Principles for the Use of Funds from the Opioid Litigation | June 29, 2021

Transcript

• 00:00Ready.
• 00:04So good afternoon I'm David Fiellin
• 00:06I'm I'm director of the Yale Program
• 00:08and Addiction medicine and I want to
• 00:11welcome you to the first talk in our
• 00:13finding solutions to the opioid crisis.
• 00:16This speaker series, in collaboration
• 00:18with the Sandgaard Foundation.
• 00:20We're joined today by Doctor Josh.
• 00:24Sharfstein, who will speak on principles
• 00:26for the use of funds from the opioid
• 00:29litigation before we get started,
• 00:30we just want to review a few housekeeping
• 00:33items on the following slides.
• 00:37First, we encourage you to stay
• 00:39up to date with the latest in the
• 00:41Finding Solutions series and the
• 00:43Yale Program in Addiction Medicine.
• 00:45By visiting our website.
• 00:47Following us on Twitter and
• 00:49joining our program listserv.
• 00:52Second, I'd like to invite Kyle Henderson,
• 00:55the executive director of
• 00:57the Sandgaard Foundation,
• 00:58to say a few words and share about the
• 01:00mission and work of the foundation.
• 01:03Thank you David and thank
• 01:04you everyone for joining us.
• 01:06It's an honor to be aligned with the
• 01:09health program in addiction medicine.
• 01:11The Sandgaard Foundation is exclusively
• 01:14focused on the opioid epidemic.
• 01:17The founder of our foundation actually
• 01:20started a publicly traded medical device
• 01:23company that helps reduce pain through
• 01:25electrotherapy and gets people off of opioid.
• 01:30Related pain killers and he's had some
• 01:32family members that also struggled with it.
• 01:35We've all lost so near and dear
• 01:37to us to this horrible crisis.
• 01:39Right now we're focused on Narcan,
• 01:42naloxone distribution around the country.
• 01:44So we've distributed over 400,000 units of
• 01:47naloxone and over 21 states thus far with
• 01:50direct relief in the Clinton Foundation.
• 01:52And we just launched our
• 01:55Colorado naloxone project.
• 01:56Which is one of the first
• 01:58in the nation where?
• 01:59We're making sure that all at
• 02:02risk patients that go to the ER.
• 02:04Come out with naloxone in their hand as
• 02:07opposed to having the fill prescription.
• 02:09Subsequent and overcome stigma and
• 02:11everything else that goes along with it.
• 02:14So we're rolling that out
• 02:16through the hospitals.
• 02:17We've got about 60% of the hospitals
• 02:20covered in Colorado so far.
• 02:21And now we're working on
• 02:23recovery homes as well.
• 02:24We're also funding movies in the
• 02:27space that focus on the cause.
• 02:29So not just films but documentaries
• 02:32and the recovery fest and recover
• 02:35Out loud concert in September,
• 02:37which we encourage you all to learn
• 02:39more about through the Voices project.
• 02:41But we're helping to fund that cause,
• 02:43and we just locked in Macklemore as
• 02:45one of our. Lead talents and artists.
• 02:49But we've got some more fun people
• 02:52getting aligned with that and iHeartRadio
• 02:54and Google are all coming alongside
• 02:56to help maximize just the reach there.
• 02:58But it's a free event so we'd love for
• 03:00everyone to attend virtually with us.
• 03:02But again.
• 03:03Doctor Shark Scene and thank you for your
• 03:06time today and your incredible work.
• 03:08We're all thrilled just to hear
• 03:11from you and your perspective.
• 03:13You know,
• 03:14this great great need in our nation,
• 03:15but thank you David for the
• 03:17opportunity to align with you guys
• 03:18on this great speaker series.
• 03:21My pleasure and thank you, Kyle.
• 03:23As a reminder for the
• 03:25speaker series coming up,
• 03:26we'll be welcoming welcoming Maritza Perez,
• 03:29who's the director of the Office
• 03:32of National Affairs at the Drug
• 03:34Policy Alliance on July 13th.
• 03:36Miss Perez will speak on decriminalization
• 03:39and public health approaches to drug policy.
• 03:41Registration is now open and
• 03:43we hope to see you there.
• 03:46Finally, CME credit is available for
• 03:48today's event and to receive credit,
• 03:51please text the code and
• 03:54read to the number in red.
• 03:56And then now I'd like to introduce
• 03:58you to our speaker for today,
• 03:59Doctor Joshua Sharfstein.
• 04:00Josh is a vice Dean for public health
• 04:03practice and community engagement and
• 04:05director of the Bloomberg American
• 04:07Health Initiative professor of the
• 04:09practice and health policy and management
• 04:11at John Hopkins School of Medicine,
• 04:13School of Public Health,
• 04:14and previously he served as
• 04:16Secretary of the Maryland Department
• 04:18of Health and Mental Hygiene,
• 04:20the Principal Deputy Commissioner
• 04:21of the United States Food and Drug
• 04:24Administration and as Commissioner
• 04:26of Health for Baltimore City.
• 04:27And a health policy adviser
• 04:30for Congressman Henry Waxman.
• 04:31He's an elected member of the National
• 04:34Academy of Medicine and National
• 04:35Academy of Public Administration and
• 04:37Josh work digit diligently over the
• 04:39past few years with a variety of states,
• 04:42including our own Connecticut,
• 04:44to develop strategic plans to
• 04:46address the opioid crisis.
• 04:47So it's a great pleasure to have Josh
• 04:49speak today on a national effort.
• 04:51He and others are involved in
• 04:52that relates to the principles for
• 04:54the use of funds from the opioid.
• 04:56Litigation, Josh. Please take it away.
• 05:00Thanks so much, David.
• 05:02Thanks for having me Kyle.
• 05:03It's great to meet you.
• 05:04Thanks so much for your support of
• 05:06this and so many other good projects.
• 05:09I am going to see if I can share
• 05:12my slides here and jump in.
• 05:15I really look forward to the
• 05:17discussion so I don't have
• 05:18an massive amount prepared,
• 05:20so we'll we'll walk through
• 05:22this topic and then I'm sure
• 05:24have a pretty great discussion.
• 05:26Hold on one second.
• 05:34The. If that working now.
• 05:40Yes. Yep, you can see the slide.
• 05:43OK, great. So what I'm going to do
• 05:47today is talk 1st about the overdose
• 05:50crisis very quickly just to set
• 05:52everyone at the same starting point.
• 05:55Then I'm going to talk about the
• 05:57politics of drug policy a little bit
• 06:00from my perspective and experience,
• 06:01and that's going to feed into a
• 06:04discussion of where the opioid
• 06:06litigation stands and hopefully
• 06:07add up to a strategy for the opioid
• 06:09settlements that we'll be talking about.
• 06:15So this is some of the most recent
• 06:17CDC data showing that the annual
• 06:20number of deaths that they calculated
• 06:22most recently is now crossed
• 06:2490,000 for all overdose deaths,
• 06:25and you can see the curve here on the
• 06:28right showing that it was pretty flat
• 06:30to increasing even before the pandemic.
• 06:33But really the pandemic has had a
• 06:36really negative effect on overdose,
• 06:38and you can also see that the map of which
• 06:42states are having improvements versus.
• 06:45Worsening is not looking like
• 06:46a good color generally.
• 06:52And there are many reasons which we
• 06:54won't probably get into for why overdose
• 06:56tests are climbing during the pandemic,
• 06:58the disruption in the drug supply.
• 07:02Hopelessness, loneliness,
• 07:03economic dislocation,
• 07:05and other things like that.
• 07:08So many people have talked
• 07:10about how people have, you know,
• 07:12relapse facing incredible
• 07:13stress in their lives,
• 07:14that the trauma of people dying from
• 07:18COVID can trigger substance use so.
• 07:22Where there are just so many stories,
• 07:24we have a Twitter account.
• 07:26I think it's at opioid updates.
• 07:28Maybe that cracks, you know,
• 07:31local stories and there's so many
• 07:33local stories about the worsening
• 07:34overdose crisis during the pandemic.
• 07:40So I want to transition from this.
• 07:42Here we are with one pandemic
• 07:44fading in the United States,
• 07:46but the opioid and the overdose
• 07:49epidemic continuing to worsen.
• 07:51Just ask the question, why hasn't
• 07:53the United States made more progress?
• 07:56And and I think that's a good question,
• 07:58because, you know,
• 07:59we faced a COVID pandemic,
• 08:01and while there were all kinds of
• 08:03challenges with the national response,
• 08:04it was a pretty impressive
• 08:07mobilization that you know,
• 08:09level of progress has not happened
• 08:11with the overdose epidemic.
• 08:14In fact, it's continued to get
• 08:16worse with as that curve showed,
• 08:18and one of the reasons for why
• 08:21the US hasn't made progress,
• 08:23I think I covered with Doctor.
• 08:26Can build Olson.
• 08:27Who is the real addiction
• 08:30expert in our household?
• 08:32We wrote about the role of evidence
• 08:35in the US response to the opioid
• 08:38crisis and a paper that I think
• 08:41came out during the pandemic.
• 08:45And we kind of summed it up like this.
• 08:47The steps that generate popular enthusiasm
• 08:50often or may have little evidence to
• 08:52support them while at the same time.
• 08:55And if she gives back by science
• 08:57as necessary to save lives,
• 08:58may be ignored or rejected altogether.
• 09:02In other words, what we want
• 09:04to do isn't what we need to do.
• 09:08What we need to do isn't what we want to do,
• 09:10and that is something that is pretty.
• 09:15Impressive for the drug crisis,
• 09:18more than other public health issues,
• 09:20and I've worked on a lot of different
• 09:23public health issues and oftentimes
• 09:24everybody agrees what needs to be done.
• 09:27But you can't. You know,
• 09:28maybe you can't get the money,
• 09:29or you can't.
• 09:30You know, there are political
• 09:32obstacles in the path here.
• 09:34There's a real fundamental political
• 09:37challenge that what generates the
• 09:39most political excitement in terms of
• 09:42response isn't necessarily what actually.
• 09:44Would make a difference in sometimes
• 09:46the things that get supported
• 09:49wind up making things worse.
• 09:51I'm sure many of you are
• 09:53familiar with these statistics.
• 09:54A couple papers that came out recently.
• 09:57That even addiction treatment facilities
• 10:00often do not provide the care that
• 10:04evidence indicates is life saving.
