCEPT AND TOPICS HIV RESERVOIR HAS GAINED MUCH ATTENTION IN RECENT YEARS. YET WE STILL KNOW VERY LITTLE ABOUT EXACTLY WHERE AND WHAT IS HIV RESERVOIR. WHEN DETAILED INFORMATION CONCERNING CONTEXT OF HIV LYMPHOID AND BRAIN RESERVOIRS. HIV INFECTION, HIV CONDITION INFECTED THROUGH IV INJECTION OF DRUGS AS WELL AS SEXUAL TRANSMISSION. YETD UNCLEAR WHETHER -- YET UNCLEAR WHETHER ROUTE OF INJECTION INFLUENCED HIV RESERVOIR. IT IS PROMISING TO LEARN THAT SEVERAL SIGNIFICANT PROGRESS HAS BEEN MADE IN THIS FIELD IN RECENT YEARS, THEY IMPROVED IN SITU HYBRIDIZATION TECHNIQUE HAS ENABLED DETAILED CHARACTERIZATIONS OF HIV RESERVOIR IN TISSUES. IN IMPROVED IN IN VIVO IMAGING TECHNIQUES HAS ENABLED MUCH IMPROVE ABILITY TO VISUALIZE THE HIV RESERVOIR IN LIVING TISSUES THAT COULD FACILITATE CHARACTERIZATIONS OF HIV RESERVOIRS IN LIVING TISSUES AND INDIVIDUALS. SO THIS FOA WILL SUPPORT EXPLORATORY AND MECHANISTIC STUDIES THAT TO EXPORT ADVANCES IN SITU OR IN VIVO IMAGING TECHNIQUES TO INVESTIGATE LAYTANT LYMPHOID AND PRAIN HIV OR SIV RESERVOIRS IN HUMANS OR IN PRIMATES AND TO COMPARE INJECTION DRUG VERSUS OTHER ROUTES OF INFECTION. WE EXPECT KNOWLEDGE GAINED FROM THE STUDY WILL FACILITATE HIV CARE APPROACHES IN SUBSTANCE USE DISORDER PATIENTS. WE ENABLE MONITORING OF THE THERAPEUTIC STRATEGIES FOSH -- FOR HIV TREATMENT AND ENABLE MONITORING OF HIV RESERVOIRS CHANGES IN RESPONSE TO ADDICTIVE SUBSTANCES AND THEIR TREATMENTS. WITH THAT I WILL INVITE COUNCIL COMMENTS AND ADVICE. >> THANKS VERY MUCH. [APPLAUSE] >> THE NEXT PRESENTATION IS GIVEN BY DR. ROGER LITTLE AND ON INDUCING CUTTING EDGE TOOLS TO STUDY MECHANISMS OF OPIOID ACTION. DAY -- DA-YU. I'M SORRY. THE NEXT ONE IS DR. DA-YU WU ON HIV PATHOLOGY AND LATENCY STUDIES USING LIVE IN HUMAN CELLS CHIME RA ANIMAL BRAINS. >> THANK YOU, NORA. GOOD AFTERNOON. SO THE TITLE IS HUMAN CELL ANIMAL CHIME RAS TO STUDY HIV LATENCY AND PATHOLOGY, ROGER SOUTHERNSON AND I WORK ON THIS PARTICULAR CONCEPT TOGETHER. SO HIV DOES NOT INFECT ANIMAL CELLS. AND THIS LIMIT IT IS USE OF ANIMAL MODELS TO STUDY HIV VIROLOGY AND ERADICATION. HUMAN CELLS TRANSPLANT INTO NEWBORN IMMUNODEFICIENT MOUSE CAN DIFFERENTIATE IN WIDELY SPREAD IN THE MOUSE BRAIN. AND HIV CAN BE USED INFECT YUM CELLS AND -- HUMAN CELLS AND PROVIDE TRANSLATIONAL MODEL FOR STUDYING HIV VIROLOGY AND HUMAN CELL PATHOLOGY. SO THIS IS AN EXAMPLE HOW TRANSPLANTED HUMAN MICROGLIAL CELLS WIDE WILL I DISTRIBUTE IN THE MOUSE CORTEX AND SUB CORTICAL AREAS. THESE MICROGLIA CAN BE INFECTED BY HIV, AS SHOWN HERE BY THE STAINING OF TP ANTI-HIV ANTIBODY AND VIRAL LOAD CAN REACH HIGH LEVEL SIX WEEKS AFTER INFECTION. SO THE GOALS OF THIS INITIATIVES ARE TO PROMOTE USE OF THIS PARTICULAR TRANSLATIONAL RODENT MODEL TO STUDY HIV VIROLOGY AND LATENCY TO STUDY HIV NEUROPATHOLOGY AND ITS CO-MORBIDITY WITH SUBSTANCE USE DISORDER. AND THEIR IMPACT TO HUMAN NEURONS GLIA AND MICROGLIA IN A FULLY FUNCTIONAL AWAKE BEHAVING ANIMAL FOR -- FROM SINGLE CELL TO NEURAL CIRCUITS TO BEHAVIOR. ALSO TO GENERATE AND PROVIDE RESOURCES FOR OPTIMIZING AND VALIDATING THIS CHIMERIC RODENT MODEL FOR HIV STUDIES, AND ITS ERADICATION IN HUMAN CELLS. THAT'S IT. THANKS. >> QUESTIONS? (OFF MIC) >> YEAH. GOOD POINT. WE WILL PUT THAT INTO OUR NOTES. >> WE HAVE PRESENTED ONE OF THE CONCEPTS THAT WE ARE PRESENTING AT THE SATELLITE SYMPOSIUM IS THE USE OF TOOLS AND TECHNOLOGIES TO DEVELOP FOR THE BRAIN TO ACTUALLY BE ABLE TO ADVANCE NEUROSCIENCE, THIS IS RELEVANT BECAUSE IT ALLOWS YOU TO CHARACTERIZE CELL TYPES THAT GO BEYOND BUT BEFORE WE COULDN'T AND NOW WE CAN. (OFF MIC) WE SHOULD EXPLICITLY STATE WE ENCOURAGE THESE CELL SPECIFIC CHARACTERIZATIONS. >> YES. GOOD POINT. >> ANY OTHER POINTS, COMMENTS, QUESTIONS? IF NOT, NOW I CAN CORRECT MY ARROW. THANKS VERY MUCH. [APPLAUSE] USING CUTTING EDGE TOOLS FOR STUDYING MECHANISMS OF OPIOID ACTION IN RODENT BRAIN CIRCUITS AND CELLS. >> >> I'M ON HERE ON BEHALF OF (INDISCERNIBLE) IN MY DIVISION WHO DEVELOPED IT. THE TITLE OF THIS IS USING BRAIN TOOLS TO STUDY MECHANISMS OF OPIOID ACTION IN RODENT BRAIN CELLS AND CIRCUITS. THE IDEA HERE IS TO USE NEW TECHNOLOGIES THAT ALLOW TEMPORALLY PRECISE CELL RESOLUTION SNAP SHOTS OF ACTIVITY BASED ON IMMEDIATE EARLY GENE ACTIVATION, CALCIUM FLUCTUATION, AND RECEPTOR ACTIVATION. SO THIS WOULD ALLOW US TO CATCH CELL ACTIVATION AT IMPORTANT TIME POINTS SUCH AS FIRST EXPOSURE TO DRUG REUPTAKE OF DRUG WHEN DRUG BECOMES SELF-ADMINISTERED DURING ABSTINENCE, TIMES THAT ARE IMPORTANT IN THE CYCLE OF DRUG ABUSE AND WE WOULD BE ABLE TO IMAGE AND SEE BRAIN ACTIVITY IN REAL TIME ALMOST USING THESE APPROACHES. SO THESE COULD INCLUDE ANALYSIS WITH LIGHT SHEET MICROSCOPY AND TISSUE CLEARING, WHICH WOULD ALLOW US THE SEE HOW THESE CELLS ARE DISTRIBUTED ACROSS THE BRAIN. VIRAL BASED TRACING TO SEE HOW THE CELLS ARE CONNECTED. CAUSAL MANIPULATION USING OPTO GENETICS AND DREADS APPROACHES WHICH WOULD HELP US UNDERSTAND WHAT CELLS AND CELL TYPES ARE NECESSARY FOR THE ACTIVATION AND SIGNALING. AND THEN SINGLE CELL TRANSCRIPT OMIX WHERE WE CAN SEE WHAT GENOMICS AND GENETICS CHANGES ARE OCCURRING IN TEMPORALLY RESTRICTED WAYS. SO THAT DATA COULD LOOK LIKE THIS, YOU ARE ABLE TO SORT BY CELL TYPE, AND SEE THE LANDSCAPE OF CELLS THAT ARE INVOLVED. HIKE WISE YOU COULD ALSO SEE BASED ON GENOMICS PROFILING THE SPATIAL DISTRIBUTION OF GENETIC CHANGES. SO THIS CONCEPT SUPPORTS RESEARCH PROJECTS THAT INVESTIGATE HOW OPIOIDS CHANGE BRAIN CELLS AND CIRCUITS THROUGH UNBIASED APPROACHES TO IDENTIFY CELL ENSEMBLES, ENGAGED IN OPIOID RESPONSE AND THEIR CONNECTIONS. THAT'S THE BROAD VIEW. AND THEN THE DEEP VIEW IS YOU GET SINGLE CELL LEVEL AND BRAIN REGION SPECIFIC INFORMATION ABOUT CELLS THAT ARE INVOLVED IN OUD SIGNALING AND THEN WE WOULD MAKE THIS DATA PUBLICLY AVAILABLE TO THE SCIENTIFIC COMMUNITY FOR DATA MINING TO IDENTIFY AND UNDERSTAND NEW PATTERNS AND RELATIONSHIPS IN THE DATA THAT MIGHT NOT BE OBVIOUS ON ITS FACE. SO THE SIGNIFICANCE IS THAT THIS WILL DELIVER FOUNDATIONAL KNOWLEDGE TO IMPROVE OUR MECHANISTIC UNDERSTANDING OF OPIOID USE DISORDERS. AND OPIOID RECEPTOR SIGNALING. AND IT WILL ALSO I THINK EXPOSE NEW BIOLOGY THAT WE DON'T CURRENTLY HAVE THAT WOULD ALLOW FUTURE THERAPEUTIC APPROACHES TO BE DEVELOPED THAT WE CERTAINLY CAN'T FOR SEE AT THIS POINT. THANK YOU. [APPLAUSE] >> ONE SURPISING THINGS SINGLE CELL SEQUENCING IS (INAUDIBLE) DRUGS OF ABUSE OR (INAUDIBLE) NOT NEURONS NOT ASTROCTES OR MICROGLIA, THEY ARE EXOTIC CELLS WE NO LONGER -- IN THE BRAIN. CAN MANIPULATE THEM REALLY SO WOULD BE NICE TO SEE AN INITIATIVE TO UNDERSTAND WHAT THE HELL ELSE IS GOING ON IN THERE. >> WE HAVE A MIND. I COMPLETELY AGREE. I THINK WE HAVE HAD A VERY NUSH-SEN -- NEURON-CENTRIC VIEW BECAUSE WE HAD NEURON-CENTRIC TOOLS AND METHODS AND I HOPE THIS WILL EXPOSE THIS DARK BIOLOGY GOING ON THAT'S REALLY IMPORTANT. >> IN THE LINE OF THINKING THERE ARE TWO OF COURSE, AND IN IN THE THE BRAIN WAS CRITICIZED FOR BEING NARROW AND CENTRIC SO THERE'S A VERY PROACTIVE STANCE TO TRY TO EXPAND THAT INTO ASTROCYTES AND MICROGLIA. BUT AS IMPORTANT ARE ENDOTHELIAL CELLS AND END ENDOTHELIAL CELLS ARE ALSO VERY, VERY SENSITIVE TO THE EFFECTS OF DRUGS AND DRIVE A LOT OF TOXICITY AND PATHOLOGY. SO STRATEGIES LIKE THIS ONE, I MEAN, THAT CHARACTERIZE THE EFFECTS OF OPIATES, THIS IS JUST OPIOIDS, BUT IT IS A START TO TRY TO CREATE A SYSTEMATIC UNDERSTANDING. THIS INITIATIVE WHICH IS ACTUALLY ONE THAT HAD REITERATIONS FROM THE BEGINNING WAS ONE THAT VICTOR HAVE BEEN ADVOCATING TO PUT FORWARD FOR THE HEEL INITIATIVE BECAUSE WHAT'S INTERESTING IS WE KNOW RELATIVELY LITTLE ABOUT HOW OPIOIDS THAT RECEPTOR THE ENDOGENOUS PEPTIDES AND ENZYMES REALLY CHANGE THEIR DYNAMICS, THEIR INTERACTIONS. AND THEY ARE EXTRAORDINARILY COMPLEX SO WE WANTED TO HAVE PAY SICK SCIENCE FOR UNDERSTANDING. BUT DUE TO THE PRIORITY TO COME WITH INITIATIVES THAT SHOW RESULTS RAPIDLY, THIS DOES NOT MAKE IT. BUT I THINK THAT IT IS A VERY WORTHWHILE ENDEAVOR TO DO. ANY MORE QUESTIONS IN THIS ONE? >> THANK YOU. >> THANKS A LOT, ROGER. THEN I THINK THAT THIS IS THE LAST ONE IS DR. IVAN MONTOYA, DEVELOPMENT OF MEDICATION TO PREVENT AND TREAT OPIOID USE DISORDERS AND OVERDOSES. IVAN, WELCOME. >> THANK YOU. SO THIS CONCEPT IS TO REISSUE