6_10_21_Hansen_Yale Addiction Medicine Rounds

December 09, 2022

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00:00So everybody, this slide is just a
00:03reminder that there are many ways for
00:06you to stay connected with the Yale.
00:09Program in addiction medicine.
00:12You can visit our website.
00:14You can ask to be added to our listserv.
00:18And also you can follow our programs on
00:22Twitter at Yale Adm and at Yale Champions,
00:26so encourage you to continue to follow us.
00:31Next month, our addiction medicine rounds
00:34will be given by Helena Rutherford.
00:37Helena is a, and this is amazing.
00:40To have two helenas in a row is, I think,
00:43very impressive and unprecedented,
00:45at least for our addiction medicine rounds.
00:49Helena is an assistant professor
00:51in the Child Study Center here
00:53at Yale School of Medicine,
00:54and she will be talking about
00:57maternal addiction and its insights
00:59from social neuroscience.
01:00So we're very excited to look at.
01:02To have Helena next month.
01:06And then another announcement,
01:07you may be aware of that we're starting
01:10a special series that's funded by
01:13the Sand Guard Foundation and that
01:15will start at the end of June,
01:17are to kick that off,
01:20we've got Josh Sharfstein,
01:21who is the vice Dean for public practice
01:24and community engagement at the Johns
01:26Hopkins Bloomberg School of Public Health.
01:29And the focus of his talk will be
01:32what to do with the funds that will be
01:36coming from the opioid litigations.
01:38He and others have worked to.
01:42Propagate a set of principles
01:45for how to spend those funds and
01:47especially at the level of the state.
01:49So Josh has been instrumental in working
01:51with states to develop strategic plans
01:53and so I think that will be a very
01:56special talk for folks to to hear.
02:00So just to reminder, we do provide CME,
02:04you can text this number to the number listed
02:07and we'll put that in the chat as well.
02:13So I'm really excited to have our
02:16speaker today, Doctor Helena Hansen.
02:18She's a psychiatrist and an
02:21anthropologist and professor and chair
02:23of research team and Translational
02:25social social science and HealthEquity,
02:28as well as the associate director of
02:30the Center for Social Medicine at
02:32UCLA's David Geffen School of Medicine.
02:35Helena earned an MD and a PhD in
02:39cultural anthropology as part of
02:41Yales NIH funded medical science.
02:43Planning program and it was at
02:45that time that I had the distinct
02:48opportunity to meet her and to learn
02:50a different way to look at medicine.
02:53While at Yale,
02:54she completed her field work in
02:57Havana on Cuban AIDS policy and
02:59in Puerto Rico on faith healing
03:01in event evangelical Christian
03:03Addiction ministries founded and
03:06run by self identified ex addicts.
03:09She completed a residency in
03:11psychiatry at NYU Bellevue.
03:13During which she undertook and through
03:15ethnographic study of the introduction
03:17of new addiction medications and
03:19examine the social and political
03:21complications of clinicians efforts
03:23to establish addiction as a biomedical
03:25rather than a moral or social condition.
03:29As well as the ways that neurochemical
03:32treatments may be re inscribing
03:34hierarchies of ethnicity and race.
03:37And it is this work she will likely touch on.
03:39Today she's published widely on faith
03:42healing and addiction in Puerto Rico,
03:45psychiatric disability under welfare reform,
03:47opioids and Wraith race,
03:49ethnic marketing of pharmaceuticals
03:52and structural competency.
03:54Her first book,
03:55addicted to Christ was published
03:57by UC Press in 2000 and.
04:0018 and the subtitle is remaking men in
04:03Puerto Rican Pentecostal drug ministries.
04:06For second book is structural competency
04:08and medicine and mental health,
04:09a case based approach to treating the
04:12social determinants of health with
04:14Co editor Jonathan Jonathan Metzel
04:15and that was published in 2019.
04:18And then her third book whiteout
04:21how capital racism,
04:23how racial capitalism changed the
04:25color of heroin in America with policy
04:28analyst Jules Netherland and historian.
04:30David Hertzberg is forthcoming from UC press.
04:34She's a recipient of multiple awards,
04:37the Robert Wood Johnson Health Policy
04:39Investigator Award and NIH K award,
04:41the Kaiser Permanente Birch
04:43Minority Leadership Award,
04:45and a Melon Sawyer Award.
04:47So with all of that,
04:48I really it's an honor to introduce and
04:52welcome Helena back to Yale to speak
04:55with us about beyond magic bullets,
04:57white race as a social determinant
04:59of the opioid crisis.
05:01I look forward to hearing what
05:02she has to say, Helena.
05:05Thank you so much for that
05:08generous introduction.
05:09I just want to mention that David Falleen,
05:12you were my first teacher
05:15of addiction medicine.
05:17And inspired me to go on to specialize
05:19in addiction do addiction research.
05:21I first worked as David Flynn's
05:24medical student and Wednesday evening
05:26clinic and got a glimpse of the early
05:29clinical trials of buprenorphine
05:31buprenorphine under his supervision
05:33and that of Patrick O'Connor.
05:35And it's stuck with me,
05:37as you can tell from my current work.
05:40So I'm going to try to share my
05:42screen right now and see if it works.
05:45Are you seeing my screen?
05:47OK, terrific.
05:49So again, thank you so much, David,
05:51and also to Jean to Troll who organized
05:54this and the many behind the scenes
05:57organizer of the organizers of the
06:00Yale Addiction Medicine Program,
06:01which is really a leader
06:04nationally and internationally.
06:06So whoops,
06:07I'm skipping ahead in my slides,
06:11but I just want to start by putting
06:14in context my unusual approach to
06:16the topic of race and the opioid.
06:19Increasingly the overdose crisis, right?
06:21Because it's a polysubstance.
06:24Problem at this point in time,
06:27I've been studying the intersection
06:29of race with the opioid crisis and
06:31the growing field of addiction
06:33medicine for over a decade.
06:35And the introduction,
06:36the generous introduction that
06:38David Fleen made alluded to that.
06:40So I started over a decade ago,
06:43at a time when the media was publishing
06:46stories about the surprise of white
06:49suburban and rural opioid addiction.
06:51Since that time,
06:52though,
06:53unfortunately the plot has only thickened
06:56and we're seeing overdose deaths in the US.
06:59The death rate that's increased more
07:01than 40% since the onset of COVID.
07:04The overdose rate has gone up the
07:06fastest among black residents,
07:08primarily in Western and southern states.
07:10That's the early those are the
07:12early reports that we're getting
07:14on the impact of COVID.
07:17And I think what we're going to see
07:20moving forward is the overdose crisis
07:22and policies that are addressing it.
07:25They're going to be increasingly
07:27framed as a racial justice issue.
07:29But of course, what makes the overdose
07:32crisis of the past 20 years different
07:35from in many other people's minds?
07:37Is the way that the white identity
07:39of sufferers has been highlighted
07:41in media and in public policy,
07:44so I'm going to today.
07:48Give you a glimpse of an approach to
07:51race and health from an angle that's
07:54unusual in medicine by examining
07:56hidden mechanisms of whiteness.
07:59I'm going to share a study of the
08:01hidden but active maintenance of white
08:03exclusivity in medicine as the cause
08:05of what we often call in healthcare.
08:07Field disparities quote UN quote
08:10among underserved minorities,
08:12so these are groups typically
08:14described in a passive manner as quote
08:17UN quote lacking access to care.