• 10:06In 2016,
• 10:08just 36% of substance use
• 10:11treatment facilities offered any
• 10:13form of medication treatment for
• 10:15opioid use disorder and in 2017.
• 10:17This is really just incredible.
• 10:18I mean, that is well into what
• 10:20people were calling the opioid.
• 10:22Epidemic medications were used in just 17.7%
• 10:26of admissions in residential treatment.
• 10:28Who are opioid use disorder and that was
• 10:30just in the states that expanded Medicaid.
• 10:32It was less than 2%.
• 10:34I mean,
• 10:35given that medications are particularly
• 10:37buprenorphine and methadone are associated
• 10:39with a staggering drop in the rate of death,
• 10:42and the rate of overdose death,
• 10:44it's just,
• 10:44you know,
• 10:45you just got to look at that
• 10:47statistic and realize few of the
• 10:48one in 50 people with this problem.
• 10:50We're getting treatment that
• 10:52could actually save their lives.
• 10:55So it really brings up the question
• 10:58of politics versus evidence.
• 11:00And interestingly,
• 11:01here I'm not at all talking
• 11:03about electoral politics.
• 11:04In fact, my experiences,
• 11:06these issues are pretty bipartisan that
• 11:09you have evidence of what can make a
• 11:13difference for overdose and addiction.
• 11:16But that's fighting up Hill
• 11:17against kind of small P politics,
• 11:20which includes the legacy of stigma,
• 11:23criminalization and racism, and drug policy.
• 11:26Difficulty accepting addiction
• 11:28as a chronic illness.
• 11:30And and local experts on drug
• 11:31policy may be the people who run
• 11:34a treatment program that doesn't
• 11:36provide evidence based care.
• 11:37You know, oftentimes with my students,
• 11:39I'll say,
• 11:39like you know who are the most powerful
• 11:41local voices on the addiction crisis,
• 11:43and in a sense,
• 11:45they've they've earned their authority.
• 11:46You know that includes family
• 11:48members of people who have died.
• 11:50You know law enforcement officials who've
• 11:52worked on the drug crisis for many years,
• 11:55from whatever perspective they
• 11:57bring and treatment providers
• 11:58and sometimes all three of those
• 12:01can be resistant to the idea of
• 12:03addiction being a chronic illness.
• 12:05Family members are looking for gonna
• 12:07be looking for kind of quick fixes.
• 12:09Sometimes you have the law
• 12:12enforcement view of this being
• 12:15kind of a moral failure or crime,
• 12:18and you have 28 day programs,
• 12:21or like you know, we can really.
• 12:23Passed you up and get somebody back.
• 12:24You don't need treatment for a long time
• 12:27with medicine so you have these local,
• 12:29often very powerful forces
• 12:32that mean that when
• 12:34people are looking for what to do,
• 12:37they're looking and what they're hearing is
• 12:41answers that aren't where the evidence is.
• 12:47So you know, for those of us
• 12:49who've worked in these issues at
• 12:51the local level state level at
• 12:53different places across the country,
• 12:54the issue of the opioid litigation
• 12:56kind of begs this question.
• 12:58Will the opioid settlements reflect
• 13:00the existing biases in drug policy?
• 13:02Are we going to get more
• 13:03of what doesn't work,
• 13:04or are we going to get more of what works?
• 13:06Or is this a shifting point to more
• 13:08effective strategy for this country?
• 13:10Or are we stuck with more of the same?
• 13:12A lot of money being spent
• 13:14but not real progress?
• 13:17So let's pause for a second,
• 13:19just review where we are with the major
• 13:21lawsuits, and I apologize in advance.
• 13:23I know that they're probably if there's
• 13:25anybody you know from the law school
• 13:27on you probably understand these suits
• 13:28a lot better than me and I learned a
• 13:30lot about this from Abby Gluck at Yale
• 13:33before she went to the White House, so.
• 13:38We have different places, suing many,
• 13:40many places all around the country,
• 13:42suing state cities, counties,
• 13:44territories, tribes.
• 13:45The defendants in these
• 13:47lawsuits are multiple.
• 13:49Also, you've got manufacturers of
• 13:51opioids and a number of companies,
• 13:54including some generic manufacturers
• 13:56from brand new manufacturers.
• 13:57Purdue Pharma is the maker of Oxycontin.
• 14:00You also have lawsuits
• 14:01against the distributors,
• 14:03including the Big Three Witcher,
• 14:05Cardinal Health, Amerisource,
• 14:07Bergen, and McKesson.
• 14:09Lawsuits against pharmacies
• 14:10saying that they were,
• 14:12you know,
• 14:13selling too many of good
• 14:14should've known better.
• 14:15And also Mackenzie there
• 14:17probably others getting sued.
• 14:18McKenzie is a management consulting
• 14:20firm getting sued for the advice
• 14:22that it gave opioid manufacturers,
• 14:24including Purdue.
• 14:29So some of these lawsuits have been resolved.
• 14:33Kentucky settled with Purdue
• 14:35Pharma for 24 million and 2015.
• 14:38West Virginia has done some settlements.
• 14:40New York just recently.
• 14:42I think last week settled for 230
• 14:45million with Johnson and Johnson,
• 14:47Oklahoma won a big lawsuit verdict
• 14:50against Johnson and Johnson
• 14:52settled with Purdue Pharma.
• 14:53Have an endo. We're seeing some
• 14:57suits with settlements by counties,
• 15:00including Cuyahoga and Summit County in Ohio,
• 15:03and the Mackenzie did a national settlement,
• 15:06so there are a number of these
• 15:09lawsuits are starting to resolve.
• 15:11Uhm?
• 15:14But we still have.
• 15:16Some really important lawsuits and
• 15:19litigation pending there's something
• 15:21called Multi District litigation
• 15:23where all the States and counties
• 15:26and all the the plaintiffs have come
• 15:29together to sue the distributors.
• 15:31Johnson, Johnson and Teva,
• 15:32and so that that's a very complex
• 15:35litigation that is pending.
• 15:37They're also continuing to be state
• 15:40trials and county trials happening.
• 15:43And separately from that you have Purdue.
• 15:46Pharma is now in bankruptcy,
• 15:48and so there's a lot of litigation
• 15:51about what it owes people through the
• 15:54bankruptcy and that I I'm again not
• 15:56going to be the legal expert in that.
• 15:58But there are billions of dollars at stake
• 16:00between the Purdue Pharma bankruptcy
• 16:01and the Multi district litigation.
• 16:07So, given that there may be billions
• 16:09or even more than $10 billion,
• 16:10that will flow to state cities and counties.
• 16:13With these cases over the next several years.
• 16:16The key question is like how decisions
• 16:19will get made and how to spend it.
• 16:21A lot of these decisions will be made at the
• 16:24local level from what we can best understand.
• 16:26The litigation itself will set set
• 16:28up some guide rules for the kinds of
• 16:31things that States and localities.
• 16:32The plaintiffs themselves will
• 16:33be able to spend the money on,
• 16:35but then there'll be a lot
• 16:37of discretion for states,
• 16:38localities, tribes,
• 16:39others to decide how to spend the money and.
• 16:43The concept of writing a big check
• 16:45to a state of locality and as part of
• 16:48this litigation is a little fraught
• 16:50because of what happened with tobacco.
• 16:52So you know, our key question is,
• 16:54you know,
• 16:55will this money be used to help reset drug
• 16:58policy and help actually bend that curve?
• 17:01Or will it be kind of more of the same,
• 17:03recapitulating the problems we've
• 17:05had before the tobacco settlement
• 17:07is not an inspiring example.
• 17:09In that case a very small amount
• 17:12of money actually went.
• 17:13To support tobacco control programming.
• 17:17A small fraction,
• 17:192.4% of what states actually received.
• 17:24And you know there are all
• 17:26these depressing followups.
• 17:2820 years after the tobacco settlement.
• 17:30Did you know that Niagara County
• 17:32spent money for sprinkler system
• 17:34on a golf course or that Wrangell,
• 17:36Alaska, you know was spent money
• 17:39to renovate shipping docks?
• 17:41North Carolina even spent money to market.
• 17:48So the question that I've kind of leading
• 17:50up to at this point is if you're with
• 17:52me so far that we have challenges in
• 17:54drug policy that these challenges are
• 17:56not just we don't have the evidence,
• 17:58but we can't effectively put
• 18:00that evidence into use,
• 18:02and we also have this unfortunate shadow
• 18:04from the tobacco litigation that people
• 18:06might use money for whatever they want.
• 18:09You know, what can we do so that opioid
• 18:12settlements are spent well and put
• 18:14the US on a path to save more lives?
• 18:20So out of that. We have been working
• 18:25with Doctor Falin and his colleagues
• 18:27and others who developed 5 principles to
• 18:31guide opioid spending and the idea was
• 18:34to really have a strong voice for smart
• 18:37spending of this funding that could make a
• 18:41difference and not just leave it to the,
• 18:44you know broad menu that States
• 18:46and localities might get as a
• 18:48result of the litigation.
• 18:49We also recognize that
• 18:51evidence is very important,
• 18:52but just providing evidence might not get us.
• 18:54Of where we want to go.
• 18:55It has never done that really.
• 18:57In the overdose crisis, our goal was.
• 19:01To have a bit of a map for
• 19:03navigating the politics,
• 19:04the process, the evidence,
• 19:05and the outcome of opioid settlements.
• 19:08And we wanted to make it simple.
• 19:12So we worked with the whole bunch of groups,
• 19:14so go through some of them in a minute.
• 19:16But we came up with five principles.
• 19:19Spend the money to save lives.
• 19:21Use evidence to guide spending.
• 19:24Invest in prevention with youth.
• 19:26Focus on racial equity.
• 19:27Sorry, not radical equity.
• 19:29Although it is fun,
• 19:30fun ways that racial equity develop
• 19:33a fair and transparent process for
• 19:35deciding where to spend the funding.
• 19:38You can read these principles in a lot
• 19:39of materials we have about this at
• 19:43opioidprinciples.jhsph.edu.
• 19:47And we got more than 50 organizations
• 19:49to support it from the American
• 19:51Society of Addiction Medicine,
• 19:52the Legal Action Center of
• 19:54the Harm Reduction Coalition.
