WEBVTT NOTE duration:"01:20:38.8800000" NOTE language:en-us NOTE Confidence: 0.8167095 00:00:00.000 --> 00:00:02.968 Um, I'm going to be introducing our grand NOTE Confidence: 0.8167095 00:00:02.968 --> 00:00:05.684 round speaker in just a minute, but I NOTE Confidence: 0.8167095 00:00:05.684 --> 00:00:08.323 wanted to make some general comments given. NOTE Confidence: 0.8167095 00:00:08.330 --> 00:00:11.036 The incredible array of of experiences NOTE Confidence: 0.8167095 00:00:11.036 --> 00:00:13.770 that we've had in the Department NOTE Confidence: 0.8167095 00:00:13.770 --> 00:00:16.717 of the past three or four weeks. NOTE Confidence: 0.8167095 00:00:16.720 --> 00:00:20.446 Obviously we're all shaken by the NOTE Confidence: 0.8167095 00:00:20.446 --> 00:00:24.300 rioting and in Washington and and the. NOTE Confidence: 0.8167095 00:00:24.300 --> 00:00:28.160 The message is that the. NOTE Confidence: 0.8167095 00:00:28.160 --> 00:00:33.175 Rioters sent carrying Confederate flags NOTE Confidence: 0.8167095 00:00:33.175 --> 00:00:39.940 into the Capitol building and many other. NOTE Confidence: 0.8167095 00:00:39.940 --> 00:00:42.616 Other kinds of racist imagery to NOTE Confidence: 0.8167095 00:00:42.616 --> 00:00:46.080 see that in the Capitol building, NOTE Confidence: 0.8167095 00:00:46.080 --> 00:00:50.050 the place where we all. NOTE Confidence: 0.8167095 00:00:50.050 --> 00:00:54.334 Believe that our best hopes lie in terms of. NOTE Confidence: 0.8167095 00:00:54.340 --> 00:00:57.316 Of legislation that can address racism NOTE Confidence: 0.8167095 00:00:57.316 --> 00:01:00.699 in our society and in disparities. NOTE Confidence: 0.8167095 00:01:00.700 --> 00:01:04.435 An and. Rights, people's rights, NOTE Confidence: 0.8167095 00:01:04.435 --> 00:01:07.645 and to see all that happen. NOTE Confidence: 0.8167095 00:01:07.650 --> 00:01:11.268 All that those images in the NOTE Confidence: 0.8167095 00:01:11.268 --> 00:01:14.360 Capitol building was just just. NOTE Confidence: 0.8167095 00:01:14.360 --> 00:01:17.849 Extraordinarily upsetting and. NOTE Confidence: 0.8167095 00:01:17.850 --> 00:01:19.354 A number of folks, NOTE Confidence: 0.8167095 00:01:19.354 --> 00:01:21.234 probably on grand rounds today, NOTE Confidence: 0.8167095 00:01:21.240 --> 00:01:22.888 attending grand rounds today NOTE Confidence: 0.8167095 00:01:22.888 --> 00:01:24.948 participated in our town Hall NOTE Confidence: 0.8167095 00:01:24.948 --> 00:01:26.679 meeting yesterday afternoon. NOTE Confidence: 0.8167095 00:01:26.680 --> 00:01:30.675 And their reactions were really NOTE Confidence: 0.8167095 00:01:30.675 --> 00:01:34.670 very touching and thought provoking. NOTE Confidence: 0.8167095 00:01:34.670 --> 00:01:38.086 From from the devastation and fear and anger, NOTE Confidence: 0.8167095 00:01:38.090 --> 00:01:41.350 an outrage that people were NOTE Confidence: 0.8167095 00:01:41.350 --> 00:01:43.306 experiencing but also. NOTE Confidence: 0.8167095 00:01:43.310 --> 00:01:46.495 Some people who felt that these events NOTE Confidence: 0.8167095 00:01:46.495 --> 00:01:50.139 were yet just another expression of of. NOTE Confidence: 0.8167095 00:01:50.140 --> 00:01:55.096 Of the paradox in our country of. NOTE Confidence: 0.8167095 00:01:55.100 --> 00:01:57.288 Of efforts to preserve NOTE Confidence: 0.8167095 00:01:57.288 --> 00:01:59.476 white dominance and two. NOTE Confidence: 0.869708 00:02:01.700 --> 00:02:04.856 In the very structures and institutions NOTE Confidence: 0.869708 00:02:04.856 --> 00:02:07.270 that were promoting democracy so. NOTE Confidence: 0.869708 00:02:07.270 --> 00:02:09.943 It's clear that there are other at a lot NOTE Confidence: 0.869708 00:02:09.943 --> 00:02:12.809 is roiling in our in our community now, NOTE Confidence: 0.869708 00:02:12.810 --> 00:02:15.194 and I hope that we will find ways NOTE Confidence: 0.869708 00:02:15.194 --> 00:02:17.546 to talk about this in each of NOTE Confidence: 0.869708 00:02:17.546 --> 00:02:19.660 the settings in which we work. NOTE Confidence: 0.869708 00:02:19.660 --> 00:02:21.580 Because it was clear in that NOTE Confidence: 0.869708 00:02:21.580 --> 00:02:23.240 discussion that various groups of NOTE Confidence: 0.869708 00:02:23.240 --> 00:02:25.160 staff and trainees and others were NOTE Confidence: 0.869708 00:02:25.160 --> 00:02:26.832 feeling very isolated in their NOTE Confidence: 0.869708 00:02:26.832 --> 00:02:28.462 distress that they were experiencing NOTE Confidence: 0.869708 00:02:28.462 --> 00:02:30.418 in relation to the recent events. NOTE Confidence: 0.89266753 00:02:32.520 --> 00:02:34.228 The other the other. NOTE Confidence: 0.89812535 00:02:38.390 --> 00:02:39.861 Experiences that we've had NOTE Confidence: 0.89812535 00:02:39.861 --> 00:02:41.696 over the last several years. NOTE Confidence: 0.89812535 00:02:41.700 --> 00:02:43.168 Several weeks excuse me NOTE Confidence: 0.89812535 00:02:43.168 --> 00:02:45.003 over the last three weeks, NOTE Confidence: 0.89812535 00:02:45.010 --> 00:02:48.237 we've lost three members of our faculty. NOTE Confidence: 0.89812535 00:02:48.240 --> 00:02:50.750 Um Nancy Suchman died first. NOTE Confidence: 0.89812535 00:02:50.750 --> 00:02:53.530 Nancy was an associate professor NOTE Confidence: 0.89812535 00:02:53.530 --> 00:02:56.310 in our Department are a NOTE Confidence: 0.89812535 00:02:56.412 --> 00:02:59.588 remarkable person who developed. NOTE Confidence: 0.89812535 00:02:59.590 --> 00:03:01.658 Psychotherapeutic approaches NOTE Confidence: 0.89812535 00:03:01.658 --> 00:03:04.760 for addicted mothers. NOTE Confidence: 0.89812535 00:03:04.760 --> 00:03:06.800 Really remarkably challenging. NOTE Confidence: 0.89812535 00:03:06.800 --> 00:03:10.200 A space to work clinically, NOTE Confidence: 0.89812535 00:03:10.200 --> 00:03:14.127 and yet she developed and then validated. NOTE Confidence: 0.89812535 00:03:14.130 --> 00:03:17.170 With Tom McMahon and others, NOTE Confidence: 0.89812535 00:03:17.170 --> 00:03:19.057 the Linda Mays, NOTE Confidence: 0.89812535 00:03:19.057 --> 00:03:22.202 this novel psychotherapy an it NOTE Confidence: 0.89812535 00:03:22.202 --> 00:03:25.596 was getting traction when she NOTE Confidence: 0.89812535 00:03:25.596 --> 00:03:28.961 developed a the illness that NOTE Confidence: 0.89812535 00:03:28.961 --> 00:03:31.828 ultimately took her life and. NOTE Confidence: 0.89812535 00:03:31.830 --> 00:03:39.040 She died 2 weeks ago at the young age of 63. NOTE Confidence: 0.89812535 00:03:39.040 --> 00:03:41.344 And then last week. NOTE Confidence: 0.89812535 00:03:41.344 --> 00:03:43.648 We lost Kathy Carroll. NOTE Confidence: 0.89812535 00:03:43.650 --> 00:03:44.760 And Kathy. NOTE Confidence: 0.8857974 00:03:47.170 --> 00:03:49.672 Is one of those unique once NOTE Confidence: 0.8857974 00:03:49.672 --> 00:03:51.934 in a generation scientists who NOTE Confidence: 0.8857974 00:03:51.934 --> 00:03:54.509 contributes to transforming a field. NOTE Confidence: 0.8857974 00:03:54.510 --> 00:03:57.792 In this case the psychotherapy of NOTE Confidence: 0.8857974 00:03:57.792 --> 00:04:00.291 addiction disorders. Kathy was the NOTE Confidence: 0.8857974 00:04:00.291 --> 00:04:02.626 Alberty Kent professor of psychiatry. NOTE Confidence: 0.8857974 00:04:02.630 --> 00:04:05.240 She emerged as a national NOTE Confidence: 0.8857974 00:04:05.240 --> 00:04:08.380 leader in the context of the. NOTE Confidence: 0.8857974 00:04:08.380 --> 00:04:10.575 Largest and most elaborate psychotherapy NOTE Confidence: 0.8857974 00:04:10.575 --> 00:04:14.220 study done in the field of alcohol research, NOTE Confidence: 0.8857974 00:04:14.220 --> 00:04:17.080 which was called project match. NOTE Confidence: 0.8857974 00:04:17.080 --> 00:04:20.326 And she continued to be innovator NOTE Confidence: 0.8857974 00:04:20.326 --> 00:04:22.490 throughout her entire career. NOTE Confidence: 0.8857974 00:04:22.490 --> 00:04:28.720 Um, she came to Yale in the late 80s. NOTE Confidence: 0.8857974 00:04:28.720 --> 00:04:31.520 She every grant that she wrote was NOTE Confidence: 0.8857974 00:04:31.520 --> 00:04:36.700 funded on the 1st submission. And. NOTE Confidence: 0.8857974 00:04:36.700 --> 00:04:42.524 And. Died after a very brief and NOTE Confidence: 0.8857974 00:04:42.524 --> 00:04:45.948 unexpected illness at the age of 62. NOTE Confidence: 0.8857974 00:04:45.950 --> 00:04:49.317 And a terrible, terrible loss for us. NOTE Confidence: 0.8857974 00:04:49.320 --> 00:04:52.900 Terrible loss for the field. NOTE Confidence: 0.8857974 00:04:52.900 --> 00:04:59.444 Amen. On Monday. Ron Casey died. NOTE Confidence: 0.8857974 00:04:59.444 --> 00:05:03.520 Ron is a member of the volunteer faculty. NOTE Confidence: 0.8857974 00:05:03.520 --> 00:05:06.340 He has been supervising trainees NOTE Confidence: 0.8857974 00:05:06.340 --> 00:05:10.470 for 40 years in our Department. NOTE Confidence: 0.8857974 00:05:10.470 --> 00:05:18.486 Was a very respected clinician and had been. NOTE Confidence: 0.8857974 00:05:18.490 --> 00:05:20.415 Played a very special role NOTE Confidence: 0.8857974 00:05:20.415 --> 00:05:21.955 in Connecticut as the. NOTE Confidence: 0.8857974 00:05:21.960 --> 00:05:23.944 As you might say, NOTE Confidence: 0.8857974 00:05:23.944 --> 00:05:26.424 the consulting psychologist for the NOTE Confidence: 0.8857974 00:05:26.424 --> 00:05:29.646 Episcopal Church in Connecticut an for the NOTE Confidence: 0.8857974 00:05:29.646 --> 00:05:32.669 United Church of Christ in Connecticut. NOTE Confidence: 0.8857974 00:05:32.670 --> 00:05:34.946 So you know 3. NOTE Confidence: 0.8857974 00:05:34.946 --> 00:05:38.360 Three important losses for our Department NOTE Confidence: 0.8857974 00:05:38.462 --> 00:05:42.118 in just a very short period of time. NOTE Confidence: 0.8857974 00:05:42.120 --> 00:05:44.930 That makes us think about. NOTE Confidence: 0.8857974 00:05:44.930 --> 00:05:47.625 About the fragility of life and the NOTE Confidence: 0.8857974 00:05:47.625 --> 00:05:49.948 importance of our of our friends, NOTE Confidence: 0.8857974 00:05:49.950 --> 00:05:52.086 connections to friends and NOTE Confidence: 0.8857974 00:05:52.086 --> 00:05:53.688 family and colleagues. NOTE Confidence: 0.8857974 00:05:53.690 --> 00:05:56.048 This is particularly hard after a NOTE Confidence: 0.8857974 00:05:56.048 --> 00:05:58.512 long year where we lost randumb NOTE Confidence: 0.8857974 00:05:58.512 --> 00:06:00.960 and at the beginning of February NOTE Confidence: 0.8857974 00:06:00.960 --> 00:06:03.290 and then Bob Nelson in June. NOTE Confidence: 0.8857974 00:06:03.290 --> 00:06:05.924 And extraordinary year. NOTE Confidence: 0.8857974 00:06:05.924 --> 00:06:10.314 Of Of of Loss and. NOTE Confidence: 0.9061929 00:06:13.870 --> 00:06:19.585 And we hope that 2021 will be much more. NOTE Confidence: 0.9061929 00:06:19.590 --> 00:06:25.458 Hopeful. A year for us. NOTE Confidence: 0.9061929 00:06:25.460 --> 00:06:27.890 So let me change the subject. NOTE Confidence: 0.9061929 00:06:27.890 --> 00:06:29.105 Speaking of longstanding NOTE Confidence: 0.9061929 00:06:29.105 --> 00:06:30.725 friends and and collaborators, NOTE Confidence: 0.9061929 00:06:30.730 --> 00:06:33.210 it's it's really my extraordinary NOTE Confidence: 0.9061929 00:06:33.210 --> 00:06:36.147 pleasure today to introduce our Grand NOTE Confidence: 0.9061929 00:06:36.147 --> 00:06:39.139 Round Speaker Sally set up for those of NOTE Confidence: 0.9061929 00:06:39.139 --> 00:06:42.218 you who were a little bit early to the NOTE Confidence: 0.9061929 00:06:42.218 --> 00:06:44.805 call you heard Sally and I reminiscing NOTE Confidence: 0.9061929 00:06:44.805 --> 00:06:48.136 about how we first met before, when I, NOTE Confidence: 0.9061929 00:06:48.136 --> 00:06:50.554 when we were both medical students NOTE Confidence: 0.9061929 00:06:50.554 --> 00:06:53.609 before we before we came to the NOTE Confidence: 0.9061929 00:06:53.609 --> 00:06:55.779 psychiatry residency here at Yale. NOTE Confidence: 0.9061929 00:06:55.780 --> 00:06:58.708 And they were classmates in internship NOTE Confidence: 0.9061929 00:06:58.708 --> 00:07:01.678 and residency here in psychiatry and NOTE Confidence: 0.9061929 00:07:01.678 --> 00:07:04.926 joined the faculty at the same time NOTE Confidence: 0.9061929 00:07:04.926 --> 00:07:07.576 around the same time and and had NOTE Confidence: 0.9061929 00:07:07.576 --> 00:07:11.128 careers at the VA before Sally went off. NOTE Confidence: 0.9061929 00:07:11.128 --> 00:07:13.813 To become a very distinctive NOTE Confidence: 0.9061929 00:07:13.813 --> 00:07:16.708 voice and in American Society, NOTE Confidence: 0.9061929 00:07:16.710 --> 00:07:18.204 in American psychiatry. NOTE Confidence: 0.9061929 00:07:18.204 --> 00:07:22.257 Um, Sally was a resident scholar at the NOTE Confidence: 0.9061929 00:07:22.257 --> 00:07:25.143 American Enterprise Institute and for a NOTE Confidence: 0.9061929 00:07:25.143 --> 00:07:28.698 long time was a staff psychiatrist at NOTE Confidence: 0.9061929 00:07:28.698 --> 00:07:31.734 a methadone clinic in Washington DC. NOTE Confidence: 0.9061929 00:07:31.740 --> 00:07:32.847 As I mentioned, NOTE Confidence: 0.9061929 00:07:32.847 --> 00:07:35.061 she had been in assistant professor NOTE Confidence: 0.9061929 00:07:35.061 --> 00:07:37.518 in psychiatry at Yale and remains NOTE Confidence: 0.9061929 00:07:37.518 --> 00:07:39.533 a lecture in our Department. NOTE Confidence: 0.9061929 00:07:39.540 --> 00:07:41.454 She was a Robert Wood Johnson NOTE Confidence: 0.9061929 00:07:41.454 --> 00:07:43.230 policy fellow with the Senate, NOTE Confidence: 0.9061929 00:07:43.230 --> 00:07:46.490 Labor and Human Resources Committee. NOTE Confidence: 0.9061929 00:07:46.490 --> 00:07:48.854 As she developed her, NOTE Confidence: 0.9061929 00:07:48.854 --> 00:07:52.400 careeer continued to focus on public NOTE Confidence: 0.9061929 00:07:52.504 --> 00:07:56.230 issues and has been very visible NOTE Confidence: 0.9061929 00:07:56.230 --> 00:07:59.384 commentator on mental health and NOTE Confidence: 0.9061929 00:07:59.384 --> 00:08:02.744 addiction issues in venues like the NOTE Confidence: 0.9061929 00:08:02.744 --> 00:08:07.085 New York Times, Wall Street Journal, NOTE Confidence: 0.9061929 00:08:07.085 --> 00:08:12.270 and another other. Public media. NOTE Confidence: 0.9061929 00:08:12.270 --> 00:08:15.630 She's written six books. NOTE Confidence: 0.9061929 00:08:15.630 --> 00:08:17.542 The first drug treatment, NOTE Confidence: 0.9061929 00:08:17.542 --> 00:08:20.592 the caseworker version, came out in 1999. NOTE Confidence: 0.9061929 00:08:20.592 --> 00:08:23.987 As she wrote a book about about NOTE Confidence: 0.9061929 00:08:23.987 --> 00:08:25.739 political correctness, NOTE Confidence: 0.9061929 00:08:25.740 --> 00:08:27.459 how political correctness NOTE Confidence: 0.9061929 00:08:27.459 --> 00:08:29.178 is corrupting medicine. NOTE Confidence: 0.9061929 00:08:29.180 --> 00:08:31.940 One nation under therapy in 2005, NOTE Confidence: 0.9061929 00:08:31.940 --> 00:08:34.240 the health Disparity Myth 2006, NOTE Confidence: 0.9061929 00:08:34.240 --> 00:08:36.524 when altruism isn't enough. NOTE Confidence: 0.9061929 00:08:36.524 --> 00:08:38.808 The case for compensating NOTE Confidence: 0.9061929 00:08:38.808 --> 00:08:40.720 kidney donors in 2009. NOTE Confidence: 0.9061929 00:08:40.720 --> 00:08:43.075 And her recent book coauthored NOTE Confidence: 0.9061929 00:08:43.075 --> 00:08:44.959 with Emory Psychologists got NOTE Confidence: 0.9061929 00:08:44.959 --> 00:08:47.009 Lowenfeld is called Brainwashed. NOTE Confidence: 0.9061929 00:08:47.010 --> 00:08:49.354 The seductive appeal of NOTE Confidence: 0.9061929 00:08:49.354 --> 00:08:50.526 mindless neuroscience. NOTE Confidence: 0.9061929 00:08:50.530 --> 00:08:53.970 This book was a finalist for the 2013 NOTE Confidence: 0.9061929 00:08:53.970 --> 00:08:57.467 Los Angeles Times book Price and Science. NOTE Confidence: 0.9061929 00:08:57.470 --> 00:09:02.640 As you can tell from the titles of her book, NOTE Confidence: 0.9061929 00:09:02.640 --> 00:09:06.252 Sally does not shy away from the NOTE Confidence: 0.9061929 00:09:06.252 --> 00:09:07.891 most challenging, complicated, NOTE Confidence: 0.9061929 00:09:07.891 --> 00:09:12.098 and and contentious issues in our field. NOTE Confidence: 0.9061929 00:09:12.100 --> 00:09:15.406 Um, she has, as I said, NOTE Confidence: 0.9061929 00:09:15.410 --> 00:09:18.890 been an independent voice. NOTE Confidence: 0.9061929 00:09:18.890 --> 00:09:22.240 Anne Anne. NOTE Confidence: 0.9061929 00:09:22.240 --> 00:09:24.250 Provoked thought and discussion in NOTE Confidence: 0.9061929 00:09:24.250 --> 00:09:26.710 very constructive ways in our field, NOTE Confidence: 0.9061929 00:09:26.710 --> 00:09:29.130 and we're thrilled Sally to NOTE Confidence: 0.9061929 00:09:29.130 --> 00:09:33.570 have you back home. Virtually. NOTE Confidence: 0.9061929 00:09:33.570 --> 00:09:36.120 Two yeah today for for four NOTE Confidence: 0.9061929 00:09:36.120 --> 00:09:37.395 grand rounds thanks. NOTE Confidence: 0.9061929 00:09:37.400 --> 00:09:38.678 Thanks for coming. NOTE Confidence: 0.9061929 00:09:38.678 --> 00:09:39.956 Oh thank you NOTE Confidence: 0.8272139 00:09:39.960 --> 00:09:43.344 so much and you know I always start NOTE Confidence: 0.8272139 00:09:43.344 --> 00:09:45.934 writing talks like weeks before and NOTE Confidence: 0.8272139 00:09:45.934 --> 00:09:49.354 'cause I'm still a pre Med at heart NOTE Confidence: 0.8272139 00:09:49.354 --> 00:09:52.308 and I remember thinking I you know, NOTE Confidence: 0.8272139 00:09:52.310 --> 00:09:54.440 I hope Kathy likes this. NOTE Confidence: 0.8272139 00:09:54.440 --> 00:09:57.200 You know, I've known Kathy Carroll NOTE Confidence: 0.8272139 00:09:57.200 --> 00:10:00.110 for over 30 years so she was. NOTE Confidence: 0.8272139 00:10:00.110 --> 00:10:01.667 Such an important. NOTE Confidence: 0.8272139 00:10:01.667 --> 00:10:04.781 Really important person to me in NOTE Confidence: 0.8272139 00:10:04.781 --> 00:10:07.853 a wonderful friend and anyway so NOTE Confidence: 0.8272139 00:10:07.853 --> 00:10:12.243 on to on to Ironton OH so I called NOTE Confidence: 0.8272139 00:10:12.243 --> 00:10:15.003 this talk my year abroad because NOTE Confidence: 0.8272139 00:10:15.010 --> 00:10:18.496 to someone like me who's never. NOTE Confidence: 0.8272139 00:10:18.500 --> 00:10:20.964 I mean, I've never lived in a small NOTE Confidence: 0.8272139 00:10:20.964 --> 00:10:23.360 town unless they were associated with. NOTE Confidence: 0.8272139 00:10:23.360 --> 00:10:24.744 I went to Cornell, NOTE Confidence: 0.8272139 00:10:24.744 --> 00:10:26.474 but with a major University. NOTE Confidence: 0.8272139 00:10:26.480 --> 00:10:28.556 Otherwise, I've lived in big cities, NOTE Confidence: 0.8272139 00:10:28.560 --> 00:10:29.601 so small town, NOTE Confidence: 0.8272139 00:10:29.601 --> 00:10:32.030 consigned to seem like a foreign country, NOTE Confidence: 0.8272139 00:10:32.030 --> 00:10:34.502 although in other ways it can turn out NOTE Confidence: 0.8272139 00:10:34.502 --> 00:10:37.928 to be just place with universal ways of life, NOTE Confidence: 0.8272139 00:10:37.930 --> 00:10:41.400 play out an ice all out of that as well. NOTE Confidence: 0.8272139 00:10:41.400 --> 00:10:44.658 Well, since 2015 I thought I wanted to go NOTE Confidence: 0.8272139 00:10:44.658 --> 00:10:48.565 to Apple Acha and see how I could be helpful. NOTE Confidence: 0.8272139 00:10:48.570 --> 00:10:52.574 My recollection, even though that the opioid. NOTE Confidence: 0.8272139 00:10:52.580 --> 00:10:54.930 You know crisis had been NOTE Confidence: 0.8272139 00:10:54.930 --> 00:10:58.140 going on for over a decade. NOTE Confidence: 0.8272139 00:10:58.140 --> 00:10:59.091 In 2050, yes. NOTE Confidence: 0.8272139 00:10:59.091 --> 00:11:00.359 Well over a decade. NOTE Confidence: 0.8272139 00:11:00.360 --> 00:11:01.497 At that time, NOTE Confidence: 0.8272139 00:11:01.497 --> 00:11:03.771 I think it really burst into NOTE Confidence: 0.8272139 00:11:03.771 --> 00:11:05.320 public consciousness. NOTE Confidence: 0.8272139 00:11:05.320 --> 00:11:07.630 For people who lived in areas NOTE Confidence: 0.8272139 00:11:07.630 --> 00:11:09.630 that weren't that affected in NOTE Confidence: 0.8272139 00:11:09.630 --> 00:11:11.575 around 2015 during the primary, NOTE Confidence: 0.8272139 00:11:11.580 --> 00:11:12.798 the presidential primary, NOTE Confidence: 0.8272139 00:11:12.798 --> 00:11:15.234 I remember when Hillary Clinton went NOTE Confidence: 0.8272139 00:11:15.234 --> 00:11:17.829 to a town Hall meeting in Manchester, NOTE Confidence: 0.8272139 00:11:17.830 --> 00:11:20.176 NH, which was very afflicted town, NOTE Confidence: 0.8272139 00:11:20.180 --> 00:11:21.377 and, you know, NOTE Confidence: 0.8272139 00:11:21.377 --> 00:11:23.771 was just stunned that people really NOTE Confidence: 0.8272139 00:11:23.771 --> 00:11:26.029 didn't want to talk about jobs NOTE Confidence: 0.8272139 00:11:26.029 --> 00:11:28.296 that much or immigration or other NOTE Confidence: 0.8272139 00:11:28.296 --> 00:11:30.336 things they were focusing on. NOTE Confidence: 0.8272139 00:11:30.340 --> 00:11:32.300 Opioids an other, I think. NOTE Confidence: 0.8272139 00:11:32.300 --> 00:11:34.615 Other candidates had that experience NOTE Confidence: 0.8272139 00:11:34.615 --> 00:11:37.687 as well that she was the only NOTE Confidence: 0.8272139 00:11:37.687 --> 00:11:40.025 one who came up with a plan. NOTE Confidence: 0.8272139 00:11:40.030 --> 00:11:43.396 But in any case, and that's when I decided, NOTE Confidence: 0.8272139 00:11:43.400 --> 00:11:43.770 well, NOTE Confidence: 0.8272139 00:11:43.770 --> 00:11:45.620 you know you keep reading NOTE Confidence: 0.8272139 00:11:45.620 --> 00:11:47.510 about places that don't have. NOTE Confidence: 0.8272139 00:11:47.510 --> 00:11:48.632 Psychiatrists don't have NOTE Confidence: 0.8272139 00:11:48.632 --> 00:11:49.380 addiction specialists, NOTE Confidence: 0.8272139 00:11:49.380 --> 00:11:51.250 don't have people with waivers, NOTE Confidence: 0.8272139 00:11:51.250 --> 00:11:54.966 and I had all of that, so it took awhile. NOTE Confidence: 0.8272139 00:11:54.966 --> 00:11:57.980 But I but I finally was able to, NOTE Confidence: 0.8272139 00:11:57.980 --> 00:12:01.238 you know, find a place that. NOTE Confidence: 0.8272139 00:12:01.240 --> 00:12:03.370 You could use a psychiatrist. NOTE Confidence: 0.8272139 00:12:03.370 --> 00:12:06.498 I contacted a friend who had a lot NOTE Confidence: 0.8272139 00:12:06.498 --> 00:12:10.165 of Ohio connections and he sent me up. NOTE Confidence: 0.8272139 00:12:10.170 --> 00:12:12.744 Contacted in fact people who who NOTE Confidence: 0.8272139 00:12:12.744 --> 00:12:14.985 ran so called Community Action NOTE Confidence: 0.8272139 00:12:14.985 --> 00:12:17.649 organizations and I think there are NOTE Confidence: 0.8272139 00:12:17.649 --> 00:12:20.370 almost about 50 of those in Ohio. NOTE Confidence: 0.8272139 00:12:20.370 --> 00:12:20.880 Basically, NOTE Confidence: 0.8272139 00:12:20.880 --> 00:12:22.410 Community Action organizations NOTE Confidence: 0.8272139 00:12:22.410 --> 00:12:26.293 were started in the 19 in 1964 like NOTE Confidence: 0.8272139 00:12:26.293 --> 00:12:28.904 President Johnson is part of the War NOTE Confidence: 0.8272139 00:12:28.904 --> 00:12:32.399 on Poverty and these were all anti poverty. NOTE Confidence: 0.8272139 00:12:32.400 --> 00:12:34.806 Agencies they were about 1000 nationwide. NOTE Confidence: 0.8272139 00:12:34.810 --> 00:12:36.550 Many of them failed, NOTE Confidence: 0.8272139 00:12:36.550 --> 00:12:40.259 but many of them were going and that was NOTE Confidence: 0.8272139 00:12:40.259 --> 00:12:44.059 the one and so I went to one in Ironton, NOTE Confidence: 0.8272139 00:12:44.060 --> 00:12:46.472 OH which was still going and NOTE Confidence: 0.8272139 00:12:46.472 --> 00:12:48.080 a very successfully they. NOTE Confidence: 0.8272139 00:12:48.080 --> 00:12:50.887 They ran the Head Start program there, NOTE Confidence: 0.8272139 00:12:50.890 --> 00:12:52.900 they job placement and weatherization. NOTE Confidence: 0.8272139 00:12:52.900 --> 00:12:56.078 You know for people who were unable NOTE Confidence: 0.8272139 00:12:56.078 --> 00:12:59.465 to insulate their homes in the in the NOTE Confidence: 0.8272139 00:12:59.465 --> 00:13:02.169 winter that kind of thing so that. NOTE Confidence: 0.8272139 00:13:02.170 --> 00:13:05.182 That's where I went and let NOTE Confidence: 0.8272139 00:13:05.182 --> 00:13:07.190 me just show you NOTE Confidence: 0.7752987 00:13:07.306 --> 00:13:11.240 where it is odear. All of a sudden my NOTE Confidence: 0.7752987 00:13:11.240 --> 00:13:13.509 thing is not working. We were just. NOTE Confidence: 0.8857765 00:13:17.940 --> 00:13:21.630 OK, we're here. It's OK, you can. NOTE Confidence: 0.8857765 00:13:21.630 --> 00:13:23.226 You can escape, but if you want NOTE Confidence: 0.8857765 00:13:23.226 --> 00:13:24.945 and trying it back into it, well, NOTE Confidence: 0.8857765 00:13:24.945 --> 00:13:27.220 you want to advance it for me. NOTE Confidence: 0.8857765 00:13:27.220 --> 00:13:30.145 I can do that OK. Pull them up. NOTE Confidence: 0.8857765 00:13:30.145 --> 00:13:32.710 This audit was just working before. If NOTE Confidence: 0.76996106 00:13:32.710 --> 00:13:36.370 you hit this, if you hit the hit the key, NOTE Confidence: 0.76996106 00:13:36.370 --> 00:13:39.943 the slide is let me Orient you a little NOTE Confidence: 0.76996106 00:13:39.943 --> 00:13:43.847 bit of obviously the Upper North Midwest. NOTE Confidence: 0.76996106 00:13:43.850 --> 00:13:48.062 Northeast, but the the Red dot NOTE Confidence: 0.76996106 00:13:48.062 --> 00:13:52.089 is Lawrence County in Ohio in. NOTE Confidence: 0.76996106 00:13:52.090 --> 00:13:56.215 Southern, southeastern Ohio You'll NOTE Confidence: 0.76996106 00:13:56.215 --> 00:13:58.945 see that they in Pitts Burg, NOTE Confidence: 0.76996106 00:13:58.950 --> 00:14:02.002 but Pittsburgh actually should be off more NOTE Confidence: 0.76996106 00:14:02.002 --> 00:14:05.790 off to the left as part of Philadelphia, NOTE Confidence: 0.76996106 00:14:05.790 --> 00:14:08.070 Philadelphia, Ohio is right there. NOTE Confidence: 0.76996106 00:14:08.070 --> 00:14:11.255 I can, under Detroit, under the Erie, NOTE Confidence: 0.76996106 00:14:11.260 --> 00:14:13.540 Lake Erie and Lawrence County. NOTE Confidence: 0.76996106 00:14:13.540 --> 00:14:15.364 In which direction resides NOTE Confidence: 0.76996106 00:14:15.364 --> 00:14:18.940 in the southeast corner, OK? NOTE Confidence: 0.76996106 00:14:18.940 --> 00:14:20.776 So I just wanted people to NOTE Confidence: 0.76996106 00:14:20.776 --> 00:14:22.270 get a general sense of. NOTE Confidence: 0.76996106 00:14:22.270 --> 00:14:24.814 At the air is about 8 hour drive, NOTE Confidence: 0.76996106 00:14:24.820 --> 00:14:26.740 9 hour drive from Washington DC. NOTE Confidence: 0.76996106 00:14:26.740 --> 00:14:28.654 And then I'm going to drill NOTE Confidence: 0.76996106 00:14:28.654 --> 00:14:31.610 down a little bit, OK. NOTE Confidence: 0.76996106 00:14:31.610 --> 00:14:33.550 Now you can see Ohio, NOTE Confidence: 0.76996106 00:14:33.550 --> 00:14:35.098 Kentucky, and West Virginia. NOTE Confidence: 0.76996106 00:14:35.098 --> 00:14:37.033 I never heard of Ironton. NOTE Confidence: 0.76996106 00:14:37.040 --> 00:14:40.144 You can't even see it on this map, NOTE Confidence: 0.76996106 00:14:40.150 --> 00:14:40.926 but again, NOTE Confidence: 0.76996106 00:14:40.926 --> 00:14:43.642 it's it's at the tip of Lawrence NOTE Confidence: 0.76996106 00:14:43.642 --> 00:14:46.358 County and it's right where these NOTE Confidence: 0.76996106 00:14:46.358 --> 00:14:48.608 three states converge where the NOTE Confidence: 0.76996106 00:14:48.686 --> 00:14:51.166 Ohio River join in a way kind of NOTE Confidence: 0.76996106 00:14:51.166 --> 00:14:55.948 guy sex or tries to axe them and. NOTE Confidence: 0.76996106 00:14:55.950 --> 00:14:58.692 One side is Ohio or again NOTE Confidence: 0.76996106 00:14:58.692 --> 00:15:00.063 Ironton in particular. NOTE Confidence: 0.76996106 00:15:00.070 --> 00:15:03.038 The other part of the tristate area NOTE Confidence: 0.76996106 00:15:03.038 --> 00:15:06.028 in terms of cities is Ashland, NOTE Confidence: 0.76996106 00:15:06.030 --> 00:15:08.809 Ky, which is in Boyd County and NOTE Confidence: 0.76996106 00:15:08.809 --> 00:15:11.546 then there is Huntington, WV. NOTE Confidence: 0.76996106 00:15:11.546 --> 00:15:14.948 OK, can you see that there's a NOTE Confidence: 0.76996106 00:15:14.948 --> 00:15:17.289 little airplane there 'cause? NOTE Confidence: 0.76996106 00:15:17.290 --> 00:15:20.097 There is an airport and Huntington WV, NOTE Confidence: 0.76996106 00:15:20.100 --> 00:15:22.518 though I never heard of Ironton. NOTE Confidence: 0.76996106 00:15:22.520 --> 00:15:26.286 I certainly heard of Huntington WV because. NOTE Confidence: 0.76996106 00:15:26.290 --> 00:15:28.330 That was a place that, NOTE Confidence: 0.76996106 00:15:28.330 --> 00:15:30.844 with Drew national attention in 2016 NOTE Confidence: 0.76996106 00:15:30.844 --> 00:15:33.618 when 26 people overdosed within 4 hours, NOTE Confidence: 0.76996106 00:15:33.620 --> 00:15:36.056 like two of them Fatal E. NOTE Confidence: 0.76996106 00:15:36.060 --> 00:15:36.466 Anyway, NOTE Confidence: 0.76996106 00:15:36.466 --> 00:15:39.308 I was there from 2018 to 2019, NOTE Confidence: 0.76996106 00:15:39.310 --> 00:15:42.159 and so for a year I prescribed NOTE Confidence: 0.76996106 00:15:42.159 --> 00:15:43.380 even Orfina nycholat, NOTE Confidence: 0.76996106 00:15:43.380 --> 00:15:44.331 a group therapy, NOTE Confidence: 0.76996106 00:15:44.331 --> 00:15:47.088 and I spoke to a lot of people NOTE Confidence: 0.76996106 00:15:47.088 --> 00:15:49.800 about the town trying to understand NOTE Confidence: 0.76996106 00:15:49.800 --> 00:15:52.750 the history in the local dynamics. NOTE Confidence: 0.76996106 00:15:52.750 --> 00:15:56.404 And of course, how the drug situation fit in. NOTE Confidence: 0.76996106 00:15:56.410 --> 00:15:58.770 I also. NOTE Confidence: 0.76996106 00:15:58.770 --> 00:16:01.470 Being somewhat from New York. NOTE Confidence: 0.76996106 00:16:01.470 --> 00:16:04.522 Looked in vain for a good everything NOTE Confidence: 0.76996106 00:16:04.522 --> 00:16:06.400 bagel couldn't be found. NOTE Confidence: 0.76996106 00:16:06.400 --> 00:16:09.088 I learned the basics of quilting. NOTE Confidence: 0.76996106 00:16:09.090 --> 00:16:14.046 Now this slide is accidentaly on purpose. NOTE Confidence: 0.76996106 00:16:14.050 --> 00:16:16.492 Refer a speaker you know wrong NOTE Confidence: 0.76996106 00:16:16.492 --> 00:16:17.713 direction because frankly, NOTE Confidence: 0.76996106 00:16:17.720 --> 00:16:19.152 it's so unlike me. NOTE Confidence: 0.76996106 00:16:19.152 --> 00:16:22.337 So I thought that was kind of an NOTE Confidence: 0.76996106 00:16:22.337 --> 00:16:24.245 interesting metaphor for that. NOTE Confidence: 0.76996106 00:16:24.250 --> 00:16:26.954 And the other thing I did was I NOTE Confidence: 0.76996106 00:16:26.954 --> 00:16:29.549 went to church affair amount. NOTE Confidence: 0.76996106 00:16:29.550 --> 00:16:32.406 Now that's not a church in Ironton. NOTE Confidence: 0.76996106 00:16:32.410 --> 00:16:34.858 That's lavish for Ironton but Ashland, NOTE Confidence: 0.76996106 00:16:34.860 --> 00:16:37.709 as I mentioned, was nearby and Kentucky. NOTE Confidence: 0.76996106 00:16:37.710 --> 00:16:40.593 And this is somewhat bigger city, Ohio. NOTE Confidence: 0.76996106 00:16:40.593 --> 00:16:44.057 Ironton is a 10,000 to about 10,600 people. NOTE Confidence: 0.76996106 00:16:44.060 --> 00:16:48.038 Ashland has about 20,000 people and. NOTE Confidence: 0.76996106 00:16:48.040 --> 00:16:50.288 And the reason why I went to church NOTE Confidence: 0.76996106 00:16:50.288 --> 00:16:52.340 being a Jewish atheist with not NOTE Confidence: 0.76996106 00:16:52.340 --> 00:16:54.464 the place you'd expect to find NOTE Confidence: 0.76996106 00:16:54.529 --> 00:16:56.685 me is because everyone I met was NOTE Confidence: 0.76996106 00:16:56.685 --> 00:16:58.615 this very very religious and two NOTE Confidence: 0.76996106 00:16:58.615 --> 00:17:00.625 of my best friends taught Sunday NOTE Confidence: 0.76996106 00:17:00.625 --> 00:17:02.490 school and they were devoted to NOTE Confidence: 0.76996106 00:17:02.490 --> 00:17:04.332 the church and and really devoted NOTE Confidence: 0.76996106 00:17:04.332 --> 00:17:05.897 to the poor and devoted. NOTE Confidence: 0.76996106 00:17:05.900 --> 00:17:06.860 They were wonderful, NOTE Confidence: 0.76996106 00:17:06.860 --> 00:17:07.500 wonderful people, NOTE Confidence: 0.76996106 00:17:07.500 --> 00:17:11.010 so I spent a lot of time with them and I'll, NOTE Confidence: 0.76996106 00:17:11.010 --> 00:17:13.236 and when they'd introduce me to preach, NOTE Confidence: 0.83109707 00:17:13.240 --> 00:17:16.108 you know, the. NOTE Confidence: 0.83109707 00:17:16.110 --> 00:17:18.140 Pastor and whatever they always say this NOTE Confidence: 0.83109707 00:17:18.140 --> 00:17:20.460 is Sally from Washington and they'd say, NOTE Confidence: 0.83109707 00:17:20.460 --> 00:17:22.637 well, what church do you go to? NOTE Confidence: 0.83109707 00:17:22.640 --> 00:17:24.817 And I said how the Jewish atheist NOTE Confidence: 0.83109707 00:17:24.817 --> 00:17:26.737 and they go, oh that's great. NOTE Confidence: 0.83109707 00:17:26.737 --> 00:17:28.711 They were just very enthusiastic about NOTE Confidence: 0.83109707 00:17:28.711 --> 00:17:30.418 having anyone show any you know, NOTE Confidence: 0.83109707 00:17:30.420 --> 00:17:32.268 interest in in what they did NOTE Confidence: 0.83109707 00:17:32.268 --> 00:17:34.149 and what their life was like. NOTE Confidence: 0.83109707 00:17:34.150 --> 00:17:36.406 So the other thing I did was I NOTE Confidence: 0.83109707 00:17:36.406 --> 00:17:38.738 walked a lot because in these small NOTE Confidence: 0.83109707 00:17:38.738 --> 00:17:41.403 places all you do is drive an you NOTE Confidence: 0.83109707 00:17:41.403 --> 00:17:44.130 could get a lot of weight so I want NOTE Confidence: 0.83109707 00:17:44.130 --> 00:17:46.405 like crazy and I would see these. NOTE Confidence: 0.83109707 00:17:46.410 --> 00:17:50.920 Interesting signs like this one. NOTE Confidence: 0.83109707 00:17:50.920 --> 00:17:53.657 And I also saw some Confederate flags, NOTE Confidence: 0.83109707 00:17:53.660 --> 00:17:56.327 which is something you don't see unless NOTE Confidence: 0.83109707 00:17:56.327 --> 00:17:59.936 you were on the Capitol two days ago anyway, NOTE Confidence: 0.83109707 00:17:59.940 --> 00:18:03.158 so. That's what I did. NOTE Confidence: 0.83109707 00:18:03.158 --> 00:18:04.366 OK enough about me. NOTE Confidence: 0.83109707 00:18:04.370 --> 00:18:07.042 So let me tell you a little bit NOTE Confidence: 0.83109707 00:18:07.042 --> 00:18:09.508 more about the place because it's a NOTE Confidence: 0.83109707 00:18:09.508 --> 00:18:12.658 stand in for a lot of rural America. NOTE Confidence: 0.83109707 00:18:12.660 --> 00:18:14.900 And how the opioid crisis. NOTE Confidence: 0.83109707 00:18:14.900 --> 00:18:17.980 And now I know it's morphing nationally NOTE Confidence: 0.83109707 00:18:17.980 --> 00:18:21.172 and especially in Ironton you know into NOTE Confidence: 0.83109707 00:18:21.172 --> 00:18:23.860 a methamphetamine crisis as as well. NOTE Confidence: 0.83109707 00:18:23.860 --> 00:18:26.996 I'm also going to draw some lessons, NOTE Confidence: 0.83109707 00:18:27.000 --> 00:18:29.240 some inspired by my experience, NOTE Confidence: 0.83109707 00:18:29.240 --> 00:18:32.299 I'm inspired by the data as it's NOTE Confidence: 0.83109707 00:18:32.299 --> 00:18:34.763 been accumulating over the years NOTE Confidence: 0.83109707 00:18:34.763 --> 00:18:36.895 specifically about the nature NOTE Confidence: 0.83109707 00:18:36.895 --> 00:18:39.027 of prescription drug abuse. NOTE Confidence: 0.83109707 00:18:39.030 --> 00:18:41.739 I'm going to touch on my perspectives NOTE Confidence: 0.83109707 00:18:41.739 --> 00:18:44.050 on addiction and drug epidemics, NOTE Confidence: 0.83109707 00:18:44.050 --> 00:18:46.927 and I'm going to end with a NOTE Confidence: 0.83109707 00:18:46.927 --> 00:18:49.978 reminder that our work in clinical NOTE Confidence: 0.83109707 00:18:49.978 --> 00:18:52.274 medicine and public health. NOTE Confidence: 0.83109707 00:18:52.280 --> 00:18:54.332 Is extremely important, NOTE Confidence: 0.83109707 00:18:54.332 --> 00:18:58.436 but it's also just two dynamics NOTE Confidence: 0.83109707 00:18:58.436 --> 00:19:02.367 in a huge ecosystem that an NOTE Confidence: 0.83109707 00:19:02.367 --> 00:19:06.440 ecosystem of forces that has shaped. NOTE Confidence: 0.83109707 00:19:06.440 --> 00:19:10.226 Vulnerability to drug use and that NOTE Confidence: 0.83109707 00:19:10.226 --> 00:19:13.346 is relevant to informing remedies NOTE Confidence: 0.83109707 00:19:13.346 --> 00:19:16.280 so that we all need to. NOTE Confidence: 0.83109707 00:19:16.280 --> 00:19:18.230 You know humility about that NOTE Confidence: 0.83109707 00:19:18.230 --> 00:19:20.180 because it's it's bigger than NOTE