08:19And what that doesn't show is
08:21that whiteness is central to our
08:23environment of profit motives,
08:25commodification and the use of racial
08:28hierarchies to segment and open
08:30markets in the US healthcare landscape.
08:32Here is the slide that I accidentally
08:35gave you a preview of. Umm.
08:40Just to hide to under score that this.
08:43This hidden but active white
08:46exclusivity involves the mutual racial
08:48racialization of drugs and people.
08:51What I mean is that drugs can be white,
08:53as in targeted to white people,
08:56as a market,
08:57they can pharmaceutically enhance the
08:59whiteness of people whose privilege.
09:01Is in question because the stigmatizing
09:04diagnosis like substance use
09:06disorder or addiction in my time.
09:09So I first encountered office based
09:11medication for opioid dependence really
09:13under the supervision of David Feline
09:16and Patrick O'Connor in the late 1990s.
09:18I was a medical student working
09:21with them at a time that they're
09:23running early clinical trials of
09:25Pupin orphan which would later be
09:27manufactured with the lock zone
09:28under the commercial name Suboxone
09:30and what I heard Wednesday evening.
09:32Clinics in our group discussions
09:34of addiction medicine was a lot
09:37of excitement about buprenorphine,
09:39which many people said in this research
09:42team and clinical team was going to
09:45change the culture of medicine by
09:47defining addiction as a chronic disease,
09:50treatable alongside diabetes hyper.
09:51Retention and asthma in the same clinics,
09:55primary care clinics,
09:56and in the same way with
09:58pharmaceutical maintenance.
09:59So this definitely caught my ear.
10:01As an MD PhD student studying cultural
10:05anthropology, I wanted to know.
10:07What could it mean to change
10:09the culture of medicine?
10:11And what would drive a change
10:12in the culture of medicine?
10:14So as it turns out, my attendings were right.
10:17So in the course of my career I saw a shift,
10:22a profound change in the ways that
10:25clinical practitioners frame addiction.
10:27So my field of addiction treatment swang
10:31from largely drug free philosophy in
10:34the late in the early 1990s towards
10:37opioid maintenance as a first line of
10:39treatment for opioid use disorder.
10:41During the 2000s,
10:42and as I finished an addiction
10:44psychiatry fellowship and I took a
10:47faculty position in psychiatry anthropology,
10:49I was also able to document stark
10:52differences between buprenorphine patients
10:54and methadone patients by race and class.
10:57So what began as a study of the
10:59culture of medicine began became
11:01a study of how the opioid crisis
11:04came to be seen as white,
11:06ironically at the same time that
11:09racially targeted drug policies.
11:11Led to mass incarceration of
11:13Black and Latinx Americans and
11:15gave the US the highest
11:17incarceration rate in the world.
11:19So tonight, I'm going to give you an analysis
11:21for my forthcoming book on opioids and race,
11:23and it's based on research supported by Nida,
11:25the Robert Wood Johnson Foundation,
11:27American Psychiatric Association, and the
11:29New York State Office of Mental Health.
11:32And I want to say that while narcotics
11:35have long been criminalized through
11:37association with marginalized racial groups,
11:39and that was this next slide,
11:41such as turn of the century images
11:44of Chinese opium dens or *****
11:47cocaine themes and the South.
11:49This is 1914.
11:51New York Times or Mexican marijuana madness.
11:55We don't often look at how symbolic
11:58association with white middle class
12:00markets has legitimated widespread
12:02prescription of narcotics including
12:05post World War Two epidemic overdose
12:08from barbiturates and benzodiazepines,
12:10later benzodiazepines that haunted white
12:13middle class America mothers little helper.
12:16We rarely ask how a drug can assume whiteness
12:19within a pharmaceutical logic based on race.
12:24But this yet this process of pharmaceutical
12:27whiteness is at the core of the widely
12:31cited and widely asked question.
12:33I'm going to go ahead to this slide.
12:35The widely asked question why is the life
12:38expectancy of white Americans suddenly
12:40falling while the life expectancy of
12:43almost every other racial group is rising?
12:45And how did overdose become their
12:48primary immediate cause of excess death?
12:50So I want to go beyond the
12:52received wisdom that unemployed.
12:53White Americans in the post industrial
12:56Rust Belt turned to opioids for solace,
12:58so that might be true,
13:00but it begs the question, why opioids?
13:02Why white people and why now?
13:05So I'm going to argue that the
13:07current generation of opioids were
13:08designed to have white racial
13:10identities and that in our stratified
13:12healthcare and justice systems,
13:13the social technologies shaping
13:16opioid consumption reinforce
13:18racial inequalities while at the
13:21same time harming white Americans.
13:23Key to this story is an unrecognized
13:26form of ethnic marketing that,
13:28because it targets white Americans,
13:30works by not marking itself as racial.
13:34So the story is invisible by design.
13:36And it was only through years of
13:38observation and interviews with key
13:39actors that I've been able to unravel
13:41the threads I've observed drug policy
13:43and addiction science meetings and
13:44clinical interactions over the past decade,
13:47interviewed 200 addiction scientists,
13:49treatment advocates,
13:50pharma executives,
13:51policymakers, administrators.
13:53Prescribers and patients.
13:55So let's start where I started
13:57this story study,
13:58which is with Suboxone or buprenorphine.
14:02It's easiest to see it's racial identity
14:04by comparing it to its predecessor,
14:06methadone.
14:06And here is a bar graph from the
14:09first nationally representative study
14:11to compare buprenorphine patients to
14:14methadone patients by race and class.
14:16And sadly, more recent studies like this one,
14:20which came out in JAMA Psychiatry,
14:222019,
14:23demonstrate that this pattern continues.
14:25So this study showed that white
14:27Americans with opioid use disorder
14:29were three to four times as likely
14:31as black Americans with opioid
14:33use disorder to get buprenorphine.
14:35And tellingly, the form of treatment,
14:38the form of payment that most
14:40buprenorphine payments used was
14:42out of pocket for quite expensive
14:45medication followed by private.
14:46Insurance and much further down the
14:48list Medicaid or public insurance.
14:50So that gives you a sense of to
14:53the state the demographics of who
14:56is receiving beeping orphan.
14:58But what we don't know from graphs like
15:01this is by what process did orphan
15:04and methadone gain their racial identities?
15:07And for that we have to go back in time.
15:10So I'm going to go to 1965.
15:13Race riots have burned through Harlem,
15:16Philadelphia and Watts, Los Angeles.
15:20The unemployment rate for black Americans
15:23is twice that of white Americans.
15:26And organized crime gains control
15:28of Asian heroin imports,
15:30recruiting a sales force from
15:32Black and Latinx inner cities.
15:34So meanwhile,
15:35Rockefeller University metabolic
15:37researcher Vincent Doyle,
15:39who thinks of heroin addiction
15:42as opiate receptor deficiency,
15:43analogous to insulin deficiency and diabetes.
15:47Publishers findings from the first
15:49clinical trial trial of methadone
15:51maintenance and this and he publishes
15:54with coauthors Marie Nyswander and
15:56Mary Jane Creek who is still with
15:58us and doing research to this day.
16:00The study subjects are African-American
16:02heroin injecting men from Harlem and its
16:06outcomes of reduced criminal activity
16:08and arrests and increased employment by
16:10six months brings it national attention.
16:13So by 1970 news of methadone
16:16as a pharmacological.