• 19:55Many, many groups across addiction,
• 19:58medicine, harm reduction prevention,
• 20:00advocacy recovery, and academia,
• 20:01including the Yale Program
• 20:03in Addiction Medicine.
• 20:07I'm going to just spend a little
• 20:09time on each principle because
• 20:11we tried to develop some specific
• 20:14items underneath these principles,
• 20:16so spend money to save lives is a
• 20:19way of saying spend the money on
• 20:22the overdose crisis like don't.
• 20:24Do the golf sprinkler stuff.
• 20:26You know you know,
• 20:28do something that it's entirely different.
• 20:31You know that that there's still so
• 20:33many lives to be saved with the crisis.
• 20:36At its peak, the moment.
• 20:38So we are recommending establishing a
• 20:41dedicated fund so the money doesn't get lost.
• 20:44In general spending supplement,
• 20:46rather than supplant existing funding.
• 20:49Don't spend it all at once.
• 20:51Spend some of it overtime.
• 20:52Make smart investments,
• 20:53and report to the public where the
• 20:56money is going so people can have
• 20:58some transparency about the fund.
• 21:02Item 2 is used evidence to guide
• 21:06spending given that we have evidence
• 21:08direct funds to program supported
• 21:10by evidence and at the same time
• 21:13not spend money on programs that
• 21:15are not supported by evidence.
• 21:17Remove policies that may block the
• 21:19adoption of programs that work.
• 21:21This is a good moment to say well
• 21:22if we want to spend for this,
• 21:23but we're not allowed 'cause we
• 21:25have some weird policy on it.
• 21:26Let's change that policy and at
• 21:28the same time build data collection
• 21:30capacity so you know how the pro.
• 21:32Problem is it's going.
• 21:33You know,
• 21:34one reason or the difference between
• 21:38how we have approached COVID and.
• 21:42The overdose crisis is that we get
• 21:43some pretty good data on COVID pretty
• 21:45quickly in this country and in a lot
• 21:47of places you can go online and see
• 21:48how many cases there were yesterday,
• 21:50what's going on?
• 21:51You know the the overdose crisis is much,
• 21:54much harder to get a handle
• 21:55on on a day to day basis,
• 21:58and for that reason you know the the
• 22:01responsiveness of like, well, did that work?
• 22:03Did that work?
• 22:04Did that work?
• 22:05You don't get that kind of
• 22:07feedback on drug policy,
• 22:09which opens up the opportunity for politics.
• 22:12They play a larger role.
• 22:15Third one was invest in
• 22:17prevention with youth.
• 22:19Particularly long term investments
• 22:20and effective programs and
• 22:22strategies for Community change,
• 22:24which of course the evidence
• 22:25indicates that generally,
• 22:26not like we're going to have
• 22:29an after school program to
• 22:30tell kids to not use drugs.
• 22:33It's these programs are really
• 22:35about supporting success of youth
• 22:39in school with careers and building
• 22:42resilience and coping mechanisms.
• 22:45Those sorts of things tend to
• 22:46have more evidence for them, but.
• 22:48We also suggest that there should
• 22:51be a strong evaluation component.
• 22:554th one is racial equity that there should
• 22:59be significant funds to communities
• 23:01affected by years of discriminatory
• 23:03policies and now experiencing
• 23:04substantial increases in overdoses.
• 23:06And you know, there is little bit of a
• 23:11risk that people will use the money from
• 23:14the opioid settlement since they are
• 23:16settlements that relate to prescription
• 23:18drugs and just take like the last
• 23:21year prescription drug overdoses and
• 23:23send the money to where there are a
• 23:25lot of prescription drug overdoses,
• 23:26not recognizing that.
• 23:27The epidemic has been different
• 23:29in different places and in like.
• 23:31For example, my city of Baltimore.
• 23:33It's very clear that the prescription
• 23:36drug problems very much caused a surge
• 23:40in the City of drug use and eventually
• 23:43that was translated into heroin and
• 23:46fentanyl because it's widely available here.
• 23:48But a lot of people who are dying of
• 23:50fentanyl and heroin overdoses started
• 23:52with prescription drugs because
• 23:53of some of the problems that the
• 23:56litigation speaks to you directly.
• 23:57If you just looked at what people are.
• 23:59Dying from eventually you
• 24:01might think Oh well,
• 24:02the prescription drug issue
• 24:03didn't really happen in Baltimore,
• 24:05and that would be wrong.
• 24:06And really putting out cities and
• 24:09places like Baltimore from funding
• 24:11and not really realizing the
• 24:13responsibility that society has to
• 24:15to places that have had all kinds
• 24:17of problems because of the way the.
• 24:21Policies on drugs have been implemented.
• 24:23You know,
• 24:24those mistakes shouldn't be repeated?
• 24:27So specific ideas are listed here.
• 24:30Investing communities affected by
• 24:32discriminatory policies support
• 24:34diversion from arrest and incarceration,
• 24:36fine anti stigma campaigns and involve
• 24:39community members in the solutions.
• 24:45And then our last principle has
• 24:47to do with the process itself.
• 24:49Decisions should be guided by public
• 24:51health leaders with the active engagement
• 24:54of people and families with lived
• 24:56experience as well as other key groups.
• 24:59And so it's not enough just to say you know,
• 25:03well, we decided to do this.
• 25:04You want a good process guided by
• 25:08public health principles and leaders.
• 25:10That really is inclusive in
• 25:12the way it is designed.
• 25:14And I'm going to show you something that
• 25:17might shock and offend some of you here,
• 25:21which is the title of an article that
• 25:23I wrote in the Milbank quarterly
• 25:26called Banishing Stakeholders.
• 25:28Now for you, click off your zoom here.
• 25:31I'm going to explain what I meant.
• 25:34I was trying.
• 25:35I read about the word stakeholders,
• 25:38not the people who are stakeholders.
• 25:41For the people who are referred
• 25:43to as stakeholders,
• 25:43I really detest the word stakeholders.
• 25:46It actually comes from people who have
• 25:48a financial interest in the outcome.
• 25:50Literally the state that is
• 25:52the derivation of that word.
• 25:54And oftentimes when you people
• 25:55think of a process,
• 25:57the immediate gut reaction is let's
• 25:59bring together the stakeholders
• 26:00and then they think of whoever
• 26:02is possibly involved in.
• 26:03Let's have like a 30 or 40 person committee
• 26:06and let's try to figure out what to do.
• 26:08The challenge I think particularly
• 26:09on this issue is when you do that.
• 26:12You wind up with the same types of challenges
• 26:16in letting evidence be an important guide.
• 26:20Then, as you do,
• 26:22just in general,
• 26:23your re capitulating the political
• 26:25challenges that you have on drug policy.
• 26:28And I've seen many of these committees really
• 26:31founder because people have fundamentally
• 26:33different ideas about what's going on,
• 26:35and there's not really
• 26:36a guide or an external,
• 26:38you know,
• 26:39evidence informed kind of.
• 26:42Gradient for reviewing different ideas
• 26:45so other approaches besides just saying
• 26:48anyone who has anything at stake in this,
• 26:51we should bring to the table
• 26:53and then that huge,
• 26:55unwieldy group is going to be vested
• 26:56with a certain type of authority.
• 26:58We're all just going to wait to see what
• 27:00happens that is not written in stone.
• 27:03There are other ways to do it,
• 27:04and another way to do it would be
• 27:05to have a much smaller group guided
• 27:07by public health with people who
• 27:10are trusted in in a community.
• 27:13And have that group do an enormous
• 27:16amount of outreach to to people
• 27:19who have absolutely essential
• 27:21perspectives to consider.
• 27:23And I like that phrasing maybe a
• 27:25little better than stakeholders,
• 27:27and you can really make sure
• 27:29you're hearing from, you know.
• 27:33People who use drugs, family members,
• 27:36the treatment community,
• 27:37the different kinds of the
• 27:38treatment community.
• 27:39You can bring all those things in and
• 27:41oftentimes when you have a process like this,
• 27:44that core group can be very engaging
• 27:47really explain its charge well.
• 27:50And when it actually has to disagree
• 27:53with someone then it can explain itself.
• 27:56And so we've been doing versions
• 27:58or supporting versions of
• 28:00this kind of process in different places.
• 28:03I'm from Rhode Island where this led to
• 28:05a big project to treat people in jail.
• 28:07So here there was a group
• 28:09at Brown that was convened.
• 28:11They were the public health side group.
• 28:12They did a lot of engagement activities.
• 28:14They also brought in speakers,
• 28:16including people who talked about the
• 28:18value of treatment in detention and
• 28:20they wound up being able to recommend
• 28:23that in the governor funded it.
• 28:25In other cases,
• 28:26we've had like assistant US attorneys
• 28:29come to the the public sessions
• 28:31and or the public comment periods.
• 28:33And say, you know,
• 28:35we cannot under any circumstances,
• 28:37you know, change the way we please,
• 28:39and the expert group or the
• 28:41the group that's been convened.
• 28:43its IT that public health guided
• 28:45will say we disagree with this and
• 28:47publicly explain why citing evidence.
• 28:49So you're kind of shifting the ground
• 28:52of the discussion to something to do
• 28:55an open but evidence informed process.
• 29:00Now. These processes don't make all of
• 29:03the challenges I talked about go away,
• 29:05but they do give an opportunity for
• 29:08really good ideas to come forward
• 29:10and some meaningful engagement with
• 29:12people from all types of perspectives.
• 29:15I hope you've forgiven me for trying to ban
• 29:18a stake holders at this point and understand,
• 29:21but I would soon find out.
• 29:23So we put these five principles out there,
• 29:27and we've gotten some.
• 29:29A little bit of news coverage on this.
• 29:32We've also been consulting with
• 29:34legislators who want to make sure that.
• 29:37These principles are put to good use.
• 29:42And the couple places I think have been
• 29:45introducing and maybe even passing
• 29:48legislation as they're setting up
• 29:50dedicated funds to try to do this.
• 29:52But the idea is that people should think.
• 29:57At every level are they following
• 30:00the five principles?
• 30:01Do they have a good process?
• 30:02Will there be transparency?
• 30:04Are they going to use this money
• 30:07and and use this as an opportunity
• 30:09to learn about and pivot a bit in
• 30:11addiction and overdose policy in
• 30:13order to have a bigger impact than
• 30:16people have been having today?
• 30:17And in this way the funding can be a
• 30:22spark to change not just extra funding
• 30:25that comes in and then goes out the door.