THE RFA DA 19002, WHICH IS AN RFA WITH THE SAME TITLE, AND THIS RFA WAS -- HAS BEEN VERY SUCCESSFUL IN BRINGING NEW RESOURCES AND MEDICATIONS TO TREAT OPIOID USE DISORDERS. SO THE IDEA IS TO REISSUE THAT RFA, THAT RFA IS ACTIVE UNTIL JANUARY OF 2020. SO WHAT WE WANT IS TO BE ABLE TO CONTINUE FUNDING THIS TYPE OF RESEARCH. SO BACKGROUND AND JUSTIFICATION, I DON'T THINK I NEED TO CONVINCE YOU THE IMPORTANCE OF DEVELOPING MEDICATIONS, THE MEDICATIONS THAT WE HAVE ARE EFFECTIVE BUT THEY ARE EFFICACY ESPECIALLY LONG TERM IS SUBOPTIMAL SO WE NEED NEW TARGETS, NEW MEDICATION NEW FORMULATION, NEW DELIVERY SYSTEMS. WE HAVE AN URGENT NEED TO ACCELERATE DEVELOPMENT AND OBTAIN FDA APPROVAL OF MEDICATION TO TREAT AND PREVENT AND TREAT OPIOID USE DISORDERS AND OVERDOSE. SO THE GOAL IS TO ACCELERATE THE DISCOVERY AND DEVELOPMENT OF SAFE MEDICATION AND THE IDEA IS TO FUND RESOURCES THAT GO ACROSS THE SPAN OF DEVELOPMENT THAT GOES FROM PRE-CLINICAL TO PHASE 1 PHASE 2 AND PHASE 3 CLINICAL TRIALS. THE GOAL IS TO MOVE COMPOUNDS TO THE NEXT STEP IN THE FDA APPROVAL PROCESS SO WE ACCEPT CHEMICAL ENTITIES FORMULATIONS OF MARKETING MEDICATION, COMBINATIONS OF MEDICATIONS, BIOLOGICS LIKE VACCINES AND MONOCLONAL ANTIBODIES. SO THIS IS A CONCEPT THAT WE IS CONTINUATION SO FAR UNTIL NOW WE HAVE RECEIVED 177 APPLICATIONS TO 24 OF THEM HAVE BEEN FUNDED AND WE EXPECT TO FUND MORE APPLICATIONS. THE NEXT RECEIPT DATE IS OCTOBER 1, NEXT I S JANUARY 1 AND THAT WILL BE THE END OF THE RFA. THEN WE WILL BE MOVING TO THIS NEW FUNDING OPPORTUNITY ANNOUNCEMENT. WE EXPECT TO CONTINUE FUNDING UG 3 UH 3, THAT'S THE FUNDING MECHANISM. SO I SHOULDN'T SAY -- >> FINE TO REYOU SHALL SHOE. >> OKAY -- REISSUE. >> OKAY. ANY QUESTIONS? COMMENTS? OKAY. THANK YOU. >> IVAN, THANKS VERY MUCH. I THINK THAT WHILE IT IS 10 TO 3:00, I HAVE BEEN INFORMED BY SUSAN THAT THE NEXT PRESENTATION WHICH IS GIVEN BY DIRECTOR OF THE NATIONAL CENTER FOR COMMUNICATIVE -- INTEGRATED COMPLIMENTARY AND INTEGRATED HEALTH, DR. HELENE LANGEVIN IS SCHEDULED FOR 3:30. SO WE CAN A BREAK OR BEFORE THE BREAK IF THERE ARE ANY SUBJECTS THAT WE HAVE DISCUSSED THAT YOU WOULD WANT TO BRING TO OUR ATTENTION, BEFORE WE DO A BREAK, THIS IS AN OPPORTUNITY THAT WE HAVE. WHILE YOU THINK ABOUT YOU THINK THAT MAY BE WORTHWHILE, THERE WERE TWO THOUGHTS THAT JUMP INTO MY BRAIN AS THE CONCEPT OF THE CREATION OF THE JUSTICE NETWORK WILL ALLOW US TO EXPAND OUR RESEARCH IN THAT SETTING IN JUSTICE SETTINGS. AND WE WERE DISCUSSION THE PRESENTATION OF THE HIGH RATES OF SIGNIFICANT INCREASES IN MENTAL ILLNESSES, AND THE SIGNIFICANT INCREASE IN SUICIDALTY. I WAS ACTUALLY TRYING TO FIGURE OUT AS WE ARE DOING OUR INTERVENTIONS FOR OPIOID USE DISORDERS AND TO THE FACT THAT WE KNOW A SIGNIFICANT NUMBER OF PEOPLE THAT ARE DYING FROM OVERDOSES MAY ACTUALLY HAVE DIED FROM SUICIDE. THE QUESTION EMERGE, WHAT PERCENTAGE OF THE INDIVIDUALS THAT END UP IN -- ATTEMPT OR COMMIT SUICIDE. SO I ASK TISHA DO YOU KNOW THAT, AND SHE WENT AND LOOK AT IT AND AFTER REVIEWING AND CONTACTING PEOPLE SHE SEND ME THE INFORMATION IS 3.5 HIGHER THAN IN THE GENERAL POPULATION. SO SUICIDAL RISK IS VERY HIGH IN JUSTICE SETTINGS. WE KNOW THAT INDIVIDUALS WITH SUBSTANCE USE DISORDERS ARE ACTIVE IN GREAT ARREST SO IN THE CONCEPT AS WE THINK ABOUT TARGETED INTERVENTIONS, IT ALSO BEHOOVES THIS MAYBE A VERY GOOD OPPORTUNITY TO ACTUALLY ADDRESS MENTAL ILLNESS AND AS WELL AS SUICIDALTY. THAT IS ONE THING THAT I'M ACTUALLY THROWING AT YOU. AND THEN WITH RESPECT TO I THINK THE HIV, IF YOU HAVE CONCEPTS OR IDEAS THAT RELATE TO HOW TO BASICALLY CONVEY THAT MESSAGE THAT CARLOS WAS DISCUSSING IN TERMS OF EXPANDING THE NOTION THAT IS NOT JUST INJECTION DRUG USE THAT IS RELEVANT, BECAUSE THOSE ARE THE PRY IMRORTIES -- PRIORITIES IN A WAY THAT RECOGNIZED AS ONE OF THE PRIORITIES FOR THE NIH, OTHERWISE IT DOESN'T GET RANK. THESE OTHER ELEMENTS THAT RELATE TO ADVERSELY AFFECTING BEHAVIOR OF PEOPLE THAT ARE SUBSTANCE USERS IN PEOPLE UNABLE TO BE COMPLIEBT WITH ED MANYCATION OR ENPHAGOING IN IS ARE -- RISKY, THOSE ARE TWO ASPECTS THAT I WELCOME YOUR THINKING. THE ENTERMINGLING OF MENTAL HEALTH WITH SUBSTANCE USE DISORDER IS SO MYRIAD, SO STRONGLY LINK THAT -- AND WE HAVE BEEN STUDYING THEM SEPARATELY BUT I THINK THAT THAT IS INTERFERING WITH OUR ABILITY TO ADVANCE THINGS. WHEN IT IS IMPACTED IN MY BRAIN, WE ARE ADVANCING SCIENCE IN MENTAL HE WILL HEALTH, LOOK AT THE NUMBERS, WE ARE GOING IN THE OPPOSITE DIRECTION. >> DISPL WE TALKED ABOUT THIS BEFORE -- >> WE TALKED ABOUT THIS BEFORE BUT IN THE CLINICAL TRIALS NETWORK WE HAVE HAD INITIATIVES OVER THE YEARS TO TRY TO DO CO-MORBIDITY STUDY WITH DEPRESSION, FOR EXAMPLE, IT SEEMS TO ALWAYS HANG UP PARTLY ON ISSUE WHOSE TURF IS IT, NIDA'S TURF OR NIMH'S TURF. >> EXCLUDING CO-MORBIDITIES. >> YEAH. AND ACTUALLY AS PART OF THE HEAL INITIATIVE NUMH CAME OUT WITH A PROGRAM ANNOUNCEMENT BUT I MUST SAY MYSELF AND MY COLLEAGUES IN ADDICTION PSYCHIATRY DOING CO-MORBIDITY RESEARCH FOUND THE RFA A LITTLE PECULIAR. LIKE IT WASN'T WRITTEN BY AN ADDICTION PERSON. SO I THINK IT'S THE FUNDING AGENCY IS A LITTLE SILOED ON THIS. THERE WAS A WAY TO ISSUE A JOINT RFA OR SOMETHING OF THAT SORT. >> >> I THINK THIS IS SOMETHING THAT WOULD BE -- SOMETIMES THE STRUCTURE REALLY CANNOT TAKE NEGATIVELY (INAUDIBLE) FACILITATE IT. (OFF MIC) AND CERTAINLY I MET WITH GEORGE TO DISCUSS HOW (INAUDIBLE) TO TAKE ADVANTAGE OF THE INITIATIVES THE NIMH WAS -- BUT THEY HAVE ALREADY HAD PROIL SELECTED. SO NONE OF THE PROPOSALS ARE SELECTED, I THINK IT BEHOOVES US TO TRY FIGURE OUT (INAUDIBLE). THAT'S WHERE WE HAVE TO GO MORE ON (INAUDIBLE) BUT YOU ARE ABSOLUTELY RIGHT. IT HAS GONE IN (INAUDIBLE) THEY HAVE GONE (INAUDIBLE) BECAUSE BASICALLY DOESN'T NOBODY REALLY OWNS IT, NOBODY OWNS CO-MORBIDITY. THAT'S MORE (INAUDIBLE). >> THERE WAS SOMETHING IN THE WASHINGTON POST, TALKING ABOUT THIS AT LUNCH TODAY, DURING THE SPRING THERE WERE TWO CHARTS ON DIFFERENT DAYS BUT WITHIN THE SAME PERIOD OF TIME. ONE SHOWED THE ADDITIONAL FUNDING BEING SPENT ON OPIOID DEATH. AND THE DEATH RATE THEY ARE BOTH GOING UP AT THE SAME RATE, THE TRAJECTORY, THEY ARE PAIR HELL LINES MOVING UP, THE MORE MONEY THE MORE DEATH. THERE WAS A SUBSEQUENT CHART SIMILAR TO SUICIDE PREVENTION. THE MORE MONEY, THE MORE DEATH. SOME OF THAT COULD BE HOW THOSE ARE REPORTED. BUT NEVERTHELESS, THOSE TRENDS ARE DISTURBING AND IT SPEAKS TO THIS POINT OF NOT GETTING AHEAD OF IT BECAUSE WE ARE DEALING WITH TWO PARTS OF THE SAME BODY MAYBE, I DON'T KNOW HOW ELSE TO DESCRIBE IT. BUT I THINK IT BEHOOVES US TO TAKE STOCK OF WHAT WE ARE DOING AND ASKING FOR MORE MONEY. I WOULD HAVE A HARD TIME AGREEING WITH THAT, WHEN THE TRAJECTORY IS PARALLEL. AND IT SHOULDN'T BE. THOSE SHOULD BE COMING DOWN AND THOSE TWO TOPICS WE HAVE TO FIGURE HOW TO WORK TOGETHER TO REALIZE THAT THEY ARE SO CONNECTED. >> I THINK TWO ISSUES. I AGREE BUT I ALSO DISAGREE. WHILE YOU HAVE AN EPIDEMIC, BECAUSE YOU ARE PUTTING MORE RESOURCES IT MAYBE -- YOU GOT TO THINK WHAT WOULD HAVE HAPPENED IF WE HADN'T PUT RESOURCES SO YOU SHOULD NOT EXPECT IT TO COME DOWN RIGHT AWAY. THERE WERE MILLIONS OF DOLLARS PUT TO HIV RESPONSE BEFORE WE STARTED TO SEE A DECREASE IN DEATH. THIS WILL TAKE SOME TIME, THOSE THINGS DON'T HAPPEN AUTOMATICALLY. SO I WOULD JUST BE VERY CAUTIOUS TO TRY TO LINK IT ESPECIALLY DOESN'T HAPPEN SO QUICKLY IN SUCH A CONCEPT EPIDEMIC IS NOT GOING TO HAPPEN SO QUICKLY. FOR HIV NORA, WE NEED TO BE MORE EFFECTIVE, THE CONCEPT OF U EQUALS U, THE CONCEPT OF UNDETECTABLE EQUALS UNTRANSMISSIBLE GAINED MOMENTUM IN THE HIV COMMUNITY. TOENY AT CDC ARE CONVINCED IT'S ABSOLUTELY TRUE SO WITH WE NEED TO BE SURE THE STUDIES WE DO WE LOOK AT UNDETECTABILITY AS A KEY OUTCOME OF STUDIES BECAUSE AGAIN, THAT'S THE PAPER WE PUBLISHED IN CID SHOWING THAT BETTER CONTROL LED TO LESS -- LOWER -- BETTER VIRAL SUPPRESSION CONTROL ADDICTION LED TO BETTER SUPPRESSION IS CRITICAL ACHIEVING U EQUALS U SO I ENCOURAGE RFA TO LOOK AT U EQUALS U AS ONE OF THE OUTCOMES OF STUDIES THAT YOU ARE LOOKING AT. MUCK MIC (OFF MIC) >> AGAIN T OTHER ISSUE IS, YOU GUYS WITH FUNDING OF THE LIVE COHORT, SHOWED THIS NICELY. DRUG USERS HAPPEN TO HAVE SEX AND MOST OF THE TRANSMISSION AMONG DRUG USERS IS SEXUAL