16:18Answered urban heroin reaches
16:20President Nixon,
16:21who appoints pioneering methadone
16:23psychiatrist Jerome Jaffe as
16:25the nation's first drug czar,
16:27and Nixon targets inner city black and
16:30Latinx Americans along with returning
16:32Vietnam Veterans with methadone,
16:34the major weapon in his war on drugs to
16:38prevent diversion and St sale of methadone,
16:40the DEA regulates methadone clinics,
16:42requiring requiring daily observed
16:44dosing and regular urine testing
16:47due to community resistance.
16:49The location of methadone
16:51programs in their neighborhoods.
16:53Methadone clinics are located
16:55in remote marginalized areas,
16:57neighborhoods in the city that are
16:59not close to other clinical services.
17:01So from the inception, from its inception,
17:03methadone has had a quasi medical and
17:08perhaps quasi criminalized status.
17:10So let's Fast forward to October 8th,
17:142002.
17:15A new kind of opioid problem has developed
17:17following Purdue Pharmaceuticals
17:18aggressive marketing of Oxycontin as
17:21a minimally addictive pain reliever.
17:23Quote UN quote.
17:24And most of these newly dependent
17:26people are white,
17:27many of them middle to upper income.
17:30Most of these newly,
17:31so the FDA has just approved the
17:35synthetic opiate buprenorphine.
17:37Commercially packaged with unlocks
17:38and suboxone for maintenance,
17:40treatment of opiate dependence and
17:42buprenorphine certified doctor's offices.
17:44Pharmacologically similar to methadone
17:46and that it blocks opiate receptors
17:48in the brains of addicted patients,
17:50buprenorphine, unlike methadone,
17:51can be prescribed monthly for use at home,
17:55while methadone is still restricted
17:57to DEA regulated clinics with
18:00directly observed dosing.
18:02Office space buprenorphine represents
18:04a reversal of national policy.
18:06It's the first time.
18:08In 80 years since the 1914 Harrison Act,
18:11that private office doctors are permitted
18:14to use opioids to treat opiate dependence.
18:17And to accomplish this,
18:19the manufacturers of buprenorphine
18:20and the architects of buprenorphine
18:23policy had to distinguish buprenorphine
18:26symbolically and spatially from methadone.
18:28So in essence,
18:30buprenorphine pharmacologically in
18:31the same drug class as methadone,
18:33had to be whitened.
18:36So this is Mike.
18:37He's in an Internet ad for Suboxone.
18:40Seated in his Ohio diner,
18:42he's flanked by American flags,
18:44talking about returning to coaching
18:45his son's baseball team and singing in
18:48his church choir after buprenorphine
18:49rescued him from a prescription
18:51opioid habit following a back
18:52injury in the diner that he owns.
18:55And so I invite you for a moment to
18:58play anthropologist and think about the
19:00race and class coding in an ad like this.
19:03You know,
19:04basically it,
19:05it completely reverses the
19:07image of who's an addict.
19:09That had been popularized in the
19:12press and media and public policy
19:15policy for almost the last century.
19:18So Mike is apple pie.
19:22But I argue that this ad was
19:24just the tip of the iceberg,
19:26that the whiteness of buprenorphine
19:28was actively achieved using what
19:30I call social technologies.
19:31And I'm going to give you an
19:33analysis of the contemporary white
19:34opioid crisis in terms of what I
19:36call technologies of whiteness.
19:38That is, social technologies
19:40of neuroscientific metaphors,
19:42policy and industry strategies
19:44that maintain racial boundaries
19:46around biomedical uses of opioids.
19:49And this scheme is informed
19:51by whiteness studies.
19:52Which is an offshoot of critical race theory.
19:55It proposes that one whiteness is a
19:57category of exclusion and therefore
19:59requires cultural and political
20:01maintenance of its boundaries.
20:03You know who counts as a white
20:05person in the United States and
20:08what privileges and and structural
20:10accesses are available to that person.
20:13As a result, #2 white race is unmarked.
20:17So as they assumed norm in the United States,
20:20it's rarely explicitly named,
20:21either in public policies or in the media.
20:23So typically a newspaper article that
20:26says that someone is American without
20:29mentioning race will lead readers to
20:31assume that that person is a white person.
20:34And racist typically mentioned
20:36when it's not white race.
20:38I want to also argue that
20:39there has been a notable shift.
20:44Definitely due to the surprise
20:46of white opioid dependent
20:48people and the opioid crisis,
20:50and especially over the past four years,
20:52whiteness is entered into national
20:54discourse in a way that it happened before.
20:57But it's the exception that proves the rule.
20:59You know that if you look at media
21:01coverage and mentions of whiteness,
21:03you understand how whiteness
21:05has for so long been unmarked.
21:08And then third,
21:09whiteness is defined by its other so white.
21:13On one hand and black or
21:15non white on the other hand,
21:17are interdependent categories and punitive.
21:20American drug policy has long had
21:22a mutually defining twin of legal
21:25narcotics for white Americans,
21:27who've had access to personal
21:28doctors starting with morphine
21:30and over-the-counter heroin from
21:31middle class Victorian housewives,
21:33then moving to post World War Two.
21:36Barbiturates stimulant diet pills and Valium,
21:39then Valium,
21:40otherwise known as Mother's Little Helper,
21:42now back to prescription.
21:44Pain relief and then, finally,
21:47white privilege has its cost.
21:50White consumers pay inflated prices
21:52for patented prescription opioids,
21:54but they also pay with their lives
21:56in the form of overdose by lethal
21:58substances to which they have,
22:00quote UN quote, privileged access.
22:03So the four technologies of whiteness that
22:05I'm going to run through our addiction,
22:07neuroscience, new biotechnologies,
22:09regulation and marketing.
22:10And I'll start with the least visible
22:13technology of race make making,
22:14which is brain science.
22:15So I want to put an orphan development
22:18on the backdrop of President Bush,
22:20the first decade of the brain.
22:23It was an era in which the
22:24National Institute on Drug Abuse,
22:26Nida,
22:26was directed to look for neuro molecular
22:29basis for addiction in anticipation of
22:31breakthroughs from the Human Genome Project.
22:34And in the process,
22:36neida remains.
22:37And the addiction of chronic brain disease.
22:39This was supported by leading Knight of
22:42researchers who co-authored this widely
22:44cited article in JAMA in the year 2000,
22:46and I credit David Fleen with giving me
22:49the citation when it was first published.
22:51So in this article,
22:53the authors argued that narcotics
22:55dependence was comparable to diabetes,
22:57hypertension and asthma in
22:58terms of its heritability,
22:59treatment adherence and relapse rates,
23:01and as such it should be treated
23:03as a chronic medical disease.
23:05So the scientists involved in this movement.
23:07Had a social justice intent.
23:10They wanted to destigmatize addiction
23:12by demonstrating that it's legitimate.
23:14Biologically based condition,
23:15not a problem of morality or choice.
23:19But they didn't anticipate was
23:22that scientific universalism,
23:23because it implied a standard
23:25white male subject,
23:27would help to open white
23:28markets to new opioids,
23:29and that the unequal ways that
23:32biotechnologies are disseminated
23:33in this country would enhance the
23:36social stratification of addiction.
23:38So what do I mean by that, for instance?
23:40Brain images like this one by
23:42taking out the subject and his
23:44or her trappings of gender,
23:45race and class,
23:46taking the taking the subject
23:48out of the picture,
23:49and by taking the offending organ,
23:51the brain itself, out of the body.