Confidence: 0.83109707 00:19:20.256 --> 00:19:22.476 it's bigger than our professions. NOTE Confidence: 0.83109707 00:19:22.480 --> 00:19:23.378 I think. NOTE Confidence: 0.83109707 00:19:23.378 --> 00:19:26.521 So I mentioned I worked for the NOTE Confidence: 0.83109707 00:19:26.521 --> 00:19:28.485 Community Action Organization and NOTE Confidence: 0.83109707 00:19:28.485 --> 00:19:32.322 this was one of the nicer and more NOTE Confidence: 0.83109707 00:19:32.322 --> 00:19:36.039 beautiful places in Iron 10 as a 22 room. NOTE Confidence: 0.83109707 00:19:36.040 --> 00:19:38.566 Building a house that was built NOTE Confidence: 0.83109707 00:19:38.566 --> 00:19:41.240 in 1850 by this gentleman, NOTE Confidence: 0.83109707 00:19:41.240 --> 00:19:44.078 whose name is John Campbell Ann. NOTE Confidence: 0.83109707 00:19:44.080 --> 00:19:46.084 He owned many furnaces. NOTE Confidence: 0.83109707 00:19:46.084 --> 00:19:49.635 The name Ironton is named for iron NOTE Confidence: 0.83109707 00:19:49.635 --> 00:19:52.743 and this town was really North of NOTE Confidence: 0.83109707 00:19:52.743 --> 00:19:55.908 what you think of as deep Apple. NOTE Confidence: 0.83109707 00:19:55.910 --> 00:20:00.174 ACHA and its main product was iron ore. NOTE Confidence: 0.83109707 00:20:00.180 --> 00:20:01.630 An Ironton produced some of NOTE Confidence: 0.83109707 00:20:01.630 --> 00:20:03.430 the best was called Pig Iron, NOTE Confidence: 0.83109707 00:20:03.430 --> 00:20:04.900 which is just an unrefined. NOTE Confidence: 0.83109707 00:20:04.900 --> 00:20:07.740 It needs to be smelted. NOTE Confidence: 0.83109707 00:20:07.740 --> 00:20:11.574 Iron and in in the world at that time, NOTE Confidence: 0.83109707 00:20:11.580 --> 00:20:14.996 so they say, but definitely in the country. NOTE Confidence: 0.83109707 00:20:15.000 --> 00:20:17.989 At that time he owned many furnaces. NOTE Confidence: 0.83109707 00:20:17.990 --> 00:20:19.814 Furnaces, did the smelting, NOTE Confidence: 0.83109707 00:20:19.814 --> 00:20:23.540 they were all over southern Ohio at the time. NOTE Confidence: 0.83109707 00:20:23.540 --> 00:20:26.529 He was also an important town leader, NOTE Confidence: 0.83109707 00:20:26.530 --> 00:20:29.519 and he was also a staunch abolitionist. NOTE Confidence: 0.83109707 00:20:29.520 --> 00:20:32.466 And what makes that building so NOTE Confidence: 0.83109707 00:20:32.466 --> 00:20:35.430 wonderfully historic was that his home NOTE Confidence: 0.83109707 00:20:35.430 --> 00:20:38.622 was a station on the Underground Railroad. NOTE Confidence: 0.83109707 00:20:38.630 --> 00:20:41.605 And as you saw from the slide, NOTE Confidence: 0.83109707 00:20:41.610 --> 00:20:43.735 given the proximity of Southern NOTE Confidence: 0.83109707 00:20:43.735 --> 00:20:45.860 Ohio to Kentucky and Virginia, NOTE Confidence: 0.83109707 00:20:45.860 --> 00:20:48.828 which were slave states at the time, NOTE Confidence: 0.83109707 00:20:48.830 --> 00:20:50.960 Virginia hadn't become West Virginia. NOTE Confidence: 0.83109707 00:20:50.960 --> 00:20:53.510 Then that didn't happen till 1863. NOTE Confidence: 0.8598264 00:20:53.510 --> 00:20:55.635 That slaves would cross the NOTE Confidence: 0.8598264 00:20:55.635 --> 00:20:57.760 River and be brought to. NOTE Confidence: 0.8598264 00:20:57.760 --> 00:21:00.310 He was not the only one, NOTE Confidence: 0.8598264 00:21:00.310 --> 00:21:02.860 but he was an important station. NOTE Confidence: 0.8598264 00:21:02.860 --> 00:21:05.828 And then he brought to his house, NOTE Confidence: 0.8598264 00:21:05.830 --> 00:21:08.638 kept in the. NOTE Confidence: 0.8598264 00:21:08.640 --> 00:21:11.868 Maybe in the basement for several NOTE Confidence: 0.8598264 00:21:11.868 --> 00:21:15.500 hours or overnight and then be taken NOTE Confidence: 0.8598264 00:21:15.500 --> 00:21:18.727 the next day by cold actually was. NOTE Confidence: 0.8598264 00:21:18.730 --> 00:21:20.725 A band that he would use to NOTE Confidence: 0.8598264 00:21:20.725 --> 00:21:22.629 move his iron further North. NOTE Confidence: 0.8598264 00:21:22.630 --> 00:21:24.255 And you know some some NOTE Confidence: 0.8598264 00:21:24.255 --> 00:21:25.880 slaves just stay in Ohio, NOTE Confidence: 0.8598264 00:21:25.880 --> 00:21:28.715 but the idea was to get North. NOTE Confidence: 0.8598264 00:21:28.720 --> 00:21:29.436 To Canada, NOTE Confidence: 0.8598264 00:21:29.436 --> 00:21:32.300 and if you can remember the first slide, NOTE Confidence: 0.8598264 00:21:32.300 --> 00:21:34.196 the Lake Erie is the northern NOTE Confidence: 0.8598264 00:21:34.196 --> 00:21:36.366 border and if you cross that NOTE Confidence: 0.8598264 00:21:36.366 --> 00:21:38.026 you're you're into Canada. NOTE Confidence: 0.8598264 00:21:38.030 --> 00:21:39.820 So it was a popular, NOTE Confidence: 0.8598264 00:21:39.820 --> 00:21:41.610 very prosperous place back then. NOTE Confidence: 0.8598264 00:21:41.610 --> 00:21:44.284 Every grandparent I talked to in town NOTE Confidence: 0.8598264 00:21:44.284 --> 00:21:46.412 remembers first person accounts of that NOTE Confidence: 0.8598264 00:21:46.412 --> 00:21:49.130 went back to the Civil War when Ironton, NOTE Confidence: 0.8598264 00:21:49.130 --> 00:21:51.986 as I said, was just an enormous producer, NOTE Confidence: 0.8598264 00:21:51.990 --> 00:21:53.775 and this this is obviously NOTE Confidence: 0.8598264 00:21:53.775 --> 00:21:54.846 a stylized picture. NOTE Confidence: 0.8598264 00:21:54.850 --> 00:21:57.718 But if you look on the. NOTE Confidence: 0.8598264 00:21:57.720 --> 00:22:00.490 On the left I mean the whole idea was that NOTE Confidence: 0.8598264 00:22:00.560 --> 00:22:03.395 they were just furnaces belching out smoke, NOTE Confidence: 0.8598264 00:22:03.400 --> 00:22:04.906 you know 24/7, NOTE Confidence: 0.8598264 00:22:04.906 --> 00:22:08.420 and it was an enormously productive place. NOTE Confidence: 0.8598264 00:22:08.420 --> 00:22:09.884 After World War Two, NOTE Confidence: 0.8598264 00:22:09.884 --> 00:22:11.348 it became a thriving NOTE Confidence: 0.8598264 00:22:11.348 --> 00:22:13.050 producer of iron casting, NOTE Confidence: 0.8598264 00:22:13.050 --> 00:22:16.524 which was used mainly in cars at the time, NOTE Confidence: 0.8598264 00:22:16.530 --> 00:22:19.506 and you can see the in the 50s NOTE Confidence: 0.8598264 00:22:19.506 --> 00:22:22.317 car off on the on the right, NOTE Confidence: 0.8598264 00:22:22.320 --> 00:22:24.245 but other plants would make NOTE Confidence: 0.8598264 00:22:24.245 --> 00:22:25.400 aluminum enough chemicals, NOTE Confidence: 0.8598264 00:22:25.400 --> 00:22:26.184 fertilizer it. NOTE Confidence: 0.8598264 00:22:26.184 --> 00:22:28.536 But the economy was really never NOTE Confidence: 0.8598264 00:22:28.536 --> 00:22:31.188 white hot again after World War One, NOTE Confidence: 0.8598264 00:22:31.190 --> 00:22:33.476 although in every every war actually NOTE Confidence: 0.8598264 00:22:33.476 --> 00:22:37.025 was was a real boon to a town like NOTE Confidence: 0.8598264 00:22:37.025 --> 00:22:38.970 this because they always needed. NOTE Confidence: 0.8598264 00:22:38.970 --> 00:22:39.686 Ordnance and, NOTE Confidence: 0.8598264 00:22:39.686 --> 00:22:42.550 and that's what an iron was very important, NOTE Confidence: 0.8598264 00:22:42.550 --> 00:22:43.978 and obviously making steel. NOTE Confidence: 0.8598264 00:22:43.978 --> 00:22:45.763 And also as I said, NOTE Confidence: 0.8598264 00:22:45.770 --> 00:22:47.560 iron itself could be used. NOTE Confidence: 0.8598264 00:22:47.560 --> 00:22:48.586 So the 40s, NOTE Confidence: 0.8598264 00:22:48.586 --> 00:22:50.296 fifties and 60s there were NOTE Confidence: 0.8598264 00:22:50.296 --> 00:22:52.219 were really were great years. NOTE Confidence: 0.8598264 00:22:52.220 --> 00:22:54.040 People who graduated from high NOTE Confidence: 0.8598264 00:22:54.040 --> 00:22:56.260 school could always get a good NOTE Confidence: 0.8598264 00:22:56.260 --> 00:22:57.935 paying job in the factory. NOTE Confidence: 0.8598264 00:22:57.940 --> 00:23:00.088 These were obviously labor intensive jobs, NOTE Confidence: 0.8598264 00:23:00.090 --> 00:23:01.955 but they were very financially NOTE Confidence: 0.8598264 00:23:01.955 --> 00:23:04.207 secure and most mom stayed home NOTE Confidence: 0.8598264 00:23:04.207 --> 00:23:06.405 with the kids and and middle class NOTE Confidence: 0.8598264 00:23:06.405 --> 00:23:08.678 life was really vibrant and mean. NOTE Confidence: 0.8598264 00:23:08.680 --> 00:23:10.750 Here's just one example of. NOTE Confidence: 0.8598264 00:23:10.750 --> 00:23:14.047 Mrs Statehouse, but they were the downtown. NOTE Confidence: 0.8598264 00:23:14.050 --> 00:23:17.458 Looked very nice. NOTE Confidence: 0.8598264 00:23:17.460 --> 00:23:19.295 Then the economy began to NOTE Confidence: 0.8598264 00:23:19.295 --> 00:23:22.087 realign in the six late 60s and NOTE Confidence: 0.8598264 00:23:22.087 --> 00:23:23.835 two major factories closed, NOTE Confidence: 0.8598264 00:23:23.840 --> 00:23:26.630 and that initiated a wave. NOTE Confidence: 0.8598264 00:23:26.630 --> 00:23:28.510 Of layoffs and plant Closings, NOTE Confidence: 0.8598264 00:23:28.510 --> 00:23:31.128 and then in the 70s there oil. NOTE Confidence: 0.8598264 00:23:31.130 --> 00:23:32.255 Have you know, NOTE Confidence: 0.8598264 00:23:32.255 --> 00:23:34.880 a lot of folks were around them, NOTE Confidence: 0.8598264 00:23:34.880 --> 00:23:38.030 but it was a time of oil shocks emanating NOTE Confidence: 0.8598264 00:23:38.030 --> 00:23:40.506 from turmoil in the Middle East. NOTE Confidence: 0.8598264 00:23:40.510 --> 00:23:42.006 Inflation was really high. NOTE Confidence: 0.8598264 00:23:42.006 --> 00:23:44.677 Japanese and German carmakers started to be NOTE Confidence: 0.8598264 00:23:44.677 --> 00:23:46.879 very competitive with the US manufacturers. NOTE Confidence: 0.8598264 00:23:46.880 --> 00:23:48.760 So from a business standpoint, NOTE Confidence: 0.8598264 00:23:48.760 --> 00:23:50.260 things were being threatened. NOTE Confidence: 0.8598264 00:23:50.260 --> 00:23:51.010 The community, NOTE Confidence: 0.8598264 00:23:51.010 --> 00:23:51.384 however, NOTE Confidence: 0.8598264 00:23:51.384 --> 00:23:52.880 was still pretty good, NOTE Confidence: 0.8598264 00:23:52.880 --> 00:23:54.760 and families were largely intact. NOTE Confidence: 0.8598264 00:23:54.760 --> 00:23:57.455 But then that process you know kept. NOTE Confidence: 0.8598264 00:23:57.460 --> 00:23:59.820 Kept. NOTE Confidence: 0.8598264 00:23:59.820 --> 00:24:01.880 The spiral downwards pull of NOTE Confidence: 0.8598264 00:24:01.880 --> 00:24:03.940 living wage jobs contracted and NOTE Confidence: 0.8598264 00:24:04.013 --> 00:24:06.347 skilled workers moved out of town, NOTE Confidence: 0.8598264 00:24:06.350 --> 00:24:08.588 and today there was a real NOTE Confidence: 0.8598264 00:24:08.588 --> 00:24:10.626 hollowing out of the middle NOTE Confidence: 0.8598264 00:24:10.626 --> 00:24:12.470 class because of that. NOTE Confidence: 0.8598264 00:24:12.470 --> 00:24:14.740 By 1980 the place was NOTE Confidence: 0.8598264 00:24:14.740 --> 00:24:17.010 bankrupt and here are just NOTE Confidence: 0.8454514 00:24:17.107 --> 00:24:20.317 some. Slides that evoke was kind of decay. NOTE Confidence: 0.8454514 00:24:20.320 --> 00:24:22.660 These are probably won't call hoppers, NOTE Confidence: 0.8454514 00:24:22.660 --> 00:24:25.006 and they were filled with fertile. NOTE Confidence: 0.8454514 00:24:25.010 --> 00:24:27.578 Is that fertilizer that we delivered NOTE Confidence: 0.8454514 00:24:27.578 --> 00:24:30.736 to barges that were on the Ohio River NOTE Confidence: 0.8454514 00:24:30.736 --> 00:24:33.610 was the good old days, then there was. NOTE Confidence: 0.87440103 00:24:35.790 --> 00:24:37.770 And there's this off on the NOTE Confidence: 0.87440103 00:24:37.770 --> 00:24:39.420 right of the slide. Actually, NOTE Confidence: 0.87440103 00:24:39.420 --> 00:24:41.730 that's not the front of the building, NOTE Confidence: 0.87440103 00:24:41.730 --> 00:24:43.380 that's the back of it. NOTE Confidence: 0.87440103 00:24:43.380 --> 00:24:45.360 But that was just a beautiful. NOTE Confidence: 0.87440103 00:24:45.360 --> 00:24:47.340 It's called the Grand Army of NOTE Confidence: 0.87440103 00:24:47.340 --> 00:24:48.660 the Republic Memorial Hall, NOTE Confidence: 0.87440103 00:24:48.660 --> 00:24:51.560 and it was built in 1892 as a meeting Hall NOTE Confidence: 0.87440103 00:24:51.638 --> 00:24:54.270 for veterans who fought for the Union. NOTE Confidence: 0.87440103 00:24:54.270 --> 00:24:56.580 And then it became a City Hall. NOTE Confidence: 0.87440103 00:24:56.580 --> 00:24:58.560 And then it was a jail. NOTE Confidence: 0.87440103 00:24:58.560 --> 00:25:00.210 And then it went through NOTE Confidence: 0.87440103 00:25:00.210 --> 00:25:01.530 various iterations of things. NOTE Confidence: 0.87440103 00:25:01.530 --> 00:25:03.510 Boy Scout troops would meet there, NOTE Confidence: 0.87440103 00:25:03.510 --> 00:25:06.230 but in 2014 it was knocked down and. NOTE Confidence: 0.87440103 00:25:06.230 --> 00:25:07.988 It still looks like this fact. NOTE Confidence: 0.87440103 00:25:07.990 --> 00:25:10.216 You can see some of them if NOTE Confidence: 0.87440103 00:25:10.216 --> 00:25:12.397 you look some of those things NOTE Confidence: 0.87440103 00:25:12.397 --> 00:25:14.677 that are standing up in the. NOTE Confidence: 0.87440103 00:25:14.680 --> 00:25:17.696 Yard are actually jail of the bars of NOTE Confidence: 0.87440103 00:25:17.696 --> 00:25:21.043 the jail and then there was this place NOTE Confidence: 0.87440103 00:25:21.043 --> 00:25:24.438 which makes the Bates Motel look inviting. NOTE Confidence: 0.87440103 00:25:24.440 --> 00:25:28.220 And then there was the big. NOTE Confidence: 0.87440103 00:25:28.220 --> 00:25:30.140 Movie theater in town, NOTE Confidence: 0.87440103 00:25:30.140 --> 00:25:33.562 which was as you you get the NOTE Confidence: 0.87440103 00:25:33.562 --> 00:25:36.184 idea it it was a thriving, NOTE Confidence: 0.87440103 00:25:36.190 --> 00:25:36.659 exciting, NOTE Confidence: 0.87440103 00:25:36.659 --> 00:25:38.535 entertaining place and that NOTE Confidence: 0.87440103 00:25:38.535 --> 00:25:40.880 went that deteriorated as well. NOTE Confidence: 0.87440103 00:25:40.880 --> 00:25:43.225 So the social fabric really NOTE Confidence: 0.87440103 00:25:43.225 --> 00:25:45.570 began to unravel as well, NOTE Confidence: 0.87440103 00:25:45.570 --> 00:25:49.147 with men not working and families broke NOTE Confidence: 0.87440103 00:25:49.147 --> 00:25:52.693 down and welfare and disability rules NOTE Confidence: 0.87440103 00:25:52.693 --> 00:25:55.888 grew and substance abuse escalated. NOTE Confidence: 0.87440103 00:25:55.890 --> 00:25:58.293 Taking it to the 90s now about any kid NOTE Confidence: 0.87440103 00:25:58.293 --> 00:26:00.929 who had a shot at the future would just. NOTE Confidence: 0.87440103 00:26:00.930 --> 00:26:04.864 Pursue it elsewhere so you had a NOTE Confidence: 0.87440103 00:26:04.864 --> 00:26:07.300 town increasingly dominated by you. NOTE Confidence: 0.87440103 00:26:07.300 --> 00:26:09.328 Know people who were. NOTE Confidence: 0.87440103 00:26:09.328 --> 00:26:12.370 You know fairly well offer managing NOTE Confidence: 0.87440103 00:26:12.462 --> 00:26:15.304 and a town with people who were, NOTE Confidence: 0.87440103 00:26:15.310 --> 00:26:18.270 you know, and really desperate. NOTE Confidence: 0.87440103 00:26:18.270 --> 00:26:21.786 Situations the poverty rate there is NOTE Confidence: 0.87440103 00:26:21.786 --> 00:26:26.470 20 is almost 21% the poverty rate in NOTE Confidence: 0.87440103 00:26:26.470 --> 00:26:32.070 Ohio is 14% and 13.4% in the nation. NOTE Confidence: 0.87440103 00:26:32.070 --> 00:26:32.920 The last NOTE Confidence: 0.8670395 00:26:35.900 --> 00:26:38.595 Department of Ohio Department of NOTE Confidence: 0.8670395 00:26:38.595 --> 00:26:41.290 Education report card gave the NOTE Confidence: 0.8670395 00:26:41.385 --> 00:26:43.870 schools there a between AD&C. NOTE Confidence: 0.8670395 00:26:43.870 --> 00:26:46.120 Android is now is completely normalized, NOTE Confidence: 0.8670395 00:26:46.120 --> 00:26:47.995 going on his third and NOTE Confidence: 0.8670395 00:26:47.995 --> 00:26:49.120 sometimes 4th generation. NOTE Confidence: 0.8670395 00:26:49.120 --> 00:26:51.766 Almost everyone is like 1 degree of NOTE Confidence: 0.8670395 00:26:51.766 --> 00:26:54.061 separation from someone who has been NOTE Confidence: 0.8670395 00:26:54.061 --> 00:26:56.616 afflicted at the precise rates of addiction. NOTE Confidence: 0.8670395 00:26:56.620 --> 00:26:58.870 There were hard to come by. NOTE Confidence: 0.8670395 00:26:58.870 --> 00:27:01.300 There were certain kinds of number NOTE Confidence: 0.8670395 00:27:01.300 --> 00:27:03.750 keeping that didn't seem to be done, NOTE Confidence: 0.8670395 00:27:03.750 --> 00:27:06.000 or I couldn't get access to, NOTE Confidence: 0.8670395 00:27:06.000 --> 00:27:08.250 but every time I'd ask people. NOTE Confidence: 0.8670395 00:27:08.250 --> 00:27:10.614 Well, just let your estimate of NOTE Confidence: 0.8670395 00:27:10.614 --> 00:27:13.221 what's the rate of drug involvement NOTE Confidence: 0.8670395 00:27:13.221 --> 00:27:15.586 and kept it pretty vague. NOTE Confidence: 0.8670395 00:27:15.590 --> 00:27:17.525 They would say about one NOTE Confidence: 0.8670395 00:27:17.525 --> 00:27:20.090 in four to one and three. NOTE Confidence: 0.8670395 00:27:20.090 --> 00:27:23.434 So my task was to help a brilliant NOTE Confidence: 0.8670395 00:27:23.434 --> 00:27:25.410 social worker run a group. NOTE Confidence: 0.8670395 00:27:25.410 --> 00:27:28.674 I haven't run group since my residency days. NOTE Confidence: 0.8670395 00:27:28.680 --> 00:27:32.864 This was John Herlihy was a social worker. NOTE Confidence: 0.8670395 00:27:32.870 --> 00:27:35.286 Ran it and I mean he's a dead NOTE Confidence: 0.8670395 00:27:35.286 --> 00:27:37.818 ringer for Santa Claus and he had NOTE Confidence: 0.8670395 00:27:37.818 --> 00:27:40.350 you know this twinkly eyed persona. NOTE Confidence: 0.8670395 00:27:40.350 --> 00:27:42.552 He was just wonderful and you NOTE Confidence: 0.8670395 00:27:42.552 --> 00:27:45.114 know in some ways I could have NOTE Confidence: 0.8670395 00:27:45.114 --> 00:27:47.466 been still in DC or New Haven. NOTE Confidence: 0.8670395 00:27:47.470 --> 00:27:50.396 I mean there are a lot of NOTE Confidence: 0.8670395 00:27:50.396 --> 00:27:52.080 universals about people who. NOTE Confidence: 0.8670395 00:27:52.080 --> 00:27:54.135 Find themselves in with drug NOTE Confidence: 