TRANSMISSION, IT'S NOT NEEDLE SHARING. (OFF MIC) THOUGH EVIDENCE IS QUITE STRONG BECAUSE OF ETIOLOGICAL PERSPECTIVES IT IS NOT (INAUDIBLE) WHEN DISCUSSING ISSUE OF STIGMA, WE HAVE TO THINK ABOUT SOCIAL THINGS RELATED TO (INAUDIBLE) AND I THINK THAT I SEE IT AND I (INAUDIBLE) IT I'M VERY WORRIED THAT ONE (INAUDIBLE) STIGMATIZING PEOPLE THAT (INAUDIBLE) OBVIOUSLY PAIN MEDICINE CAN BE TRANSFERRING PEOPLE THAT BECAME ADDICTED BECAUSE THEY (INAUDIBLE) I HAVE SEEN IT BECAUSE OF THE COMMENT OF PEOPLE THAT I RESPECT A LOT HAVE COME TO ME AND SAID (INAUDIBLE) MAKE IT CLEAR TO EVERYONE THAT WAS (INAUDIBLE) SO THE YOU SHALL SHOE IN TERMS OF -- SO THE ISSUE IN TERMS OF STIGMA ALSO RELATES TO (INAUDIBLE) (OFF MIC) SO SPEAKING TO THAT, ANOTHER ASPECT (INAUDIBLE) IS THAT WE CREATE EVIDENCE BASED GAPS AND WE DEMAND QUALITY OF CARE (INAUDIBLE) TO JUSTIFY (INAUDIBLE) 1.1 MILLION PEOPLE (INAUDIBLE) CONSIDERING THAT WE HAVE 2.1 MILLION, (INAUDIBLE) (OFF MIC) ONE OF THOSE CIRCUMSTANCES WHERE IF THAT WERE THE CASE (INAUDIBLE) >> I JUST WANTED TO FINISH ON THAT. GO AHEAD. (OFF MIC) >> SORRY. ONE THING I STRUGGLE WITH IS PEOPLE HAVE MORE EXPERIENCE WITH ME COMPARING THE HIV EM DEMIC TO THE -- EPIDEMIC TO THE OVERDOSE EPIDEMIC. YOU DIDN'T HAVE THE PROBLEMS WE HAD WHEN THIS WAS YOUR FIGHT. NOBODY SAID DURING THE HIV EPIDEMIC, MAYBE THEY DID EARLY ON, LET'S TAKE ALL THE PEOPLE WITH HIV, BEAT STHEM OVER THE HEAD AND THROW THEM IN JAIL. WHERE THE MONEY IS GOING -- RIGHT BUT THAT WAS NOT -- HOW MANY YEARS INTO THE FAILED WAR ON DRUGS, THAT'S ALWAYS BEEN THE PLAN, 30 YEARS IN WE WEREN'T SAYING THE SAME THING WITH HIV. SO IT'S NOT IN MY OPINION THE AMOUNT OF RESOURCES THAT WE HAVE, IT'S WHERE WE PUT THE RESOURCES. DRUG COURTS SUPER DANGEROUS IN MY OPINION. FEEDING THE POLICE STATE TO BE A RESPONSE TO PEOPLE WHO USE DRUGS, ALSO SUPER DANGEROUS. CAN BE DONE VERY WELL BUT ALSO DONE VERY POORLY. SO IT'S NOT ABOUT THE NUMBER OF RESOURCES WHERE WE -- IT'S NOT LIKE WE ARE BLANKETING NALOXONE, WE HAVE A SHORTAGE IN MY STATE THAT HAS A GOOD NALOXONE PROGRAM. WE HAVE A SHORTAGE OF GOOD TREATMENT, IT'S TOM FOOLERY TREATMENT IN SEVERAL PLACES. I'M A MEMBER OF A 12 STEP COMMUNITY SO I WANTED TO LIKE HIGHLIGHT THAT IT'S NOT JUST WHERE THE RESOURCES, THE AMOUNT OF RESOURCES BUT IT'S WHERE THEY GO. AND SOMETIMES WHERE THEY GO IS ACTUALLY MORE DANGEROUS. I DON'T THINK INCREASING THE SIZE OF THE POLICE STATE FIXES THE OVERDOSE EPIDEMIC, THAT'S WHAT IT'S DONE A LOT OF. >> TO FOLLOW-UP ON THAT. . WHEN THE PUBLIC IS GIVEN PUBLIC INFORMATION AND THAT'S WHAT WE MOVE FORWARD ON, IF WE TALK CHANGING CULTURE AND PUBLIC WILL AND SUPPORTING RESEARCH DOLLARS, I THINK A BOLD STATEMENT ABOUT ACKNOWLEDGING HOW MENTAL HEALTH AND SUBSTANCE USE DISORDERS CERTAINLY HAVE AN OVERLAP AND CDC HAS ENOUGH DATA RIGHT NOW THAT ARE DEMONSTRATING THAT WILL THERE IS -- NOT EVERY OVERDOSE IS ACCIDENTAL. AND TO PUT SOME OF THAT OUT THERE, THIS IS A RESEARCH PRIORITY, I THINK THERE'S A LONG WAY TO START TO SHIFT THE PUBLIC'S VIEW AND SUPPORT FOR THIS KIND OF RESEARCH. IT FEELS DIFFERENT AND IT FEELS NEW AND MAKES SENSE. >> THIS IS ALSO IN LINE WITH STIGMA ASPECTS. WE TALKED ABOUT A BIT AT LUNCH IN TERMS OF AD BAD AS THE SUICIDE RATE IS IN THE UNITED STATES, WE ARE TWO-THIRDS OF WHAT IT IS IN EUROPE. AND ASIA. AFRICA IS TWO-THIRDS OF US AND MEDITERRANEAN ARE TWO-THIRDS OF AFRICANS. SO THERE'S HUGE GLOBAL DIFFERENCES ON SUICIDE RATES. BUT ONE OF THE ASPECTS THAT SEEMS TO PREDICT SOME OF THIS IS STIGMA. WHAT DO PEOPLE THINK ABOUT SUICIDE. AND THESE DIFFERENT CULTURES. MARIE MENTIONED THIS SHOW 13 REASONS I HAVEN'T SEEN YET BUT WONDERING MORE FROM YOUR WORLD AND REALM, ARE WE DOING THINGS RIGHT OR WRONG TO CHANGE THE STIGMA OR SELF STIGMA, LIKE YOUR VERSION OF THAT IN TERMS OF WHAT IT MEANS TO COMMIT SUICIDE IN TERMS OF WHETHER IT'S RO MANT SIZED, POPULARIZED IN SCHOOLS, IN MY POPULATION THERE'S A BIG ASPECT OF REVENGE SUICIDE. MY PARENTS WILL REALIZE HUH BAD THEY WERE ONCE I'M GONE. THIS IDEA OF STRIKING BACK AT OTHERS BY DOING -- NOT REALIZING THEY'RE NOT GOING TO BE THERE TO ENJOY THE -- THAT THRILL. BUT THAT'S WHAT THEY ARE THINKING. YOU WILL BE SORRY WHEN I'M GONE. I DON'T KNOW IF THAT'S THE SAME DYNAMIC FOR THE AGE GROUPS AND STUFF. BUT I THINK I REALLY LIKE WHEN YOU SAID NOTION OF SELF STIGMA I REALIZE IT'S NOT JUST WHAT OTHER PEOPLE ARE THINKING, IF ANYTHING CAN BE DONE ON THAT. GLOBALLY IT'S OBVIOUSLY NOT INCOME IN TERMS OF IT'S NOT NOTHING TO DO WITH INCOME OF THAT COUNTRY AND SUICIDE RATE, IF ANYTHING NEGATIVE, IT'S NOT PARTICULARLY DUE TO RELIGIOUS ADHERENCE. BUT I THINK THIS IDEA OF STIGMA, DIFFERENT CULTURES HAVE DIFFERENT NOTIONS OF WHAT SUICIDE MEANS TO THEIR COMMUNITIES AND FAMILIES. MAYBE THAT'S ONE OF THE THOUSAND AND ONE PARTS OF THE INCREASE. >> DESTIGMATIZING IS ACTUALLY HAVING THE OPPOSITE AFFECT? >> YEAH. I WISH I WOULD HAVE SEEN THIS SERIES NOW BUT IT'S SORT OF THIS -- IN HIGH SCHOOLS AND STUFF OFTEN, LIKE EVEN PEOPLE WHO ARE NOT POPULAR ARE SORT OF MADE HEROES. HE WAS THE BEST PERSON. THERE'S THIS ALL THIS ATTENTION GIVING TO THE PERSON WHICH LEADS TO THE CON DAY YOUS AS CONTAGIOUS. DESTIGMATIZING AS IN THERE'S SOMETHING NOBLE OR EXTREME ABOUT IT. SOMEBODY WHO GAVE THEIR ALL FOR -- MISGUIDED BUT THERE'S THIS ASPECT THAT IT'S TOO DESTIGMATIZED MAYBE IN SOME WAYS. >> YOU ARE GOING TO DESPICE THE 13 REASONS SHOW BECAUSE IT'S ALL ABOUT REVENGE SUICIDE. AND REALLY DISMAL. IT WAS ALSO FOR WILSON AND OTHER PREVENTION EXPERTS, IT'S LIKE LOOKING AT COMPLETE AND UTTER LACK OF PROTECTIVE FACTORS IN AB INDIVIDUAL WHO IS A FICTIONAL CHARACTER. IT WAS REALLY DIFFICULT. BUT ONE THING I WANT TO THROW OUT THERE, WE HAVE LEARNED FROM HOW WE HAVE SOME GUIDELINES FOR THE MEDIA HOW TO REPORT ON SUICIDES BECAUSE YOU CAN SEE THAT CONTAGIOUS ASPECT BASED ON REPORTING AND HOW WE DISCUSS IT. I THINK WE NEED TO KEEP THAT AT THE FOREFRONT. BUT ALSO BE MINDFUL OF DIFFERENTIATING STIGMA LANGUAGE, STIGMA IS ABOUT PEOPLE, IT'S NOT ABOUT SUICIDE OR OTHER ITEMS. WHEN YOU ENTER THE ADDICTION SPACE IT GETS TRICKY TO DIFFERENTIATE THE PERCEPTION OF HARM OF SUBSTANCES FROM THE STIGMA AGAINST INDIVIDUALS. THERE SHOULD BE A PERCEPTION OF HARM AROUND SUICIDE, HARM TO YOUR FAMILY, HARM TO YOUR COMMUNITY. HARM TO YOUR LOVED ONES. WHILE NOT HAVING STIGMA AGAINST THOSE THAT HAVE SERIOUS MENTAL ILLNESS OR STRUGGLING WITH MENTAL HEALTH DISORDERS THAT ARE DOING IT. I THINK MAKING SURE OUR VOCABULARY IS SORT OF MINDFUL OF DIFFERENTIATING STIGMA VERSUS PERCEIVED HARM, STIGMA IS ABOUT WHAT WE SORT OF YOLK ON PEOPLE THAT ARE DEALING AND STRUGGLING WITH THINGS WHETHER ADDICTION OR MENTAL ILLNESS. >> WE WILL GO TO THE PRESENTATION. DISPL THIS IS AN INCREDIBLY IMPORTANT DISCUSSION AND I STRONGLY SUPPORT EXPANDING THE PORTFOLIO ONCO MORBIDITY RESEARCH, THIS HAS COME UP A FEW PRIOR COUNCIL MEETINGS AND IT'S GREAT TO SEE HOW MUCH MOMENTUM THIS TOPIC IS GETTING AT THIS COUNCIL THAN IN THE PAST AND I WANT TO UNDERSCORE THAT. I WANTED TO BRING UP A DIFFERENT TOPC WHICH IS A FEW COUNCIL MEETINGS AGO WE REVIEWED A FAIRLY DETAILED PROPOSED SET OF RESEARCH GAPS AND OPPORTUNITIES IN CANNABIS RESEARCH. AND THIS WAS GENERATED BY A COMMITTEE WHICH INCLUDED SOME MEMBERS OF COUNCIL. AND I WANTED TO JUST REVISIT THAT IN HERE WHERE THAT DISCUSS HAS GONE BECAUSE I HAVEN'T -- PERHAPS MISSED BUT I HAVEN'T SEEN A LOT IN PRIOR OCCURRENCE SORT OF CONCEPT PROPOSALS BEING PRESENTED, OR FUNDING REQUESTS IN THIS SPACE. AND I -- NORA AND THE FUNDED PORTFOLIO AND GIVEN WHAT YOU HAVE PRESENTED THIS MORNING WHAT WE ARE TALKING ABOUT, THE CHANGING LANDSCAPE OF CANNABIS AND LOT OF CONCERN AROUND WHAT'S HAPPENING RAPIDLY IN THE U.S. GIVEN WHAT CHRISTIAN WAS MENTIONING THE INTERSECTION WITH MENTAL HEALTH, SO MANY RESEARCH OPPORTUNITIES AND SO MANY GREAT IDEAS IN THAT LIST GENERATED BY THAT COMMITTEE AND I WANT TO ENCOURAGE US NOT TO LOSE PRIORITY FOCUS ON THE OPPORTUNITY AND NEED FOR ROBUST PORTFOLIO IN CANNABIS RESEARCH WHILE WE ARE ALSO WORKING ALL THESE OTHER INCREDIBLY IMPORTANT AREAS AS WELL. >> ABSOLUTELY. WHAT WE CAN DO IS ACTUALLY IN THE NEXT COUNCIL SESSION, HAVE A SECTION SPECIFICALLY TARGETED. BUT SUSAN WHO IS ALWAYS ON TOP OF EVERYTHING JUST HANDED ME, WE DID PUT NOTICE