23:53Altogether,
23:54the image symbolically conveys an
23:56unmarked universality of addiction
23:59Physiology and neuroscientists
24:00further reduced causation to
24:02molecular action at neuroreceptors,
24:05the ultimate disembodiment of addiction,
24:08so the apparent universality
24:09of this molecular.
24:10Model implied and assumed white norm.
24:13It took a problem long associated with
24:16black and brown crime and gave it a new
24:20implicit association with white subjects.
24:22In the process, though,
24:24it excluded social technologies and so,
24:26I'm sorry, social conditions.
24:29It excluded social conditions,
24:31and the scientists wanted to counteract
24:33a drug war mentality by erasing
24:36the social context of drug use.
24:38But they paradoxically set the stage for
24:41renewed racial stratification of opioids.
24:43Which leads me to my second
24:45technology of whiteness.
24:46That's new biotechnologies.
24:49Neuroscientists unwittingly aided
24:52corporate strategists that capitalized
24:54on the racial erasure of the social.
24:58So, building on neuroscientists ideology
25:01of technological solutions to addiction,
25:03in 96 Purdue Pharma got FDA approval
25:06for Oxycontin as a minimally
25:08addictive pain reliever suitable for
25:10chronic management of moderate pain.
25:13And this was based on its patented
25:16sustained release capsule technology,
25:17which in theory lowered the reward
25:20for users by preventing an initial
25:23rush of high concentrations
25:25of oxycodone to the brain.
25:27The manufacturer also influenced
25:28the National Joint Commission on
25:30Hospital accreditation to call for
25:32pain to be aggressively monitored
25:33and treated as the 5th vital sign,
25:35along with heart rate,
25:36respiratory rate,
25:37blood pressure and drug reps who
25:41were marketing this product to.
25:44New opioid prescribers primary
25:45care based prescribers for example,
25:48who hadn't managed opioids routinely
25:51before as a further safeguard against misuse,
25:54they encourage prescribers to
25:55direct Oxycontin to quote UN
25:58quote trustworthy patients,
25:59which in a national clinical workforce
26:01that has been shown to suspect
26:04non white patients of drug abuse,
26:05this term trustworthy implied
26:07white patients along with the
26:10imagery that went along with the
26:12marketing materials for Oxycontin.
26:14And sister products.
26:17So of course what the model of addiction
26:20proof biotechnology left out was the
26:23social inventiveness of drug use.
26:24Oxycontin users interested in a rush
26:27quickly learned to crush and snort or
26:31inject the oxycodone in each capsule.
26:34And after steep increases in the
26:36non medical use of Oxycontin and
26:38sister products as well as overdose,
26:40public pressure mounted for
26:42intervention and in August of 2010,
26:46just as the original.
26:47That non Oxycontin was running out.
26:48Purdue Pharma introduced its tamper
26:51resistant time release formulation,
26:53which embedded oxycodone into polymers
26:56that converted tablets into dummies
26:58should users attempt to crush and
27:01dissolve them to snort or inject them.
27:03By keeping prices high and representing
27:06Oxycontin as technologically
27:07sealed off from this use,
27:08you know,
27:09using this newly patented technology,
27:11the manufacturer strove to keep
27:14Oxycontin symbolically a step ahead
27:17of urban non white St markets.
27:19Another biotechnology developed specifically
27:21in response to the white suburban and
27:24rural prescription opioid epidemic,
27:26at least introduced federally in
27:29response to it as buprenorphine itself
27:33combined with opioid antagonist in
27:35the loxone and branded Suboxone.
27:36Reckitt Ben Keyser pharmaceutical
27:38promoted this combination as a smart drug.
27:41Although buprenorphine is an abusable opioid,
27:44the naloxone with which it's combined
27:46causes withdrawal symptoms of injected,
27:48but not if dissolved under the
27:50tongue is prescribed.
27:51Because naloxone can't be absorbed
27:53sublingually and also buprenorphine
27:55posed a lower risk of overdose
27:57deaths death than many other opioids.
28:00In the 1990s,
28:01night a subsidized suboxone manufacturer
28:03with $23 million to test it for use
28:06in addiction treatment and sharply
28:08distinguished it from methadone,
28:10lobbying Congress and the DEA to
28:12lower the abuse potential rating of
28:14Suboxone from narcotics Schedule 2,
28:15which is where Oxycontin and
28:17methadone fall to schedule 3 along
28:19with codeine cough syrup.
28:21And this is what made it
28:23possible to prescribe Suboxone
28:24and private doctor's offices.
28:26The manufacturer also lobbied Congress
28:28to get Suboxone included under
28:30an orphan drug clause designed to
28:33promote pharmaceutical development
28:34for unprofitable diseases and low
28:36income countries like malaria drugs.
28:38Suboxones designation as an orphan
28:40drug got it a a patent extension
28:44through 2009 on a drug initially
28:47developed in the late 1960s.
28:49So in a race and class stratified
28:51healthcare system such as we have in
28:52the US where access to general doctors
28:54is often limited to those who can.
28:56A patented expensive technologies for
28:59private office delivery in themselves,
29:01in code, white race and middle class.
29:06So the next technology of whiteness
29:09is regulation.
29:10Although by 2004 prescription
29:12opioids overtook heroin as the
29:14primary opiate of abuse in the US,
29:17the arrest rate for the illegal
29:19possession of prescription opioids
29:21was 1/4 that for possession of heroin
29:24and arrests for illegal sale of
29:26prescription drugs was less than 1/5
29:28that of arrest for selling heroin.
29:31Not coincidentally,
29:32the non medical use of pain relievers
29:34was twice as high among white Americans
29:36as black Americans at that time,
29:38while rates of heroin use among black.
29:40White and Latinx Americans
29:42was almost identical.
29:44Since suburban and rural white opioid
29:47users were not politically popular
29:48targets for drug law enforcement,
29:50as a response, the DEA and other regulators
29:53focused their surveillance and their
29:56enforcement on prescription opioid
29:58prescribers and pharmacists instead.
30:01And this is captured by the spread of
30:04prescription drug monitoring programs
30:05eventually enacted in all states,
30:08half of which mandate prescriber
30:10participation with threats
30:11of loss of license.
30:12And many of you are probably enrolled.
30:15In these programs,
30:16and know that you have to check the
30:19database before prescribing a narcotic to
30:21see if a patient has gotten a narcotic
30:26prescription with another prescriber.
30:28This was a really unique approach to
30:32drug policy, in essence criminalizing
30:34prescribers and pharmacists,
30:36pharmacists instead of people
30:38who use narcotics.
30:40So returning to buprenorphine,
30:42otherwise known as Suboxone,
30:44and it should open up the show again.
30:49The drug Addiction Treatment Act of 2000.
30:53Dated 2000.
30:54Passed by Congress in that year enabled
30:58any certified physician to prescribe
31:00Suboxone in the privacy of their own offices.
31:03In congressional debates leading
31:04to the passage of data 2000,
31:06there's a clear emphasis on a quote
31:08new kind of user, one that's young,
31:11suburban, and quote UN quote,
31:13not ********.
31:14This is coded language for implicitly
31:18white users.
31:19Recorded testimony from federal officials
31:21stressed that buprenorphine was uniquely
31:24appropriate for a new kind of opioid user,
31:26as opposed to methadone.
31:27Quote,
31:28which tends to concentrate in urban areas
31:30and is a poor fit for the suburban spread
31:33of narcotic addiction and of quote.