• 30:31I should point out that there's
• 30:33some great companion documents
• 30:34that we also have on the website,
• 30:36including from Harvard walking through a
• 30:39bunch of good recommendations for places,
• 30:42and another part of Harvard which has
• 30:44like a huge compendium of the evidence
• 30:47for each different type of intervention.
• 30:50And so we're trying to encourage States
• 30:52and localities to use resources like
• 30:54that as they think about you know,
• 30:56embracing these principles supported
• 30:58by so many different organizations.
• 31:01And so you know what's next?
• 31:05Obviously we're in the process
• 31:07of advocating for people to admit
• 31:09to these principles,
• 31:11and we're also worried working on
• 31:12developing an assessment tool to see
• 31:14whether they're being followed and then
• 31:16monitoring the implementation of the of
• 31:18the for the in the spending of the funding.
• 31:20Advocacy this is called
• 31:22the advocacy sandwich.
• 31:23We're constantly trying to figure
• 31:25out how to add support at the
• 31:27principals in different ways.
• 31:30We are working to develop a set of metrics,
• 31:32align with the principles that will
• 31:34post on the website that people can
• 31:37use to see if states, counties,
• 31:38others are spending the litigation
• 31:40funds in accordance with them.
• 31:42For example, does the state have
• 31:44or the county have a dedicated
• 31:46fund for the litigation dollars?
• 31:53So to conclude.
• 31:58It's not probably right.
• 31:59Think of the upper litigation
• 32:01as the knight in shining armor.
• 32:04That's going to save the day
• 32:05from the overdose crisis.
• 32:06It's not changing the underlying
• 32:07challenges of opioid and drug policy,
• 32:09it's just adding more money so,
• 32:12but it does create an opportunity,
• 32:15and it creates the opportunity for a
• 32:18strategy that is is engaged with politics,
• 32:23science and advocacy.
• 32:24And so the five principles
• 32:26are what we are working on.
• 32:28With many partners to try to.
• 32:32I create a push in in the right direction.
• 32:34Of course at the local level,
• 32:37you know when they're particular budgets.
• 32:38We hope that people in.
• 32:42I'm all backgrounds,
• 32:43including schools of public health,
• 32:45schools of medicine.
• 32:47Community members are really engaged
• 32:49with how their locality is going to
• 32:51spend the money and that you know
• 32:54there are a lot of local opportunities
• 32:56and in the end of our peace,
• 32:59doctor Olson and I wrote that,
• 33:02you know,
• 33:02we can write a lot of papers
• 33:04about what needs to be done,
• 33:06but this is really a moment when
• 33:08people have to come out from
• 33:10behind their computers and really
• 33:12speak to the policy world because.
• 33:14There is money coming not just from this,
• 33:16but also from the federal
• 33:18government more coherently,
• 33:19and people really need to hear
• 33:21what would make a difference and
• 33:23what wouldn't it if they really
• 33:25hard political challenge.
• 33:27But it's necessary for everybody to
• 33:29think about how they can best engage.
• 33:34And I'd just like to thank
• 33:36Sarah Whaley and Josh Rising.
• 33:38They're leading this effort on the
• 33:40principles and all the principals
• 33:42partners and Bloomberg plan fees
• 33:44for their financials for this.
• 33:55Thank you Josh. That was wonderful.
• 33:57We do have some questions
• 33:59in the Q&A and I'll.
• 34:01Try to read those to you.
• 34:06Next, Abros asks is there anything
• 34:08that can happen at the national
• 34:10level to hold states accountable
• 34:12on how the funds are being used?
• 34:17Uhm? So. That's a good question.
• 34:20I think there are a number of groups working
• 34:23kind of across the country that you know we
• 34:25have some very strong partner shatterproof.
• 34:27Once it created a National
• 34:29accountability project around this.
• 34:31But if you're asking the federal government,
• 34:33there's nothing, there's no.
• 34:35Direct legal hook.
• 34:37There are some somewhat indirect legal hooks,
• 34:39and I'll give you an example of 1.
• 34:42There are some clawback rules meaning
• 34:48the federal government gets to keep
• 34:50some money under some circumstances.
• 34:53If the federal government is
• 34:55spent money in federal programs,
• 34:57and so the federal government
• 34:58might be able to say we will.
• 35:01If if you're spending money,
• 35:03well, we won't.
• 35:04Clawback money for Medicaid,
• 35:07but if you are not,
• 35:09if you're spending money on
• 35:11things that don't make sense.
• 35:13And maybe we will try to take some of the
• 35:16back so that we can use it some other way.
• 35:18That is,
• 35:19I think a heavy lift for the federal
• 35:22government to do at that level of detail,
• 35:24but it's possible that there
• 35:27are some federal aspects of this
• 35:30that still have to be explored.
• 35:32I think most likely it's going to
• 35:34be very hard for the programmer
• 35:36to have two strong hand in this,
• 35:39because this was litigation brought
• 35:40by States and they're getting
• 35:42the money directly. In counties.
• 35:45Let let me I I thought about this recently.
• 35:48The issue of linking various
• 35:52datasets at across the state.
• 35:58Within a state has seemingly
• 36:00been a useful tool that some
• 36:02states have been able to achieve,
• 36:04but not very many, so I'm wondering
• 36:08if there is an opportunity for.
• 36:12And entities such as the CDC
• 36:15to either create incentives or.
• 36:20You know requirement that the
• 36:22outcomes that are can only be
• 36:25achieved by linking datasets be
• 36:28reported on a on a regular basis.
• 36:31Well, I don't think there's there's
• 36:33really a built-in reporting requirement
• 36:35for the federal government to set
• 36:37for the litigation, but the issues
• 36:39that you raised are really good ones.
• 36:41And it could relate.
• 36:42I mean, look, the federal government is
• 36:44giving States and localities a lot of
• 36:46money and and over the last few years
• 36:49has not really asked that much in terms of,
• 36:52you know, standards from them.
• 36:53So I think probably the federal
• 36:55government could get at some of these
• 36:57same issues through the money the
• 36:58federal government is distributing.
• 37:00And that's going to be a big
• 37:02challenge for particularly Samsung.
• 37:03But also the CDC this year,
• 37:05I think the CDC has invested
• 37:07in some great programs,
• 37:08but what are really the minimum expectations
• 37:10for this level of federal funding?
• 37:12That's going to be a really important area
• 37:14to watch separate from the litigation.
• 37:15Although I agree it.
• 37:17I.
• 37:19Yeah, so thank you.
• 37:22Doctor Wesley Clark has a
• 37:24few questions for night.
• 37:25Neither open up his mic so you can ask them,
• 37:28but I will start reading.
• 37:30Public health usually uses the
• 37:33construction of stakeholders.
• 37:35And I think he's wondering whether
• 37:37substance use disorders should move
• 37:39away from this traditional paradigm.
• 37:42So you know I,
• 37:44it just makes my skin crawl every
• 37:46time I see the word stakeholders.
• 37:49I'll just be totally honest because
• 37:51I'm I come from you know,
• 37:53all these discussions,
• 37:56oftentimes involving, you know,
• 37:58commercial interests which are
• 38:00literally stakeholders and sometimes,
• 38:02and I'm going far afield from
• 38:05from this particular.
• 38:07This particular issue and the
• 38:09stakeholder construction puts
• 38:10everyone on exactly the same footing.
• 38:13I think it's very important to hear
• 38:14from people with commercial interests,
• 38:15but I think we should think of them
• 38:17as people with commercial interests
• 38:19or businesses that are involved in
• 38:21the particular issue as opposed to
• 38:23everyone has the same title like I
• 38:25think of like patients affected by a
• 38:27situation very differently than the
• 38:30companies affected by a situation,
• 38:31and both of them you know should
• 38:33be listened to and appreciated.
• 38:35But a single term that just
• 38:37sort of lumps everyone together.
• 38:38I just I just don't like that
• 38:40much and I think we should be more
• 38:43specific about who we mean when we
• 38:45say stakeholders who's you know whose
• 38:47perspectives we really need to get people.
• 38:50Another way to think about this?
• 38:51There's a lot of discussion
• 38:52about involving people,
• 38:53for example, who have used drugs,
• 38:55or use drugs and in thinking
• 38:56about some of these challenges,
• 38:58you know, then we should do that.
• 38:59We should say that we shouldn't
• 39:01say stakeholders and people say
• 39:02like we had a lot of stakeholders,
• 39:04you know and feel like they've checked
• 39:05the box for something that really isn't what.
• 39:08We might want to have included,
• 39:10so I'm I'm basically making a
• 39:12call for more specifics,
• 39:13but I'm not saying that people who
• 39:15are involved or have a perspective
• 39:17on something shouldn't be engaged
• 39:19or listen to at all, and so I would,
• 39:21you know,
• 39:22refer you to the Milbank quarterly for
• 39:24my full top fund on stake holders.
• 39:26I think I said something like.
• 39:29The only legitimate stakeholder
• 39:31is Van Helsing,
• 39:32who I think was the person
• 39:34who killed Dracula.
• 39:38I get it.
• 39:41So Wes has another question,
• 39:44wondering whether the governors
• 39:45and the attorney generals have
• 39:46agreed to the five principles,
• 39:48great, great.
• 39:49Another great question from Doctor Clark.
• 39:51It's great to know that you're here.
• 39:52Doctor Clark. The answer is no
• 39:56governors or attorney generals as yet.
• 39:58I think we are getting
• 39:59interest in state legislators.
• 40:00I think there's a lot of interest
• 40:02in the principles as we've
• 40:03talked to different places,
• 40:05but they don't really know yet.
• 40:07For a lot of these settlements,
• 40:08how they're going to pan out
• 40:10so they don't want to commit,
• 40:11you know, kind of in advance of
• 40:13doing what the settlement is,
• 40:14but I think there will be a moment
• 40:16where hopefully people will
• 40:18have to answer on this question
• 40:20in to become possible.
• 40:25Robert Kerns says I haven't heard
• 40:27you mentioned a third public health
• 40:29crisis, namely poor management of.
• 40:34Poorly managed pain and especially
• 40:37high impact chronic pain.
• 40:39Other countries have invested in large
• 40:41public health campaigns to promote.
• 40:43Adaptive pain, self management and
• 40:45other investments in prevention
• 40:47and care for persons with pain.