OF SPECIAL INTEREST FOR PUBLIC HEALTH RESEARCH ON CANNABIS. WE ALREADY DID THAT. >> IT JUST CAME OUT. >> WE WILL BE HAPPY TO DO IT AND GET YOUR FEEDBACK IN TERMS OF WHAT AREAS AND WHERE WE SHOULD BE GOING. THE OTHER ASPECT YOU MAY NOT BE AWARE BUT THIS IS A STRUGGLE WE ALWAYS ARE COMING BACK, WE HAVE A LIMITED AM OF RESOURCES SO HOW MUCH DO WE COMMIT THOSE RESOURCES INTO VERY SPECIFIC REQUEST FOR PROPOSALS. AT THE SAME TIME PROTECTING RESOURCES THAT WILL ALLOW ANY INVESTIGATOR TO COME UP WITH THE IDEAS. WHICH I DON'T WANT TO CURTAIL. IT IS A BALANCE WE IDENTIFY PRIORITY AREAS BUT AT THE SAME TIME I WANT TO BE RESPECTFUL OF BUT I THINK IT MAYBE A VERY GOOD SUBJECTS FOR NEXT COUNCIL. BUT I'M GOING TO STOP HERE BECAUSE I'M VERY HAPPY THAT TODAY WE ARE HERE FOR A TREAT. WE HAVE THE NEW DIRECTOR FOR THE NATIONAL CENTER FOR COMP MEN TIR TEAR AND INTEGRATIVE HEALTH DR. HELENE LANGEVIN WHO CAME TO NIH, ONE YEAR AGO? EIGHT MONTHS AGO. BEFORE SHE CAME HERE, SHE SERVE AS DIRECTOR OF THE OSHA CENTER FOR INTEGRATIVE MEDICINE AT BRIGHAM AND WOMEN'S HOSPITAL IN HARVARD MEDICAL SCHOOL, CHRONIC MUSCULO SKELETAL PAIN AND MECHANISMS OF ACUPUNCTURE, MANUAL AND MOVEMENT BASE THERAPIES. SHE OVERSEES PORTFOLIO ANSWERING IMPORTANCE SCIENTIFIC PUBLIC HEALTH QUESTIONS ABOUT NATURAL PRODUCTS MIND AND BODY PRACTICES AND PAIN MANAGEMENT. IT HAS BEEN A PLEASURE ALSO TO WORK WITH HELENE IN THE HEEL INITIATIVE BECAUSE OF COURSE WITH HER EXPERTISE SHE HAS A VERY NEW FRESH PERSPECTIVE HOW WE CAN DO MORE INTEGRATIVE TREATMENT INTO THE MANAGEMENT OF OPIOID USE DISORDER. SO HELENE THANK YOU FOR TAKING THE TIME AND COMING AND SPEAKING TO NIDA COUNCIL. WELCOME. [APPLAUSE] >> YES. YES. YES. >> THANK YOU SO MUCH, NORA. IT REALLY TRULY IS A MEASURE FOR ME -- PLEASURE TO BE HERE AND I LOOK FORWARD TO DISCUSSION ON REALLY SORT OF COMMON INTERESTS AND GOALS THAT WE HAVE WITH NIDA . WE ARE CONCERNED ABOUT THE WELFARE OF PATIENTS ESPECIALLY IN THE CONTEXT OF THESE SERIOUS PROBLEMS WE HAVE WITH ADDICTION BUT ALSO WITH PAIN. THE INTERSECTION OF THE TWO IS SUCH AN IMPORTANT TOPIC. I WANT TO GIVE YOU AN OVERVIEW OF WHAT OUR AREAS OF FOCUS IS AT NCCIH. AND I'M GOING TO START BY THE C. COMPONENT OF NCCIH. WHICH IS COMPLIMENTARY. WHAT DOES THAT MEAN? IT'S AN INTERESTING BECAUSE WE SPEND A LOT OF TIME THINKING ABOUT THAT OURSELVES. IT USED TO BE WE USED TO CALL ALTERNATIVE TREATMENTS. AND THAT WE DIDN'T REALLY LIKE THAT. WE WANTED TO MOVE TOWARDS COMPLIMENTARY BECAUSE THE TYPES OF TREATMENTS THAT WE TU DI AT NCCIH ARE NOT CONSIDERED TO BE USED INSTEAD OF. CONVENTIONAL, THEY ARE MEANT TO BE USED TOGETHER WITH. SO WHAT ARE THESE TYPES OF TREATMENT? WELL, THERE ARE THREE BROAD CATEGORIES OF TREATMENTS, ONE WE CALL NUTRITIONAL. AND THE OTHER ONE MIGHT BE PSYCHOLOGICAL AND THE OTHER ONE MIGHT BE PHYSICAL. SO WHAT DOES THAT LOOK LIKE? THIS KIND OF A MAP OF THE TYPES OF NOT MEANT TO BE EXCLUSIVE, BUT THE TYPES OF TREATMENT THAT THOSE WHAT WE CALL COMPLIMENTARY TREATMENT. AND AS YOU CAN SEE HERE, I GUESS I CAN USE THE POINTER. SO THAT IS THE ADVANCE -- THE POINTER IS WHICH? TINY POINTER. THAT'S PROBABLY STRONGER. SO IN NUTRITIONAL SORT OF AREA, WE HAVE THINGS LIKE FOR EXAMPLE NUTRITIONAL SUPPLEMENTS, NATURAL PRODUCTS WE CALL INCLUDING PRODUCTS DERIVED FROM CANNABIS. WE HAVE DIFFERENT TYPES OF PRO BUYIOTICS FOR EXAMPLE. AND INTERESTINGLY ENOUGH, SOME OF THESE PRODUCTS REALLY GET USE A LOT LIKE DRUGS. ESPECIALLY WHEN PURIFIED AND A LOT OF DRUGS ESSENTIALLY START FROM NATURAL PRODUCTS SO THERE IS A BIT OF AN OVERLAP BETWEEN NUTRITIONAL TREATMENTS OR COMPONENTS AND PHARMACO LOGICAL DRUGS. IN THE PSYCHOLOGICAL AREA, WE HAVE A VARIETY OF DIFFERENT TYPES OF TREATMENT, OFTEN TIME DIFFICULT TO DETERMINE THE BOUNDARY BETWEEN WHAT IS COMPLIMENTARY AND WHAT IS MAINSTREAM. FOR EXAMPLE, COGNITIVE BEHAVIOR THERAPY, THIS IS YOU WOULD SAY A RATHER CONVENTIONAL TYPE OF PSYCHOTHERAPY BUT INCREASINGLY COGNITIVE BEHAVIORAL THERAPY TREATMENTS WILL INCORPORATE ELEMENTS OF MINDFULNESS FOR EXAMPLE BASED MEDITATION OR RELAXATION TECHNIQUES. SO SIT'S ALMOST LIKE THE FIELDS ARE BLEEDING INTO ONE ANOTHER. YOU SEE A LOT OF THIS ALSO GOING ON IN THE PHYSICAL THERAPY FIELD. IN THE PHYSICAL REALM. PHYSICAL THERAPISTS ARE INCREASINGLY CROSS TRAINING AND GOING AND TAKING WORKSHOPS IN MASSAGE AND CHIROPRACTIC SPINAL MANIPULATION, USED TO BE MORE PERFORMED BY SPECIFIC PROFESSIONAL GROUPS BUT NOW THERE'S MUCH MORE CROSS FERTILIZATION I WOULD SAY SO INCREASINGLY WE ARE TALKING MORE ABOUT INTEGRATION. SO WHAT DOES THAT -- INTEGRATION MEAN? THE WORD -- THIS IS THE I WORD HERE. CLASSICALLY WE THINK OF INTEGRATION AS BRINGING COMPLIMENTARY OR WHAT USED TO BE ALTERNATIVE TREATMENTS, TOGETHER AND COORDINATING THEM IN THE CARE OF A PATIENT. BUT AT NCCIH WE ARE THINKING OF THE WORD INTEGRATION IN A LARGER SENSE. WHAT DOES THAT MEAN? IT'S REALLY MEAN ARRIVING AT UNDERSTANDING OF THE WHOLE PERSON AS A UNIT. AND NOT JUST FROM POINT OF VIEW OF TREATMENT. ALSO FROM THE POINT OF VIEW OF BASIC PHYSIOLOGY AND PATHOPHYSIOLOGY. SO WHAT DO I MEAN BY THAT? A LOT OF TIMES, IT IS FAIR TO SAY IF YOU ASK PATIENTS THEY WILL COMPLAIN A LOT THAT THEY REALLY FEEL THEIR HEALTHCARE IS FRAGMENTED. YOU GO TO LIKE THE FOOT DOCTOR FOR YOUR FOOT AND LUNG DOCTOR FOR YOUR LUNG. EVEN THOUGH I WOULD SAY PRIMARY CARE FOR EXAMPLE IS MAKING A GREAT EFFORT IN REALLY TREATING THE WHOLE PERSON BUT OUR SYSTEM OF MEDICINE IS REALLY BY NATURE VERY SPECIFICKIZED. AND THIS -- SPECIALIZED. THIS DERIVES FROM THE VERY ORGANIZATION OF MEDICINE, BASED ON HOW PHYSIOLOGICAL SYSTEMS WERE MAPPED OVER A CENTURY AGO. LATE 19TH CENTURY, CARDIOVASCULAR RESPIRATORY, ET CETERA, GASTRO INTESTINAL SYSTEMS HAVE KIND OF DETERMINED THE STRUCTURE OF OUR ACADEMIC MEDICAL SCHOOLS. AND OF OUR MEDICAL SPECIALTIES. SO WE REALLY DO TEND TO SEE THE BODY AS A SET OF DIFFERENT SYSTEMS. IT'S A LOT EASIER TO STUDY A SYSTEM WITHIN ITSELF THAN TO UNDERSTAND THE CONNECTION BETWEEN A SYSTEM. THERE ARE SYSTEMS INHERENTLY CONNECTED TO ALL THE OTHERS. THE NERVOUS SYSTEM, WE UNDERSTAND A LOT, CONNECTIONS BETWEEN THE NERVOUS SYSTEM AND THE OTHER ORGANS BECAUSE WE KNOW ABOUT THE AUTONOMIC NERVOUS SYSTEM. BUT THINK ABOUT OTHER EXAMPLES. SO GASTRO INTESTINAL SYSTEM AND IF YOU WERE ASKED SOMEBODY WHO -- TO DO YOGA FOR EXAMPLE OR IS IT POSSIBLE THAT HOW YOU BREATHE INFLUENCES YOUR DIE YES, DIGESTION? SOME PEOPLE WOULD SAY YES. BUT IF YOU DO A PUBMED SEARCH FOR ANYTHING PULMONARY AND GI, YOU GET ALMOST NOTHING WHEN YOU COMBINE THEM TOGETHER. WHY IS THAT? GASTRO INTESTINAL AND PULMONARY RESEARCH IS OCCURRING IN DIFFERENT GROUPS OF PEOPLE SOMETIMES DIFFERENT DEPARTMENTS, SOMETIMES DIFFERENT BUILDINGS AND THERE IS VERY LITTLE CROSS FERTILIZATION AT THAT LEVEL. SO YOU KNOW, I THINK THIS IS SOMETHING WORTHY OF SOME THOUGHT. I WANT TO FOCUS ON AN AREA OF WHAT I FEEL IS A DISCONNECT THAT IS A PARTICULAR RELEVANCE TO PAIN. AND THIS IS THE BRAIN AND REST OF THE BODY. THIS IS AN AREA THAT I THINK WE NEED TO MAKE A LOT OF PROGRESS ESPECIALLY IN THE AREA OF MUSCULO SKELETAL PAIN. I THINK THAT IT'S FAIR TO SAY THAT I WOULD SAY MOST OF THE 20TH CENTURY UNTIL ABOUT I WOULD SAY 20 YEARS AGO OR SO, WE USED TO THINK OF MUSCULO SKELETAL PAIN VERY MUCH IN THE IN TERMS OF ORTHO PEE ORTHO PEEDIC PROBLEM. WHAT IS THE PART THAT NEEDS TO BE FIX AND HOW? USUALLY SURGERY OR SOME PHYSICAL MODALITY PHYSICAL THERAPY, ET CETERA. BUT THERE WAS -- AROUND THE TURN OF THE 21ST CENTURY REALLY, THERE WAS A SHIFT IN EMPHASIS TO MORE THE NEUROLOGICAL AND EFFECTIVE COMPONENTS OF PAIN IN ENGINE AND MUSCULO SKELETAL PAIN FOLLOWED SUIT. IN THAT WE REALLY STARTED TO GET MUCH MORE INTERESTED IN WHAT IS GOING ON IN THE BRAIN WHEN PEOPLE HAVE SPECIALLY CHRONIC PAIN? VERY, ERY IMPORTANT PROBLEM. WE KNOW THAT THERE ARE A LOT OF IMPORTANT CHANGES THAT OCCUR IN THE BRAIN AS THE PAIN TRAN SIGNATURES FROM ACUTE TO CHRONIC . THE PAIN BECOMES VERY SELF-AMPLIFYING, THERE ARE PERIPHERAL AND CENTRAL SENSITIZATION THAT HAPPENS. NEUROPLASTIC CHANGES OCCUR. WE UNDERSTAND WE CAN SEE THAT THERE ARE STRUCTURAL CHANGES EVEN IN THE BRAIN THAT OCCUR IN PATIENTS WITH CHRONIC PAIN. SO WE REALLY STARTED TO THINK MORE ABOUT CHRONIC PAIN AND CHRONIC MUSCULO SKELETAL PAIN AS DISEASE OF THE