31:35Then Health and Human services director
31:37Donna Shalala was but one of many
31:39officials who noted that buprenorphine
31:40as an alternative to methadone would
31:42serve a quote new kind of addict,
31:44including citizens who would not
31:46normally be associated with the
31:48term addiction and of quote.
31:50So with this racially coded
31:52language in which suburban and new
31:54kind of addict referred to middle
31:57class white Americans data,
31:582000 passed Congress and reversed 80
32:01years of federal provision prohibition
32:03of private position opioid maintenance.
32:05For opioid dependence.
32:07So data 2000 kept the restrictive
32:09methadone system intact and did nothing
32:11to alter the drug laws that mandated
32:13inner city heroin users to prison.
32:16But it did create a new treatment track
32:18for those with the resources to use
32:20it and to give additional assurance
32:22to the DEA that buprenorphine would
32:24not spill over into illicit markets,
32:26buprenorphine's manufacturer,
32:27along with the federal substance abuse
32:29and Mental Health Services Administration,
32:31developed an 8 hour certification
32:33course that was required for doctors
32:35to prescribe buprenorphine the 1st.
32:37And only prescription drug in the US
32:40to come with such a requirement for
32:44extra training and certification.
32:46Public sector doctors tell me that
32:48this certification requirement is a
32:50major barrier to making buprenorphine
32:52available to low income people because
32:54public clinics don't provide time or
32:56incentives to pursue certification,
32:57while prescribers in the private
32:59sector can charge fees of up to $1000,
33:01citing this from New York City for
33:04an initial half an hour induction
33:06visit for buprenorphine.
33:08So the shortage of public sector
33:10prescribers, along with the
33:11cost of buprenorphine itself,
33:12have long kept buprenorphine
33:15in the private sector.
33:17And then the last technology
33:18fitness is marketing and media.
33:23Oxycontin's legendary commercial success
33:24hinged on its designation as a conical
33:27minimally addictive opioid analgesic.
33:30And when Oxycontin was
33:31under review at the FDA,
33:32Purdue estimated the addictive
33:33potential of Oxycontin be less than
33:351% based on testing among terminally
33:38ill cancer patients for three month period.
33:41In 1996, the FDA accepted these
33:43claims and enabled Purdue to open
33:45an opioid market that had previously
33:47been restricted to those with severe
33:49acute pain like post surgical or
33:51cancer pain to a new much larger
33:53market of patients with moderate
33:55chronic pain like lower back pain.
33:57So Purdue Pharma hired almost 700 drug
34:00reps who canvassed a call list of
34:03100,000 physicians in the first few few
34:05years alone and Purdue targeted general
34:08doctors in white suburban and rural areas.
34:11Serving patients that the public
34:12and the DEA did not think of as
34:15at high risk of addiction,
34:16this strategy was successful.
34:18It led to a tenfold increase in
34:20prescription opioids nationally,
34:21with disproportionate uptake.
34:23By prescribers in white suburban and
34:25rural areas of states like Maine,
34:28Ohio, Kentucky and West Virginia.
34:31So in a newspaper content
34:33analysis that I completed,
34:35I found that in contrast to
34:37articles about the criminality
34:39of black and Latinx drug users,
34:41suburbanites addicted to Oxycontin were
34:43portrayed sympathetically in the media,
34:46as victims of over prescription,
34:47or as people struggling with
34:50real or existential pain.
34:52Ironically,
34:52Purdue Pharmaceuticals technological
34:54response to the first wave of white
34:58prescription opioid overdose deaths,
35:00they're tamper resistant formulations
35:01of oxycodone combined with new
35:04prescription drug monitoring
35:05programs that many of these new
35:07opioid users to look for heroin
35:09when pills became harder to get.
35:10And a consequence of this has been
35:13a whitening of the media coverage
35:15of heroin users who had long been
35:17portrayed as black or brown.
35:19So this is a.
35:21A school teacher from suburban
35:23upstate New York,
35:24and this is a college athlete from Arizona.
35:27Just two of myriad images that came out
35:30in the papers around this time around 2014,
35:342015 on the new face of addiction.
35:38The targeted intervention for
35:39these new heroin users,
35:41buprenorphine otherwise known as Box one,
35:43was marketed to middle class insured
35:46patients over the Internet.
35:47So manufacturer sponsored web-based
35:49public service announcements on
35:51for example this site National
35:53Alliance of Advocates for people
35:55norfin treatments sponsored by
35:56the manufacturer of Suboxone,
35:58Reckitt Benckiser Pharma.
36:01They. Featured white professionals,
36:05business owners on Suboxone maintenance
36:07and again I invite you to look at the race
36:10and class coding of the images of this
36:12home page on the lower left hand side.
36:14Many of you may actually use this website
36:17on a regular basis to help patients find
36:20prescribers in the lower left hand corner.
36:23Patients find if you've
36:24been offering prescription,
36:25that's prescription or physician.
36:27That's a physician locator system
36:30developed by Reckitt Benckiser,
36:32manufacturers of Suboxone.
36:34Collaboration with Sanchez,
36:36the substance abuse and Mental
36:37Health Services Administration.
36:38So you put in your ZIP code and
36:40you get a readout of certified
36:41prescribers in your area,
36:43which more than likely will be
36:46primarily private practice positions.
36:49So these strategies together
36:51created an exclusive but lucrative
36:54segment of the market for Suboxone,
36:56making it a blockbuster drug at over
36:59a billion and a half dollars in sales
37:02per year by 2012 in the US alone.
37:05And it was second only in that year
37:07to Oxycontin, which reported U.S.
37:09sales that year a $3 billion.
37:13So in conclusion.
37:14This racial segmentation of drug
37:17markets into licit and illicit,
37:20white and black, clinical and recreational.
37:24It creates a moving target of time
37:26bound patents on new technologies that
37:28initially target the white middle class.
37:30And this is an old cycle,
37:32so it was started by Bayer
37:35Pharmaceuticals own heroin,
37:37marketed as a non addictive treatment
37:39for morphine addiction among middle
37:41class Victorian housewives in 1898.
37:46So what can we learn from this,
37:48as clinicians, researchers,
37:51policymakers, advocates,
37:53and I want to argue that, number one.
37:56Magic bullets are a myth.
37:59As the failed promises of Oxycontin
38:02to sustain the Oxycontin sustained
38:04release capsule and of the inability
38:07of unilateral buprenorphine expansion
38:09to stem overdoses as shown,
38:11biotechnology alone cannot stop the
38:13harms of narcotics without systemic and
38:16social intervention to go along with it.
38:18And to under score that point,
38:20I want to turn to an international
38:22comparison that's often used by American
38:23advocates of people orphan expansion.
38:25So, for example in France,
38:27where buprenorphine was
38:28adopted for general physician.
38:30Treatment of opiate dependence in
38:3295 it was billed not as a stigma
38:34reducing agent for middle class market,
38:36but as a public health intervention to
38:39stem overdose and HIV among low income,
38:42largely immigrant heroin injectors.
38:43So buprenorphine was widely adopted among
38:46primary care doctors in poor communities.
38:49And I want to under score in a
38:51country with universal healthcare,
38:53that's a really important point in a
38:56country with universal healthcare.
38:59So the opioid overdose rate in
39:02France dropped 80% in the first five
39:04years after buprenorphine approval.
39:05That's what this set of graphs represents.