• 40:49Do you believe that such an
• 40:51investment fits within your framing
• 40:52of how opioid litigation funds
• 40:54should be appropriately spent?
• 40:58That's a terrific question,
• 40:59and I do think it it can fit in,
• 41:03particularly as you realize,
• 41:05as the point that you're making about
• 41:08the importance of evidence based
• 41:11care for people with pain and just
• 41:13the gaps that exist in that system,
• 41:15I think that is relevant to
• 41:17the principle of using evidence
• 41:18to guide policy in this area.
• 41:20It's certainly relevant to.
• 41:23Using evidence and and using
• 41:25these funds to save lives.
• 41:26So I I certainly would think it
• 41:28would be a reasonable thing for
• 41:31a location to use a portion of
• 41:34these funds to to expand access
• 41:36to really a great care for pain.
• 41:42OK, Sidney Fox is wondering for
• 41:44states where public health is already
• 41:47indoctrinated in doctrine and belief
• 41:49of large multidisciplinary stakeholder
• 41:52committees to generate policy.
• 41:54How you approaching and educating
• 41:55public health at the highest
• 41:57levels to consider this approach?
• 42:01So. It's a great question,
• 42:04you know generally,
• 42:05what we say is, you know,
• 42:08let's say you've got like a unwieldy
• 42:11you know stakeholder committee,
• 42:13and most likely are frustrated with it.
• 42:16Like if it's going well and then you
• 42:18know there's nothing you're going to say.
• 42:19But a lot of times I'll talk to
• 42:21people and they're frustrated.
• 42:22And frankly, oftentimes the people
• 42:24on those committees are frustrated.
• 42:26They feel like they're not getting anywhere.
• 42:28I believe in Rhode Island there
• 42:30was a committee that like the.
• 42:32Avidan's Journal was editorializing
• 42:34about being notoriously inefficient,
• 42:36and it was frustrating so many people.
• 42:38And so you don't have to disband
• 42:41that committee.
• 42:42You can just create a,
• 42:44you know a much smaller nimbler group
• 42:46with a specific charge and one of
• 42:49the things you say is they've got to
• 42:51go really listen to this committee.
• 42:53They they can then structure a discussion
• 42:56with the bigger group and listen to
• 42:58what they're saying and respond to them.
• 43:00To me, the response is incredibly important.
• 43:03It's really a principle of administrative law
• 43:05that you can't be arbitrary and capricious,
• 43:07but and as a result that leads agencies
• 43:10to have to explain what they're doing.
• 43:12I think in these kinds of things we
• 43:14you can adapt our principle and say,
• 43:16and let's have a smaller group
• 43:18and let's have that smaller group,
• 43:20you know, make actual recommendations
• 43:22and try to explain them.
• 43:23So, for example, in Rhode Island Dr.
• 43:25Jody Rich,
• 43:26who was one of the leaders of
• 43:28the smaller group,
• 43:30got up in front of this bigger group
• 43:32and said and was quoted saying I
• 43:34can't wait to hear all your ideas,
• 43:37but we can't do everything all at once.
• 43:39I'm I'm paraphrasing,
• 43:40and he said something like, you know.
• 43:42My job here is to find what's going
• 43:44to matter the most to save lives,
• 43:46and I'm going to be honest with
• 43:47you about what I think that is.
• 43:48I'm going to respond to all
• 43:50these different ideas,
• 43:51but I want you to know why
• 43:52I'm here and what I'm doing.
• 43:53And and people, didn't, you know,
• 43:55respond by throwing him out of the room?
• 43:56They he was a credible person
• 43:57in Rhode Island.
• 43:58They listened to him and he,
• 44:00you know,
• 44:00mixed it up with people and and
• 44:01had conversations with people.
• 44:02And so you create a smaller group
• 44:04with a charge that gets you more
• 44:06forward momentum and then they
• 44:08can work with those other groups.
• 44:10And frankly those other groups
• 44:12suddenly are excited.
• 44:13A lot of them that something
• 44:14is actually moving forward.
• 44:15Now,
• 44:15obviously if they're investing
• 44:17in something that some of those
• 44:19people don't like,
• 44:20you know you're going to have you're
• 44:20going to have to deal with that,
• 44:21but the majority of that group is
• 44:24quite likely going to be excited
• 44:26to see things going forward.
• 44:30So I'll take my proactive and say you know
• 44:32to your point about you can't do everything.
• 44:34There are just so many things to be done.
• 44:38In other areas of medicine and public
• 44:41health we often use modeling or other
• 44:44techniques to help us determine what will
• 44:46give us the greatest return on investment.
• 44:50Quote UN quote, the biggest bang for our
• 44:52buck, and to your first point about,
• 44:54you know the first principle is to
• 44:56save lives and I would add to that.
• 44:57Save lives now, not a generation from now.
• 45:02Should we be using more sophisticated
• 45:05modeling strategies to dictate which
• 45:08of the 100 things we could do,
• 45:11or the three or four that will make the
• 45:13biggest difference in the short term?
• 45:15Yes, I'm I'm not an expert in these studies.
• 45:17There have been some published.
• 45:19I think there was one out of Hopkins
• 45:21by Caleb Alexander and Jeremy Barrett,
• 45:23and I think there's some out of Stanford.
• 45:26That have been published that go through
• 45:27a bunch of different options I did.
• 45:29I do think that that that that's helpful.
• 45:31I think the trick here is look,
• 45:33there's a way of thinking about this.
• 45:35It's saying here's what every
• 45:36place needs to invest in.
• 45:38Here's exactly the budget you know,
• 45:40for if you've got sort of like if you only
• 45:43have a few days and you know neuro Shell,
• 45:46what do you do in New Rochelle?
• 45:47If you have five days in Neuro Shell,
• 45:49what do you do in New Rochelle?
• 45:50You know, you know,
• 45:51if you only if you're going to
• 45:53get $200,000 from the settlement,
• 45:54what do you do if you get 500,000
• 45:56you get 2,000,000 what?
• 45:57You know how you spend it?
• 45:58Spend it exactly on this.
• 46:00I think the concept behind the principles is,
• 46:02you know, that's not how it's going to work.
• 46:05It's not going to be realistic
• 46:07that we want to that we're dealing
• 46:09with some pretty fierce obstacles.
• 46:11And if you come in with something
• 46:12that is not realistic,
• 46:14it'll just get brushed brushed
• 46:15aside so you have to balance.
• 46:18You know some degree of understanding
• 46:20that look, these people brought lawsuits.
• 46:23They're entitled to some,
• 46:24you know,
• 46:25discretion how to spend the money
• 46:27recognizing there are.
• 46:27Unique local situations,
• 46:29but trying to create a process
• 46:32and a mandate for you.
• 46:34Know evidence to be very influential in this,
• 46:37and you know,
• 46:38I I just given just how poorly funds
• 46:40are often spent in this area to expect
• 46:42it all to turn on a dime just because
• 46:45it happens to be coming from the
• 46:47litigation I think is unrealistic,
• 46:48but let's let's start to create
• 46:50that momentum and absolutely in that
• 46:52discussion you know you can do that.
• 46:54One of the things that is worked really
• 46:56well in all these places that we've worked.
• 46:58Is when you have a public meeting,
• 47:00you know the general default
• 47:02is like open mic night.
• 47:04You know people can come
• 47:05and say whatever they want,
• 47:06and that's really important.
• 47:07I like to stop and structure that
• 47:09so that people who are you know
• 47:11talking on similar themes maybe
• 47:13so you can hear it I'll I'll happy
• 47:16to share all my advice here.
• 47:18Well, another thing is,
• 47:19I think that when people what I
• 47:21don't like about open night Mic
• 47:22night is people feel like they're
• 47:24just screaming into the abyss.
• 47:25You know you get people together
• 47:26and like you got 100 people.
• 47:28They're all standing behind the microphone,
• 47:29they're all aggravated.
• 47:30They they yell at.
• 47:31They don't think anybody is
• 47:32listening much better to have people.
• 47:34Often I recommend bringing people
• 47:36up on stage and having them seated
• 47:38four or five at a time.
• 47:40They give their testimony and
• 47:41then you've got a group
• 47:43that's reacting to that.
• 47:44That's your you know, public health group.
• 47:46They ask them questions so people
• 47:48have to think about what they're
• 47:50saying and and and they respond and.
• 47:54You know, if you if you have something
• 47:56like that and you got everybody there,
• 47:58the other thing you can do is you
• 47:59can bring in external experts.
• 48:01So let's say we were in,
• 48:03you know County X and County X has
• 48:05got to decide how to spend the money.
• 48:08You know you could have as a zoom in
• 48:10with somebody who's done a great,
• 48:12you know, a computer model that
• 48:14explains what would be the most
• 48:16important thing in that county,
• 48:17and then everybody who's there
• 48:19has to listen to that.
• 48:20And that becomes part of the discussion.
• 48:22That is kind of the approach that
• 48:24Rhode Island took to being able to
• 48:26treat everyone you know in jail in
• 48:28prison with medications is they
• 48:29brought in an outside expert and at
• 48:31a big public meeting before people
• 48:33got up to say what was on their
• 48:35mind and haven't back and forth.
• 48:37They had an whole expert discussion
• 48:39about that,
• 48:39so I think that they're sort of
• 48:41like these administrative tools in
• 48:43a way that can help shape people's
• 48:44understanding of the issue.
• 48:45And again,
• 48:46get evidence into the process
• 48:48a little more effectively.
• 48:53So Melanie Racine says the principal
• 48:57focused on racial equity highlights
• 48:59investments in communities affected by
• 49:02discriminatory discriminatory policies and
• 49:04tackling root causes of health disparities.
• 49:07I'm wondering how broadly this principle
• 49:09is conceptualizing and will later be
• 49:12measuring such community investment.
• 49:14Can you give some examples and thank
• 49:17you for your presentation. Sure,
• 49:20well, I think we're at least conceptualizing
• 49:24at very high level that the process
• 49:27that gets set up will be recognizing
• 49:29this history and asking itself.
• 49:32Are we spending the money
• 49:33in a way that counters it,
• 49:35and being able to point to specific
• 49:38investments that the counter it?
• 49:40It may be, you know,
• 49:41in one place that that looks
• 49:44like investments in housing for
• 49:46people who are in drug treatment.
• 49:49Or are you know using drugs
• 49:53that because of the.