0.8670395 00:27:54.135 --> 00:27:57.269 problems and a lot of the stories. NOTE Confidence: 0.8670395 00:27:57.270 --> 00:27:59.590 The special part of the story is that. NOTE Confidence: 0.8670395 00:27:59.590 --> 00:28:01.900 Was the same where why people came NOTE Confidence: 0.8670395 00:28:01.900 --> 00:28:04.189 in and it's usually the same. NOTE Confidence: 0.8670395 00:28:04.190 --> 00:28:07.014 You know my wife is gonna leave me. NOTE Confidence: 0.8670395 00:28:07.020 --> 00:28:09.150 My boss is gonna fire me. NOTE Confidence: 0.8670395 00:28:09.150 --> 00:28:10.915 My probation officers gonna violate NOTE Confidence: 0.8670395 00:28:10.915 --> 00:28:13.400 me my my kids hate me anyway. NOTE Confidence: 0.8670395 00:28:13.400 --> 00:28:16.634 The point is that people are NOTE Confidence: 0.8670395 00:28:16.634 --> 00:28:19.190 usually pressured to come in. NOTE Confidence: 0.8670395 00:28:19.190 --> 00:28:20.480 Now the pills were different. NOTE Confidence: 0.8670395 00:28:20.480 --> 00:28:22.680 That was there was a lot of use of pills NOTE Confidence: 0.8670395 00:28:22.735 --> 00:28:25.095 and I didn't see that and methadone clinic. NOTE Confidence: 0.8670395 00:28:25.100 --> 00:28:27.326 I worked in Washington DC and some NOTE Confidence: 0.8670395 00:28:27.326 --> 00:28:29.802 of the people in Ironton by the time NOTE Confidence: 0.8670395 00:28:29.802 --> 00:28:32.190 I got there had moved on to heroin. NOTE Confidence: 0.8670395 00:28:32.190 --> 00:28:35.086 But every now and then a patient would NOTE Confidence: 0.8670395 00:28:35.086 --> 00:28:37.746 say to John Oh my problems started NOTE Confidence: 0.8670395 00:28:37.746 --> 00:28:41.195 when I went to the doctor and he gave NOTE Confidence: 0.8670395 00:28:41.195 --> 00:28:45.290 me Oxycontin an John said to them. NOTE Confidence: 0.8670395 00:28:45.290 --> 00:28:47.705 He would wink and he'd say, oh, NOTE Confidence: 0.8670395 00:28:47.705 --> 00:28:50.465 I see so the directions on the prescription, NOTE Confidence: 0.8670395 00:28:50.470 --> 00:28:52.770 she said, chop and snort. NOTE Confidence: 0.8670395 00:28:52.770 --> 00:28:56.110 Two times a day, I don't think so now I NOTE Confidence: 0.8670395 00:28:56.198 --> 00:28:59.534 could never get away with such a thing. NOTE Confidence: 0.8670395 00:28:59.540 --> 00:29:02.165 I wouldn't even dream of saying it, NOTE Confidence: 0.8670395 00:29:02.170 --> 00:29:03.169 but he could. NOTE Confidence: 0.8670395 00:29:03.169 --> 00:29:05.167 He was beloved and they kind NOTE Confidence: 0.8670395 00:29:05.167 --> 00:29:07.430 of laughed because you know, NOTE Confidence: 0.8670395 00:29:07.430 --> 00:29:09.686 these folks were in their 20s NOTE Confidence: 0.8670395 00:29:09.686 --> 00:29:10.814 thirties and 40s. NOTE Confidence: 0.8670395 00:29:10.820 --> 00:29:12.320 And then I had, NOTE Confidence: 0.8670395 00:29:12.320 --> 00:29:13.070 you know, NOTE Confidence: 0.8670395 00:29:13.070 --> 00:29:15.275 I got to know many of them and they NOTE Confidence: 0.8670395 00:29:15.275 --> 00:29:17.521 were well acquainted with intoxicants NOTE Confidence: 0.8670395 00:29:17.521 --> 00:29:19.457 before before prescription opioids NOTE Confidence: 0.8670395 00:29:19.457 --> 00:29:21.720 became part of their repertoire. NOTE Confidence: 0.8670395 00:29:21.720 --> 00:29:24.422 So what John was really doing was NOTE Confidence: 0.8670395 00:29:24.422 --> 00:29:26.950 challenging the idea of the accidental. NOTE Confidence: 0.8670395 00:29:26.950 --> 00:29:30.838 Addict Ann and you know he had to NOTE Confidence: 0.8670395 00:29:30.838 --> 00:29:35.219 because the idea that the idea that we NOTE Confidence: 0.8670395 00:29:35.219 --> 00:29:39.480 often see perpetuated in the media is that. NOTE Confidence: 0.8670395 00:29:39.480 --> 00:29:42.290 The typical. NOTE Confidence: 0.8670395 00:29:42.290 --> 00:29:44.002 Prescription pill versus addicted NOTE Confidence: 0.8670395 00:29:44.002 --> 00:29:46.142 to prescription pills or abuse NOTE Confidence: 0.8670395 00:29:46.142 --> 00:29:47.818 them was otherwise fine. NOTE Confidence: 0.8670395 00:29:47.820 --> 00:29:50.830 Life was wonderful and then they got NOTE Confidence: 0.8670395 00:29:50.830 --> 00:29:54.196 some pills for wisdom tooth or broken NOTE Confidence: 0.8670395 00:29:54.196 --> 00:29:57.178 ankle whatever and then within weeks NOTE Confidence: 0.863134 00:29:57.270 --> 00:30:00.726 to months it was life was out of control. NOTE Confidence: 0.863134 00:30:00.730 --> 00:30:02.506 I'm not, I can't tell you NOTE Confidence: 0.863134 00:30:02.506 --> 00:30:03.394 that's never happened, NOTE Confidence: 0.863134 00:30:03.400 --> 00:30:05.188 but it's just not the rule. NOTE Confidence: 0.863134 00:30:05.190 --> 00:30:07.255 Even though the media portrayed is an. NOTE Confidence: 0.863134 00:30:07.260 --> 00:30:08.690 That's an important misconception because NOTE Confidence: 0.863134 00:30:08.690 --> 00:30:10.530 it's led to some unfortunate policy's, NOTE Confidence: 0.863134 00:30:10.530 --> 00:30:12.476 and I'm going to get to that NOTE Confidence: 0.863134 00:30:12.476 --> 00:30:14.392 in a little while. But first, NOTE Confidence: 0.863134 00:30:14.392 --> 00:30:16.168 I just want to present some. NOTE Confidence: 0.8236252 00:30:18.540 --> 00:30:21.956 Some data about who abuses opioids an NOTE Confidence: 0.8236252 00:30:21.956 --> 00:30:25.066 and I'm talking bout prescription opioids NOTE Confidence: 0.8236252 00:30:25.066 --> 00:30:29.509 now and who's at risk for that and I'm NOTE Confidence: 0.8236252 00:30:29.509 --> 00:30:32.973 sure a lot of you have seen this slide. NOTE Confidence: 0.8236252 00:30:32.973 --> 00:30:35.025 It's from SAMHSA representing NOTE Confidence: 0.8236252 00:30:35.025 --> 00:30:38.615 2013 to 14 and the most important NOTE Confidence: 0.8236252 00:30:38.615 --> 00:30:41.877 part is the red part which is. NOTE Confidence: 0.8236252 00:30:41.880 --> 00:30:47.060 When they asked folks. Who had? NOTE Confidence: 0.8236252 00:30:47.060 --> 00:30:51.348 Sorry, can't read the part of top because. NOTE Confidence: 0.8236252 00:30:51.350 --> 00:30:55.510 But when they ask people who had misused NOTE Confidence: 0.8236252 00:30:55.510 --> 00:30:58.427 prescription opioids within the last year, NOTE Confidence: 0.8236252 00:30:58.430 --> 00:31:00.960 who did they get their NOTE Confidence: 0.8236252 00:31:00.960 --> 00:31:02.984 most recent pills from? NOTE Confidence: 0.8236252 00:31:02.990 --> 00:31:07.057 1/5 actually got them from a physician NOTE Confidence: 0.8236252 00:31:07.057 --> 00:31:12.178 and we even know actually there is very. NOTE Confidence: 0.8236252 00:31:12.180 --> 00:31:14.748 An interesting book called Drug Dealer, NOTE Confidence: 0.8236252 00:31:14.750 --> 00:31:16.330 MD by Anna Lemke, NOTE Confidence: 0.8236252 00:31:16.330 --> 00:31:18.700 who's a psychiatrist at Stanford and NOTE Confidence: 0.8236252 00:31:18.775 --> 00:31:21.792 she's a whole typology of patients who NOTE Confidence: 0.8236252 00:31:21.792 --> 00:31:24.190 are basically duping their doctors. NOTE Confidence: 0.8236252 00:31:24.190 --> 00:31:27.398 And that's my goodness not all of our NOTE Confidence: 0.8236252 00:31:27.398 --> 00:31:30.628 don't ever get that impression from me, NOTE Confidence: 0.8236252 00:31:30.630 --> 00:31:34.062 but I my point is that even from NOTE Confidence: 0.8236252 00:31:34.062 --> 00:31:36.685 that 22.1% some fraction of fat is NOTE Confidence: 0.8236252 00:31:36.685 --> 00:31:39.579 not even what one might consider up NOTE Confidence: 0.8236252 00:31:39.579 --> 00:31:42.209 corner quote legitimate chronic pain, NOTE Confidence: 0.8236252 00:31:42.210 --> 00:31:44.458 patient or pain patient. NOTE Confidence: 0.8236252 00:31:44.458 --> 00:31:47.830 But that's an important slide because NOTE Confidence: 0.8236252 00:31:47.925 --> 00:31:51.005 at the very least it tells us the. NOTE Confidence: 0.8236252 00:31:51.010 --> 00:31:54.300 That the supplies that though the pill NOTE Confidence: 0.8236252 00:31:54.300 --> 00:31:57.689 supplies that went directly to miss users, NOTE Confidence: 0.8236252 00:31:57.690 --> 00:32:01.848 were not being sustained by physicians. NOTE Confidence: 0.8236252 00:32:01.850 --> 00:32:02.184 Now, NOTE Confidence: 0.8236252 00:32:02.184 --> 00:32:03.520 as I said before, NOTE Confidence: 0.8236252 00:32:03.520 --> 00:32:05.816 a lot of these folks had significant NOTE Confidence: 0.8236252 00:32:05.816 --> 00:32:07.190 involvement with other drugs. NOTE Confidence: 0.8016796 00:32:09.640 --> 00:32:13.460 I've just mentioned Ted Cicero, who's that. NOTE Confidence: 0.8016796 00:32:13.460 --> 00:32:15.892 Washington University has done NOTE Confidence: 0.8016796 00:32:15.892 --> 00:32:18.932 some really excellent work in. NOTE Confidence: 0.8016796 00:32:18.940 --> 00:32:21.490 Descriptive work in the Epidemiology of NOTE Confidence: 0.8016796 00:32:21.490 --> 00:32:24.729 this population an an over several studies. NOTE Confidence: 0.8016796 00:32:24.730 --> 00:32:28.452 He's reported that between 70 and 90% of NOTE Confidence: 0.8016796 00:32:28.452 --> 00:32:32.736 people who come in for treatment for. NOTE Confidence: 0.8016796 00:32:32.740 --> 00:32:34.360 Scription use disorder had NOTE Confidence: 0.8016796 00:32:34.360 --> 00:32:36.385 used at least one another, NOTE Confidence: 0.8016796 00:32:36.390 --> 00:32:39.638 not opioid drug in the months before cocaine. NOTE Confidence: 0.8016796 00:32:39.640 --> 00:32:40.858 Methamphetamine hallucinogens Ben, NOTE Confidence: 0.8016796 00:32:40.858 --> 00:32:42.888 so this kind of thing, NOTE Confidence: 0.8016796 00:32:42.890 --> 00:32:45.725 and if you look at tox screens, NOTE Confidence: 0.8016796 00:32:45.730 --> 00:32:49.384 you'll see that there is also a big range, NOTE Confidence: 0.8016796 00:32:49.390 --> 00:32:51.420 but seems at the bottom. NOTE Confidence: 0.8016796 00:32:51.420 --> 00:32:53.445 The bottom part of the NOTE Confidence: 0.8016796 00:32:53.445 --> 00:32:57.648 range is 60% of people who. NOTE Confidence: 0.8016796 00:32:57.650 --> 00:33:00.458 Have toxicology screens at after overdose. NOTE Confidence: 0.8016796 00:33:00.460 --> 00:33:04.108 60% have more than one drug and then NOTE Confidence: 0.8016796 00:33:04.108 --> 00:33:07.500 there was one study from for that. NOTE Confidence: 0.8016796 00:33:07.500 --> 00:33:09.840 Follow data from from Florida NOTE Confidence: 0.8016796 00:33:09.840 --> 00:33:13.706 and 90% so 9 out of 10 people who NOTE Confidence: 0.8016796 00:33:13.706 --> 00:33:16.880 died of a with an opioid. NOTE Confidence: 0.8016796 00:33:16.880 --> 00:33:19.200 Related death had other drugs NOTE Confidence: 0.8016796 00:33:19.200 --> 00:33:22.040 in their talk screens as well, NOTE Confidence: 0.8016796 00:33:22.040 --> 00:33:25.155 so this suggests that people who develop NOTE Confidence: 0.8016796 00:33:25.155 --> 00:33:27.850 significant problems with prescription pills. NOTE Confidence: 0.8016796 00:33:27.850 --> 00:33:32.230 Raffin experienced users and. NOTE Confidence: 0.8016796 00:33:32.230 --> 00:33:34.450 And that's important to know. NOTE Confidence: 0.8016796 00:33:34.450 --> 00:33:37.010 Now you could say that, NOTE Confidence: 0.8016796 00:33:37.010 --> 00:33:39.058 well, maybe you know. NOTE Confidence: 0.8016796 00:33:39.058 --> 00:33:42.130 Going back to that pie chart, NOTE Confidence: 0.8016796 00:33:42.130 --> 00:33:43.693 you know well, NOTE Confidence: 0.8016796 00:33:43.693 --> 00:33:46.298 maybe they maybe they sustained NOTE Confidence: 0.8016796 00:33:46.298 --> 00:33:48.269 their use this way, NOTE Confidence: 0.8016796 00:33:48.270 --> 00:33:51.861 but maybe they were mostly initiated into NOTE Confidence: 0.8016796 00:33:51.861 --> 00:33:54.419 prescription problems through their doctor. NOTE Confidence: 0.8016796 00:33:54.420 --> 00:33:57.486 But I think that it's mitigated. NOTE Confidence: 0.8016796 00:33:57.490 --> 00:34:00.400 Interpretation is mitigated against by the NOTE Confidence: 0.8016796 00:34:00.400 --> 00:34:04.899 by data on the addictiveness among patients. NOTE Confidence: 0.8016796 00:34:04.900 --> 00:34:06.070 Excuse me, NOTE Confidence: 0.8016796 00:34:06.070 --> 00:34:08.410 the addictiveness of prescription NOTE Confidence: 0.8016796 00:34:08.410 --> 00:34:10.750 opioids prescription pain relievers NOTE Confidence: 0.8016796 00:34:10.829 --> 00:34:13.134 among patients for whom those NOTE Confidence: 0.8016796 00:34:13.134 --> 00:34:15.439 pain relievers are prescribed so. NOTE Confidence: 0.8016796 00:34:15.440 --> 00:34:18.848 This is data from. NOTE Confidence: 0.8016796 00:34:18.850 --> 00:34:21.300 Um, that's Ted Cicero's group, NOTE Confidence: 0.8016796 00:34:21.300 --> 00:34:21.804 too. NOTE Confidence: 0.8016796 00:34:21.804 --> 00:34:25.332 I think he's not the first author NOTE Confidence: 0.8016796 00:34:25.332 --> 00:34:28.336 where 7000 people looked at NOTE Confidence: 0.8016796 00:34:28.336 --> 00:34:31.486 their prescriptions and the key. NOTE Confidence: 0.8016796 00:34:31.490 --> 00:34:34.244 Figure there is .3% developed opioid NOTE Confidence: 0.8016796 00:34:34.244 --> 00:34:37.543 use and addiction within a year after NOTE Confidence: 0.8016796 00:34:37.543 --> 00:34:39.848 receiving at least one prescription. NOTE Confidence: 0.8016796 00:34:39.850 --> 00:34:43.198 Another study, this one from Harvard. NOTE Confidence: 0.8016796 00:34:43.200 --> 00:34:45.840 Published in the British Medical NOTE Confidence: 0.8016796 00:34:45.840 --> 00:34:48.820 Journal is consistent with that .6. NOTE Confidence: 0.8016796 00:34:48.820 --> 00:34:51.886 Let's under 1% for over half NOTE Confidence: 0.8016796 00:34:51.886 --> 00:34:53.419 a million people. NOTE Confidence: 0.8016796 00:34:53.420 --> 00:34:54.450 Privately insured. NOTE Confidence: 0.8016796 00:34:54.450 --> 00:34:57.025 Misses some brat study is NOTE Confidence: 0.8016796 00:34:57.025 --> 00:34:59.040 definitely about acute pain, NOTE Confidence: 0.8016796 00:34:59.040 --> 00:35:03.018 and the survey above probably combines NOTE Confidence: 0.8016796 00:35:03.018 --> 00:35:05.670 acute and chronic prescribing. NOTE Confidence: 0.8016796 00:35:05.670 --> 00:35:08.141 So that's important and I think I NOTE Confidence: 0.8016796 00:35:08.141 --> 00:35:10.562 think the public would be pretty NOTE Confidence: 0.8016796 00:35:10.562 --> 00:35:12.712 surprised to see those relatively NOTE Confidence: 0.8016796 00:35:12.712 --> 00:35:14.570 low numbers now when you. NOTE Confidence: 0.86199266 00:35:17.050 --> 00:35:18.935 Drill down on chronic pain NOTE Confidence: 0.86199266 00:35:18.935 --> 00:35:20.820 things get a little different. NOTE Confidence: 0.86199266 00:35:20.820 --> 00:35:23.459 There's much, much more of a range. NOTE Confidence: 0.86199266 00:35:23.460 --> 00:35:26.280 For example, the Edlin study for NOTE Confidence: 0.86199266 00:35:26.280 --> 00:35:28.470 the Research Triangle showed up. NOTE Confidence: 0.86199266 00:35:28.470 --> 00:35:31.917 A range of .12 to 6.1 in a half NOTE Confidence: 0.86199266 00:35:31.917 --> 00:35:36.550 a million patients. That's big. NOTE Confidence: 0.86199266 00:35:36.550 --> 00:35:38.490 But then the Cochrane Library, NOTE Confidence: 0.86199266 00:35:38.490 --> 00:35:41.706 which as you know is a very respected NOTE Confidence: 0.86199266 00:35:41.706 --> 00:35:43.919 international database and they do reviews. NOTE Confidence: 0.86199266 00:35:43.920 --> 00:35:47.016 They found that less again back to under NOTE Confidence: 0.86199266 00:35:47.016 --> 00:35:49.350 1% developed signs of opioid abuse. NOTE Confidence: 0.86199266 00:35:49.350 --> 00:35:52.454 Then there is the third study I'm mentioning. NOTE Confidence: 0.86199266 00:35:52.460 --> 00:35:53.960 These are all representative, NOTE Confidence: 0.86199266 00:35:53.960 --> 00:35:57.077 so an and I'm happy to provide people NOTE Confidence: 0.86199266 00:35:57.077 --> 00:35:59.453 with much more of a bibliography NOTE Confidence: 0.86199266 00:35:59.453 --> 00:36:01.767 if they if they want anyway, NOTE Confidence: 0.86199266 00:36:01.770 --> 00:36:04.388 an article in the New England Journal NOTE Confidence: 0.86199266 00:36:04.388 --> 00:36:07.099 of Medicine by VAALCO Anne McLellan. NOTE Confidence: 0.86199266 00:36:07.100 --> 00:36:10.988 Again, rates averaging less than 8%. NOTE Confidence: 0.86199266 00:36:10.990 --> 00:36:15.950 But that's a range up to 8% AMI 8% is. NOTE Confidence: 0.86199266 00:36:15.950 --> 00:36:18.150 You know it's not trivial, NOTE Confidence: 0.86199266 00:36:18.150 --> 00:36:20.350 So what is that about? NOTE Confidence: 0.86199266 00:36:20.350 --> 00:36:20.901 Why? NOTE Confidence: 0.86199266 00:36:20.901 --> 00:36:24.207 Why does that range exist an NOTE Confidence: 0.86199266 00:36:24.207 --> 00:36:27.270 and there's a study from. NOTE Confidence: 0.86199266 00:36:27.270 --> 00:36:29.235 Out of the University of NOTE Confidence: 0.86199266 00:36:29.235 --> 00:36:30.807 Miami by David Fishbrain, NOTE Confidence: 0.86199266 00:36:30.810 --> 00:36:34.338 which sheds a lot of light on this question, NOTE Confidence: 0.86199266 00:36:34.340 --> 00:36:37.252 his group did a review of 24 studies NOTE Confidence: 0.86199266 00:36:37.252 --> 00:36:40.429 of this is chronic pain of patients NOTE Confidence: 0.86199266 00:36:40.429 --> 00:36:43.289 prescribed opioids and and he did NOTE Confidence: 0.86199266 00:36:43.289 --> 00:36:46.187 find a relatively low rate of 3.27%. NOTE Confidence: 0.86199266 00:36:46.190 --> 00:36:48.591 But then when he separated out the NOTE Confidence: 0.86199266 00:36:48.591 --> 00:36:50.616 four studies that had specifically NOTE Confidence: 0.86199266 00:36:50.616 --> 00:36:52.926 excluded patients with previous or NOTE Confidence: 0.86199266 00:36:52.926 --> 00:36:55.638 current history of addiction or abuse, NOTE Confidence: 0.86199266 00:36:55.640 --> 00:36:57.413 it dropped significantly. NOTE Confidence: 0.86199266 00:36:57.413 --> 00:36:59.186 And in fact, NOTE Confidence: 0.86199266 00:36:59.190 --> 00:37:01.390 the Cochrane report specifically NOTE Confidence: 0.86199266 00:37:01.390 --> 00:37:04.690 says that their reported low rates. NOTE Confidence: 0.86199266 00:37:04.690 --> 00:37:07.264 Remember that was .27 should not NOTE Confidence: 0.86199266 00:37:07.264 --> 00:37:09.739 be generalized to an unselected NOTE Confidence: 0.86199266 00:37:09.739 --> 00:37:13.114 population or to individuals taking NOTE Confidence: 0.86199266 00:37:13.114 --> 00:37:15.139 opioids without supervision, NOTE Confidence: 0.86199266 00:37:15.140 --> 00:37:17.340 because the conference study, NOTE