39:09And I want to contrast that with this
39:12country where the opioid overdose death
39:14rate is now over five times that what
39:17it was when buprenorphine was first
39:19introduced 2 decades ago in 22,002.
39:24And based on my interviews with
39:26white and non white people trying
39:28to access buprenorphine and stay
39:30on buprenorphine maintenance,
39:31I suggest that the public health
39:33potential of buprenorphine is severely
39:35limited by our race and class segregated
39:37market driven healthcare system in which
39:40patients have patchy insurance coverage
39:41and tenuous access to prescribers.
39:44So France has a universal healthcare system.
39:47It also has a robust social safety net.
39:50In France, they spend roughly twice what
39:52we spend per capita on social services.
39:55And another point is that in France much
39:58of the addiction of the buprenorphine
40:01that is prescribed, which is offer
40:04also offered alongside methadone,
40:06it's prescribed in community based
40:09comprehensive addiction centers.
40:11In which people have access to medications,
40:14people, norfin and methadone.
40:16They also have access to comprehensive
40:19clinical care. And social services.
40:22Help with employment,
40:24housing, many other needs.
40:26As well as harm reduction.
40:28So in the same location,
40:30community based centers,
40:31people can access syringes,
40:33clean syringes they can access these days,
40:36also supervised medical consumption,
40:38supervised consumption,
40:40medically supervised consumption,
40:42safe injection facilities.
40:43So in France,
40:45harm reduction,
40:45social services and medical treatment
40:47are all combined in one site and this
40:50may have a lot to do with their success.
40:53Umm.
40:54And I also just quickly want to
40:57mention on the note of regulation that.
41:00Another big difference between
41:02France and the US is that in France,
41:05a review body has to approve any
41:07new pharmaceutical that's being
41:09introduced into their universal
41:11healthcare system for its safety,
41:13for its advantage over other existing
41:16treatments that might be of lower price.
41:19And members of that review body
41:22very strictly are prohibited from
41:24any industry tired industry ties.
41:26Prior to,
41:26during or after their service
41:28on the Review Commission.
41:30So in essence Oxycontin and Sister
41:33products were never approved in France
41:35for the same uses that they were
41:37in the US so France never had the
41:40opioid overdose crisis that we had,
41:42not the same proportions.
41:44And I just want to go back to this
41:46slide to point out to point to
41:47the lower or that the upper left
41:49hand corner of this graph graph,
41:51the blue line represents overdoses
41:54at its peak in France.
41:56Overdoses were 565 in a country
41:59of 60 million.
42:00That's 565 people in a country of 60 million.
42:06Couple of orders of magnitude lower than
42:08the overdose rate in the United States.
42:10So they never had a crisis,
42:12an overdose crisis of the proportion
42:14that we had.
42:15And that had a lot to do with their.
42:19Pharmaceutical review and approval process.
42:23So this should make us skeptical about
42:25the power of the market to protect the
42:28public and rectify inequalities in health
42:30in our for profit healthcare system.
42:32Buprenorphine maintenance has followed
42:33the pattern predicted by theorists
42:35of fundamental causes of disease.
42:37Bruce Link and Joe Phalen that new
42:41biotechnologies in a society with large
42:44social inequalities unless those social
42:47inequalities are addressed as a part
42:49of introducing new biotechnologies.
42:51The biotechnologies will only widen,
42:54rather than narrow health inequalities.
42:56And that's exactly what we've
42:58seen with buprenorphine,
42:59along with many other things,
43:01many other medical interventions.
43:04So we would have to address
43:06the social inequalities in
43:07order to avoid that happening,
43:09because by definition,
43:10in a society like ours,
43:12the more privileged are going to
43:14have access to new biotechnologies if
43:16they have an advantage over old ones.
43:18And then my second point is
43:21that addiction is biosocial.
43:24We should reconsider what it means that
43:27addiction is a chronic brain disease.
43:29Basic neuroscientists are increasingly
43:31seeing the brain as a plastic,
43:34socially responsive organ that has evolved
43:37to adapt to complex social systems.
43:42Emerging life science
43:44models of neuroplasticity,
43:45epigenetics and the microbiome have
43:48underscored that human biology is not fixed,
43:50it's dynamically shaped in
43:53interaction with social environment.
43:55So these more sophisticated biological
43:58or biosocial models inherently
44:00call on us to invest in research
44:03on the impact of social systems.
44:06On health and biological outcomes,
44:08as well as research on interventions
44:11that create healthy social context,
44:13including robust social services recovery
44:15support networks that give dignity,
44:17meaning, and structure to people's lives.
44:19If we were to take seriously the comparison
44:21of drug dependence with diabetes,
44:23asthma, and hypertension,
44:24we'd recognize that each of these
44:26conditions has strong social determinants,
44:29and that success in their treatment
44:31and prevention requires things like
44:32social support, access to fresh food,
44:34safe, unpolluted.
44:35Walkable neighborhoods and the list goes on.
44:39And then third, I want to come
44:41to the idea of deaths of despair,
44:44which was coined by Ann and Case and
44:46Angus Deaton after their 2015 report on
44:49decline in US white life expectancy.
44:51It's it's really notable that
44:53Ann case and Angus Deaton,
44:54we're not epidemiologists
44:56or clinical researchers.
44:57They were, they are economists.
45:01And their analysis of the
45:02root cause of the overdose?
45:03That was the primary driver of the
45:07reduced life expectancy that they found,
45:09along with suicides and cirrhosis.
45:12That their analysis lately not
45:14in nerve receptors or genetics,
45:16but in the deindustrialization
45:17of American Rust Belt towns,
45:19where the departure of manufacturing
45:21and mining industries left behind high
45:24unemployment and social disintegration.
45:26So a study, a sociological study
45:29that followed their report,
45:31showed overdose rates that were
45:33linked to thin social networks.
45:35And accordingly,
45:36case and Deaton popularized
45:37the idea that overdoses were,
45:38quote UN quote, deaths of despair.
45:40So this is a persuasive argument to me.
45:42You know,
45:43it calls for social and economic
45:45revitalization through policies
45:46that promote social integration,
45:48stable employment with livable
45:49wages and benefits,
45:50and not just public private
45:52partnerships to develop,
45:53quickly,
45:53prove and disseminate new
45:55medications and new.
45:57Delivery devices as are often
45:59prioritized in federal policy.
46:04But case and deaton's focus on white
46:06Americans makes their analysis incomplete,
46:09and it makes black and Latinx
46:11overdose deaths invisible.
46:12It has largely until now.
46:13So case and Deaton don't have a
46:15clear explanation of why Black and
46:17Latinx life expectancy do not decline
46:19in the time period of their study.
46:21But I want to propose that black and Latin
46:24next Americans saw an overdose crisis 30
46:26to 4030 to 40 years prior to this one,
46:29with the influx of heroin to inner city
46:32neighborhoods from the 1960s to 80s.
46:34Blue collar workers and black and Latinx
46:36neighborhoods were often barred from unions.
46:38They were the last hired first fired.
46:40They saw massive unemployment
46:42much earlier than white workers
46:44who were initially protected by
46:46industrial racial discrimination.
46:48And this earlier black and Latinx opioid
46:50crisis was not seen as a health crisis.
46:52It was seen and reported in the popular
46:54press as an epidemic of crime leading
46:57to white flight from cities in the US
46:59and further disinvestment from Black
47:01and Latinx inner city neighborhoods.
47:03So we're left from.
47:04Provide with survivors of this
47:06earlier crisis.