BRAIN. HOWEVER, THERE'S IMPORTANT RESEARCH THAT IS STILL GOING ON IN THE BACKGROUND, A LOT PHYSICAL THERAPY REALM THAT KEEPS REMINDING US THAT IT'S IMPORTANT TO REALLY KEEP THINKING ABOUT THE BODY AS WELL. NOT FORGET THE BRAIN OF COURSE. WHY IS THAT? WE REALLY KNOW THAT THE WHOLE MUSCULO SKELETAL SYSTEM IS COMPOSED, REALLY A SCAFFOLD. IT'S COMPOSED AND I REPRESENTED HERE IN THIS DIAGRAM OF STRUTS AND CABLES. SO THE COMPRESSION ELEMENT ARE THE BONES, THEN YOU HAVE THE CONNECTIVE TISSUE THAT SURROUNDS THAT THAT PROVIDES APPROXIMATE ELEMENT AND THAT'S CONNECTIVE TISH -- PROTECTIVE TISSUE AND YOU HAVE MUSCLES PULLING ON THESE STRUCTURES AND INFLUENCING THEIR REMODELING BECAUSE WE KNOW OUR ENTIRE SCAFFOLD REMODELS OVER TIME. IT REMODELS IN RESPONSE TO MECHANICAL FORCES EXERTED BY MUSCLES ON THE CONNECTIVE TISSUES THAT RESPOND TO THIS AND CHANGE SHAPE. IN RESPOND TO THE FORCES. THIS HAPPENS OVER OUR ENTIRE LIFE. IMPORTANTLY, THE CONNECTIVE TISSUE RESPONDS TO THE MOVEMENTS THAT WE DO. BUT ALSO TO THE MOVEMENTS THAT WE DO NOT DO. IF YOU SPEND TIME IN A HABIT OF POSTURE AND YOU DO NOT MOVE IN A SPECIFIC DIRECTION SOON YOU CAN'T MOVE IN THAT DIRECTION BECAUSE THE CONNECTIVE TISSUES REMODEL AND YOU BECOME TOO STIFF TO MOVE IN THAT DIRECTION. SO THIS IS A STLAWRL REMODELING WHICH KIND OF SETS THE STAGE -- STRUCTURAL REMODELING WHICH SETS THE STAGE. WHAT HAPPENS AFTER THAT? WHEN MUSCLES BECOME UNBALANCED, SOME OF THEM BECOME SHORTENED, OTHERS LENGTHENED, IF POSTURE IS ASYMMETRIC AND THAT DOES NOT FAVOR A GOOD FUNCTION OF THE MUSCLE WHICH CAN BECOME WEAK AND ATROPHY AND BECOME INFILTRATED WITH FAT OR AD POSE TISSUE WHICH DOES NOT PROVIDE ADEQUATE SUPPORT THE LIGAMENTS THAT SUPPORT IT IS SKELETON. SO THIS PRE-DISPOSES TO INJURIES. WE KNOW THIS. SO INJURIES DON'T NECESSARILY HAPPEN TO BE VERY BIG OR DRAMATIC. IF YOU SHOVEL TOO MUCH SNOW, IF YOU HAVE THIS KIND OF ACUTE BACK SPRAIN OR SPRAIN IN YOUR NECK USUALLY WHAT HAPPENS IS THERE IS INFLAMMATION THAT PEAKS ABOUT 48, 72 HOURS, YOU HAVE PAIN A WHILE THEN IT TBOAS AWAY. BUT SOMETIMES IT DOESN'T AND SOMETIMES PAIN BECOMES CHRONIC. THERE'S A LOT OF DEBATE IN THE LITERATURE ABOUT WHETHER CHRONIC MUSCULO SKELETAL PAIN IS ACCOMPANIED BY CHRONIC INFLAMMATION. WE KNOW THERE'S NOT A LOT OF RESEARCH IN THIS AREA BUT THERE ARE SOME ANIMAL MODELS THAT SUGGEST THAT THERE IS. THIS IS A NICE EXAMPLE OF REPETITIVE MOTION MODEL INDUCED VOLITIONALLY, RATS TRAINED TO PULL A LEVER TO GET A REWARD. THEY ARE NOT FORCED TO DO THIS MOVEMENT THEY DO IT VOLUNTARILY BUT THE FORCE THAT THEY HAVE TO EXERT GRADUALLY THEY DEVELOP SORT OF ALMOST LIKE A CARPAL TUNNEL SITUATION, WHERE THEY DO GET CHRONIC INFLAMMATION IN THE CONNECTIVE TISSUES OF THE LIMB THEY PREFER. THIS IS ACCOMPANIED BY CHRONIC INFLAMMATION. SO THERE IS SOME EVIDENCE THAT HAVE THE INFLAMMATION IN THE TISSUES CAN BE ONGOING. NOW, OVER TIME, INFLAMMATION LEADS TO FIBROSIS, THIS IS A CONSEQUENCE OF EVEN IF THE INJURIES HEAL, THE LAYERS THAT ARE NORMALLY SUPPOSED TO GLIDE AND MOVE PAST ONE ANOTHER BECOME FUSED AND DON'T MOVE AND THIS REDUCTION CHANGES OF MOVEMENT CHANGES THE BIOMECHANICAL STRUCTURE WHICH THEN PRETTIES POSES TO MORE SERIOUS INJURY SUCH AS DEGENERATION OF CARTILAGE PANNED INTERVERTEBRAL DISC THAT LEADS TO MORE SERIOUS PROBLEMS THAT ARE AT THAT POINT LESS REVERSIBLE. NOW, SOMETIMES THERE IS NO -- IF THERE'S FOR EXAMPLE A COMPRESSION OF NERVE ROOT STARTS TO GET NEUROLOGICAL SYMPTOMS THERE IS NO CHOICE TO HAVE SOMETHING LIKE A SPINAL FUSION, WHICH THEN VERY OFTEN RESULTS IN A CONSIDERABLE AMOUNT OF PROBLEMS THAT CAN OCCUR INCLUDING CHRONIC PAIN THAT PERSISTS. SO WHAT CAN WE DO ABOUT THIS? GOOD NEWS IS THAT UP AND TO CERTAIN POINT ALL THE CONNECTIVE TISSUE AND MUSCLE CHANGES THAT I WAS JUST DESCRIBING ARE REVERSIBLE. MUSCLES CAN BE RETRAINED IF THE MOVEMENT IS PERFORMED IN AN APPROPRIATE WAY AND ESPECIALLY IF THERE IS A MINDFUL ATTENTION TO MOVEMENT AND STRETCHING BEING PERFORMED. SO TECHNIQUES SUCH AS YOGA CAN BE USED FOR GRADUAL REHABILITATION AS LONG AS THEY ARE PERFORMED VERY CAREFULLY UNDER THE GUIDANCE OF A PROFESSIONAL. THIS IS VERY IMPORTANT, I CANNOT STRESS ENOUGH. AND THIS IS IMPORTANT ALSO THAT WE NEED TO DO RESEARCH TO UNDERSTAND WHAT EXACTLY ARE THE BIOMECHANICAL PARAMETERS THAT GUIDE WHAT IS A BENEFICIAL PROVEMENT VERSUS A PROVEMENT THAT IS GOING TO -- MOVEMENT THAT WILL FURTHER INJURE THE JOINT. ANOTHER TYPE OF TECHNIQUE THAT CAN BE VERY HELPFUL FOR REDUCING THESE FIBROTIC CHANGES AND REVERSING THEM, LIBERATING THE CONNECTIVE TISSUES AN ALLOWING MOVEMENT TO TAKE PLACE ARE MANUAL THERAPY SUCH ASTHMA SAJ. I'LL SHOW YOU -- AS, MASSAGE, THIS IS USING THE SAME RAT MODEL I SHOWED YOU BEFORE WHERE REPET AT THIS TIME MOTION WAS INDUCED BY PULLING THE LEVER AND THEN RANDOMIZED RATS TO MASSAGE. THERE IS A WONDERFUL VIDEO WHICH I WON'T SHOW YOU NOW BUT IF YOU ARE CURIOUS BE HAPPY TO SEND YOU THE LINK, THESE RATS ARE CONSCIOUS, HELD COMFORTABLY BY THE THERAPIST WHO MASSAGES THEIR LIMB AND THEY ARE PERFECTLY HAPPY. THE RATS WHO BECAME MASSAGED NOT ONLY DID NOT DETERIORATE FUNCTION BUT IMPROVED FUNCTION OVER THE COURSE OF THE EXPERIMENT VERSUS THE NON-MASSAGE RATS. STAYED PRETTY MUCH THE SAME. AND ALSO THE DER MISCOLLAGEN -- COLLAGEN CONTENT WAS NORMAL SO LESS FIBROSIS IN RESPONSE TO THE CHRONIC REPETITIVE MOVEMENT. ANOTHER STUDY WHERE THEY LOOKED AT PERINEURAL FIBROSIS AS WELL AS MARKERS OF NEURAL DEGENERATION AND THEY FOUND MASSAGE RATS BOTH IMPROVE SOD THIS IS LAND MARK RESEARCH JUST PUBLISHED THAT NCCIH FUNDED. IN MY OWN LAB, THIS WAS WORK THAT WAS AT -- FROM WHEN MY LAB AT THE BRIGHAM WOMEN'S HOSPITAL WE LOOK AT STRETCHING IN RATS, AGAIN CONSCIOUS RATS, THAT WE GENTLY COAXED TO STRETCH AND BY GENTLY SUSPENDING THEM HOLDING THEM BY THE BASE OF THE TAIL, VERY GENTLY, ALLOWING THEM TO GRASP TO THE EDGE OF A BAR, THEN THEY GRADUALLY STRETCHED THE ENTIRE TRUNK AND WE DID THIS FOR TEN MINUTES AS TOLERATED, ONCE A DAY. AND THERE WAS -- THIS WAS A MODEL OF CHRONIC INFLAMMATION OF THE SUBCUTANEOUS TISSUES OF THE BACK. THERE WAS REDUCTION IN PAIN SENSITIVITY AS WELL AS REDUCTION IN TOTAL NUMBER OF MACRO FAINLS IN THE TISSUE -- MACROPHAGES IN THE TISSUE. THIS IS IMPORTANT TO THINK THAT STRETCHING MAY BE GOOD -- WE KNOW THAT IT FEELS GOOD TO STRETCH. BUT STRETCHING ON A DAILY BASIS MAY BE ALSO VERY IMPORTANT FOR THE HEALTH OF THE TISSUES. WE ALSO FOUND THAT THE MECHANISM BY WHICH THE INFLAMMATION WAS REDUCED INVOLVED ACTIVATION OF A NATURAL PRO-RESOLUTION MECHANISM WE ALL HAVE ENDOGENOUSLY THAT INVOLVES MOLECULES THAT ARE DERIVED FROM DIETARY FATTY ACID, LIKE FOR EXAMPLE, FISH OIL, EPA AND DHA THAT LEADS TO PRODUCTION OF THESE PRO RESOLVING MEDIATORS. THESE ARE MEDIATORS THAT TERMINATE INFLAMMATION, THEY ARE NOT ANTI-INFLAMMATORY, THEY ALLOW THE NATURAL INFLAMMATION TO TAKE ITS COURSE BUT WHEN INFLAMMATION IS NO LONGER NEEDED, IT NEEDS TO END. WHEREAS IF THE BALANCE IS IN FAVOR OF PROINFLAMMATORY MEDIATORS, CHRONIC INFLAMMATION AND FIBROSIS ENSUES SO IN OUR INFLAMED RATS, THE PRO RESOLVING MEDIATORS WERE INCREASED AT THE SAME TIME THE INFLAMMATION WAS REDUCED. SO THIS SUGGESTS THE SORT OF THE SUPPORT THAT STRETCHING PROMOTES OR SUPPORTS A NATURAL ENDOGENOUS MECHANISM OF HEALING. THE OTHER THING THAT THIS SUGGESTS IS YOU REMEMBER I WAS TALKING ABOUT THE INTERFACE BETWEEN THE BODY SYSTEMS. WE THINK OF THE MUSCULAR SYSTEM BEING MORE CONCERNED WITH BODY MOVEMENT AND MECHANICAL FORCES. AND WE THINK OF THE IMMUNE SYSTEM AS BEING THIS KIND OF BIG SORT OF WHOLE BODY SOUP, WHERE THE IMMUNE CELLS ARE CIRCULATING AND FLUID OR WHEREVER IT IS AND LOOKING FOR TROUBLE AND REPORTING BACK TO THE LYMPH NODES BUT IF WE THINK ABOUT IT, A LOT OF TERRAIN IN WHICH A LOT OF THESE IMMUNE RESPONSES TAKE PLACE, ARE IN CONNECTIVE TISSUE, WHEN THE IMMUNE CELLS LEAVE BLOOD VESSELS WHERE TO THEY GO? NOT EXTRA CELLULAR SPACE, NO. THEY ARE GOING TO CONNECTIVE TISSUE. THAT IS WHERE THEY DO A LOT OF THEIR WORK. AND THEY GET -- GO BACK TO LYMPH NODES. SO THE MECHANICAL ENVIRONMENT OF THE CONNECTIVE TISSUE MAYBE IMPORTANT FOR REGULATING THOSE IMMUNE RESPONSES. SO AGAIN, CONNECTION BETWEEN MUS MUSCULO SKELETAL SYSTEM AN IMMUNE SYSTEM VIA MOVEMENT. THIS IS AN AREA AGAIN ACROSS SYSTEM INTEGRATION WE THINK