• 49:55Enormous gaps that are there and and
• 49:57the fact that that location feels like
• 49:59that's a real high priority I'm, I'm just,
• 50:01you know, throwing that out there.
• 50:03But like it,
• 50:04it may not look exactly the
• 50:07same in every place we do have.
• 50:09We're working on the indicators to see
• 50:12how well that's being taken into account,
• 50:15but it might look like you know,
• 50:18is there a clear commitment initially
• 50:21so we think of the indicators
• 50:24as upfront and afterwards so.
• 50:26Up front is this part of the construction
• 50:28of the plan for how to spend the money.
• 50:31Is this explicit?
• 50:32And then on the back end,
• 50:34how is it manifested?
• 50:36Is there?
• 50:37Sending that can be tide
• 50:39to those those priorities,
• 50:40and is there evidence that communities
• 50:43of color were really engaged and and
• 50:46involved in the decision making?
• 50:50But we'll have specifics on that,
• 50:51as as we get it sorted out, hopefully
• 50:53on our website and people can react.
• 50:57Thank you Josh Sygnal is
• 50:59wondering whether areas with
• 51:01schools of public health,
• 51:03medical schools, etc.
• 51:04Probably have the personnel and
• 51:06will to implement these principles.
• 51:09What about rural areas where
• 51:10the expertise doesn't exist?
• 51:14Yeah, well obligate relationship
• 51:17between sort of experts and
• 51:19expertise and the implementation.
• 51:23I think that's where some of these
• 51:25other resources come into play.
• 51:27I mean, we are so you know,
• 51:29we have a whole page of different resources.
• 51:32If people are interested in following it,
• 51:33they can, you know,
• 51:34get ahold of all these compendiums
• 51:36of evidence based practices models.
• 51:38Other things we've we're trying
• 51:41to actually set up ways for.
• 51:45Uh. People to reach out if they
• 51:48want help like look if there's
• 51:49somebody in a rural area who's
• 51:51interested like we're interested,
• 51:52we'll figure you know we'll
• 51:54we'll match them someplace and.
• 51:58But but I do think that this is.
• 52:03A factor in,
• 52:04particularly because so many non states
• 52:06are going to be getting direct funding.
• 52:10A obvious concern is going to
• 52:12be whether or not there is.
• 52:17And.
• 52:20You know whether there's sufficient
• 52:23public health options to guide
• 52:26is this is really something that
• 52:27the field of public health also
• 52:28has to be prepared to take on.
• 52:33And Sanjeev Kumar, what lessons have
• 52:34we learned from the use of tobacco
• 52:37settlement money that can be deployed
• 52:38for more efficient use of the settlement
• 52:40money for opioid use disorders?
• 52:45I mean, I think the big lesson
• 52:46is don't do what we did for
• 52:47the tobacco settlement money.
• 52:48I mean, it was just.
• 52:50Really unhelpful, you know.
• 52:52I mean, I think some of these
• 52:54lessons are being learned.
• 52:55I mean, I think the attorney generals
• 52:57would say the attorneys general would say.
• 53:00That they are.
• 53:03Not hoping that places you know
• 53:07that that they're putting in some
• 53:09bounds on how the money can be used,
• 53:11so you just can't use it to pave
• 53:12roads or put sprinklers in golf
• 53:14courses or character mask or
• 53:16whatever it was being used before.
• 53:17It's not just general fund.
• 53:19But within the lists of provable
• 53:23spending are a bunch of things that
• 53:26are kind of vague and in some cases
• 53:28it might be like reimbursements
• 53:30for you know policing activities
• 53:33or reimbursements for the county's
• 53:35expenses at the jail, or reimbursements,
• 53:37and that just winds up all going
• 53:39back to the same place.
• 53:40So you know, I, I think that.
• 53:44You know,
• 53:45I think you've got the biggest
• 53:47lesson from the tobacco settlement
• 53:49is to be very suspicious and
• 53:52to try to build in as a strong.
• 53:54Of the framework as possible for
• 53:56how the funds could be spent
• 53:58spent and really develop people.
• 53:59Understanding that this really
• 54:01matters to save lives.
• 54:02And in this community now and isn't just,
• 54:05you know, a free pool of money.
• 54:10OK, and one anonymous
• 54:11attendee is wondering what?
• 54:13What is the role of supply reduction
• 54:15control and addressing this problem?
• 54:16How do you approach that community?
• 54:23I wish I could ask the anonymous
• 54:25attendee a little bit more about
• 54:26what they're thinking, you know?
• 54:29I think that. The traditional law
• 54:34enforcement approach to overdose
• 54:37has not been particularly helpful.
• 54:38In some cases.
• 54:39It's made things worse and that is
• 54:42the conclusion the National Research
• 54:44Council and others who have looked
• 54:46at all the evidence. So in general,
• 54:49I think at the local level there may be.
• 54:54I mean I I would.
• 54:56Be a little bit.
• 54:59Concerned about, you know?
• 55:00Rushing to spend a lot of
• 55:01money on supply control.
• 55:03I think the supply issues that
• 55:05are probably most salient have to
• 55:08do with the synthetic opioids,
• 55:10which you know are coming in from
• 55:13different places and are uniquely deadly.
• 55:16And you know getting a better
• 55:18handle on what the drug supply is.
• 55:21If there are ways to do that,
• 55:24and I'm not, I think diplomacy may.
• 55:28Turned out to be one of the
• 55:29most effective ways to do that,
• 55:31but you know,
• 55:32I I don't rule out like all supply
• 55:34issues when you have these just
• 55:37incredibly dangerous compounds around.
• 55:39But I think we have to be pretty
• 55:42deliberate about investing in
• 55:43a local supply kind of strategy
• 55:46given the very poor track record.
• 55:51Couple more questions when Carolyn
• 55:53Missouri asks when resources are allotted,
• 55:56it seems essential to recognize
• 55:57that women and men have different
• 55:59routes to addiction and have
• 56:01very different treatment needs.
• 56:03Can you speak to whether this
• 56:04has been part of the discussion
• 56:06and developing the principles?
• 56:10I think that's a great question.
• 56:12It has not been a big part of the discussion.
• 56:15I think. Be interested in.
• 56:18Thinking about the.
• 56:21You know how that might be referenced
• 56:23in the principles and we could put
• 56:25it up in the resources section,
• 56:27and I think the principles are
• 56:30sufficiently flexible to incorporate that.
• 56:32We certainly don't have a one size fits all
• 56:35approach I've been reading recently about.
• 56:39This is not exactly on point,
• 56:41but the idea that in in many
• 56:44places reimbursement does not cover
• 56:46different types of family therapy.
• 56:48For addiction treatment and that may
• 56:50be very helpful to certain people.
• 56:53But you know if there are particular
• 56:56particular ways to categorize spending
• 56:59and make sure that populations
• 57:02are not overlooked,
• 57:04I think that we we could certainly
• 57:06make those kinds of resources
• 57:08available through the website.
• 57:09And emphasize that.
• 57:12I think you're hiding something
• 57:13I I don't know as well.
• 57:14I bet I met Doctor Olson here,
• 57:16knows a lot better than me.
• 57:21Back to West Clark. Doctor Clark.
• 57:24How do you reconcile the federal
• 57:26billions devoted to the opioid epidemic?
• 57:29In the MDL settlement dollars,
• 57:32when is there too much money in the
• 57:34pot and and to that point you know
• 57:37we look and talk a lot about these
• 57:39settlement dollars as if they're
• 57:41functionally different and you know.
• 57:44I guess the big picture question is you
• 57:47know what is their size in relation
• 57:50to the overall you know pot of money
• 57:53to be spent and should the principles
• 57:56that you've developed guide all of
• 57:58the spending for for those funds but
• 58:01to to doctor Clark Clark's point,
• 58:02when is there too much money in the pot?
• 58:06Are all good and related questions.
• 58:09I think that given.
• 58:13It's not just about the
• 58:14amount of money, right?
• 58:16It's about whether or not the kinds of
• 58:18investments we're making are good ones,
• 58:20and that's why we're, you know,
• 58:22trying to use the momentum of
• 58:24the settlements to get people to
• 58:27really pause and think about it.
• 58:29And I think that in theory the federal
• 58:32government could do doing something
• 58:34quite similar in parallel for its
• 58:37money that it's giving out the federal
• 58:40government could require different
• 58:42kinds of planning documents that.
• 58:45Might be inclusive of some of this
• 58:47additional spending that that there
• 58:49being a very clear priorities that are
• 58:51guiding the spending and in different places.
• 58:53And I think we're again we're
• 58:55trying to hit a sweet spot of
• 58:58keeping something that's really,
• 59:00you know,
• 59:01focused enough and able to take advantage
• 59:03of this opportunity without trying
• 59:05to swallow everything all at once.
• 59:07Our hope would be that if people.
• 59:11Have the principle that we want to
• 59:13spend this money as wisely as possible,
• 59:15that they're then able to, you know,
• 59:18use prophecies that exist.
• 59:20If there's some good ones or generate
• 59:23new processes that can be used for
• 59:25spending some of this other money,
• 59:27but I think it might be a lot to try
• 59:31to force that right at the beginning.
• 59:34I do think one of the biggest
• 59:37questions is going to be how the
• 59:39federal government goes about,
• 59:40you know, spending the money that
• 59:43is continuing to be allocated.
• 59:45I don't think it's too much.
• 59:46I mean, this is a 90,000 live a year problem.
• 59:50I'm not worried about that.
• 59:52I'm more worried about where
• 59:53the money is going and is it,
• 59:55you know being spent wisely?
• 59:57Are we making good long term investments
• 60:00and that I'm very worried about
• 01:00:02and and I think this is sort of the
• 01:00:06a spark that can be used locally
• 01:00:08to rethink you know the approach.
• 01:00:11But you know,
• 01:00:12we it's it's very easy for us to,
• 01:00:16you know,
• 01:00:16be on the zoom and say they should do this.
• 01:00:18They should do that.
• 01:00:19I mean in out out there it is
• 01:00:21very difficult for people to.
• 01:00:27Run away from some of the most
• 01:00:28credible voices that they have
• 01:00:29in their community that are
• 01:00:30telling them to do something else,
• 01:00:31and so you know we're trying to
• 01:00:34position this as a as a least a
• 01:00:36one lever of change in in in that
• 01:00:39and hopefully inform some of those
• 01:00:41voices so that they get more.