47:07Even as the CDC reports that black
47:10Americans are now the group with
47:12the fastest rising overdose deaths.
47:14While we work towards race and class,
47:16justice and economic policy,
47:17I want to argue that we should concern.
47:20We should use the concern about the
47:22current opioid crisis to go beyond
47:24drug development and to invest
47:26number one in universal healthcare
47:28with psychosocial interventions
47:30including trauma informed therapy,
47:32attention to psycho, psychiatric comorbidity,
47:35peer navigation, recovery support,
47:37assistance with housing and employment,
47:39to name a few.
47:41And that too,
47:42we need to divert people with substance
47:45use disorder from the criminal
47:47legal system and promote treatment
47:49and harm reduction as a national
47:52response to opioids and nationally,
47:54not through local initiatives.
47:55Why do I say that?
47:57Well, in New York City,
47:58for example,
47:59we have a program called Project Hope
48:02that was started in Staten Island.
48:04Local community activists
48:06collaborated with the District
48:08Attorney to redirect people with low.
48:10Low level drug charges away from
48:13sentencing and towards treatment
48:15with peer navigation and they have
48:17succeeded in redirecting people to
48:19treatment and peer navigation and
48:21over half of the cases through this
48:24program over the past few years.
48:26But the problem is that project hope.
48:29It's it really remains most active
48:32in Staten Island,
48:34which is New York City's most
48:37affluent and whitest borough.
48:39It is not really active in the low
48:41income Black and Latinx S Bronx with
48:44the largest number of overdoses
48:45in the city and we're sentencing
48:47continues at high rates and
48:49incarceration itself is a major risk
48:52factor for overdose post release.
48:55So I I think among this group,
48:57I don't have to go into details about
48:59why the period of release from jail or
49:01prison is such a risky time for overdose.
49:04This disproportionately affects black
49:06and Latinx people because they are the
49:09ones incarcerated at the highest rates.
49:12And in that post release period,
49:13not only do they have lower tolerance,
49:15but they are legally prohibited from
49:18many social services, including housing.
49:20They often are quite disconnected from
49:23medical care and exposed to fentanyl.
49:25Another high potency opioids on the market.
49:28So it's very it incarceration itself
49:31greatly increases the risk for overdose,
49:34and it's probably one of the major reasons
49:37that black and Latinx Americans have such
49:40a fast rising overdose rate right now.
49:43But it's long.
49:44Here's the point.
49:44As long as it's up to empowered
49:46communities like Staten Island,
49:47who partnered with their District
49:49Attorney to start Project Hope,
49:51decriminalization and treatment will focus
49:52on the white middle class by definition.
49:55So it must be, for racial justice reasons,
49:58a national strategy.
50:00And then third, I just want to end with.
50:03Public resources must be moved from
50:06drug development of magic bullets
50:08to research on and implementation
50:11of innovative biosocial community
50:13based treatment approaches.
50:15And these approaches include peer based
50:17recovery networks involving the arts,
50:19urban gardening,
50:21community based organizations that includes
50:24spiritual and religious organizations.
50:26So for example,
50:27your very own Ionic Jordan and
50:29Sherelle Bellamy have done research
50:31in this placing addiction treatment in
50:34faith-based organizations as a way of
50:36reaching black and Latinx patients who
50:38have great have really solid reasons to
50:42avoid and distrust mainstream clinical care.
50:45Which they often encounter to
50:48be discriminatory and abusive.
50:50So trusted community based
50:52organizations as service providers.
50:54So these kinds of approaches
50:57necessarily integrate medications
50:58with recovery networks of support,
51:00harm reduction,
51:02social services delivered by
51:04trusted community members and peers.
51:07And you know,
51:08this has this really has increasing
51:11urgency with so the vast majority of U.S.
51:14states reporting increases
51:16in overdose deaths right now.
51:20Proactive measures like this will
51:22move us beyond incarceration and
51:25racialized for profit biomedicine
51:27as the only two options available.
51:30In response to drugs problem
51:31drug use toward a third path,
51:33a public health approach that reduces
51:35the harm to both white and non white
51:38Americans of our racialized drug industries.
51:42So on that note,
51:43I want to use the last remaining
51:44few questions to hear from you
51:46and have a discussion.
51:50Thank you, Helena. That was wonderful.
51:55Very provocative and insightful.
51:58And helped me to think about different
52:03challenges to the paradigms that we
52:06that we found ourselves encountering.
52:09I think it also reminds me that we want
52:11to make sure we're useful to our students.
52:14So. And the fact that I met Helena when
52:19she was a student, I hope I was useful
52:22and also can't even begin
52:24to tell you how useful,
52:26but also that we all are living history.
52:28I mean, this is only 20 years ago.
52:32And what we do now will dictate
52:34what happens in the next 20 years.
52:36So please, if you have any questions,
52:39please put those in the chat and I'm sure
52:41Helena will be happy to to respond to them.
52:52So actually, I wonder if I could put,
52:53while people kind of collect their thoughts,
52:55if I could put a question out to you,
52:59David, and other members of your
53:02incredible addiction sachitra unit
53:04or addiction medicine, I'm sorry,
53:07addiction medicine unit about.
53:09Racial justice.
53:10Now you know we're well into
53:12the third decade of what we call
53:15the contemporary opioid crisis.
53:16Converting into,
53:17more broadly the overdose crisis as Poly
53:21substance use is clearly a huge problem.
53:24I'm I'm wondering about the racial
53:28justice agenda and how that.
53:30How you see that fitting with the really
53:34important work that has gone on in.
53:38Taking problem substance use out of
53:41criminalized settings and placing
53:43people with problem substance
53:45use in clinical settings.
53:47Just wondering what what the
53:48conversations have been?
53:51There are a number of folks here
53:52who I think can speak to that,
53:54certainly with respect to
53:56the the efforts at Yale,
53:57including Jeanette Tetro,
54:00Melissa Weimer, Kim Sue and others.
54:04I will start by saying my my view is
54:09that the epidemic started back in
54:12the 60s and 70s and we just didn't
54:16call it such having trained in the.
54:2080s and 90s and seeing families that were
54:24ravaged by an epidemic of heroin and HIV,
54:28it was clear that that we we can't
54:32ascribe any of this to prescription drugs.
54:35That that really started much, much earlier.
54:40I think there's a important force,
54:43and I think I've learned,
54:45and you and I have discussed this,
54:47of social justice that is intertwined.
54:51And all of the the efforts that we
54:54pursue clinical research policy,
54:56educational around addiction and
54:59that seems to resonate with the
55:03newer generation of individuals who
55:06seem to now see addiction medicine
55:09as a verified field.
55:11As a validated field,
55:13I I personally felt like I spent
55:15the 1st 20 years of my career just.
55:18Helping my physician colleagues
55:21understand the issues around neurobiology
55:23and the rationale for treatment
55:26and and I think there's luckily a
55:29generation who is coming through now.
55:31I think the the issues of faculty
55:35and trainees in addiction medicine
55:37is is something that we're constantly
55:40trying to address and we need more
55:43mentors and more senior folks.
55:46Luckily, we do have Ayana.
55:48And we do have Yusef Brantome and
55:50others and we have some wonderful
55:52residents and medical students
55:54that we are paying attention to.
55:56But I'd be curious.
55:58I think Jeanette and and Kim,
56:00you might want to address this as well.
56:07Going to let Kim go, but I don't,
56:10I don't know if she's unmuted.