COULD BE VERY IMPORTANT FOR UNDERSTANDING HOW THE BODY WORKS BUT ALSO HOW SOME OF THESE TRIEMENTS -- TREATMENTS CAN WORK. ONE REASON WE ARE STUCK RIGHT NOW IN MUS MUSCULO SKELETAL PAIN RESEARCH, THERE IS A LOT OF RESEARCH BUT IT'S SILOED. THERE IS A LOT OF RESEARCH IN NEUROSCIENCE IN THE PAIN ASPECT OF THE BRAIN AND NEUROLOGICAL AND NEUROSCIENCE NEUROPHYSIOLOGICAL ASPECTS OF PAIN, THERE IS LOT OF PHYSICAL THERAPY REESSENTIAL ON MOTOR BEHAVE -- RESEARCH ON MOTOR BEHAVIOR MOTOR PATTERNS MORE BIOCHEMICAL AND STRUCTURAL TISSUES ON BIONKAL FORCES, -- BIOMECHANICAL FORCES, IN TERMS OF INMA'AMTORY RESPONSES BUT THERE IS NOT A LOT OF RESEARCH THAT REALLY PUTS THIS WHOLE PICTURE TOGETHER. THAT IS WHAT WE NEED. CLEARLY, THERE IS NOT ONE SINGLE EXPERIMENT THAT CAN ADDRESS ALL FOR US, AS FUNDING AGENCIES WE CAN PROMOTE THAT, WE CAN PROMOTE THIS THINKING BY FOSTERING SAY PROGRAMS OR ENCOURAGING INVESTIGATORS TO WORK ACROSS DISCIPLINES. SO I THINK THIS IS SOMETHING WHERE WE CAN MAKE A LOT OF PROGRESS BY HAVING AN INTEGRATIVE APPROACH. SO FINALLY, THE LAST LETTER OF NCCIH, HEALTH, ADDRESSES A ASPECT OF HEALTH THAT I THINK IS NOD ENOUGH APPRECIATED, WHICH IS, WHAT WE REFER TO AS HEALTH RESERVATION. WE THINK OF HEMENT -- HEALTH, WHAT IS HEALTH REALLY? IF YOU WILL INDULGE ME A MINUTE, I WOULD INVITE YOU TO CONSIDER THESE THREE PLANTS, THE PLANT ON THE LEFT LOOKING HEALTHY ENOUGH BUT THE PLANT ON THE RIGHT LOOKS LIKE IT HAS A DISEASE. THE MIDDLE PLANT? DOESN'T LOOK WELL BUT IF YOU HAVE SENSE IT GOT MORE CARE PERHAPS MAYBE A LITTLE LESS WATER OR MAYBE A LITTLE MORE SUN SHINE, IT MIGHT GO BACK TO THAT AT SOME POINT, WHEREAS THIS ONE MAY NEED A LITTLE BIT MORE DRASTIC OR IT MIGHT DIE. SO THE IDEA IS THERE ARE INTERMEDIARY STAGES BETWEEN HEALTH AND DISEASE, AND WHAT ARE THEY IN HUMANS? OF COURSE, THE IDEA THAT REVERSIBILITY HERE BETWEEN DISEASE AND I CALL THIS SOMETIMES UNHEALTH, NOT REALLY HEALTH AND NOT REALLY DISEASE, MAY NOT BE AS EASY BUT HERE YOU HAVE A SENSE THAT AT THIS TIME'S QUITE POSSIBLE. IN HUMANS Z BECAUSE WE ARE NOT PLANTS WE HAVE THE ABILITY TO INFLUENCE OUR OWN IRMT VOO. -- OWN ENVIRONMENT. TO SOME DEGREE, NOT COMPLETELY, BUT WE MAKE CHOICES. WHAT FOODS WE EAT, WHAT WE DO. ET CETERA. SO A GOOD EXAMPLE OF THIS WHERE THERE'S A TRANSITION BETWEEN HEALTH AND DISEASE, THE INTERMEDIATE AREA STAGES WE NO A LOT ABOUT IS DIABETES OBVIOUSLY. YOU START WITH SMOB WHO IS HEALTHY, -- SOMEBODY WHO IS HEALTHY, HAS NO EVIDENCE OF METABOLIC FUNCTION IS FINE. THEN THAT PERSON STARTS TO INDULGE TOO MUCH IN DIET AND DIET, THEY START TO GAIN WEIGHT. SOON YOU START SEEING EVIDENCE OF NOT YET DIABETES BUT GLUCOSE INTOLERANCE. AND AT SOME POINT THERE'S A CROSS OVER TO A POINT WHERE THERE IS FRANK DIABETES. THERE IS THE DEBATE AT THE MOMENT WHERE EXACTLY IS THIS LINE BETWEEN PRE-DIABETES AN DIABETES. WHEN SHOULD WE START IN TYPE 2 DIABETES, WHEN SHOULD WE START ORAL MEDICATION TO REDUCE THE BLOOD SUGAR? AND TREAT THE HYPERINLYNNEMIA. THIS STAGE IF WE KNOW IF AN INDIVIDUAL IS ABLE TO LOSE WEIGHT THEY CAN GO BACK SO IT IS STILL REVERSIBLE. THE QUESTION IS, IS THE TREATMENT, IS THE BEHAVIORAL TREATMENT GOING TO BE SUCCESSFUL OR NOT? IS IT GOING TO BE IMPLEMENTED? IS THE PATIENT GOING TO DO IT? SO WE ARE VERY GOOD OBVIOUSLY IN IN DISEASE, WHERE MEDICIN IS JUST THE STRONGEST. WE KNOW HOW TO CONTROL DISEASE, WE KNOW HOW TO MANAGE DISEASE. WE ARE VERY EXCELLENT AT STOPPING THE PROGRESSION AT THIS STAGE, WE ALSO KNOW A LOT HOW TO PREVENT DISEASE, WE HAVE STRATEGIES THAT ARE EFFECTIVE PREVENTING DISEASE FROM HAPPENING. WHAT ABOUT GOING ON -- IN THE GREEN ARROW DIRECTION? NOT JUST PREVENTING DISEASE BUT ALSO RESTORING HEALTH. THIS IS AN AREA WE DO NOT HAVE AS MUCH KNOWLEDGE. IF YOU READ BOOKS FOR EXAMPLE OF NOVELS FROM LIKE 19TH CENTURY, THERE IS A LOT OF ATTENTION PAID TO WHAT PEOPLE USED TO CALL CONVALESCENCE. WHAT HAPPENS WHEN YOU HAVE BEEN SICK BUT NOT QUITE SICK T YET, YOU ARE NOT SICK ANY MORE BUT NOT QUITE HEALTHY. WHAT NEEDS TO HAS HAPPEN TO GO BACK TO HEMENT, ARE THERE -- HEALTH, ARE THERE STEPS SOMEBODY CAN TAKE? ARE THERE TREATMENTS OR SUPPORTIVE APPROACHES THAT CAN HELP THE PERSON GO BACK TO FULL HEALTH? WE DON'T STUDY THAT MUCH, THIS IS AN AREA AT NCCIH WE WANT TO EXAMINE THOSE MECHANISMS, WHAT ARE THE MECHANISMS OF RESTORATION? A LOT ARE WORDS THAT BEGINS WITH RE. SO REPAIR, REGENERATION, THIS RESOLUTION I WAS TELLING YOU ABOUT, INFLAMMATORY RESOLUTION, ROW SILL YENS RESILIENCE IS A PSYCHOLOGICAL MECHANISM. ALL CIENTDZ OF MECHANISMS THAT HAVE TO DO WITH RETURN. BACK TO HEALTH. I SHOWED YOU ANOTHER EXAMPLE THAT I THINK THAT CAN APPLY NICELY TO THIS MODEL OF HEALTH TO DISEASE. SOFT POSTURE DETIER YOUR RAYING FOLLOWED BY MORE SMALL LITTLE INJURIES THAT DON'T NECESSARILY ARE NOT DIAGNOSED AS ANYTHING SPECIFIC OTHER THAN NON-SPECIFIC PAIN, DISJOINT DISEASE THAT NEEDS TREATMENT. SO I THINK THAT THIS IS THE OPPORTUNITY HERE. THIS WHOLE AREA BEFORE DISEASE BECOMES MANIFEST. THERE IS OTHER IMPORTANT CO-MORBID CONDITIONS THAT OCCUR THAT AT THE SAME TIME SOMEBODY WILL GO AND TRANSITION TO CHRONIC PAIN THAT AT THE SAME TIME WE SEE A LOT OF THE SEA OF THESE TYPES OF PROBLEMS. PSYCHOLOGICAL STRESS WHICH CAN BE CAUSED BY THE PAIN BUT CAN MAKE THE PAIN WORSE. SLEEP DISTURBANCES. WE KNOW THAT'S ALSO A TWO WAY STREET. IF YOU HAVE PAIN, IT'S DIFFICULT TO SLEEP BUT IF YOU DON'T HAVE GOOD SLEEP, PAIN SENSITIVITY GETS INCREASED. WE KNOW THIS. SO THESE ARE AREAS THAT ARE/R VERY IMPORTANT TO CONSIDER. THE GOOD NEWS T SAME TYPE O TREATMENT HELPFUL FOR MUSCULO SKELETAL PAIN ARE ALSO HELPFUL FOR DEALING WITH A LOT OF STRESS AND SYMPTOMS AND WITH THE SLEEP. SO TO CONSIDER NOT ONLY THE CO-MORBIDITY BUT ALSO THE CO-TREATMENT APPROACH AND CO-RESTORATIVE APPROACH, THIS IS AN AREA WE HAVE TO REALLY MOVE INTO. OPIATE MISUSE AND ADDICTION. I DON'T HAVE TO TELL Y'ALL THAT THESE OTHER COMPONENTS OF -- CAN BE VERY IMPORTANT NLD PUSHING SOMEBODY INTO OPIATE MISUSE AND ADDICTION. AND ALSO DEPRESSION FOR EXAMPLE. CAN BE A VERY IMPORTANT COMPONENT OF THIS. AND OF COURSE SUICIDE AND OVERDOSE WHICH IS ARE THE UNFORTUNATE ENPOINT FOR TOO MUCH PATIENTS. SO THIS IS A AREA AGAIN WHERE THE QUESTION THAT WE ARE ASKING OURSELVES, IS WELL, ALL RIGHT HOW MUCH OF THESE BEHAVIORAL AND INTERVENTIONS CAN WE USE TO PREVENT ALL THIS FROM HAPPENING? THAT IS ONE PIECE, THE SECOND PIECE, HOW MUCH CAN WE HELP RESTORE HEALTH? THIS IS I THINK A VERY BIG OPEN QUESTION. THIS IS AN AREA WHERE WE ALSO SPEND A LOT OF TIME THINKING ABOUT AND THAT IS BEING ADDRESSED AS PART OF THE HEAL INITIATIVE. SO THE HEAL INITIATIVE IS AS Y'ALL KNOW VERY WELL, IS -- HAS MANY DIFFERENT OBVIOUSLY COMPONENT AND THERE ARE TWO COMPONENTS NCCIH IS PARTICULARLY BEEN INVOLVED IN. ONE IS BRIM WHICH IS BEHAVIORAL RESEARCH TO IMPROVE ADHERENCE TO MEDICATION BASED TREATMENT. FOR UD AND THE OTHER ONE, PRISON L, PRAGMATIC AND IMPLEMENTATION STUDY FOR THE MANAGEMENT OF PAIN TO REDUCE OPIOID PRESCRIBING. WE ARE IN THE MIDDLE OF THIS, IN THE MIDDLE OF ALL FUNDING DECISIONS. BUT I WANT TO TAKE THIS OPPORTUNITY TO HIGHLIGHT ONE PAPER THAT WAS JUST PUBLISHED JUST A FEW WEEKS AGO. THAT WAS A PRECURSOR, THIS WAS A STUDY FUNDED AT NCCIH JUST PRIOR TO HEAL. BUT IT WAS PART OF AN ORIGINAL STUDY IN COLLABORATION WITH SAMSA. THIS IS A MINDFULNESS ORIENTED RECOVERY ENHANCEMENT. THAT WAS USED TO REDUCE CRAVING AMONG INDIVIDUALS WITH OPIOID USE DISORDERS AND CHRONIC PAIN, THIS IS IMPORTANT. THIS IS PATIENTS WITH CHRONIC PAIN AND THEY USED AN INTERESTING CALLED ECOLOGICAL MONETARY ASSESSMENT SO THEY WERE SENDING PEOPLE RANDOM PROBLEMS THROUGH THEIR CELL PHONES TO ASK THEM ABOUT CRAVINGS. AND THE SUBJECT, THIS WAS A SMALL PILOT STUDY, NOT A LARGE STUDY, IT WAS ONLY 30 SUBJECTS THEY RANDOMIZED TO THIS, BUT IT WAS PROMISING IN A SENSE THAT THEY WERE ABLE TO CONTROL FOR THE AMOUNT OF ATTENTION PEOPLE DEPOSIT. PEOPLE RANDOMIZED TO MINDFULNESS RECOVERY GROUP AND PEOPLE WHO RANDOMIZE TO THE USUAL CARE, BOTH HAD BALANCED AMOUNT OF TIME WITH COUNSELING. SO THIS WAS -- THEY WERE BOTH -- THEY BOTH HAD COUNSELING BUT THE DIFFERENCE IS THE MINDFULNESS GROUP FOCUSED ON AWARENESS OF CRAVINGS. AND STRATEGIES TO DEAL WITH THEM. AND SO I'M JUST GOING TO SHOW YOU A FIGURE FROM THIS PAPER