• 01:00:45You know more more aligned
• 01:00:46with where the evidence is.
• 01:00:51So we have a couple of questions,
• 01:00:53ones on stigma ones on prevention.
• 01:00:57Sidney Schnoll says we more frequently
• 01:01:00talk about evidence based treatment,
• 01:01:02but what about evidence based prevention?
• 01:01:06And that's obviously one of the principles.
• 01:01:09I guess it it does raise the question and
• 01:01:13I think you alluded to this in your talk
• 01:01:15is that we specific to opioid initiation
• 01:01:18and the development of opioid use disorder.
• 01:01:22We have less evidence about the efficacy.
• 01:01:28Or effectiveness of prevention interventions.
• 01:01:30And so how do we?
• 01:01:32How do we reconcile that?
• 01:01:36Yeah, I think it says the challenge.
• 01:01:38This is another one where.
• 01:01:40The politics and the evidence
• 01:01:42can be a little bit off.
• 01:01:44People like to announce that they've
• 01:01:46got a special program in schools,
• 01:01:48for example, and a lot of those
• 01:01:50special programs that get set up.
• 01:01:52May not have a lot of
• 01:01:54evidence behind them at all,
• 01:01:55and so then you've spent money for
• 01:01:58something that doesn't really work.
• 01:02:00It may not be quite as bad as
• 01:02:01some of the other investments
• 01:02:02which actually backfire,
• 01:02:03but it's just not a very
• 01:02:07efficient investment.
• 01:02:08I, I think that my understanding
• 01:02:10the evidence and doctor putting
• 01:02:12you should obviously jump in here,
• 01:02:14but that particularly with
• 01:02:16respect to prevention,
• 01:02:17that it's often more general kinds of.
• 01:02:23Programs, resources,
• 01:02:26other other things that are going to be
• 01:02:30helpful to people and to communities.
• 01:02:34I remember when I was health
• 01:02:36Commissioner Baltimore and we had a.
• 01:02:41$1,000,000 a year came to us
• 01:02:43in Samsa prevention grants.
• 01:02:45And the question was,
• 01:02:46well, how do we spend it?
• 01:02:47And we're like, well,
• 01:02:48how are we spending it?
• 01:02:48And we're spending it on like 2 after
• 01:02:51school programs for like 15 kids each.
• 01:02:54You know, and they were getting just
• 01:02:56a tremendous amount of like don't
• 01:02:58use drugs training and it would.
• 01:02:59I think these programs were considered like
• 01:03:01evidence based in the sense that like they,
• 01:03:03kids were reporting slightly
• 01:03:05less interest in using drugs.
• 01:03:06At the end, I don't remember exactly,
• 01:03:10but we wound up taking that money
• 01:03:11and doing something very different.
• 01:03:13We wound up saying, like, look big picture.
• 01:03:15Most kids who start using drugs
• 01:03:18have had trouble in school.
• 01:03:21First, it's rarely it is possible,
• 01:03:23certainly, but it's rarely the
• 01:03:25straight a kid who gets into drugs.
• 01:03:27Who winds up, you know,
• 01:03:29really in trouble.
• 01:03:30It's more often kids who are frustrated
• 01:03:33and failing in school and dropping out
• 01:03:35of school that wind up turning to drugs.
• 01:03:38And there's some good evidence from that
• 01:03:40from some longitudinal research in Baltimore,
• 01:03:43so we said, well, you know.
• 01:03:44And and that research pointed to 6th grade.
• 01:03:47Is like a big key point in middle school
• 01:03:48like her kids going to stay on the
• 01:03:50track or they going to fall off back.
• 01:03:52And if you're falling off track in 6th grade,
• 01:03:547th grade, 8th grade.
• 01:03:55You're in real trouble from,
• 01:03:57uh, you know,
• 01:03:58a lot of public health
• 01:03:59challenges coming your way,
• 01:04:00including drug use.
• 01:04:03Another not all kinds of terrible things.
• 01:04:05So if we can help more kids
• 01:04:07succeed in 6th grade.
• 01:04:08So it turned out that there was a
• 01:04:10big 6th grade attendance initiative
• 01:04:12getting started in Baltimore,
• 01:04:14so we used that $1,000,000 to put.
• 01:04:18Mental health providers on
• 01:04:20all of the school teams.
• 01:04:23That they could be part of an
• 01:04:25interdisciplinary approach to helping
• 01:04:26the kids who are at greatest risk
• 01:04:29for having trouble in 6th grade.
• 01:04:30Now there was an evaluation found some
• 01:04:33beneficial things, some challenges.
• 01:04:35I don't know whether that was,
• 01:04:37you know, perfect program,
• 01:04:38but I would say that's was the principal
• 01:04:41around prevention that we want to
• 01:04:43help people stay on track with what
• 01:04:45they want to do in their lives and
• 01:04:47the opportunities available to them.
• 01:04:48That kind of you know,
• 01:04:52investment.
• 01:04:52In different ways can maybe
• 01:04:55better than the very targeted,
• 01:04:57targeted and you know messaging
• 01:04:59type interventions I I don't know
• 01:05:01doctor feeling if that comports
• 01:05:03with your sense of the evidence,
• 01:05:05and I think I think you raise an
• 01:05:08important caution when we think
• 01:05:10about allocating funds to to be
• 01:05:12sure we're clear on what targets
• 01:05:14we think were impacting that.
• 01:05:16Yes, we know that there are some
• 01:05:19modestly effective prevention
• 01:05:20strategies as it relate to tobacco.
• 01:05:23In alcohol and probably cannabis and youth,
• 01:05:27but we shouldn't assume that because those
• 01:05:30programs impact those that substance
• 01:05:33initiation that it's also going to
• 01:05:37impact opioid initiation and so you know,
• 01:05:40quite frankly,
• 01:05:41I think we need to double down and
• 01:05:43invest in better strategies that are
• 01:05:46targeted towards this major public
• 01:05:48health crisis as well as youth targeted
• 01:05:51programs to address smoking vaping.
• 01:05:54And and other in alcohol initiation.
• 01:05:59So there's a question about stigma.
• 01:06:01I just want to let folks know
• 01:06:03that in this series we're going to
• 01:06:05have Gary Mendell come and talk
• 01:06:07about stigma and the the work that
• 01:06:09shatterproof is doing to address that.
• 01:06:12But Judith Stoner,
• 01:06:14just at Judith Stangor asks.
• 01:06:16You mentioned anti stigma campaigns
• 01:06:18as a strategy and we've been working
• 01:06:20on these for years and I'm not
• 01:06:22sure how far the needle has moved.
• 01:06:24Do you have any strategies for best
• 01:06:27practices? Let's take my reduction.
• 01:06:31That is a great question and actually
• 01:06:34we have some great at Johns Hopkins.
• 01:06:37We have a place called the Stigma Lab,
• 01:06:40which is not where you,
• 01:06:42you know they bring in medical
• 01:06:45students to get stigmatized.
• 01:06:46But it's not the signal at the stigma
• 01:06:49lab is where they ustads different
• 01:06:54messages for Sigma and they try to really
• 01:06:58understand how people think about Sigma.
• 01:07:01Halle Berry and Beth McGinty
• 01:07:02run that Beth McGinty.
• 01:07:04It's actually been advising some states on
• 01:07:06how to think about smart stigma strategies,
• 01:07:10and Colleen has a wicked presentation
• 01:07:12which at some point you may want to
• 01:07:15invite her to give where she shows
• 01:07:17all these different campaigns and
• 01:07:19how they wind up actually testing.
• 01:07:21One of the things I've noticed in
• 01:07:23my experiences in public health is
• 01:07:24that you know people don't wake
• 01:07:26up in the morning and then go.
• 01:07:28I've got an idea for the new
• 01:07:29design of a spaceship.
• 01:07:30You know not that many people.
• 01:07:32Or, you know,
• 01:07:33I know I have a new technique to do
• 01:07:35some weird neurosurgical repair.
• 01:07:36I I just.
• 01:07:37It just came to me,
• 01:07:38but literally everybody in this
• 01:07:40was very clear during the pandemic
• 01:07:42as an opinion about public health
• 01:07:44and knows what it is and often
• 01:07:46times when it comes to messaging,
• 01:07:48people pick messages that.
• 01:07:50You know,
• 01:07:51resonate with them personally and
• 01:07:53not really thinking about the
• 01:07:55audience that you really want
• 01:07:56the message to resonate with,
• 01:07:58and you have to do good research to be
• 01:08:01able to to find that resonating message.
• 01:08:04And I think Beth has and we could
• 01:08:08pull it up pretty easily and a
• 01:08:10couple great blog posts where she
• 01:08:12talks about what she recommends
• 01:08:15for states for campaigns around
• 01:08:17stigma and how to think about that.
• 01:08:19So I would probably.
• 01:08:21Defer to that,
• 01:08:22but you know a lot of it is really
• 01:08:25doing your research ahead of time.
• 01:08:28Monitoring the impact of it.
• 01:08:30She really likes language based
• 01:08:33interventions that can be done
• 01:08:35relatively quickly so that people are,
• 01:08:37you know,
• 01:08:38not discussing stigma programs
• 01:08:40with stigmatizing language and.
• 01:08:44So you know I, I do think that there
• 01:08:45is at least an evidence base out
• 01:08:47there that that can guide guide us.
• 01:08:49One of the projects we're doing at
• 01:08:52Johns Hopkins is who understands stigma
• 01:08:54better within healthcare institutions
• 01:08:55because there's a lot of stigma about
• 01:08:57people who use drugs and drug use
• 01:08:59within and the treatments for drug
• 01:09:01use within health care institutions.
• 01:09:03And we're really trying to follow
• 01:09:05those those basic principles which.
• 01:09:10R. To be very thoughtful about how
• 01:09:14to put together the campaign and to
• 01:09:17study it very carefully before really
• 01:09:19deciding that it's it's ready to go.
• 01:09:21Because this is an area where you
• 01:09:23think you're telling people not to
• 01:09:24use drugs and what you're actually
• 01:09:26doing is demoralizing people more.
• 01:09:27And you know having something
• 01:09:29that's actually?
• 01:09:36OK, two more questions.