Confidence: 0.86199266 00:37:17.340 --> 00:37:20.090 I think also weeded out. NOTE Confidence: 0.8444297 00:37:22.470 --> 00:37:27.375 We did out studies that had that that had NOTE Confidence: 0.8444297 00:37:27.375 --> 00:37:31.416 included people with these histories of. NOTE Confidence: 0.8444297 00:37:31.420 --> 00:37:34.288 Substance abuse, and that's really really NOTE Confidence: 0.8444297 00:37:34.288 --> 00:37:37.203 important because there is an abundance NOTE Confidence: 0.8444297 00:37:37.203 --> 00:37:39.987 of data confirming that patients with NOTE Confidence: 0.8444297 00:37:39.987 --> 00:37:43.133 prior addiction to alcohol or drugs or NOTE Confidence: 0.8444297 00:37:43.133 --> 00:37:45.278 people who are experiencing depression NOTE Confidence: 0.8444297 00:37:45.280 --> 00:37:48.928 are those who will report taking an extra NOTE Confidence: 0.8444297 00:37:48.928 --> 00:37:51.749 pain reliever to manage stress with. NOTE Confidence: 0.8444297 00:37:51.750 --> 00:37:55.878 These are the folks who are much more NOTE Confidence: 0.8444297 00:37:55.878 --> 00:37:59.767 likely to progress on to addiction. NOTE Confidence: 0.8444297 00:37:59.770 --> 00:38:01.716 And This is why it's so important. NOTE Confidence: 0.8444297 00:38:01.720 --> 00:38:03.388 Of course, for doctors before they NOTE Confidence: 0.8444297 00:38:03.388 --> 00:38:04.500 prescribe any addictive medicine, NOTE Confidence: 0.8444297 00:38:04.500 --> 00:38:05.277 not just opioids, NOTE Confidence: 0.8444297 00:38:05.277 --> 00:38:07.550 but as to what gather a very decent, NOTE Confidence: 0.8444297 00:38:07.550 --> 00:38:09.630 you know, a very detailed. NOTE Confidence: 0.8444297 00:38:09.630 --> 00:38:11.285 Information on their prior experience NOTE Confidence: 0.8444297 00:38:11.285 --> 00:38:12.940 with substance use, current consumption, NOTE Confidence: 0.8444297 00:38:12.940 --> 00:38:14.260 and how they've managed. NOTE Confidence: 0.8444297 00:38:14.260 --> 00:38:16.246 If they've been on no prescription NOTE Confidence: 0.8444297 00:38:16.246 --> 00:38:17.570 opioids in the past, NOTE Confidence: 0.8444297 00:38:17.570 --> 00:38:19.466 how they manage them and since NOTE Confidence: 0.8444297 00:38:19.466 --> 00:38:21.475 primary care doctors you know we're NOTE Confidence: 0.8444297 00:38:21.475 --> 00:38:23.195 doing much of this prescribing. NOTE Confidence: 0.83243984 00:38:25.610 --> 00:38:28.004 It's fairly evident that they I mean NOTE Confidence: 0.83243984 00:38:28.004 --> 00:38:30.299 there everyone is busy and pressured, NOTE Confidence: 0.83243984 00:38:30.300 --> 00:38:32.508 and but that they probably we NOTE Confidence: 0.83243984 00:38:32.508 --> 00:38:34.395 doctors in general probably didn't NOTE Confidence: 0.83243984 00:38:34.395 --> 00:38:36.789 do their as much diligence as they NOTE Confidence: 0.83243984 00:38:36.789 --> 00:38:38.967 should have in terms of screening. NOTE Confidence: 0.83243984 00:38:38.970 --> 00:38:41.910 People who are at risk and NOTE Confidence: 0.83243984 00:38:41.910 --> 00:38:44.620 now there all kinds of of. NOTE Confidence: 0.83243984 00:38:44.620 --> 00:38:47.188 Instruments to screen for that kind of thing, NOTE Confidence: 0.83243984 00:38:47.190 --> 00:38:49.302 and in fact there are a number of NOTE Confidence: 0.83243984 00:38:49.302 --> 00:38:50.898 surveys of primary care doctors NOTE Confidence: 0.83243984 00:38:50.898 --> 00:38:53.250 where the majority of them say when NOTE Confidence: 0.83243984 00:38:53.310 --> 00:38:55.530 we're very uneasy with treating pain, NOTE Confidence: 0.83243984 00:38:55.530 --> 00:38:56.990 we don't know how, NOTE Confidence: 0.83243984 00:38:56.990 --> 00:39:00.168 and also that they don't know how to NOTE Confidence: 0.83243984 00:39:00.168 --> 00:39:02.448 treat addiction that might develop. NOTE Confidence: 0.83243984 00:39:02.450 --> 00:39:05.258 Now people. Do you have vulnerabilities? NOTE Confidence: 0.83243984 00:39:05.260 --> 00:39:06.680 It doesn't mean that doctors NOTE Confidence: 0.83243984 00:39:06.680 --> 00:39:08.100 should avoid prescribing for them, NOTE Confidence: 0.83243984 00:39:08.100 --> 00:39:09.945 but they obviously have to NOTE Confidence: 0.83243984 00:39:09.945 --> 00:39:12.610 monitor them a lot more carefully. NOTE Confidence: 0.83243984 00:39:12.610 --> 00:39:13.828 You should also, NOTE Confidence: 0.83243984 00:39:13.828 --> 00:39:16.264 in addition to looking for these NOTE Confidence: 0.83243984 00:39:16.264 --> 00:39:18.725 more kind of conventional point NOTE Confidence: 0.83243984 00:39:18.725 --> 00:39:20.207 details of history, NOTE Confidence: 0.83243984 00:39:20.210 --> 00:39:23.570 they really have to appraise the NOTE Confidence: 0.83243984 00:39:23.570 --> 00:39:26.660 patients current well being because. NOTE Confidence: 0.83243984 00:39:26.660 --> 00:39:29.680 You know there are situations. NOTE Confidence: 0.90037054 00:39:33.220 --> 00:39:36.220 Is it? There are definitely NOTE Confidence: 0.90037054 00:39:36.220 --> 00:39:38.020 situations in which. NOTE Confidence: 0.90037054 00:39:38.020 --> 00:39:39.754 You know in which people might NOTE Confidence: 0.90037054 00:39:39.754 --> 00:39:41.362 go might begin their problems NOTE Confidence: 0.90037054 00:39:41.362 --> 00:39:43.678 with drugs or with with opioid NOTE Confidence: 0.90037054 00:39:43.678 --> 00:39:45.410 prescription opioids through a doctor, NOTE Confidence: 0.90037054 00:39:45.410 --> 00:39:47.045 but the kind of situation NOTE Confidence: 0.90037054 00:39:47.045 --> 00:39:49.110 is often one where I mean, NOTE Confidence: 0.90037054 00:39:49.110 --> 00:39:51.120 here's a sort of a classic, NOTE Confidence: 0.90037054 00:39:51.120 --> 00:39:53.213 and then I saw this in Ironton NOTE Confidence: 0.90037054 00:39:53.213 --> 00:39:55.298 where a young guy really was NOTE Confidence: 0.90037054 00:39:55.298 --> 00:39:57.163 captain of the football team. NOTE Confidence: 0.90037054 00:39:57.170 --> 00:40:00.959 Had a period have a great life he was. NOTE Confidence: 0.90037054 00:40:00.960 --> 00:40:03.192 Got a football scholarship to Ohio NOTE Confidence: 0.90037054 00:40:03.192 --> 00:40:06.134 State and then he was in a car NOTE Confidence: 0.90037054 00:40:06.134 --> 00:40:08.198 accident and it ruined his throwing NOTE Confidence: 0.90037054 00:40:08.270 --> 00:40:10.850 arm and basically his whole future NOTE Confidence: 0.90037054 00:40:10.850 --> 00:40:13.228 just collapsed before his eyes and NOTE Confidence: 0.90037054 00:40:13.228 --> 00:40:15.860 you can imagine a young boy like this NOTE Confidence: 0.90037054 00:40:15.938 --> 00:40:18.728 was just utterly devastated and he NOTE Confidence: 0.90037054 00:40:18.728 --> 00:40:21.019 was prescribed opioids because he NOTE Confidence: 0.90037054 00:40:21.019 --> 00:40:23.827 had his surgery and it was a painful NOTE Confidence: 0.90037054 00:40:23.827 --> 00:40:25.592 condition but but those opioids NOTE Confidence: 0.90037054 00:40:25.592 --> 00:40:28.819 helped a lot more than his shoulder pain. NOTE Confidence: 0.90037054 00:40:28.820 --> 00:40:30.815 I mean they really helped NOTE Confidence: 0.90037054 00:40:30.815 --> 00:40:32.810 his psychic pain as well. NOTE Confidence: 0.90037054 00:40:32.810 --> 00:40:35.337 And that put him at significant risk. NOTE Confidence: 0.90037054 00:40:35.340 --> 00:40:38.220 The fact that the fact that this accident NOTE Confidence: 0.90037054 00:40:38.220 --> 00:40:41.499 was so traumatic to him was a real risk. NOTE Confidence: 0.90037054 00:40:41.500 --> 00:40:44.554 So it's very important that we NOTE Confidence: 0.90037054 00:40:44.554 --> 00:40:47.240 think about always think about. NOTE Confidence: 0.90037054 00:40:47.240 --> 00:40:48.976 Opioid abuse and addiction. NOTE Confidence: 0.90037054 00:40:48.976 --> 00:40:52.682 As a product of the person and the NOTE Confidence: 0.90037054 00:40:52.682 --> 00:40:54.718 context and drug availability. NOTE Confidence: 0.90037054 00:40:54.720 --> 00:40:55.906 Drug availability, NOTE Confidence: 0.90037054 00:40:55.906 --> 00:40:58.871 but exposure itself is probably NOTE Confidence: 0.90037054 00:40:58.871 --> 00:41:01.787 never sufficient and this matter NOTE Confidence: 0.90037054 00:41:01.787 --> 00:41:04.417 is this accidental addict image NOTE Confidence: 0.90037054 00:41:04.417 --> 00:41:07.557 does matter because it led to NOTE Confidence: 0.90037054 00:41:07.557 --> 00:41:10.017 an exaggerated impression of the NOTE Confidence: 0.90037054 00:41:10.017 --> 00:41:14.268 addictiveness of opioid medications and. NOTE Confidence: 0.90037054 00:41:14.270 --> 00:41:17.126 And that led to a fairly NOTE Confidence: 0.90037054 00:41:17.126 --> 00:41:18.078 indiscriminate crackdown. NOTE Confidence: 0.90037054 00:41:18.080 --> 00:41:20.786 Now there's no question that doctors NOTE Confidence: 0.90037054 00:41:20.786 --> 00:41:23.310 prescribed these medications too liberally. NOTE Confidence: 0.90037054 00:41:23.310 --> 00:41:26.166 Most people needed just several days. NOTE Confidence: 0.90037054 00:41:26.170 --> 00:41:28.074 Some people probably didn't NOTE Confidence: 0.90037054 00:41:28.074 --> 00:41:29.978 need anything except Tylenol, NOTE Confidence: 0.90037054 00:41:29.980 --> 00:41:33.305 extra strength, etc is pretty darn good. NOTE Confidence: 0.90037054 00:41:33.310 --> 00:41:35.874 Anna hot water bottle. NOTE Confidence: 0.90037054 00:41:35.874 --> 00:41:39.079 So I've certainly stipulate that. NOTE Confidence: 0.90037054 00:41:39.080 --> 00:41:40.526 And of course, NOTE Confidence: 0.90037054 00:41:40.526 --> 00:41:42.936 doctors started treating pain more NOTE Confidence: 0.90037054 00:41:42.936 --> 00:41:44.813 aggressively because they had NOTE Confidence: 0.90037054 00:41:44.813 --> 00:41:46.497 undertreated pain through most NOTE Confidence: 0.90037054 00:41:46.497 --> 00:41:50.070 of the Sixties, 70s, and 80s. NOTE Confidence: 0.90037054 00:41:50.070 --> 00:41:51.610 And as. NOTE Confidence: 0.90037054 00:41:51.610 --> 00:41:52.938 As we all know, NOTE Confidence: 0.90037054 00:41:52.938 --> 00:41:55.986 in the late 90s and early 2000s the NOTE Confidence: 0.90037054 00:41:55.986 --> 00:41:58.416 Joint Commission was encouraging doctors NOTE Confidence: 0.90037054 00:41:58.416 --> 00:42:02.388 to to pay more attention to pain relief. NOTE Confidence: 0.90037054 00:42:02.390 --> 00:42:03.680 They didn't necessarily. NOTE Confidence: 0.90037054 00:42:03.680 --> 00:42:05.830 They didn't specifically mention opioids, NOTE Confidence: 0.90037054 00:42:05.830 --> 00:42:08.416 but the doctors had to be NOTE Confidence: 0.90037054 00:42:08.416 --> 00:42:09.709 much more responsive. NOTE Confidence: 0.90037054 00:42:09.710 --> 00:42:11.434 Medicare and Medicaid would NOTE Confidence: 0.90037054 00:42:11.434 --> 00:42:12.727 actually have patients, NOTE Confidence: 0.90037054 00:42:12.730 --> 00:42:15.025 would fill out patient satisfaction NOTE Confidence: 0.90037054 00:42:15.025 --> 00:42:18.174 surveys and one of the items was NOTE Confidence: 0.90037054 00:42:18.174 --> 00:42:20.953 was your pain rate cared for, and. NOTE Confidence: 0.90037054 00:42:20.953 --> 00:42:23.936 So that it is patient, said no. NOTE Confidence: 0.90037054 00:42:23.936 --> 00:42:25.601 There was some pressures and NOTE Confidence: 0.90037054 00:42:25.601 --> 00:42:27.795 brought to bear on those physicians NOTE Confidence: 0.90037054 00:42:27.795 --> 00:42:29.680 or their health care system. NOTE Confidence: 0.90037054 00:42:29.680 --> 00:42:31.460 So that was more pressure. NOTE Confidence: 0.90037054 00:42:31.460 --> 00:42:33.889 There was a whole 5th vital sign NOTE Confidence: 0.90037054 00:42:33.889 --> 00:42:36.438 of the Smiley faces and you know, NOTE Confidence: 0.90037054 00:42:36.440 --> 00:42:38.505 you know the drill state boards were NOTE Confidence: 0.90037054 00:42:38.505 --> 00:42:40.700 much more were encouraging and also NOTE Confidence: 0.90037054 00:42:40.700 --> 00:42:43.202 holding doctors harmless if they prescribed. NOTE Confidence: 0.90037054 00:42:43.210 --> 00:42:45.828 If it appeared that they were prescribing NOTE Confidence: 0.90037054 00:42:45.828 --> 00:42:48.898 high doses and we know where this all went, NOTE Confidence: 0.90037054 00:42:48.900 --> 00:42:49.612 it overshot. NOTE Confidence: 0.90037054 00:42:49.612 --> 00:42:51.036 And then in 2000. NOTE Confidence: 0.85004432 00:42:53.400 --> 00:42:58.850 11 Doctors started to reduce. NOTE Confidence: 0.85004432 00:42:58.850 --> 00:43:02.847 The amount of opioid prescriptions they were. NOTE Confidence: 0.85004432 00:43:02.850 --> 00:43:04.274 Handing out an that NOTE Confidence: 0.85004432 00:43:04.274 --> 00:43:05.698 discontinuation goes on today. NOTE Confidence: 0.85004432 00:43:05.700 --> 00:43:08.185 Now this raises a very interesting question. NOTE Confidence: 0.85004432 00:43:08.190 --> 00:43:11.284 I don't know the answer to is. NOTE Confidence: 0.85004432 00:43:11.290 --> 00:43:13.486 How much of a reduction in NOTE Confidence: 0.85004432 00:43:13.486 --> 00:43:14.950 prescribing opioids is enough, NOTE Confidence: 0.85004432 00:43:14.950 --> 00:43:16.795 but because it's been projected NOTE Confidence: 0.85004432 00:43:16.795 --> 00:43:19.427 that at the end of this month NOTE Confidence: 0.85004432 00:43:19.427 --> 00:43:21.898 it might be back to 2000 levels. NOTE Confidence: 0.85004432 00:43:21.900 --> 00:43:23.364 The year 2000 levels, NOTE Confidence: 0.85004432 00:43:23.364 --> 00:43:25.194 which is an interesting question, NOTE Confidence: 0.85004432 00:43:25.200 --> 00:43:26.660 but the important point NOTE Confidence: 0.85004432 00:43:26.660 --> 00:43:28.485 is now that opioids were. NOTE Confidence: 0.8543263 00:43:30.540 --> 00:43:33.215 Declining and and that was NOTE Confidence: 0.8543263 00:43:33.215 --> 00:43:35.890 probably good because they were, NOTE Confidence: 0.8543263 00:43:35.890 --> 00:43:39.100 as I said, they were overprescribed, NOTE Confidence: 0.8543263 00:43:39.100 --> 00:43:42.298 but unfortunately that was done with NOTE Confidence: 0.8543263 00:43:42.298 --> 00:43:47.460 a machete and not a scalpel, and. NOTE Confidence: 0.8543263 00:43:47.460 --> 00:43:50.652 Which is to say that people who NOTE Confidence: 0.8543263 00:43:50.652 --> 00:43:53.209 really needed pain opioids for. NOTE Confidence: 0.8543263 00:43:53.210 --> 00:43:55.988 Chronic pain were often denied them NOTE Confidence: 0.8543263 00:43:55.988 --> 00:43:58.449 and this situation really increased NOTE Confidence: 0.8543263 00:43:58.449 --> 00:44:01.635 dramatically after 2016 when the CDC NOTE Confidence: 0.8543263 00:44:01.635 --> 00:44:04.845 produced its guidelines from for primary NOTE Confidence: 0.8543263 00:44:04.845 --> 00:44:07.405 care doctors for prescribing opioids, NOTE Confidence: 0.8543263 00:44:07.410 --> 00:44:09.374 and I'll tell you, NOTE Confidence: 0.8543263 00:44:09.374 --> 00:44:11.338 I thought those guidelines NOTE Confidence: 0.8543263 00:44:11.338 --> 00:44:13.489 were they weren't bad. NOTE Confidence: 0.8543263 00:44:13.490 --> 00:44:16.030 I thought they were fine. NOTE Confidence: 0.8543263 00:44:16.030 --> 00:44:18.560 They urged going, you know, NOTE Confidence: 0.8543263 00:44:18.560 --> 00:44:21.920 start low, go slow. NOTE Confidence: 0.8543263 00:44:21.920 --> 00:44:24.055 Weighing the costs of the NOTE Confidence: 0.8543263 00:44:24.055 --> 00:44:25.763 benefits of the medications, NOTE Confidence: 0.8543263 00:44:25.770 --> 00:44:29.050 but in retrospect it was a disaster that NOTE Confidence: 0.8543263 00:44:29.050 --> 00:44:31.264 they suggested 90 morphine milligram NOTE Confidence: 0.8543263 00:44:31.264 --> 00:44:33.898 equivalents as as a guard rail. NOTE Confidence: 0.8543263 00:44:33.900 --> 00:44:36.868 You really should be cautious about going NOTE Confidence: 0.8543263 00:44:36.868 --> 00:44:39.829 over 90 morphine milligram equivalents. NOTE Confidence: 0.8543263 00:44:39.830 --> 00:44:42.595 That really wasn't based on any data NOTE Confidence: 0.8543263 00:44:42.595 --> 00:44:45.880 and the people who were on the task NOTE Confidence: 0.8543263 00:44:45.880 --> 00:44:48.327 force who included that caution were NOTE Confidence: 0.8543263 00:44:48.327 --> 00:44:51.119 the first to admit it and they were NOTE Confidence: 0.8543263 00:44:51.119 --> 00:44:53.798 also the CDC that these are guidelines. NOTE Confidence: 0.8543263 00:44:53.800 --> 00:44:55.348 Guidelines aren't mandates from NOTE Confidence: 0.8543263 00:44:55.348 --> 00:44:56.874 the federal government, but. NOTE Confidence: 0.8543263 00:44:56.874 --> 00:45:00.150 It was taken as if it was the 90 NOTE Confidence: 0.8543263 00:45:00.250 --> 00:45:03.398 morphine milligram of threshold, NOTE Confidence: 0.8543263 00:45:03.400 --> 00:45:05.968 honestly was understood. NOTE Confidence: 0.8543263 00:45:05.970 --> 00:45:08.340 So in such a widespread fashion, NOTE Confidence: 0.8543263 00:45:08.340 --> 00:45:10.951 as if it were written on tablets NOTE Confidence: 0.8543263 00:45:10.951 --> 00:45:13.479 and handed down from Mount Sinai, NOTE Confidence: 0.8543263 00:45:13.480 --> 00:45:16.175 and there became just a rash of NOTE Confidence: 0.8543263 00:45:16.175 --> 00:45:18.219 tapering people from high doses, NOTE Confidence: 0.8543263 00:45:18.220 --> 00:45:20.190 some perhaps didn't need it, NOTE Confidence: 0.8543263 00:45:20.190 --> 00:45:22.170 I will grant you that, NOTE Confidence: 0.8543263 00:45:22.170 --> 00:45:24.140 but many did, tapering them, NOTE Confidence: 0.8543263 00:45:24.140 --> 00:45:26.115 which is traumatic in terms NOTE Confidence: 0.8543263 00:45:26.115 --> 00:45:27.300 of precipitating withdrawal, NOTE Confidence: 0.8543263 00:45:27.300 --> 00:45:30.065 because some of them did it very, NOTE Confidence: 0.8543263 00:45:30.070 --> 00:45:31.050 very quickly. NOTE Confidence: 0.8543263 00:45:31.050 --> 00:45:33.990 There was a study from Vermont NOTE Confidence: 0.8543263 00:45:33.990 --> 00:45:36.049 Medicaid where the average. NOTE Confidence: 0.8543263 00:45:36.050 --> 00:45:39.074 Time to withdraw was one day and and so NOTE Confidence: 0.8543263 00:45:39.074 --> 00:45:41.866 some would have their doses lowered. NOTE Confidence: 0.8543263 00:45:41.870 --> 00:45:43.422 Others would have would NOTE Confidence: 0.8543263 00:45:43.422 --> 00:45:44.586 have them discontinued, NOTE Confidence: 0.8543263 00:45:44.590 --> 00:45:47.122 and then they're developed a whole NOTE Confidence: 0.8543263 00:45:47.122 --> 00:45:49.778 population of people that some have NOTE Confidence: 0.8543263 00:45:49.778 --> 00:45:52.466 called pain refugees where their doctors. NOTE Confidence: 