WHICH IS PROVOCATIVE. THIS WAS A NUMBER OF CRAVINGS THAT PEOPLE REPORTED USING THIS KIND OF RANDOM PROMPT ASSESSMENT, THEY WERE ASKED TWICE A DAY WHETHER THEY WERE EXPERIENCING AN URGE TO TAKE OPIATES RIGHT NOW. AND THIS WAS THE TREND. OVER TIME IN THE MINDFULNESS GROUP COMPARED WITH CONTROL GROUP USUAL CARE CONTROL GROUP, IT WAS AN INTERESTING DIFFERENCE IN THE TWO GROUPS BUT WHEN PEOPLE WERE ASKED INTERESTINGLY TO DO MORE LIKE A JOURNAL, A DIARY HOW MANY CRAVINGS THEY WERE HAVING EVERY DAY TO THE INVESTIGATORS TO OUR SURPRISE, THREE TIMES AS MANY REPORTS OF CRAVINGS THROUGHOUT THE DAY IN THE MINDFULNESS GROUP. BUT THEY ALSO SAID THAT THEY FELT MORE CONTROL OVER THESE CRAVINGS. SO THEY WERE MORE AWARE OF THE CRAVINGS, BUT THEY DID NOT FEEL THESE CRAVINGS RAISED ROSE TO LEVEL OF URGE TO TAKE OPIATE. SO VERY, VERY INTERESTING. I THINK THIS IS VERY PRELIMINARY RESEARCH, IT NEEDS TO BE FOLLOWED UP, HOPEFULLY INVESTIGATORS WILL BE ABLE TO CONTINUE WITH THIS MODEL BUT I THINK THIS IS AN INTERESTING, I THINK IT'S PROVOCATIVE. AN AREA WE ARE VERY, VERY MUCH INTERESTED OF COURSE FOR PAIN AND WE HAVE BEEN FOR QUITE SOME TIME AND WE HAVE BEEN WORKING WITH NIDA ON THIS AS WELL IS IN THE MILITARY. MILITARY POPULATION HAVE DISPROPORTIONATE AMOUNT OF PAIN, LOT SUFFER FROM INJURIES DURING COMBAT OR DURING TRAINING, A LOT ARE MUSCULO SKELETAL INJURIES. AND A LOT OF PROBLEMS WITH OPIATE USE. SO THIS IS A STUDY WE STARTED LAUNCHED IN SEPTEMBER 2017, TO DEVELOP THE CAPACITY TO IMPLEMENT LARGE SCALE CLINICAL TRIALS IN MILITARY AND VETERAN HEALTHCARE DELIVERIES. THESE STUDIES ARE DONE IN COLLABORATION BETWEEN NIH, VA AND DOD. SO WE ARE VERY EXCITED ABOUT THOATION. -- AB THOSE. I WANT -- ABOUT THOSE. I WANT TO FINISH BY SHOWING EXAMPLES OF SOME OF THE SIGN ONS THAT BOTH NIDA AND NCCIH PARTICIPATE IN THAT ARE NOT PART OF EITHER HEAL OR THE NIH DOD BUT THESE ARE OTHER EXAMPLES OF THINGS, EPIGENOMIC AND NON-CODING RNA REGULATION OF DEVELOPMENT MAINTENANCE AND TREATMENT OF CRON INC. PAIN -- CHRONIC PAIN. THERAPEUTIC PO TEN POTENTIAL OF ENDOCANNABINOID, WE FUNDED THIS SUMMER MECHANISMS OF MINOR TERPENES AND ENDOCANNABINOIDS FOR PAIN. CHILD HEALTH USING EXISTING DATA FROM ADOLESCENT BRAIN COGNITIVE DEVELOPMENT, ABCD STUDY, WE SIGN ON TO THAT AND MECHANISM UNDERLYING CONTRIBUTING OF SLEEP DISTURBANCE TO PAIN. SO THESE ARE ALL AREAS THAT WE HOPE TO DEVELOP FURTHER. SO JUST IN CLOSING, I WANT TO BRING YOU BACK TO THIS MATRIX AND SHOW CLEARLY COMPLIMENTARY TREATMENTS FALL WITHIN A LARGE DOMAIN THAT HAS A PLACE BUT NOT OBVIOUSLY IN ISOLATION. IT REALLY NEEDS TO BE INTEGRATED WITH THE OTHER THERAPEUTIC MODALITIES SO PATIENTS CAN GET THE BEST POSSIBLE CARE AND HAVE ACCESS TO THE MAXIMUM AMOUNT OF EFFECTIVE TREATMENT. I'M JUST GOING BACK TO THIS TO OUR BASIC FOCUS AT NIH WHICH REALLY IS TO FOSTER RESEARCH ON BASIC MECHANISMS AND ALSO TREATMENTS IN WHOLE PATIENT HEALTH RESTORATION. THIS WILL BE THE FOCUS OF OUR NEXT STRATEGIC PLAN AND WE REALLY LOOK FORWARD TO WORKING WITH YOU ALL ON THIS. THANK YOU. MAWS PLAWS BRP [APPLAUSE] >> WE WILL OPEN IT UP TO COUNCIL FOR QUESTIONS. >> IN MENTAL HEALTH THERE'S A LOT OF INTEREST IN INPLA -- INFLAMMATION IN THE BRAIN IS THAT HAPPENING IN PSYCHOSIS OR MAJOR DEPRESSION OR MANIA, ARE YOU TARGETING THAT? >> YES, NEUROIMMUNE AND CNS INFLAMMATION IS OF COURSE A VERY BIG IMPORTANT ASPECT OF CHRONIC PAIN RESEARCH. HOW MUCH CHRONIC INFLAMMATION IS HAPPENING SYSTEMICALLY, WITHIN THE CNS, AND HOW MUCH CROSS TALK IS THERE? WE HAVE VERY INTERESTING RESEARCH GOING ON WHICH ARE FUND -- WE ARE FUNDING ABOUT THE SAME INFLAMMATION RESOLUTION MECHANISMS THAT OCCUR IN PERIPHERAL TISSUE AND THE SPINAL CORD. WHERE THE -- THESE TYPES -- THESE COMPOUNDS ARE SO POTENT, THERE ARE A THOUSAND TIMES MORE POTENT THAN LIPID MOLECULES THEY DERIVE FROM EPA AND DMA. FISH OIL IS NOT KNOWN TO BE PARTICULARLY EFFECTIVE IN CHRONIC PAIN BUT THE FISH OIL DERIVATIVES WILL SUPPRESS NOT ONLY THE PERIPHERAL INFLAMMATION BUT ALSO THE CNS MICROGLIA MEDIATED INPLA NATION. SO IT -- INFLAMMATION. SO IT IS AN AREA WE ARE VERY INTERESTED IN AND THERE IS A LOT OF RESEARCH ON INFLAMMATION IN ALL PARTS OF THE CENTRAL NERVOUS SYSTEM INCLUDING THE BRAIN. >> AS YOU WERE SPEAKING ABOUT THE RESTORATION YOU HAVE ALL THESE THING THAT START WITH RE. IMMEDIATELY JUMPS INTO MY BRAIN IS RECOVERY, ONE CHALLENGE WITH SUBSTANCE A USE DISORDER IS RECOVERY. LOOKING AT VARIOUS ASPECTS THAT INTERVENTIONS, ONE OF THE ONES THAT I DIDN'T SEE, IT'S SOMETHING THAT HAS BEEN ALSO JUST CRYSTALLIZING IN MY BRAIN HOW TO BRING INTO EVIDENCE AND BETTER UNDERSTANDING, IS THE ELEMENT OF SOCIAL INTEGRATION WHICH IS SO FUNDAMENTAL FOR RECOVERY AND RESTORATION ON EVERYTHING. AND ADVERSE EFFECTS OF ISOLATION IN A WIDE VARIETY OF MEDICAL CONDITIONS. SO I THINK THAT IT WOULD BE WELL TO EXPLICITLY IDENTIFY SOCIAL CONNECTIVENESS, THAT'S BECOMING CLEARER AND CLEARER SPEAKING ABOUT THESE DISEASES OF DESPAIR, A COMMON ELEMENT IS DISRUPTION OF MEANING FLG SOCIAL INTERACTIONS. I WAS THINKENING TERMS OF WHEN& YOU ARE DOING THE MASSAGE, OBVIOUSLY YOU MAY BE DOING CIRCULATION ON ALL THINGS BUT YOU ARE ALSO DOING PHYSICAL TOUCH. AND THAT IS A SOCIAL INTERACTION. >> I AGREE. THINK IT NEEDS ANOTHER LAYER UNDERNEATH THERE. AS A MATTER OF FACT I USED TO PUT THE SOCIAL -- WE TALK ABOUT BIOPSYCHOSOCIAL MODEL. SO THE SOCIAL PIECE NEEDS TO BE IN THERE. VERY IMPORTANT. I WOULD ALMOST SEE ANOTHER LAYER UNDERNEATH WHICH AT THE -- YOU START WITH A WELL CONNECTED PERSON WHO HAS GOOD FAMILY, SUPPORT SYSTEM, THEN GRADUALLY BECOME MORE AND MORE OIS -- ISOLATED. BELONGING TO A GROUP, MASSAGE, CONNECTING WITH SOMEBODY AT A PHYSICAL BUT ALSO AT A THERAPY, I KNOW IT CAN BE AT MENTAL LEVEL. YEAH. YES. THAT'S VERY GOOD POINT. >> I THINK THAT THAT IS AGAIN AN OPPORTUNITY AS A HEAL GOES ALONG, IN TERMS OF HOW WE TACKLE THE ISSUE OF RECOVERY IS A KEY COMPONENT. >> IT'S ALL CO-MORBID. PEOPLE WHO GET MORE ISOLATED, THEY ARE LESS -- MORE AND MORE AS YOU SAY DESPERATE AND HAVE MORE AND MORE ANXIETY, MORE DIFFICULTY DEALING WITH EVERYTHING THEY HAVE TO DO EVERY DAY. >> EVERYTHING. >> AND COGNITIVE DECLINE AND SLEEP. YEP. YEP. TOTALLY RIGHT. >> I HAD THREE YEARS OF PSYCHOANALYSIS AND I ALWAYS WONDER IF TIME AND MONEY WOULD HAVE BEEN BETTER SPENT WITH MASSAGE OR PERHAPS A COMBINATION OF MASSAGE PSYCHOTHERAPY. >> THAT WOULD BE NICE. SPA. >> IT'S PROFOUND IN TERMS OF TOUCH, MASSAGE, HAVING ROBUST EFFECTS ON GENE EXPRESSION, YOU CAN TELL WHICH MOUSE HAD MASSAGE YEARS LATER AND STUFF LIKE THAT. I THINK THIS IS UNDERSTUDIED AREA. THROUGHOUT NATURE EVERYTHING THAT MOVES BY ITSELF HAS A BRAIN, NOTHING THAT DOESN'T MOVE BY ITSELF HAS A BRAIN. BRAIN AND MOVEMENT ARE LINKED. SO WITH LIKE DEPRESSION AND THINGS LIKE THAT, EVERYTHING IS SLOWER YOU BLINK SLOWER SWALLOW SLOWER THINGS TECHNOLOGIES CAN DETECT BUT HUMANS CAN'T. BUT I THINK THIS IS LIKE A -- THE PSYCHONEUROIMMUNOREALM IS GOING TO BE THE FUTURE AS WELL. THIS IS SOMETHING THAT TECHNOLOGIES NOW CAN HELP US GET A HANDLE ON, WE CAN TELL HOW MUCH PEOPLE MOVE. AND BOTH MICROMOVEMENTS AND LIKE IT PREDICTS ILLNESS ACROSS THE LIFE SPAN AND JUST WHERE YOU ADD AT ON GLOBE, GPS POSITIONING. WHEN PHYSICALLY OR MENTALLY ILL YOU DON'T GO OUT AS MUCH, YOU DON'T GO TO THE STORE. YOU DON'T SOCIALIZE. 