• 01:09:38One issue with this is from Melissa Baney,
• 01:09:40who says one issue with tobacco
• 01:09:43settlements was that many mandated
• 01:09:45state taxes on tobacco sales,
• 01:09:47which rendered states dependent on the
• 01:09:49continued sale of harmful products
• 01:09:51for their budgets in the long term,
• 01:09:53and even less willing to spend on smoking
• 01:09:56prevention and cessation initiatives.
• 01:09:58Are there any similar risks of incentivizing
• 01:10:01potentially harmful practices?
• 01:10:03In the opioid settlements.
• 01:10:07This is a great question as I'm answering
• 01:10:10that I'm going to put where would I put?
• 01:10:16Open authentic hears.
• 01:10:18These are the best mic indeed.
• 01:10:21Principles and stigma.
• 01:10:23I think that the biggest.
• 01:10:26Concern here has to do with
• 01:10:28what happens to Purdue Pharma.
• 01:10:31And most of the other stuff
• 01:10:33I think is is largely,
• 01:10:35and I'm not a total expert on this,
• 01:10:37but largely transfers of funds,
• 01:10:40but there's a very interesting
• 01:10:41question which I did not get
• 01:10:43into in the presentation about
• 01:10:45what happens to Purdue Pharma.
• 01:10:46And there's a concept that's floated
• 01:10:49that it could become a public
• 01:10:52corporation of some kind and basically
• 01:10:54would continue to sell opioids
• 01:10:56with the proceeds going to the.
• 01:11:00Plaintiffs but suddenly the plaintiffs
• 01:11:02are now in the opioid business.
• 01:11:05I think it does raise some of
• 01:11:08those questions in some cases.
• 01:11:10Some of the ideas of actually involved
• 01:11:12the plaintiffs literally running the
• 01:11:14company like appointing the board
• 01:11:16and stuff like that other places.
• 01:11:18Other iterations of the idea had been
• 01:11:21that it's basically some external third
• 01:11:23party running it on behalf of the plaintiffs,
• 01:11:26and they're sort of saying here turn it over.
• 01:11:28But what's interesting is when they.
• 01:11:32Are saying how big this settlement is like,
• 01:11:34oh, this is a $15 billion
• 01:11:36settlement or whatever it is.
• 01:11:37It could be that like 12 of the $15
• 01:11:40billion are from selling opioids overtime.
• 01:11:44And so that is that's raises some very,
• 01:11:47very serious issues,
• 01:11:50and I think that.
• 01:11:53We're going to have to.
• 01:11:56You know, be very, very cautious about that,
• 01:11:59and I think some of the state attorney
• 01:12:01generals are being very cautious about that.
• 01:12:04And it's it's really uncharted territory.
• 01:12:06I mean it, it's it.
• 01:12:08It's one thing to say for tobacco that like
• 01:12:10we're dependent on the tobacco industry,
• 01:12:12is, you know, continuing to sell.
• 01:12:14It's another.
• 01:12:14It's like you're the tobacco industry.
• 01:12:16That's kind of what?
• 01:12:17What is contemplated here?
• 01:12:18So I I don't have a have not
• 01:12:20thought this through entirely
• 01:12:22other than to say like boy,
• 01:12:24that's really a minefield and you really
• 01:12:26have to think about how that's done.
• 01:12:28Well, it may not make sense
• 01:12:30to constructive alone.
• 01:12:34One more question.
• 01:12:36This is from Sanjeev Kumar.
• 01:12:38It seems one of the stumbling
• 01:12:39blocks when it comes to stemming
• 01:12:41opioid use disorder is deeply
• 01:12:43moral and contradictory.
• 01:12:45Nature of the treatment.
• 01:12:46Quote UN quote use of drugs or I
• 01:12:49would say medication to fight drugs.
• 01:12:52Is this issue salient in the
• 01:12:54allocation of the money?
• 01:12:57Sure, I mean this, particularly
• 01:12:59as we get to medication goes
• 01:13:00back over 100 years in this country,
• 01:13:02are ambivalent about using
• 01:13:05medication to treat addiction,
• 01:13:07particularly when those medications
• 01:13:09are opioids themselves, and.
• 01:13:12I think it's it's going to be selling its
• 01:13:15selling in every aspect of opioid policy.
• 01:13:18It's stallion at the community level.
• 01:13:20It's talian its state policy.
• 01:13:22It's salient.
• 01:13:24You know everywhere,
• 01:13:25so I would expect it to be pretty
• 01:13:28salient now I have had the experience
• 01:13:30you know of speaking to judges
• 01:13:33about treatment and big rooms back
• 01:13:36when we could meet in big rooms.
• 01:13:40And I gave one very aggressive talk
• 01:13:43to a bunch of judges who work in drug
• 01:13:47courts or associated with drug courts.
• 01:13:49And I talked about how important it
• 01:13:51was that if you were going to treat
• 01:13:54people in the criminal justice system
• 01:13:56that they get care that actually can
• 01:13:57save their lives and not get care.
• 01:13:59That actually puts them at
• 01:14:00risk for greater risk.
• 01:14:01For that, you know, just takes away their.
• 01:14:06Their tolerance and then puts
• 01:14:08them at risk for overdose.
• 01:14:09Like don't do that, you know,
• 01:14:10and I just couldn't tell you like for
• 01:14:12some some of these presentations I
• 01:14:14challenge myself to be is absolutely
• 01:14:16patient with the evidence, but in the end,
• 01:14:18just land with some very very strong
• 01:14:20statements so that there was just
• 01:14:21they could be on their phones the
• 01:14:23whole time they were looking up at me.
• 01:14:25At the end.
• 01:14:25You know, I was saying, like you know,
• 01:14:27this is the difference between
• 01:14:29people whether people will live or
• 01:14:31die that are before you in court.
• 01:14:33You know, like I was just as
• 01:14:35clear they possibly could.
• 01:14:36And what I would say is it.
• 01:14:37That part of the biggest one
• 01:14:38of these that I did I had.
• 01:14:41Some people,
• 01:14:42like literally cheering me on some
• 01:14:44people looking at me with these puzzled
• 01:14:47expressions and some people giving
• 01:14:49like every negative vibe known to man.
• 01:14:52You know, as they were looking at me,
• 01:14:54you know. And.
• 01:14:56There's just a huge mix,
• 01:14:59it's just part of our national discussion.
• 01:15:01I do think it's getting a little bit better,
• 01:15:03but it really hasn't moved a huge amount.
• 01:15:04What would it take?
• 01:15:06Maybe you know to.
• 01:15:08To move that,
• 01:15:09I will tell you when I give that talk.
• 01:15:10And like there's one judge who comes up
• 01:15:12to me like tackles me afterwards and so
• 01:15:13it's like I never thought about it this way.
• 01:15:15This is incredibly helpful.
• 01:15:16I feel like the whole trip
• 01:15:18you know was was worth it,
• 01:15:20and that has definitely happened.
• 01:15:23It's worth asking what we think about Sigma.
• 01:15:25What would it take?
• 01:15:26And I don't think it's just anti
• 01:15:28stigma campaign that tackle stigma,
• 01:15:30and I'll leave.
• 01:15:30Maybe with this last thought if it's
• 01:15:32OK and I I'm I'm going to guess that
• 01:15:34you're with me on this here at Yale,
• 01:15:36but I think that the medical.
• 01:15:39Community,
• 01:15:40truly embracing addiction treatment is not
• 01:15:43just a strategy to increase access to care,
• 01:15:46it's an anti stigma strategy.
• 01:15:49And if you think a lot about
• 01:15:51how Sigma came down for HIV,
• 01:15:53it was because it became an
• 01:15:54illness that doctors treated.
• 01:15:55It was part of the medical,
• 01:15:58you know,
• 01:15:59experience addiction in many parts of
• 01:16:02this country is still not the case.
• 01:16:06We I've just seen some recent data
• 01:16:08among some of the top scoring hospitals
• 01:16:10in the country will hopefully
• 01:16:13eventually be able to publish soon.
• 01:16:15And you know,
• 01:16:16we we asked all these great
• 01:16:17things for hospitals to be doing
• 01:16:19and one of the things that.
• 01:16:21With the least popular among
• 01:16:23the top scoring hospitals,
• 01:16:24was being able to provide buprenorphine
• 01:16:26in the emergency department in an
• 01:16:28area where he has been a huge leader.
• 01:16:29And you know,
• 01:16:30I think that that may matter
• 01:16:32as much as anything,
• 01:16:34whether the medical profession
• 01:16:35which could embrace this,
• 01:16:37whether it does embrace this,
• 01:16:39and I think.
• 01:16:41You know there there are
• 01:16:42all kinds of things that
• 01:16:43we can do in our own world
• 01:16:45to to help with this shift,
• 01:16:46and I think the idea of this
• 01:16:49talk is that the purpose of the.
• 01:16:52Of the settlement is not going to.
• 01:16:55The settlement is not going to rescue us all,
• 01:16:56but it is another leverage point to try that.
• 01:16:59You know, work with all the tools that
• 01:17:02we have to to shift the focus of of
• 01:17:05where we're headed on over to separate.
• 01:17:08Josh, I absolutely agree with your point.
• 01:17:11We will be having a talk later on
• 01:17:14in this series from Doctor Edward
• 01:17:16Coupe and Don State are talking
• 01:17:18about Ed based interventions.
• 01:17:21I agree that to the extent that
• 01:17:23we can normalize in mainstream,
• 01:17:25it will only go to address issues
• 01:17:27around stigma and and understanding.
• 01:17:30I want to thank you for your time and all
• 01:17:34of this great work you're doing, Kyle.
• 01:17:37I didn't know if you wanted to
• 01:17:40say a few words or.
• 01:17:41If we should just sign off.
• 01:17:43No, just a massive thanks to everyone,
• 01:17:46especially you Josh.
• 01:17:48Terrific presentation, very informative.
• 01:17:50I really enjoyed all the questions as well.
• 01:17:53So thank you for.
• 01:17:54Allowing us to be a part of
• 01:17:56this great speaker series.
• 01:17:58We've got some wonderful
• 01:17:59speakers coming up and.
• 01:18:00Josh, we'd love to have you
• 01:18:02join for some of those and
• 01:18:03ask some tough questions.
• 01:18:06And I'm going to have the final slides.
• 01:18:10Will include information you all
• 01:18:13will receive an email with access
• 01:18:15to this and we look forward to
• 01:18:17seeing you on our future talks.
• 01:18:19Thank you everybody and take care.
• 01:18:22Thank you.