0.8543263 00:45:52.470 --> 00:45:53.890 Wouldn't treat them anymore. NOTE Confidence: 0.8543263 00:45:53.890 --> 00:45:55.665 Some of those doctors were NOTE Confidence: 0.8543263 00:45:55.665 --> 00:45:57.175 heartbroken because they thought NOTE Confidence: 0.8543263 00:45:57.175 --> 00:45:59.000 the government was outlawing this, NOTE Confidence: 0.8543263 00:45:59.000 --> 00:46:00.092 and others were. NOTE Confidence: 0.8543263 00:46:00.092 --> 00:46:01.548 From what I gathered, NOTE Confidence: 0.8543263 00:46:01.550 --> 00:46:03.360 unfortunately pretty insensitive to it. NOTE Confidence: 0.8543263 00:46:03.360 --> 00:46:05.952 There is a lot of talk that about NOTE Confidence: 0.8543263 00:46:05.952 --> 00:46:08.312 from patient sitting there that their NOTE Confidence: 0.8543263 00:46:08.312 --> 00:46:11.174 doctor was never really wanted to keep NOTE Confidence: 0.8543263 00:46:11.174 --> 00:46:13.519 them on opioids in the 1st place, NOTE Confidence: 0.8543263 00:46:13.520 --> 00:46:16.924 so this was an excuse, but in any case, NOTE Confidence: 0.8543263 00:46:16.924 --> 00:46:18.508 whatever the motivation the NOTE Confidence: 0.8543263 00:46:18.508 --> 00:46:20.060 patients were suffering. NOTE Confidence: 0.8543263 00:46:20.060 --> 00:46:23.000 Terribly and. NOTE Confidence: 0.8543263 00:46:23.000 --> 00:46:25.076 This is just one survey that NOTE Confidence: 0.8543263 00:46:25.076 --> 00:46:27.540 was done by pain News Network, NOTE Confidence: 0.8543263 00:46:27.540 --> 00:46:29.796 which is also an advocacy group, NOTE Confidence: 0.8543263 00:46:29.800 --> 00:46:32.824 and you know, admittedly this is not a. NOTE Confidence: 0.8543263 00:46:32.830 --> 00:46:34.720 This was just a survey. NOTE Confidence: 0.8543263 00:46:34.720 --> 00:46:37.760 It isn't. It wasn't a. NOTE Confidence: 0.8543263 00:46:37.760 --> 00:46:39.520 It was a scientifically conducted, NOTE Confidence: 0.8543263 00:46:39.520 --> 00:46:42.688 so to speak, but you can see the trends, NOTE Confidence: 0.8543263 00:46:42.690 --> 00:46:45.498 my pain and quality of life is worse, NOTE Confidence: 0.8543263 00:46:45.500 --> 00:46:47.639 you know, like. NOTE Confidence: 0.8543263 00:46:47.640 --> 00:46:50.448 Spot 4 out of five and I'm no NOTE Confidence: 0.8543263 00:46:50.448 --> 00:46:51.718 longer prescribed medication NOTE Confidence: 0.8543263 00:46:51.718 --> 00:46:54.148 are prescribed a lower dose. NOTE Confidence: 0.8543263 00:46:54.150 --> 00:46:56.316 These are in the yellow highlighted NOTE Confidence: 0.8543263 00:46:56.316 --> 00:46:59.040 and people were in enormous distress. NOTE Confidence: 0.8543263 00:46:59.040 --> 00:47:01.380 A colleague to colleagues of mine NOTE Confidence: 0.8543263 00:47:01.380 --> 00:47:04.268 are keeping a registry of people who NOTE Confidence: 0.8543263 00:47:04.268 --> 00:47:06.358 committed suicide because of this, NOTE Confidence: 0.8543263 00:47:06.360 --> 00:47:08.796 and then there was pushed back. NOTE Confidence: 0.8543263 00:47:08.800 --> 00:47:10.840 This is just one example, NOTE Confidence: 0.8467653 00:47:10.840 --> 00:47:13.594 best darn analysis and pain psychologist NOTE Confidence: 0.8467653 00:47:13.594 --> 00:47:16.389 at Stanford and and they were NOTE Confidence: 0.8467653 00:47:16.389 --> 00:47:19.029 actually 100 signatures on this too. NOTE Confidence: 0.8467653 00:47:19.030 --> 00:47:22.733 Call attention to this problem of tapering NOTE Confidence: 0.8467653 00:47:22.733 --> 00:47:25.000 people indiscriminately and quickly. NOTE Confidence: 0.8467653 00:47:25.000 --> 00:47:28.171 They were also please from Human Rights NOTE Confidence: 0.8467653 00:47:28.171 --> 00:47:32.059 Watch from the American Medical Association, NOTE Confidence: 0.8467653 00:47:32.060 --> 00:47:34.775 the American Cancer Society all NOTE Confidence: 0.8467653 00:47:34.775 --> 00:47:38.055 addressing the CDC and said, please, NOTE Confidence: 0.8467653 00:47:38.055 --> 00:47:41.445 please would you clarify what you NOTE Confidence: 0.8467653 00:47:41.445 --> 00:47:45.530 really meant in the guidelines because? NOTE Confidence: 0.8467653 00:47:45.530 --> 00:47:47.870 9090 morphine milligram equivalents is NOTE Confidence: 0.8467653 00:47:47.870 --> 00:47:50.886 for some people with chronic pain is NOTE Confidence: 0.8467653 00:47:50.886 --> 00:47:53.286 just you know not enough and to the NOTE Confidence: 0.8467653 00:47:53.363 --> 00:47:55.855 CDC's credit they did clarify that in NOTE Confidence: 0.8467653 00:47:55.855 --> 00:47:58.710 an article in the New England Journal NOTE Confidence: 0.8467653 00:47:58.710 --> 00:48:02.660 in April of 2019 and that now they are. NOTE Confidence: 0.8467653 00:48:02.660 --> 00:48:04.706 Actually convened another task force with, NOTE Confidence: 0.8467653 00:48:04.710 --> 00:48:07.446 I think, a totally new complement of experts, NOTE Confidence: 0.8467653 00:48:07.450 --> 00:48:09.502 and there can be there convened NOTE Confidence: 0.8467653 00:48:09.502 --> 00:48:10.870 there working on it. NOTE Confidence: 0.8467653 00:48:10.870 --> 00:48:13.534 I'm fairly certain that any kind NOTE Confidence: 0.8467653 00:48:13.534 --> 00:48:16.099 of threshold won't won't be in it. NOTE Confidence: 0.8467653 00:48:16.100 --> 00:48:18.160 But anyway, that's that is. NOTE Confidence: 0.8467653 00:48:18.160 --> 00:48:21.072 That's why the points that I wanted NOTE Confidence: 0.8467653 00:48:21.072 --> 00:48:24.802 to bring up is that we have to be NOTE Confidence: 0.8467653 00:48:24.802 --> 00:48:27.199 very cognizant of who's at risk. NOTE Confidence: 0.8467653 00:48:27.200 --> 00:48:29.727 And we know that the majority of NOTE Confidence: 0.8467653 00:48:29.727 --> 00:48:32.258 people who abuse of prescription pills NOTE Confidence: 0.8467653 00:48:32.258 --> 00:48:35.006 were never patients to begin with, NOTE Confidence: 0.8467653 00:48:35.010 --> 00:48:38.664 but patients who did among the patients. NOTE Confidence: 0.8467653 00:48:38.670 --> 00:48:41.405 Who received opioids and develop NOTE Confidence: 0.8467653 00:48:41.405 --> 00:48:44.644 problems had had risk factors and NOTE Confidence: 0.8467653 00:48:44.644 --> 00:48:47.140 that because we had a really. NOTE Confidence: 0.80400515 00:48:50.010 --> 00:48:51.890 Sloppy and heavy handed NOTE Confidence: 0.80400515 00:48:51.890 --> 00:48:53.770 approach to the overprescribing NOTE Confidence: 0.80400515 00:48:53.770 --> 00:48:55.938 which was really ended up. NOTE Confidence: 0.80400515 00:48:55.940 --> 00:48:59.993 I think hurting a lot of chronic NOTE Confidence: 0.80400515 00:48:59.993 --> 00:49:03.359 pain patients now that part is. NOTE Confidence: 0.80400515 00:49:03.360 --> 00:49:06.720 The universal story. NOTE Confidence: 0.80400515 00:49:06.720 --> 00:49:08.480 There's an interesting I see. NOTE Confidence: 0.80400515 00:49:08.480 --> 00:49:12.864 My time is getting a little short so. NOTE Confidence: 0.80400515 00:49:12.870 --> 00:49:14.770 No, it's not. I'm good. NOTE Confidence: 0.80400515 00:49:14.770 --> 00:49:19.178 OK, I'm going to talk till about 10. NOTE Confidence: 0.80400515 00:49:19.180 --> 00:49:21.949 10 yeah, 11:15. NOTE Confidence: 0.81764907 00:49:24.440 --> 00:49:26.520 On second thought, it is getting a little NOTE Confidence: 0.81764907 00:49:26.520 --> 00:49:28.600 short, so I'm going to move on too. NOTE Confidence: 0.84128594 00:49:30.710 --> 00:49:35.274 My other point, which is to emphasize NOTE Confidence: 0.84128594 00:49:35.274 --> 00:49:40.344 how to how complicated the story NOTE Confidence: 0.84128594 00:49:40.344 --> 00:49:44.304 of addiction these addiction. NOTE Confidence: 0.84128594 00:49:44.310 --> 00:49:46.360 And epidemics are when my NOTE Confidence: 0.84128594 00:49:46.360 --> 00:49:48.410 people have said we haven't. NOTE Confidence: 0.84128594 00:49:48.410 --> 00:49:50.026 We haven't overdose epidemic NOTE Confidence: 0.84128594 00:49:50.026 --> 00:49:52.920 and I think now that is true. NOTE Confidence: 0.84128594 00:49:52.920 --> 00:49:56.200 What I mean to say was always true, NOTE Confidence: 0.84128594 00:49:56.200 --> 00:49:58.250 but but I, I'm fairly, NOTE Confidence: 0.84128594 00:49:58.250 --> 00:50:00.800 I think, data kind of. NOTE Confidence: 0.84128594 00:50:00.800 --> 00:50:02.550 Persuasive that more not many NOTE Confidence: 0.84128594 00:50:02.550 --> 00:50:04.300 more people are using drugs. NOTE Confidence: 0.84128594 00:50:04.300 --> 00:50:06.512 It's just that we've gotten to a NOTE Confidence: 0.84128594 00:50:06.512 --> 00:50:08.599 stage where the drugs people are NOTE Confidence: 0.84128594 00:50:08.599 --> 00:50:11.091 using and I'm referring now to heroin NOTE Confidence: 0.84128594 00:50:11.158 --> 00:50:13.396 and fentanyl are much more lethal, NOTE Confidence: 0.84128594 00:50:13.400 --> 00:50:15.480 so you're all familiar. NOTE Confidence: 0.84128594 00:50:15.480 --> 00:50:18.080 I'm sure with this slide. NOTE Confidence: 0.84128594 00:50:18.080 --> 00:50:21.120 We see it in your dreams and it NOTE Confidence: 0.84128594 00:50:21.120 --> 00:50:23.387 illustrates what the CDC is called. NOTE Confidence: 0.84128594 00:50:23.390 --> 00:50:26.270 So the three waves. NOTE Confidence: 0.84128594 00:50:26.270 --> 00:50:30.897 Portrait of The of the opioid crisis. NOTE Confidence: 0.84128594 00:50:30.900 --> 00:50:34.545 And you see that this slide starts in 1999. NOTE Confidence: 0.84128594 00:50:34.550 --> 00:50:37.422 I've other slides that go back to 1990 NOTE Confidence: 0.84128594 00:50:37.422 --> 00:50:41.027 and you already see opioid starting to rise, NOTE Confidence: 0.84128594 00:50:41.030 --> 00:50:44.030 and that's because of the effort to to NOTE Confidence: 0.84128594 00:50:44.030 --> 00:50:46.085 compensate for the undertreatment of NOTE Confidence: 0.84128594 00:50:46.085 --> 00:50:49.530 pain or whatever it's been called an opiate, NOTE Confidence: 0.84128594 00:50:49.530 --> 00:50:50.745 the OPO phobia. NOTE Confidence: 0.84128594 00:50:50.745 --> 00:50:53.175 That term was coined in 1983, NOTE Confidence: 0.84128594 00:50:53.180 --> 00:50:55.763 and the doctors are trying to compensate NOTE Confidence: 0.84128594 00:50:55.763 --> 00:50:58.438 now and not just cancer patients, NOTE Confidence: 0.84128594 00:50:58.440 --> 00:51:01.808 but with people with non cancer chronic pain. NOTE Confidence: 0.84128594 00:51:01.810 --> 00:51:04.610 That was a that was a very important NOTE Confidence: 0.84128594 00:51:04.610 --> 00:51:06.701 population that had definitely been NOTE Confidence: 0.84128594 00:51:06.701 --> 00:51:09.347 undertreated for pain and then started. NOTE Confidence: 0.84128594 00:51:09.350 --> 00:51:11.958 As I said in the 90s and it NOTE Confidence: 0.84128594 00:51:11.958 --> 00:51:14.510 gained and gained more momentum. NOTE Confidence: 0.84128594 00:51:14.510 --> 00:51:17.790 Oxycontin came along in 1996. NOTE Confidence: 0.84128594 00:51:17.790 --> 00:51:20.250 Out of focus is on 1996, NOTE Confidence: 0.84128594 00:51:20.250 --> 00:51:23.064 but but the trend was going NOTE Confidence: 0.84128594 00:51:23.064 --> 00:51:24.940 up way before then. NOTE Confidence: 0.84128594 00:51:24.940 --> 00:51:28.316 Um, and so that was wave one Anas. NOTE Confidence: 0.84128594 00:51:28.320 --> 00:51:32.100 I've showed you that other slide prescribing NOTE Confidence: 0.84128594 00:51:32.100 --> 00:51:35.157 actually started to go down in 2011. NOTE Confidence: 0.84128594 00:51:35.160 --> 00:51:38.954 Then wave two which started around 2010, NOTE Confidence: 0.84128594 00:51:38.960 --> 00:51:42.628 was growth of heroin. NOTE Confidence: 0.84128594 00:51:42.630 --> 00:51:45.708 And that's because it was filling NOTE Confidence: 0.84128594 00:51:45.708 --> 00:51:49.105 a vacuum that was vacated by NOTE Confidence: 0.84128594 00:51:49.105 --> 00:51:51.585 pills which were becoming. NOTE Confidence: 0.84128594 00:51:51.590 --> 00:51:54.614 Less and less available in around 2010 was NOTE Confidence: 0.84128594 00:51:54.614 --> 00:51:57.796 was really a convergence of a lot of things. NOTE Confidence: 0.84128594 00:51:57.800 --> 00:51:58.558 Pill Mills. NOTE Confidence: 0.84128594 00:51:58.558 --> 00:52:00.453 There was a really concerted NOTE Confidence: 0.84128594 00:52:00.453 --> 00:52:02.540 effort to crackdown on pill Mills, NOTE Confidence: 0.84128594 00:52:02.540 --> 00:52:04.730 and those are bogus doctors offices. NOTE Confidence: 0.84128594 00:52:04.730 --> 00:52:06.174 Basically that barely did. NOTE Confidence: 0.84128594 00:52:06.174 --> 00:52:08.750 If they even did a physical exam, NOTE Confidence: 0.84128594 00:52:08.750 --> 00:52:10.575 they may have done it NOTE Confidence: 0.84128594 00:52:10.575 --> 00:52:12.400 once when you walked in, NOTE Confidence: 0.84128594 00:52:12.400 --> 00:52:14.590 but after that they would just NOTE Confidence: 0.84128594 00:52:14.590 --> 00:52:18.246 hand out the pills, cash for pills. NOTE Confidence: 0.84128594 00:52:18.246 --> 00:52:21.174 Sometimes Medicaid for pills. NOTE Confidence: 0.84128594 00:52:21.180 --> 00:52:23.595 There was a reformulation of NOTE Confidence: 0.84128594 00:52:23.595 --> 00:52:26.570 Oxycontin so that it could not NOTE Confidence: 0.84128594 00:52:26.570 --> 00:52:29.354 as easily be crushed and snorted. NOTE Confidence: 0.84128594 00:52:29.360 --> 00:52:31.649 Physician at the PD MPs which have NOTE Confidence: 0.84128594 00:52:31.649 --> 00:52:33.961 been around for decades but really NOTE Confidence: 0.84128594 00:52:33.961 --> 00:52:36.056 became much more aggressive to NOTE Confidence: 0.84128594 00:52:36.056 --> 00:52:38.123 monitor doctor shopping and states NOTE Confidence: 0.84128594 00:52:38.123 --> 00:52:40.439 were also starting to put limits, NOTE Confidence: 0.84128594 00:52:40.440 --> 00:52:42.726 especially on prescribing for acute pain. NOTE Confidence: 0.84128594 00:52:42.730 --> 00:52:46.394 You know Jay limits this kind of thing. NOTE Confidence: 0.84128594 00:52:46.400 --> 00:52:48.035 And that allowed the creative NOTE Confidence: 0.84128594 00:52:48.035 --> 00:52:49.670 vacuum that allowed heroin to NOTE Confidence: 0.84128594 00:52:49.730 --> 00:52:51.338 come in back back in Ironton. NOTE Confidence: 0.84128594 00:52:51.340 --> 00:52:53.820 Heroin had never been around in Apple Acha. NOTE Confidence: 0.84128594 00:52:53.820 --> 00:52:55.850 It was rare and largely NOTE Confidence: 0.84128594 00:52:55.850 --> 00:52:57.474 because they had pills. NOTE Confidence: 0.84128594 00:52:57.480 --> 00:53:00.060 Then wave three start about 2014. NOTE Confidence: 0.84128594 00:53:00.060 --> 00:53:01.350 That was fentanyl, NOTE Confidence: 0.84128594 00:53:01.350 --> 00:53:04.360 and all know how potent that is, NOTE Confidence: 0.84128594 00:53:04.360 --> 00:53:06.940 100 times as potent as morphine, NOTE Confidence: 0.84128594 00:53:06.940 --> 00:53:09.950 50 times as potent as heroin and. NOTE Confidence: 0.8145069 00:53:11.970 --> 00:53:13.286 And we know now. NOTE Confidence: 0.8145069 00:53:13.286 --> 00:53:15.940 Actually in the next slide that just look NOTE Confidence: 0.8145069 00:53:15.940 --> 00:53:18.770 at the red an they don't even have meth. NOTE Confidence: 0.8145069 00:53:18.770 --> 00:53:22.004 Yeah, wrath, the red and the purple. NOTE Confidence: 0.8145069 00:53:22.010 --> 00:53:23.602 Pink show that meth, NOTE Confidence: 0.8145069 00:53:23.602 --> 00:53:25.194 methamphetamine and cocaine is NOTE Confidence: 0.8145069 00:53:25.194 --> 00:53:28.012 really on the rise and unfortunately NOTE Confidence: 0.8145069 00:53:28.012 --> 00:53:30.457 fentanyl's often sprinkled on those NOTE Confidence: 0.8145069 00:53:30.457 --> 00:53:32.384 preparations and people overdose NOTE Confidence: 0.8145069 00:53:32.384 --> 00:53:34.664 from that because typically cocaine. NOTE Confidence: 0.8145069 00:53:34.670 --> 00:53:36.830 Certainly an methamphetamine stimulus. NOTE Confidence: 0.8145069 00:53:36.830 --> 00:53:38.990 Don't have the overdose. NOTE Confidence: 0.8145069 00:53:38.990 --> 00:53:40.638 Potential that opioids too. NOTE Confidence: 0.8145069 00:53:40.638 --> 00:53:42.698 And as I mentioned before, NOTE Confidence: 0.8145069 00:53:42.700 --> 00:53:44.815 these are opioids that are NOTE Confidence: 0.8145069 00:53:44.815 --> 00:53:47.230 usually almost in when they're in. NOTE Confidence: 0.8145069 00:53:47.230 --> 00:53:48.878 Overdose are almost always NOTE Confidence: 0.8145069 00:53:48.878 --> 00:53:50.526 combined with something else. NOTE Confidence: 0.8145069 00:53:50.530 --> 00:53:52.210 When I mentioned before, NOTE Confidence: 0.8145069 00:53:52.210 --> 00:53:55.882 the tox screen showed 60 to 90% of other NOTE Confidence: 0.8145069 00:53:55.882 --> 00:53:58.348 drugs that didn't even include alcohol. NOTE Confidence: 0.8145069 00:53:58.350 --> 00:54:00.828 So OK, then fentanyl to cough, NOTE Confidence: 0.8145069 00:54:00.830 --> 00:54:03.707 and that is really been a disaster. NOTE Confidence: 0.8145069 00:54:03.710 --> 00:54:05.358 The pandemic, of course, NOTE Confidence: 0.8145069 00:54:05.358 --> 00:54:07.418 worsened everything people using alone, NOTE Confidence: 0.8145069 00:54:07.420 --> 00:54:10.097 so that if they do. Overdose. NOTE Confidence: 0.8145069 00:54:10.097 --> 00:54:13.016 There's no one there to give them NOTE Confidence: 0.8145069 00:54:13.016 --> 00:54:15.428 Narcan or take them to an ER. NOTE Confidence: 0.8145069 00:54:15.430 --> 00:54:17.274 The pandemic disrupted trafficking NOTE Confidence: 0.8145069 00:54:17.274 --> 00:54:20.589 routes so people were buying from now on. NOTE Confidence: 0.8145069 00:54:20.590 --> 00:54:22.670 Reliable usual sources and they NOTE Confidence: 0.8145069 00:54:22.670 --> 00:54:24.750 had less access to treatment. NOTE Confidence: 0.8145069 00:54:24.750 --> 00:54:25.166 Then. NOTE Confidence: 0.8145069 00:54:25.166 --> 00:54:27.662 Of course there was just more NOTE Confidence: 0.8145069 00:54:27.662 --> 00:54:30.068 hardship in general, so to the NOTE Confidence: 0.8145069 00:54:30.068 --> 00:54:33.490 extent that and I think a massive extent, NOTE Confidence: 0.8145069 00:54:33.490 --> 00:54:35.565 that addiction is basically a NOTE Confidence: 0.8145069 00:54:35.565 --> 00:54:37.225 form of self medication. NOTE Confidence: 0.8145069 00:54:37.230 --> 00:54:39.708 There was a lot more to medicate NOTE Confidence: 0.8145069 00:54:39.708 --> 00:54:42.220 in terms of social isolation. NOTE Confidence: 0.8145069 00:54:42.220 --> 00:54:43.412 Death of. NOTE Confidence: 0.8145069 00:54:43.412 --> 00:54:45.200 Friends and family. NOTE Confidence: 0.8145069 00:54:45.200 --> 00:54:47.264 Maybe job loss. NOTE Confidence: 0.8145069 00:54:47.264 --> 00:54:49.328 