56:12Yeah, no, I I think that's our
56:14I your point is well taken.
56:17Thank you, Helena for speaking
56:19in this tremendous talk and
56:22just really kind of making us
56:25think further on these issues.
56:28So but to David's point, I mean I think,
56:32I think the workforce is a big part of that.
56:34So I do think.
56:38I'm sitting outside.
56:39That's a little loud out here.
56:40You know, our our students and our
56:43residents and our clothes are so
56:45engaged and they're so ready and
56:47they look at this as their issue.
56:49This is this is the issue of their time,
56:51you know, Umm, but we really
56:54do need to develop faculty.
56:57We really new do need to find the
57:01right mentors for people to help
57:04kind of shepherd the appropriate.
57:09Community, academic partnerships
57:11to reach the people who you know.
57:17Really, you know?
57:19Reach the population that we're trying
57:20to serve and I think that that's
57:22that's an important piece of this.
57:23And you know say the REACH
57:25program which I wanna heads up,
57:27which is really meant to kind of
57:30integrate culturally informed
57:31healthcare with addiction and try to
57:33reduce disparities in that is one
57:36way but it's it's one small piece.
57:38I think there's there needs to be
57:40more widespread change through the
57:43health professions education system.
57:45But not only at the proximal level.
57:47We really need to develop faculty as well.
57:49So that's my take on it.
57:50I'd love to hear Kims. Yeah. Yeah.
57:52Thank you. That's so well said.
57:54I mean,
57:55one thing that I'm hopeful about
57:57is that there are so many people
58:00now attracted to the really rapidly
58:02growing field of addiction medicine,
58:04as well as addiction psychiatry
58:06because of their concerns with health,
58:08justice and racial justice.
58:10And so I think that the framing
58:15of the problem of.
58:17Overdose,
58:18but also just all the permutations
58:20of the long standing criminalization
58:22of drug use and.
58:24The developing the field of clinical.
58:28Clinical interventions for addiction,
58:30those are actually attracting people,
58:33you know, reframing it that way.
58:34I mean,
58:35one thing that we just finished
58:37discussing and the addiction,
58:38the addiction stigma summit that I came from.
58:42Is the the limitations of a narrowly
58:47defined brain disease model.
58:49So I think that initially framing
58:52addiction as a brain disease,
58:54you know, opioid use disorder,
58:56changing the language surrounding problem,
58:59substance use all of that was.
59:03As a first step towards countering just
59:06a centuries worth of criminalization.
59:09But now I what I see is the coming
59:13generations of trainees that are
59:15entering into our field do carry a
59:17racial justice and health justice lens.
59:20And that's not the same thing as
59:21a brain disease approach, right?
59:22Because it really requires bringing the
59:25social back in, as I've tried to argue,
59:27bringing social inequalities as bedrock,
59:30bedrock,
59:30fundamental causes of problem substance use.
59:33And they're. Consequences back in.
59:35But I think it's actually been
59:37an energizing approach,
59:39especially this year,
59:41you know,
59:42a year of lots of national conversation about
59:47tremendous inequalities in COVID testing,
59:50treatment outcomes overlaid with
59:52racialized police violence.
59:54I think there's a lot more excitement
59:57about how do we reframe problem
01:00:00substance use as a health justice issue.
01:00:04Not just a chronic brain disease issue.
01:00:07So,
01:00:07so I'm really hopeful about that,
01:00:09but it's going to require a
01:00:11lot of reorientation and
01:00:13as you mentioned,
01:00:14you know a lot of thoughtful
01:00:15care about how we train people,
01:00:17how we structure clinical care.
01:00:20It's an opportunity,
01:00:21it's a real opportunity.
01:00:22But historically we haven't been,
01:00:24we're very individualized and
01:00:26kind of profit oriented healthcare
01:00:28system and so making that
01:00:29transition won't be easy and I'm
01:00:31hopeful that addiction medicine
01:00:32can be the leading edge of that.
01:00:38We're hopeful too.
01:00:41And and not to mention the role of
01:00:44people who use drugs people with
01:00:46lived experience that's been that's
01:00:48something that coming out of this
01:00:51stigma summit I I'm glad to see it's
01:00:53really taking off and it's not the
01:00:55usual approach you know the usual
01:00:57approach is in redefining something
01:00:59as a disease it's up to the medical
01:01:01experts those with licenses those
01:01:02with lots of training and I see more
01:01:05and more room being made at the
01:01:07table and decision making circles
01:01:09for people who with lived experience.
01:01:11I think we have to pay a lot of
01:01:13attention to racial justice in
01:01:15that who's at the table?
01:01:16With with the understanding that
01:01:18white Americans are also harmed when
01:01:21we don't address racial inequalities,
01:01:23when we don't address racial
01:01:26structural racism.
01:01:27So I've been trying to use the example
01:01:29of the opioid crisis as an example
01:01:32of how racial stereotypes have hurt
01:01:35white Americans along with others.
01:01:40I want to be cognizant of of your time and
01:01:43also thank you for taking the time in the
01:01:46midst of an otherwise clearly busy day.
01:01:49There are two questions in the chat that
01:01:52you might want to take a quick look at.
01:01:54Others should obviously feel free
01:01:56to to depart if they need to.
01:01:59And then Kim, I know we queued you up,
01:02:01so I don't want to ignore the fact
01:02:04that we had asked you to respond to.
01:02:06I'll just quickly say hi to Helena.
01:02:08I also came from the stigma summit.
01:02:10You know trying to build up the these
01:02:13deep connections between social science,
01:02:15anthropology, history.
01:02:16I'm reading white drug markets by a
01:02:21historian University of Harrisburg.
01:02:23David yeah.
01:02:24So, so these are all like these are
01:02:26really important to our trainees,
01:02:28to our clinical practice.
01:02:30Specifically talking about anti racism and
01:02:33teaching that in our encounters as pedagogy.
01:02:35Now we're just working on an
01:02:37article using the Structural
01:02:39vulnerability framework and teaching
01:02:41structural racism to GM E trainees.
01:02:44As part of you know an anti racist
01:02:46practice and medicine and and you
01:02:49know debriefing some of these
01:02:50encounters we had with some of our
01:02:52trainees on the addiction service.
01:02:53Some you know and the understanding
01:02:56the deep history of structural racism
01:02:58you know that it exists in New Haven.
01:03:00You know I'm new to Connecticut but
01:03:02understanding these the harms that
01:03:04have been caused and and really again
01:03:07promoting the the experiences of you
01:03:10know drug users unions and hip and
01:03:12people who use drugs who are actively using.
01:03:14Substances even in research development
01:03:17and policy and you know so that's
01:03:19some of what I'm interested in doing
01:03:23you know harm reduction coalition
01:03:24and and also at Yale and so inspired
01:03:27and thankful for you know your
01:03:29work and training more physician
01:03:32anthropologists and likewise.
01:03:33So inspired by you Kim.
01:03:36Thank you your book.
01:03:38So thanks again.
01:03:38This has been such a pleasure
01:03:40and so great to reconnect.
01:03:41I hope we can continue this conversation.
01:03:47Thank you very much, Helena.
01:03:48And we appreciate everybody attending
01:03:50today and look forward to seeing
01:03:53you on June 29th with Doctor Josh
01:03:56Sharfstein and again in a month
01:03:58with Doctor Helena Rutherford.
01:04:00Thank you everybody.
01:04:02Thank you. Bye, bye.