'S A PREDICTER OF WELL BEING. HOW MUCH DO YOU MOVE. I THINK THIS IS EXCITING FRONTIER. BECAUSE IT'S QUITE EASY TO MONITOR MOVEMENT BLINK RATES SWALLOWING RATES, HEART RATE, HEART VARIABILITY. SO MANY THINGS ARE PHONE APP KIND OF TECHNOLOGY. IF WE CAN SORT OF LEARN HOW TO HARNESS THIS RELATIONSHIP IN TERMS OF EMPLOYING MASSAGE OR MOVEMENT THERAPY, KIND OF FINDING THE ACTIVE INGREDIENT SO TO SPEAK. I THINK ALL EXERCISE PROBABLY HAS SOME EFFECT BUT IF WE CAN DEFINE IS IT THE HEART RATE, THE STRETCHING, IS IT -- >> SOMETIMES IT'S SURPRISING IT'S NOT WHAT YOU THINK. >> MAYBE THERE WOULD BE CERTAIN EXERCISE -- THIS IS A BIG PART OF AUTISM RESEARCH AS WELL. IN TERMS SOFT ACTIVE OR PASSAGE MOVEMENT, CHANGES THE BRAIN. BUT RIGHT NOW IT'S A LITTLE HIS OR MISS OR ANECDOTAL. IT'S VERY EXCITING TO SEE YOU ARE ON THIS AND DOING -- BUT THIS RELATIONSHIP BETWEEN TOUCH, MOVEMENT AND STUFF, IT'S VERY PROFOUND TO THE BRAIN TO BE TOUCHED. IN TERMS OF LOVINGLY NON-LOVINGLY, WHAT OUR BRAINS ARE KIND OF LIKE TUNED INTO. AND IT'S BECOME VERY AWKWARD IN DAY CARE CENTER AND STUFF THE IDEA NOT THE TOUCH. >> BABIES. YEAH. >> FOR UNDERSTANDABLE REASONS BUT WE MIGHT BE KIND OF MISSING OUT ON SOMEBODY AS WELL, THAT TOUCH IS COMFORTING TO US. YOU CAN CRAVE IT AND MISS IT IF YOU DON'T HAVE IT. >> I COULDN'T AGREE MORE. IN THE ONE SURPRISING RESULT, THERE WAS A STUDY SOME YEARS AGO THAT CAUSED A LITTLE CONSTERNATION IN THE YOGA FIELD BECAUSE THEY COME PAWR YOGA -- COMPARE YOGA INTERVENTION TO SIMPLE STRETCHING EXERCISES AND BOTH GROUPS GOT MUCH BETTER COMPARED WITH USUAL CARE GROUP AND PEOPLE THOUGHT OH MY GOSH, MAYBE YOU ARE ONLY ABOUT -- OWE YOGA IS ONLY STRETCHING, I WOULDN'T GO THAT FAR BUT ISOLATE THE ACTIVE INGREDIENT. >> THERE'S INTERESTING COMPAREMENTS TO DANCE AND MMA FIGHTING IN TERMS OF BOTH HAVE ACTIVE MOVEMENT, ONE IS CONTROLLED SCRIPTED, DISCIPLINED, OTHER LESS SO AND STUFF IN TERMS OF DO THEY HAVE -- THEY BOTH HAVE A SIMILAR PHYSICAL AS SPBLGHT BUT QUITE A BIT -- ASPECT BUT QUITE A DIFFERENT -- >> AND TAI CHI. >> I WAS GOING THE MAKE THE OBSERVATION, FROM THE LUNGS, INTERACTIONS, (INAUDIBLE) WE KNOW REMARKABLY LITTLE ABOUT THE CIRCUITS BEYOND THE NTS AND THESE HIND BRAIN CIRCUITS ARE FULL OF OPIOID RECEPTORS, IN THIS CASE TINNIC RECEPTORS, DOPAMINE RESPONSIVE. THERE IS A WHOLE LANDSCAPE IN THE BACK OF THE BRAIN WE KNOW REMARKABLY LITTLE ABOUT, THOSE ARE THE VERY SITES LIKELY RECEIVING THIS PRIMAL INFORMATION FROM THE BODY. THERE IS A LOT THERE WE CAN DO. >> WE HAD A FASCINATING WORKSHOP ON INTERRECEPTION TALK ABOUT A TOPIC THAT GOT EVERYBODY'S MIND TO EXPLODE. IT WAS TWO DAYS AND WE TALKED ABOUT EVERY KIND OF ENTERRECEPTIVE SENSORY INFORMATION THAT YOU GET FROM, EVEN JUST THE SENSATION OF DRINKING A GLASS OF WATER. HOW DO YOU STOP -- HOW DO YOU KNOW HOW MUCH WATER TO DRINK WHEN YOU ARE THIRSTY? TURNS OUT YOU KNOW WAY BEFORE YOUR BLOOD GETS CORRECTED. FLOW RECEPTORS IN THE MOUTH. WHO WOULD HAVE THOUGHT THAT? (OFF MIC) >> WE ARE GETTING -- WE ARE PAYING ATTENTION TO IT. SO I THINK THIS IS VERY GOOD. LUNGS, GUT, ALL THOSE SENSATIONS, VISCERAL SENSATION SO IMPORTANT. >> YOU HAVE NUTRITIONAL ISSUES ON YOUR MAP. IN THE SUBSTANCE USE TREATMENT ARENA FROM TIME TO TIME PEOPLE HAVE OFFERED NUTRITIONAL SUPPLEMENTS ALMOST AS A PANACEA FOR WHAT AILS YOU. FROM APPLE CIDER VINEGAR TO SOME UNIQUE FORMULATIONS. WOULD YOUR INSTITUTE BE LOOKING AT THE WHOLE ISSUE OF NUTRITIONAL SUPPLEMENTS AS COMPLIMENT TO MAINSTREAM TREATMENT? >> ABSOLUTELY. ONE AREA WHERE NCCIH HAS BEEN REALLY VERY ACTIVE IS IN RIGOROUS INVESTIGATION OF THINGS LIKE SUPPLEMENTS BUT IN ORDER TO INFORM THE PUBLIC, BECAUSE THERE'S SO MUCH INFORMATION OUT THERE, THAT IS -- YOU GO INTO A HEALTH FOOD STORE OR EVEN A REGULAR PHARMACY, AND YOU SEE THESE AMAZING ARRAY OF SUPPLEMENTS, SO LITTLE INFORMATION ABOUT WHAT'S IN THEM, WHAT IS THE DOSE, WHERE DO THESE PRODUCTS COME FROM, THE REGULATIONS ARE A NIGHTMARE. SO IT'S VERY DIFFICULT AND ONE OF THE THINGS THAT WE HAVE ON OUR WEBSITE ON NCCIH WEBSITE, IS WHOLE APP WE DEVELOPED THAT HAS INFORMATION ON NUTRITIONAL SUPPLEMENTS ON HERBS, NATURAL PRODUCTS OF ALL KINDS. THIS IS CURE AITED, WE ARE VERY -- WE ALSO WORK A LOT WITH OFFICE OF DIETARY SUPPLEMENTS AT THE -- HERE AT NIH WHERE WE WORK CAREFULLY WITH THEM TO MAKE SURE THAT WHATEVER INFORMATION WE HAVE ON OUR WEBSITE, IS CONSISTENT WITH WHAT THEY HAVE. AND EDUCATION IS SO IMPORTANT. IN THIS AREA. OF COURSE CONDUCTING THE SCIENCE. AND WE FOR SOME YEARS AGO NCCIH CONDUCTED A FAIR NUMBER OF CLINICAL TRIAL, LARGE SCALE TRIAL TO LOOK AT THINGS LIKE GINKO AND PALMETTO, SUBSTANCES BEING USED FORD A SPECIFIC INDICATION. PREVENTING DIFFERENT AREAS. DIFFERENT DISEASES. AND MOST OF THESE TRIALS WERE NEGATIVE INDICATED THESE THESE COMPOUNDS WERE JUST NOT DOING THE WHAT THEY WERE. SO NOW WE HAVE SHIFTED OUR ATTENTION MORE TOWARDS LOOKING AT GOING BACK TO BASIC LAB, TAKING SOME OF THESE AND TRYING COMPOSITION INSIDE MOLECULES OF THESE PLANTS THAT MAY HAVE BIOLOGICAL ACTIVITY IN IN VITRO SYSTEMS AND START THAT WAY. AND THEN MOVE TO ANIMAL MODELS AND IF WE SEE ANYTHING THAT LOOKS LIKE IT MAY HAVE POTENTIAL TO BE DEVELOPED AS A DRUG, AND IT BECOMES MORE A DRUG DEVELOPMENT PIPELINE SO IT'S MUCH MORE RATIONALE APPROACH THAN SIMPLY SAYING WELL WE WILL STRIVE -- WE ARE JUST GOING TO GO TO THE HEALTH FOOD STORE AND DO A CLINICAL TRIAL ON THAT. WHICH WOULDN'T MAKE SENSE AT ALL. >> I LOVED THE POTTED PLANTS SLIDE AND I THIS IT'S A BEAUTIFUL OVERLAY FOR THE SUD SPACE BECAUSE RECOVERY AND WELLNESS ISN'T ABOUT JUST THE PLANT NOT DYING, IT'S ABOUT MOVING BACK ACROSS THE LEFT TO THE LEFT OF THE SCREEN, AND BEING HEALTHY AND THAT LUSH GREEN PLANT WITH ALL THAT WONDERFUL -- AND SOMETIMES I THINK WE GET A LITTLE FOCUSED IN THE OUD SPACE THAT MEDICATIONS AND WE ARE SO LUCKY TO HAVE MEDICINES BUT THERE'S MORE IN ADDITION TO THAT MEDICATION, THAT NEEDS TO BE PRESENTED FOR THAT PATIENT TO -- THAT PLANT TO GET SUPER HEALTHY AND GREEN AND THROUGH SHUS AND BEAUTIFUL. WHEN WE WORK WITH AMAZING RECOVERY COMMITTEE DOING GREAT WORK AND WE TALK ABOUT A COUPLE OF THINGS. ONE, EXERCISE, SLEEP, WHAT YOU ARE EATING, HOW MUCH SUNLIGHT YOU GOT IN YOUR FACE, DID YOU CLOSE YOUR MOVE GOAL ON YOUR APPLE WATCH, ARE YOU GETTING THE AMOUNT OF SELF CARE THAT GETS YOU THERE AND ALSO THE DURATION OF HOW LONG YOU HAVE TO FOCUS ON THAT IS 12 MONTHS, 24 MONTHS, NOT SHORT TERM BECAUSE YOU ARE CHANGING SYSTEMS THAT MAY IN THE HAVE WORKED. THE 12 STEP SPACE WE TALK ABOUT HALT. MAJOR TRIGGERS FOR RECURRENCE OF USE, HUNGRY, ANGRY, LONELY, TIRED. AND ALL THOSE COMPONENTS ARE REALLY UP THERE WITH NUTRITION, SLEEP, RIGHT, SOCIAL CONNECTEDNESS, ATTACHMENT PRO SOCIAL ENGAGEMENT, SO MUCH SNEADED HERE TO COMPLIMENT IS NEEDED TO COMPLIMENT AND PROVIDE PATIENT MUCH MR WHAT THEY NEED LONG HAUL TO GET BACK TO THE BEAUTIFUL GREEN HEALTHY PLANT. >> APPRECIATE THAT. IT'S FUNNY BECAUSE WE WERE TALKING ABOUT NEONATES, WITH THE EAT SLEEP AND CONSOLE TREATMENT FOR NEONATES. THAT HAS THOSE COMPONENTS, EAT SLEEP AND FEEL BETTER, BE EMBRACED AND CONNECTED. SO I THINK IT KEEPS COMING BACK. BUT THE FIRST STEP REALLY WHEN YOU THINK ABOUT SOMEBODY WHO IS IN A CRISIS WHO HAS -- WHO IS ADDICTED TO A SUBSTANCE, FIRST MAKE SURE THEY TAKE THEIR MEDICATION. THAT'S WHERE WE DECIDED TO START IS HELP PEOPLE STAY ON THE MEDICATION. THAT'S THE FIRST STEP. BUT THEN AS YOU SAID, THERE'S MORE. AND THAT TREATMENT NEEDS TO BE SUSTAINED. THE PROBLEM THAT WE ARE BUMPING UP AGAINST IS THAT THESE TREATMENTS ARE NOT CHEAP. IT TAKES MONEY, IT TAKES RESOURCES, IT TAKES COMMITMENT FROM THE HEALTHCARE COMMUNITY. IT TAKES REAM REIMBURSEMENT FROM INSURANCE COMPANIES, TAKES A LOT TO PI FOR THESE TREATMENTS SO THIS IS WHY WE REALLY NEED RESEARCH TO SHOW HOW IMPORTANT IT IS. THAT'S KEY. BUT IT IS FRUSTRATING HOW WE KEEP BUMPING UP AGAINST THE COST. (OFF MIC) >> GREAT. (OFF MIC) >> I'M SO HAPPY TO HEAR. THAT'S GOOD. >> THANKS VERY MUCH FOR WHAT YOU DOING AND COMING AND SHARING. >> THANK YOU VERY MUCH FOR THE INVITATION. [APPLAUSE] (OFF MIC) >> THIS BRINGS US TO THE LAST PART OF IT WILL AGENERAL DA, WHICH IS THE -- AGENDA, WHICH IS THE TIME WE ALLOCATE FOR PUBLIC COMMENT. SO IS THERE SOMEONE HERE FROM THE PUBLIC WANT TO MAKE COMMENT TO THE IDENTIFY YOUR NAME AND WHO YOU ARE ASSOCIATED WITH, AND LIMIT YOUR REMARKS TO -- IS IT THREE OR FIVE MINUTES? FIVE MINUTES. SO NOW WE ARE OPENING UP THE MICROPHONE, IF THERE IS ANYONE THAT WANTS TO MAKE ANY COMMENT OR SUGGESTIONS, THIS IS AN OPPORTUNITY. I DON'T SEE ANYONE. EVERYONE IS A WITNESS. THERE'S NO ONE AROUND. SO IF THERE'S NO ONE THAT WANTS TO MAKE A COMMENT, LET'S ADJOURN AND I WANT TO AGAIN, AS THE BEGINNING AND AT THE END, THANK YOU FOR YOUR INPUT AND I -- IF YOU HAVE ANY COMMENTS FOLLOWING UP TODAY'S PRESENTATIONS AND DISCUSSIONS, PLEASE REACH OUT TO US. WE COUNT ON YOU, RELY ON YOU, WE ARE THE MAIN BODY THROUGH WHICH WE PASS AND BRAINSTORM A LOT OF CONCEPTS. SO IF YOU CAN BE CRITICAL, THAT IS YOUR JOB. WE ARE ALL ON THIS TO TRY TO MAKE THINGS BETTER AND SO WE APPRECIATE YOUR INPUT. SO YOU KNOW HOW TO REACH US AND OTHERWISE, HAVE A GOOD TRIP BACK. WE WILL BE IN TOUCH. THANKS VERY MUCH. THANKS, EVERYONE. [APPLAUSE]