So economic pressure. NOTE Confidence: 0.8145069 00:54:49.330 --> 00:54:51.385 Now the deaths were increasing NOTE Confidence: 0.8145069 00:54:51.385 --> 00:54:53.029 even before the pandemic, NOTE Confidence: 0.8145069 00:54:53.030 --> 00:54:55.788 but the latest data show that from NOTE Confidence: 0.8145069 00:54:55.788 --> 00:54:58.732 March to May of 2020 twenty the NOTE Confidence: 0.8145069 00:54:58.732 --> 00:55:01.246 1st two months of the pandemic, NOTE Confidence: 0.8145069 00:55:01.250 --> 00:55:02.894 there was needing steeper NOTE Confidence: 0.8145069 00:55:02.894 --> 00:55:04.127 acceleration and death, NOTE Confidence: 0.8145069 00:55:04.130 --> 00:55:07.352 so that's a big problem in what's called the NOTE Confidence: 0.8145069 00:55:07.352 --> 00:55:10.288 other epidemic or the forgotten epidemic? NOTE Confidence: 0.8145069 00:55:10.290 --> 00:55:11.624 You know, NOTE Confidence: 0.8145069 00:55:11.624 --> 00:55:14.959 in the context of covid. NOTE Confidence: 0.8145069 00:55:14.960 --> 00:55:18.956 So I'm going to wrap up. NOTE Confidence: 0.8145069 00:55:18.960 --> 00:55:20.640 We've hopefully leave a lot of NOTE Confidence: 0.8145069 00:55:20.640 --> 00:55:22.546 time for Q&A because I do have NOTE Confidence: 0.8145069 00:55:22.546 --> 00:55:24.240 kind of a story about Apple Watch. NOTE Confidence: 0.8145069 00:55:24.240 --> 00:55:25.560 I want to get to, NOTE Confidence: 0.8145069 00:55:25.560 --> 00:55:27.408 but I'll fit that into the Q&A. NOTE Confidence: 0.8145069 00:55:27.410 --> 00:55:29.777 Make sure I finish the formal talk on time. NOTE Confidence: 0.7810981 00:55:40.330 --> 00:55:42.760 Give us a good enough answer, NOTE Confidence: 0.7810981 00:55:42.760 --> 00:55:46.715 like for example the accidental addict too. NOTE Confidence: 0.7810981 00:55:46.720 --> 00:55:50.710 Some find it is it's it's a. NOTE Confidence: 0.7810981 00:55:50.710 --> 00:55:53.179 Although it's disturbing. NOTE Confidence: 0.7810981 00:55:53.180 --> 00:55:54.832 It's a clean narrative. NOTE Confidence: 0.7810981 00:55:54.832 --> 00:55:56.902 You know. People were fine, NOTE Confidence: 0.7810981 00:55:56.902 --> 00:55:58.972 then they were essentially contaminated NOTE Confidence: 0.7810981 00:55:58.972 --> 00:56:01.437 by their physician who was either, NOTE Confidence: 0.7810981 00:56:01.440 --> 00:56:03.510 you know, well meaning slash, NOTE Confidence: 0.7810981 00:56:03.510 --> 00:56:07.374 duped by a drug Rep into prescribing opioids. NOTE Confidence: 0.7810981 00:56:07.380 --> 00:56:09.410 And and that was the NOTE Confidence: 0.7810981 00:56:09.410 --> 00:56:11.440 beginning of of a disaster, NOTE Confidence: 0.7810981 00:56:11.440 --> 00:56:13.876 and we've seen that you know. NOTE Confidence: 0.7810981 00:56:13.880 --> 00:56:16.848 Again, I I can't say there's that there NOTE Confidence: 0.7810981 00:56:16.848 --> 00:56:19.228 aren't people who whose lives are NOTE Confidence: 0.7810981 00:56:19.228 --> 00:56:21.580 wonderful and content and they don't NOTE Confidence: 0.7810981 00:56:21.650 --> 00:56:24.030 unravel when given a prescription. NOTE Confidence: 0.7810981 00:56:24.030 --> 00:56:26.280 But that's not the usual story NOTE Confidence: 0.7810981 00:56:26.280 --> 00:56:28.490 an even when that happens, NOTE Confidence: 0.7810981 00:56:28.490 --> 00:56:30.114 I'm fairly confident that NOTE Confidence: 0.7810981 00:56:30.114 --> 00:56:32.144 if you scratch the surface, NOTE Confidence: 0.7810981 00:56:32.150 --> 00:56:33.770 you'll see that especially NOTE Confidence: 0.7810981 00:56:33.770 --> 00:56:35.390 visiting a young person, NOTE Confidence: 0.7810981 00:56:35.390 --> 00:56:38.687 you find someone who is struggling with. NOTE Confidence: 0.7810981 00:56:38.690 --> 00:56:41.539 You know all kinds of teenage angst, NOTE Confidence: 0.7810981 00:56:41.540 --> 00:56:44.326 and in fact I did interview a NOTE Confidence: 0.7810981 00:56:44.326 --> 00:56:46.828 patient once who broke a tooth, NOTE Confidence: 0.7810981 00:56:46.830 --> 00:56:49.266 but his doctor gave him opioids. NOTE Confidence: 0.7810981 00:56:49.270 --> 00:56:51.210 He was. NOTE Confidence: 0.7810981 00:56:51.210 --> 00:56:53.208 17 and he was new that, NOTE Confidence: 0.7810981 00:56:53.210 --> 00:56:54.870 you know he's probably gay, NOTE Confidence: 0.7810981 00:56:54.870 --> 00:56:56.868 but he was terrified of revealing NOTE Confidence: 0.7810981 00:56:56.868 --> 00:56:58.200 that to his parents, NOTE Confidence: 0.7810981 00:56:58.200 --> 00:57:00.464 and it really weighed on him and became NOTE Confidence: 0.7810981 00:57:00.464 --> 00:57:02.266 so oppressive to him psychologically NOTE Confidence: 0.7810981 00:57:02.266 --> 00:57:03.830 that these medications actually NOTE Confidence: 0.7810981 00:57:03.830 --> 00:57:05.858 relieved that that stress for him, NOTE Confidence: 0.7810981 00:57:05.860 --> 00:57:10.356 and he kept taking them and taking them. NOTE Confidence: 0.7810981 00:57:10.360 --> 00:57:13.265 I think we like a 90 morphine NOTE Confidence: 0.7810981 00:57:13.265 --> 00:57:14.095 milligram equivalent. NOTE Confidence: 0.7810981 00:57:14.100 --> 00:57:16.590 Threshold is convenient, but it's more. NOTE Confidence: 0.7810981 00:57:16.590 --> 00:57:19.488 There's more to the story than that. NOTE Confidence: 0.7810981 00:57:19.490 --> 00:57:22.772 I think we like a one NOTE Confidence: 0.7810981 00:57:22.772 --> 00:57:24.960 casualty picture which is. NOTE Confidence: 0.7810981 00:57:24.960 --> 00:57:26.850 And we should worry about people NOTE Confidence: 0.7810981 00:57:26.850 --> 00:57:28.740 who became addicted and we should, NOTE Confidence: 0.7810981 00:57:28.740 --> 00:57:30.630 of course, because they are suffering. NOTE Confidence: 0.7810981 00:57:30.630 --> 00:57:32.205 But you know what about NOTE Confidence: 0.7810981 00:57:32.205 --> 00:57:33.465 the chronic pain patients? NOTE Confidence: 0.7810981 00:57:33.470 --> 00:57:35.360 I mean, this is a tradeoff. NOTE Confidence: 0.7810981 00:57:35.360 --> 00:57:36.392 I think you can. NOTE Confidence: 0.7810981 00:57:36.392 --> 00:57:39.139 I think we can do both without question. NOTE Confidence: 0.7810981 00:57:39.140 --> 00:57:40.968 I think we can. NOTE Confidence: 0.7810981 00:57:40.968 --> 00:57:43.710 Treat people for pain in a NOTE Confidence: 0.7810981 00:57:43.821 --> 00:57:45.888 rational way while. NOTE Confidence: 0.7810981 00:57:45.890 --> 00:57:47.134 Protecting people who are NOTE Confidence: 0.7810981 00:57:47.134 --> 00:57:48.067 vulnerable from addiction. NOTE Confidence: 0.7810981 00:57:48.070 --> 00:57:51.190 I think we can do that at the same time, NOTE Confidence: 0.7810981 00:57:51.190 --> 00:57:53.192 and we're going to get much better NOTE Confidence: 0.7810981 00:57:53.192 --> 00:57:55.870 at it and we're getting better at it. NOTE Confidence: 0.7810981 00:57:55.870 --> 00:57:58.656 But I think we like one villain NOTE Confidence: 0.7810981 00:57:58.656 --> 00:58:01.678 and Big Pharma is the villain here. NOTE Confidence: 0.7810981 00:58:01.680 --> 00:58:03.918 And of course there are tons NOTE Confidence: 0.7810981 00:58:03.918 --> 00:58:05.410 of lawsuits going on, NOTE Confidence: 0.7810981 00:58:05.410 --> 00:58:06.914 and massive multidistrict litigation NOTE Confidence: 0.7810981 00:58:06.914 --> 00:58:09.589 which is thrown off by the pandemic NOTE Confidence: 0.7810981 00:58:09.589 --> 00:58:11.379 but is definitely on track. NOTE Confidence: 0.7810981 00:58:11.380 --> 00:58:13.984 I'm not exonerating them, there was heavy, NOTE Confidence: 0.7810981 00:58:13.990 --> 00:58:15.106 overly aggressive marketing, NOTE Confidence: 0.7810981 00:58:15.106 --> 00:58:16.594 no question about that, NOTE Confidence: 0.7810981 00:58:16.600 --> 00:58:18.405 but the drug companies were NOTE Confidence: 0.7810981 00:58:18.405 --> 00:58:20.700 part of a big web drug. NOTE Confidence: 0.7810981 00:58:20.700 --> 00:58:22.570 Distributors were in that web, NOTE Confidence: 0.7810981 00:58:22.570 --> 00:58:24.430 drug distributor is a company, NOTE Confidence: 0.7810981 00:58:24.430 --> 00:58:26.566 and they're like really low on NOTE Confidence: 0.7810981 00:58:26.566 --> 00:58:29.280 the four high on the Fortune 500. NOTE Confidence: 0.7810981 00:58:29.280 --> 00:58:31.690 Some of the biggest ones, McKesson. NOTE Confidence: 0.7810981 00:58:31.690 --> 00:58:33.850 Whatever their normal sleep, NOTE Confidence: 0.7810981 00:58:33.850 --> 00:58:34.662 profitable companies, NOTE Confidence: 0.7810981 00:58:34.662 --> 00:58:37.098 there big industries and they what NOTE Confidence: 0.7810981 00:58:37.098 --> 00:58:39.163 they do is basically transport NOTE Confidence: 0.7810981 00:58:39.163 --> 00:58:41.133 the drugs from the medications NOTE Confidence: 0.7810981 00:58:41.133 --> 00:58:43.085 from the manufacturers warehouse NOTE Confidence: 0.7810981 00:58:43.085 --> 00:58:45.285 to hospitals and pharmacies. NOTE Confidence: 0.7810981 00:58:45.290 --> 00:58:47.930 They are bound by law to NOTE Confidence: 0.7810981 00:58:47.930 --> 00:58:49.250 report suspicious orders. NOTE Confidence: 0.7810981 00:58:49.250 --> 00:58:52.733 In other words of if if a pharmacy the NOTE Confidence: 0.7810981 00:58:52.733 --> 00:58:54.958 pharmacy works with the distributor NOTE Confidence: 0.7810981 00:58:54.958 --> 00:58:58.490 and says we need this much Oxycontin, NOTE Confidence: 0.7810981 00:58:58.490 --> 00:59:00.690 we need this much value. NOTE Confidence: 0.7810981 00:59:00.690 --> 00:59:02.301 We need this. NOTE Confidence: 0.7810981 00:59:02.301 --> 00:59:06.060 There supposed to report it if that NOTE Confidence: 0.885923530769231 00:59:06.174 --> 00:59:08.602 looks off and. There were NOTE Confidence: 0.885923530769231 00:59:08.602 --> 00:59:09.940 significant many instances, NOTE Confidence: 0.885923530769231 00:59:09.940 --> 00:59:11.720 and there's been lawsuits. NOTE Confidence: 0.7824371 00:59:14.260 --> 00:59:15.748 Many lawsuits and ongoing NOTE Confidence: 0.7824371 00:59:15.748 --> 00:59:17.608 lawsuits where they did not. NOTE Confidence: 0.7824371 00:59:17.610 --> 00:59:19.098 They weren't as conscientious NOTE Confidence: 0.7824371 00:59:19.098 --> 00:59:20.958 as they should have been. NOTE Confidence: 0.7824371 00:59:20.960 --> 00:59:23.390 the DEA missed many of these NOTE Confidence: 0.7824371 00:59:23.390 --> 00:59:25.736 suspicious orders because all of those NOTE Confidence: 0.7824371 00:59:25.736 --> 00:59:28.018 reports would also go to the DEA. NOTE Confidence: 0.7824371 00:59:28.020 --> 00:59:29.028 We may have. NOTE Confidence: 0.7824371 00:59:29.028 --> 00:59:31.044 You may have read last week NOTE Confidence: 0.7824371 00:59:31.044 --> 00:59:33.550 that Walgreens is is being sued NOTE Confidence: 0.7824371 00:59:33.550 --> 00:59:35.640 by the federal government for NOTE Confidence: 0.7824371 00:59:35.722 --> 00:59:38.188 filling fraudulent prescriptions. NOTE Confidence: 0.7824371 00:59:38.190 --> 00:59:39.618 Again, not every Walgreens, NOTE Confidence: 0.7824371 00:59:39.618 --> 00:59:41.760 but enough that this is a NOTE Confidence: 0.7824371 00:59:41.837 --> 00:59:43.655 problem at CVS in the past, NOTE Confidence: 0.7824371 00:59:43.660 --> 00:59:45.340 has been sued for such things NOTE Confidence: 0.7824371 00:59:45.340 --> 00:59:47.765 by if I add staff another factor NOTE Confidence: 0.7824371 00:59:47.765 --> 00:59:49.815 and I'm going through them, NOTE Confidence: 0.7824371 00:59:49.820 --> 00:59:51.680 I'm wrapping up and I'm going NOTE Confidence: 0.7824371 00:59:51.680 --> 00:59:53.738 through a list of factors just NOTE Confidence: 0.7824371 00:59:53.738 --> 00:59:55.970 to show how complicated this is. NOTE Confidence: 0.7824371 00:59:55.970 --> 00:59:58.254 Medicare and Medicaid expanded NOTE Confidence: 0.7824371 00:59:58.254 --> 01:00:00.938 their coverage of. A vote. NOTE Confidence: 0.7824371 01:00:00.938 --> 01:00:01.422 Yards, NOTE Confidence: 0.7824371 01:00:01.422 --> 01:00:04.326 you know on patent opioids so NOTE Confidence: 0.7824371 01:00:04.326 --> 01:00:07.285 much that 60% of all opioids NOTE Confidence: 0.7824371 01:00:07.285 --> 01:00:10.435 were paid for by the government. NOTE Confidence: 0.7824371 01:00:10.440 --> 01:00:13.868 From 2001 to 2000. NOTE Confidence: 0.7824371 01:00:13.870 --> 01:00:19.998 10 That's up from 17% before then, and. NOTE Confidence: 0.7824371 01:00:20.000 --> 01:00:22.148 Out of pocket prices dropped 81%, NOTE Confidence: 0.7824371 01:00:22.150 --> 01:00:24.122 so that's a lot. NOTE Confidence: 0.7824371 01:00:24.122 --> 01:00:26.587 I'm almost finished with my NOTE Confidence: 0.7824371 01:00:26.587 --> 01:00:28.498 list of people or. NOTE Confidence: 0.7824371 01:00:28.500 --> 01:00:31.008 Figures that need to be calculated. NOTE Confidence: 0.7824371 01:00:31.010 --> 01:00:32.570 In this understanding this, NOTE Confidence: 0.7824371 01:00:32.570 --> 01:00:34.520 this or this large ecosystem NOTE Confidence: 0.7824371 01:00:34.520 --> 01:00:37.219 of this web doctors for both NOTE Confidence: 0.7824371 01:00:37.219 --> 01:00:38.560 pressured and inexperienced, NOTE Confidence: 0.7824371 01:00:38.560 --> 01:00:40.978 but they were always the gatekeepers NOTE Confidence: 0.7824371 01:00:40.978 --> 01:00:43.094 and these drugs were always NOTE Confidence: 0.7824371 01:00:43.094 --> 01:00:45.219 scheduled to except Hydra codon NOTE Confidence: 0.7824371 01:00:45.219 --> 01:00:47.769 which was scheduled 3 until 2014, NOTE Confidence: 0.7824371 01:00:47.770 --> 01:00:51.160 but Oxycontin was always scheduled to. NOTE Confidence: 0.7824371 01:00:51.160 --> 01:00:52.708 Then there were the neighbors who NOTE Confidence: 0.7824371 01:00:52.708 --> 01:00:54.280 sold pills to their neighbors. NOTE Confidence: 0.7824371 01:00:54.280 --> 01:00:56.552 I work with a nurse who actually holds NOTE Confidence: 0.7824371 01:00:56.552 --> 01:00:58.909 those people more accountable than anything. NOTE Confidence: 0.7824371 01:00:58.910 --> 01:01:00.670 And then Lastly of course NOTE Confidence: 0.7824371 01:01:00.670 --> 01:01:02.078 there are the people. NOTE Confidence: 0.7824371 01:01:02.080 --> 01:01:04.537 The demand that came from the patients. NOTE Confidence: 0.7824371 01:01:04.540 --> 01:01:06.980 Now I could I've been to a place NOTE Confidence: 0.7824371 01:01:06.980 --> 01:01:08.852 where you see how difficult NOTE Confidence: 0.7824371 01:01:08.852 --> 01:01:11.222 and depressing and life can be. NOTE Confidence: 0.7824371 01:01:11.230 --> 01:01:12.990 And as I said before, NOTE Confidence: 0.7824371 01:01:12.990 --> 01:01:15.230 I'm a great believer in the self NOTE Confidence: 0.7824371 01:01:15.230 --> 01:01:16.860 medication theory of addiction. NOTE Confidence: 0.7824371 01:01:16.860 --> 01:01:19.884 I mean people use drugs for reasons. NOTE Confidence: 0.7824371 01:01:19.890 --> 01:01:22.221 But they use them and that demand NOTE Confidence: 0.7824371 01:01:22.221 --> 01:01:23.970 dynamic is very important. NOTE Confidence: 0.7824371 01:01:23.970 --> 01:01:26.990 So I want to end on a happy note if NOTE Confidence: 0.7824371 01:01:27.082 --> 01:01:30.274 you aren't all too distressed by now, NOTE Confidence: 0.7824371 01:01:30.280 --> 01:01:32.250 which is. NOTE Confidence: 0.7824371 01:01:32.250 --> 01:01:37.047 That in Iron 10 there is still a great. NOTE Confidence: 0.7824371 01:01:37.050 --> 01:01:38.082 Spirit of tradition. NOTE Confidence: 0.7824371 01:01:38.082 --> 01:01:41.300 This was a dog at the Memorial Day Parade, NOTE Confidence: 0.7824371 01:01:41.300 --> 01:01:42.008 which is. NOTE Confidence: 0.7824371 01:01:42.008 --> 01:01:43.070 I haven't checked, NOTE Confidence: 0.7824371 01:01:43.070 --> 01:01:45.548 but I'm going to leave Ironton colleagues. NOTE Confidence: 0.7824371 01:01:45.550 --> 01:01:48.158 It's the longest running. NOTE Confidence: 0.7824371 01:01:48.158 --> 01:01:51.418 Memorial Day Parade in the NOTE Confidence: 0.7824371 01:01:51.418 --> 01:01:54.687 country since 1868 and this is. NOTE Confidence: 0.7824371 01:01:54.690 --> 01:01:56.790 Great fact that it was even NOTE Confidence: 0.7824371 01:01:56.790 --> 01:01:58.930 held during the 1918 pandemic. NOTE Confidence: 0.7824371 01:01:58.930 --> 01:02:01.639 Not sure if that ended up being NOTE Confidence: 0.7824371 01:02:01.639 --> 01:02:03.929 a super spreader event or not, NOTE Confidence: 0.7824371 01:02:03.930 --> 01:02:06.192 but the 1918 pandemic was attended NOTE Confidence: 0.7824371 01:02:06.192 --> 01:02:08.547 by veterans of the Civil War NOTE Confidence: 0.7824371 01:02:08.547 --> 01:02:10.477 in the Spanish American War. NOTE Confidence: 0.7824371 01:02:10.480 --> 01:02:11.632 They were there. NOTE Confidence: 0.7824371 01:02:11.632 --> 01:02:13.168 I met wonderful people, NOTE Confidence: 0.7824371 01:02:13.170 --> 01:02:15.865 a lot of a lot of individuals, NOTE Confidence: 0.7824371 01:02:15.870 --> 01:02:16.638 local entrepreneurs. NOTE Confidence: 0.7824371 01:02:16.638 --> 01:02:19.284 Or, you know, just trying to. NOTE Confidence: 0.7824371 01:02:19.284 --> 01:02:22.154 He opened up Mr Fisher, right. NOTE Confidence: 0.7824371 01:02:22.154 --> 01:02:24.398 Richard Fisher opened a coffee shop, NOTE Confidence: 0.7824371 01:02:24.400 --> 01:02:26.638 a very, very artisanal coffee shop, NOTE Confidence: 0.7824371 01:02:26.640 --> 01:02:28.890 which wasn't what you'd find there. NOTE Confidence: 0.7824371 01:02:28.890 --> 01:02:30.760 But he was very enthusiastic. NOTE Confidence: 0.7824371 01:02:30.760 --> 01:02:31.508 He's retired, NOTE Confidence: 0.7824371 01:02:31.508 --> 01:02:34.500 and this is what he wanted to do, NOTE Confidence: 0.7824371 01:02:34.500 --> 01:02:36.738 and he was a former chemist. NOTE Confidence: 0.7824371 01:02:36.740 --> 01:02:38.702 So even though the name of NOTE Confidence: 0.7824371 01:02:38.702 --> 01:02:40.010 his store is the NOTE Confidence: 0.8094714 01:02:40.088 --> 01:02:41.230 Ironton Coffee, NOTE Confidence: 0.8094714 01:02:41.230 --> 01:02:44.587 a lab that iron was Effie in his news, NOTE Confidence: 0.8094714 01:02:44.590 --> 01:02:47.208 you may be able to see here. NOTE Confidence: 0.8094714 01:02:47.210 --> 01:02:50.390 He'd have open night and. NOTE Confidence: 0.8094714 01:02:50.390 --> 01:02:52.340 Even the Ronay Theater now has NOTE Confidence: 0.8094714 01:02:52.340 --> 01:02:54.783 shows and they had a Frank Sinatra NOTE Confidence: 0.8094714 01:02:54.783 --> 01:02:56.931 retrospective and there is a bike NOTE Confidence: 0.8094714 01:02:56.931 --> 01:02:59.184 path and an there's there's some NOTE Confidence: 0.8094714 01:02:59.184 --> 01:03:01.688 enthusiasm I'm not going to be naive. NOTE Confidence: 0.8094714 01:03:01.688 --> 01:03:03.722 I mean, it's still a struggle NOTE Confidence: 0.8094714 01:03:03.722 --> 01:03:05.609 in place of the pandemic. NOTE Confidence: 0.8094714 01:03:05.610 --> 01:03:07.908 Certainly hasn't helped but but it's NOTE Confidence: 0.8094714 01:03:07.908 --> 01:03:10.465 it is very gratifying to see how NOTE Confidence: 0.8094714 01:03:10.465 --> 01:03:12.684 people try to save their small towns. NOTE Confidence: 0.8094714 01:03:12.690 --> 01:03:15.168 And this is happening all over America, NOTE Confidence: 0.8094714 01:03:15.170 --> 01:03:17.970 so we'll just end with a picture of NOTE Confidence: 0.8094714 01:03:17.970 --> 01:03:21.197 this is a picture of the train tracks. NOTE Confidence: 0.8094714 01:03:21.200 --> 01:03:26.240 In downtown Ironton and what you see in. NOTE Confidence: 0.8094714 01:03:26.240 --> 01:03:27.820 The background is a wall. NOTE Confidence: 0.8094714 01:03:27.820 --> 01:03:29.632 That's the floodwall in the Ohio NOTE Confidence: 0.8094714 01:03:29.632 --> 01:03:31.599 River is on the other side, NOTE Confidence: 0.8094714 01:03:31.600 --> 01:03:34.064 and it could be a picturesque place NOTE Confidence: 0.8094714 01:03:34.064 --> 01:03:36.689 that plays place with great people who NOTE Confidence: 0.8094714 01:03:36.689 --> 01:03:39.306 are very enthusiastic and sadly a place NOTE Confidence: 0.8094714 01:03:39.306 --> 01:03:41.778 with a lot of people who are still. NOTE Confidence: 0.8094714 01:03:41.780 --> 01:03:44.830 So. So thank you very much. NOTE Confidence: 0.8168963 01:03:46.370 --> 01:03:48.054 Sally, thanks so much. NOTE Confidence: 0.8168963 01:03:48.054 --> 01:03:51.330 If you could end your screen sharing, NOTE Confidence: 0.8168963 01:03:51.330 --> 01:03:54.627 you'll be able to see the attendees NOTE Confidence: 0.8168963 01:03:54.627 --> 01:03:56.739 better and they'll be able NOTE Confidence: 0.777687925 01:03:56.740 --> 01:04:02.710 to you. I I. OK wait, why is it? NOTE Confidence: 0.82150775 01:04:05.160 --> 01:04:07.744 I don't have her over the top of NOTE Confidence: 0.82150775 01:04:07.744 --> 01:04:09.956 your screen. Maybe that green. NOTE Confidence: 0.82150775 01:04:09.956 --> 01:04:12.566 Yep. Manual CA stock share. NOTE Confidence: 0.86698914 01:04:14.300 --> 01:04:17.389 So I would suggest this OK so NOTE Confidence: 0.86698914 01:04:17.390 --> 01:04:19.595 people can raise questions by NOTE Confidence: 0.86698914 01:04:19.595 --> 01:04:21.800 writing something in the chat, NOTE Confidence: 0.86698914 01:04:21.800 --> 01:04:24.881 or you can wave your hand furiously NOTE Confidence: 0.86698914 01:04:24.881 --> 01:04:27.970 like this and will try to keep NOTE Confidence: 0.86698914 01:04:27.970 --> 01:04:33.070 track of you. On the screen. NOTE Confidence: 0.86698914 01:04:33.070 --> 01:04:35.174 I notice that there is the hand raise. NOTE Confidence: 0.86698914 01:04:35.174 --> 01:04:38.220 Oh, I guess the hand raising. NOTE Confidence: 0.86698914 01:04:38.220 --> 01:04:39.792 It's the hand raising some can NOTE Confidence: 0.86698914 01:04:39.792 --> 01:04:41.200 use the hand raising thing, NOTE Confidence: 0.86698914 01:04:41.200 --> 01:04:43.426 but I can't on my screen. NOTE Confidence: 0.86698914 01:04:43.430 --> 01:04:47.050 So, um. NOTE Confidence: 0.86698914 01:04:47.050 --> 01:04:48.904 So the quick first question is NOTE Confidence: 0.86698914 01:04:48.904 --> 01:04:50.561 Mary's research team is working NOTE Confidence: 0.86698914 01:04:50.561 --> 01:04:52.721 on a systematic review of all NOTE Confidence: 0.86698914 01:04:52.721 --> 01:04:54.440 published substance abuse treatment. NOTE Confidence: 0.86698914 01:04:54.440 --> 01:04:56.750 One of the surprise finding is that NOTE Confidence: 0.86698914 01:04:56.750 --> 01:04:59.318 none of the articles in our final NOTE Confidence: 0.86698914 01:04:59.318 --> 01:05:01.126 review are from rural settings. NOTE Confidence: 0.86698914 01:05:01.126 --> 01:05:03.196 Is it possible that the research on NOTE Confidence: 0.86698914 01:05:03.196 --> 01:05:05.401 the method of 1st Entry into drug NOTE Confidence: 0.86698914 01:05:05.401 --> 01:05:07.393 misuse in our addiction does not NOTE Confidence: 0.86698914 01:05:07.393 --> 01:05:09.522 represent rural or suburban populations NOTE Confidence: 0.86698914 01:05:09.522 --> 01:05:11.687 where demographics might be different? NOTE Confidence: 0.82181334 01:05:12.820 --> 01:05:14.695 Yeah, I think that I NOTE Confidence: 0.82181334 01:05:14.695 --> 01:05:16.195 think there's still more. NOTE Confidence: 0.82181334 01:05:16.200 --> 01:05:18.080 I don't think I know. NOTE Confidence: 0.82181334 01:05:18.080 --> 01:05:19.960 You look at CDC data. NOTE Confidence: 0.82181334 01:05:19.960 --> 01:05:23.000 There's still more pill use and more to NOTE Confidence: 0.82181334 01:05:23.000 --> 01:05:25.597 prescribing in that part of the country. NOTE Confidence: 0.82181334 01:05:25.600 --> 01:05:27.856 I fairly I wouldn't be surprised. NOTE Confidence: 0.82181334 01:05:27.860 --> 01:05:31.235 I mean in fact hit Cicero did work on. NOTE Confidence: 0.82181334 01:05:31.240 --> 01:05:33.879 He was the one who did that. NOTE Confidence: 0.82181334 01:05:33.880 --> 01:05:35.350 Almost Seminole study. NOTE Confidence: 0.82181334 01:05:35.350 --> 01:05:37.800 Now looking at people who NOTE Confidence: 0.82181334 01:05:37.800 --> 01:05:40.389 came into treatment and how. NOTE Confidence: 0.82181334 01:05:40.390 --> 01:05:43.222 You know there was a change over the NOTE Confidence: 0.82181334 01:05:43.222 --> 01:05:45.488 years where in his first sample, NOTE Confidence: 0.82181334 01:05:45.490 --> 01:05:48.031 which I think was in 2000 or NOTE Confidence: 0.82181334 01:05:48.031 --> 01:05:50.220 the paper came out in 2014. NOTE Confidence: 0.82181334 01:05:50.220 --> 01:05:52.035 The sample was done obviously NOTE Confidence: 0.82181334 01:05:52.035 --> 01:05:53.124 years before that. NOTE Confidence: 0.82181334 01:05:53.130 --> 01:05:55.062 The drug that people started on NOTE Confidence: 0.82181334 01:05:55.062 --> 01:05:56.832 in there they were initiated NOTE Confidence: 0.82181334 01:05:56.832 --> 01:05:59.316 through pills as opposed to heroin. NOTE Confidence: 0.82181334 01:05:59.320 --> 01:06:00.114 That was, NOTE Confidence: 0.82181334 01:06:00.114 --> 01:06:02.893 I think for about four and five NOTE Confidence: 0.82181334 01:06:02.893 --> 01:06:05.284 actually reported pills as how NOTE Confidence: 0.82181334 01:06:05.284 --> 01:06:07.669 they initiated their opioid use. NOTE Confidence: 0.82181334 01:06:07.670 --> 01:06:10.350 And years later he went back and followed. NOTE Confidence: 0.82181334 01:06:10.350 --> 01:06:13.365 That up, I think three or four years later, NOTE Confidence: 0.82181334 01:06:13.370 --> 01:06:15.652 and found that a much higher percentage NOTE Confidence: 0.82181334 01:06:15.652 --> 01:06:17.389 now are starting with heroin, NOTE Confidence: 0.82181334 01:06:17.390 --> 01:06:18.046 not pills. NOTE Confidence: 0.82181334 01:06:18.046 --> 01:06:20.014 But I would imagine if you NOTE Confidence: 0.82181334 01:06:20.014 --> 01:06:21.738 did that in rural area, NOTE Confidence: 0.82181334 01:06:21.740 --> 01:06:24.267 you might find still a higher percentage NOTE Confidence: 0.82181334 01:06:24.267 --> 01:06:26.322 of people initiating with with pills NOTE Confidence: 0.82181334 01:06:26.322 --> 01:06:28.436 that actually gets me into the now. NOTE Confidence: 0.82181334 01:06:28.440 --> 01:06:30.120 I don't see any other. NOTE Confidence: 0.82181334 01:06:30.120 --> 01:06:31.308 Am I missing him? NOTE Confidence: 0.82181334 01:06:31.308 --> 01:06:33.800 'cause I don't see any other questions. NOTE Confidence: 0.82181334 01:06:33.800 --> 01:06:36.172 I don't see any at the moment, NOTE Confidence: 0.82181334 01:06:36.172 --> 01:06:37.556 but great perfect because NOTE Confidence: 0.82181334 01:06:37.556 --> 01:06:39.380 that is a perfect segue. NOTE Confidence: 0.82181334 01:06:39.380 --> 01:06:42.512 Into the part of the talk that I put NOTE Confidence: 0.82181334 01:06:42.512 --> 01:06:45.320 outside just in this interest of time, NOTE Confidence: 0.82181334 01:06:45.320 --> 01:06:49.030 which is to say that there really was a very, NOTE Confidence: 0.82181334 01:06:49.030 --> 01:06:51.680 very big difference in the NOTE Confidence: 0.82181334 01:06:51.680 --> 01:06:54.330 culture of prescribing opioids in. NOTE Confidence: 0.82181334 01:06:54.330 --> 01:06:54.806 Apple, NOTE Confidence: 0.82181334 01:06:54.806 --> 01:06:57.186 ACHA and especially central Appalachia. NOTE Confidence: 0.82181334 01:06:57.190 --> 01:06:58.966 When you say central, NOTE Confidence: 0.82181334 01:06:58.966 --> 01:07:02.440 that's like Deep Apple at Eastern Kentucky, NOTE Confidence: 0.82181334 01:07:02.440 --> 01:07:04.344 an southwestern Virginia and NOTE Confidence: 0.82181334 01:07:04.344 --> 01:07:06.724 almost all of West Virginia, NOTE Confidence: 0.82181334 01:07:06.730 --> 01:07:10.132 and these are places where mining NOTE Confidence: 0.82181334 01:07:10.132 --> 01:07:13.520 was a major major industry. NOTE Confidence: 0.82181334 01:07:13.520 --> 01:07:18.553 And this is an area where prescribing NOTE Confidence: 0.82181334 01:07:18.553 --> 01:07:22.371 pills of opioids had always NOTE Confidence: 0.82181334 01:07:22.371 --> 01:07:26.176 always been heavy because of. NOTE Confidence: 0.82181334 01:07:26.180 --> 01:07:31.204 Because of the labor, because mining was a. NOTE Confidence: 0.82181334 01:07:31.210 --> 01:07:31.615 Incredibly, NOTE Confidence: 0.82181334 01:07:31.615 --> 01:07:34.450 I mean when you read about when NOTE Confidence: 0.82181334 01:07:34.450 --> 01:07:37.442 you when I have 'cause I as I NOTE Confidence: 0.82181334 01:07:37.442 --> 01:07:38.842 said coming from Queens, NOTE Confidence: 0.82181334 01:07:38.850 --> 01:07:41.834 NY I don't know about mining but I NOTE Confidence: 0.82181334 01:07:41.834 --> 01:07:45.094 do have to take a crash course in it NOTE Confidence: 0.82181334 01:07:45.094 --> 01:07:49.160 and it now it's a lot of its surface mining. NOTE Confidence: 0.82181334 01:07:49.160 --> 01:07:52.216 It's not quite as brutal, but it was. NOTE Confidence: 0.82181334 01:07:52.216 --> 01:07:53.744 It was just help. NOTE Confidence: 0.82181334 01:07:53.750 --> 01:07:56.536 If you did underground mining often the NOTE Confidence: 0.82181334 01:07:56.536 --> 01:07:59.477 coal seams were at four was called low, NOTE Confidence: 0.82181334 01:07:59.480 --> 01:08:00.659 low, low cold, NOTE Confidence: 0.82181334 01:08:00.659 --> 01:08:02.624 but there was four feet. NOTE Confidence: 0.82181334 01:08:02.630 --> 01:08:05.126 4 feet of head way to do your. NOTE Confidence: 0.832218 01:08:07.300 --> 01:08:10.870 To do your work you can you can just everyday NOTE Confidence: 0.832218 01:08:10.950 --> 01:08:14.520 for 1012 hour weekday but for 10 hours a day. NOTE Confidence: 0.832218 01:08:14.520 --> 01:08:17.464 I mean you can only fathom how that NOTE Confidence: 0.832218 01:08:17.464 --> 01:08:19.743 destroyed peoples bodies and most were NOTE Confidence: 0.832218 01:08:19.743 --> 01:08:22.327 retired by the time well retired by NOTE Confidence: 0.832218 01:08:22.327 --> 01:08:25.350 the time they were, you know 40 or 50. NOTE Confidence: 0.832218 01:08:25.350 --> 01:08:28.850 But The thing is that is before the 60s these NOTE Confidence: 0.832218 01:08:28.936 --> 01:08:32.203 folks lived on coal camps and a coal camp. NOTE Confidence: 0.832218 01:08:32.210 --> 01:08:34.376 You may have heard of them. NOTE Confidence: 0.832218 01:08:34.380 --> 01:08:37.260 I've sold my soul to the company store, NOTE Confidence: 0.832218 01:08:37.260 --> 01:08:39.300 but coal camps really were NOTE Confidence: 0.832218 01:08:39.300 --> 01:08:40.116 totalizing institutions. NOTE Confidence: 0.832218 01:08:40.120 --> 01:08:42.465 And you lived in a coal camp. NOTE Confidence: 0.832218 01:08:42.470 --> 01:08:44.717 Your kids went to school that the NOTE Confidence: 0.832218 01:08:44.717 --> 01:08:47.038 that the coal company built you went NOTE Confidence: 0.832218 01:08:47.038 --> 01:08:49.859 to church is at the coal company ran. NOTE Confidence: 0.832218 01:08:49.860 --> 01:08:51.876 They had their own police force NOTE Confidence: 0.832218 01:08:51.876 --> 01:08:52.884 so they could. NOTE Confidence: 0.832218 01:08:52.890 --> 01:08:57.386 Partly I think put down unionizing and they. NOTE Confidence: 0.832218 01:08:57.390 --> 01:08:59.418 They were very, very. NOTE Confidence: 0.7940616 01:09:03.030 --> 01:09:05.410 Just strict taskmasters to say the least, NOTE Confidence: 0.7940616 01:09:05.410 --> 01:09:08.730 so that that if a man couldn't work. NOTE Confidence: 0.7940616 01:09:08.730 --> 01:09:11.170 He was basically his house was taken away. NOTE Confidence: 0.7940616 01:09:11.170 --> 01:09:13.800 I mean the house was given to him by the NOTE Confidence: 0.7940616 01:09:13.873 --> 01:09:16.633 cold in a company and the store you had to NOTE Confidence: 0.7940616 01:09:16.707 --> 01:09:19.409 buy everything in the coal company store. NOTE Confidence: 0.7940616 01:09:19.410 --> 01:09:21.240 You weren't even paid in money. NOTE Confidence: 0.7940616 01:09:21.240 --> 01:09:22.760 You were paid in script. NOTE Confidence: 0.7940616 01:09:22.760 --> 01:09:24.968 So you had to exchange it and the NOTE Confidence: 0.7940616 01:09:24.968 --> 01:09:26.728 exchange rates were really curious. NOTE Confidence: 0.7940616 01:09:26.730 --> 01:09:28.380 But people a lot of people NOTE Confidence: 0.7940616 01:09:28.380 --> 01:09:30.080 wanted to use Sears catalogs. NOTE Confidence: 0.7940616 01:09:30.080 --> 01:09:31.742 They couldn't do that 'cause they NOTE Confidence: 0.7940616 01:09:31.742 --> 01:09:33.580 didn't have cash and they could NOTE Confidence: 0.7940616 01:09:33.580 --> 01:09:35.265 have gotten these products cheaper. NOTE Confidence: 0.7940616 01:09:35.270 --> 01:09:37.398 So anyway, the point is you were. NOTE Confidence: 0.7940616 01:09:37.400 --> 01:09:39.794 I mean you can hear stories about. NOTE Confidence: 0.7940616 01:09:39.800 --> 01:09:41.860 Good times in coal camps. NOTE Confidence: 0.7940616 01:09:41.860 --> 01:09:43.920 There's a lot of camaraderie NOTE Confidence: 0.7940616 01:09:43.920 --> 01:09:45.568 and very tight communities. NOTE Confidence: 0.7940616 01:09:45.570 --> 01:09:47.150 As you can imagine, NOTE Confidence: 0.7940616 01:09:47.150 --> 01:09:50.448 but they were so dependent on this work NOTE Confidence: 0.7940616 01:09:50.448 --> 01:09:53.395 and if they couldn't work they would. NOTE Confidence: 0.7940616 01:09:53.400 --> 01:09:55.578 They would basically be thrown off NOTE Confidence: 0.7940616 01:09:55.578 --> 01:09:58.572 the island and so Cole camp doctors NOTE Confidence: 0.7940616 01:09:58.572 --> 01:10:00.528 would prescribe generously for. NOTE Confidence: 0.7940616 01:10:00.530 --> 01:10:02.680 It's not cancer chronic pain, NOTE Confidence: 0.7940616 01:10:02.680 --> 01:10:05.248 so they were like NFL coaches. NOTE Confidence: 0.7940616 01:10:05.250 --> 01:10:06.106 You know, NOTE Confidence: 0.7940616 01:10:06.106 --> 01:10:08.674 strength coaches here is your steroid. NOTE Confidence: 0.7940616 01:10:08.680 --> 01:10:11.260 Get out there and do it. NOTE Confidence: 0.7940616 01:10:11.260 --> 01:10:12.427 Where are they? NOTE Confidence: 0.7940616 01:10:12.427 --> 01:10:12.816 Opioids? NOTE Confidence: 0.7940616 01:10:12.816 --> 01:10:16.397 I mean you people had to work so that NOTE Confidence: 0.7940616 01:10:16.397 --> 01:10:19.120 began a culture of low threshold for NOTE Confidence: 0.7940616 01:10:19.201 --> 01:10:21.976 prescribing that that still exists. NOTE Confidence: 0.7940616 01:10:21.980 --> 01:10:24.619 You know today and so that that NOTE Confidence: 0.7940616 01:10:24.619 --> 01:10:27.254 in small the small isolated towns NOTE Confidence: 0.7940616 01:10:27.254 --> 01:10:30.551 they didn't know about the JCH oh, NOTE Confidence: 0.7940616 01:10:30.560 --> 01:10:31.270 you know? NOTE Confidence: 0.7940616 01:10:31.270 --> 01:10:33.045 In terms of treating pain, NOTE Confidence: 0.7940616 01:10:33.050 --> 01:10:34.570 you know the pain movement, NOTE Confidence: 0.7940616 01:10:34.570 --> 01:10:36.095 the effort to prescribe more NOTE Confidence: 0.7940616 01:10:36.095 --> 01:10:37.620 generously than as I said, NOTE Confidence: 0.7940616 01:10:37.620 --> 01:10:39.450 really started in the mid 80s, NOTE Confidence: 0.7940616 01:10:39.450 --> 01:10:42.215 but really gain traction in the late NOTE Confidence: 0.7940616 01:10:42.215 --> 01:10:45.459 90s and mid to late 90s early 2000s. NOTE Confidence: 0.7940616 01:10:45.460 --> 01:10:48.456 Why these folks weren't aware of it? NOTE Confidence: 0.7940616 01:10:48.460 --> 01:10:49.813 If they were, NOTE Confidence: 0.7940616 01:10:49.813 --> 01:10:52.068 it wouldn't matter because they NOTE Confidence: 0.7940616 01:10:52.068 --> 01:10:54.476 wouldn't have changed their prescribing NOTE Confidence: 0.7940616 01:10:54.476 --> 01:10:57.794 habits and so when Oxycontin came to NOTE Confidence: 0.7940616 01:10:57.877 --> 01:11:00.477 town an it came to town in forest, NOTE Confidence: 0.7940616 01:11:00.480 --> 01:11:03.432 it's well documented that produce sent NOTE Confidence: 0.7940616 01:11:03.432 --> 01:11:06.630 now five times the number of drug NOTE Confidence: 0.7940616 01:11:06.630 --> 01:11:10.171 reps you know to that town to some of NOTE Confidence: 0.7940616 01:11:10.171 --> 01:11:12.950 these small towns and they they did NOTE Confidence: 0.7940616 01:11:12.950 --> 01:11:15.600 to other similarly sized places because. NOTE Confidence: 0.7940616 01:11:15.600 --> 01:11:18.302 They went where there was so much NOTE Confidence: 0.7940616 01:11:18.302 --> 01:11:19.460 prescribing and specifically NOTE Confidence: 0.7940616 01:11:19.526 --> 01:11:20.710 of its former drug, NOTE Confidence: 0.7940616 01:11:20.710 --> 01:11:22.900 which was Ms Contin morphine sulfate, NOTE Confidence: 0.7940616 01:11:22.900 --> 01:11:25.030 continuous and. NOTE Confidence: 0.7940616 01:11:25.030 --> 01:11:26.530 Because places like Kentucky NOTE Confidence: 0.7940616 01:11:26.530 --> 01:11:28.405 and West Virginia were high NOTE Confidence: 0.7940616 01:11:28.405 --> 01:11:30.168 prescribers of long acting morphine. NOTE Confidence: 0.7940616 01:11:30.170 --> 01:11:32.372 So they went there to sell NOTE Confidence: 0.7940616 01:11:32.372 --> 01:11:33.840 the same product effectively. NOTE Confidence: 0.7940616 01:11:33.840 --> 01:11:36.270 But Oxycontin and yeah you know NOTE Confidence: 0.7940616 01:11:36.270 --> 01:11:38.619 they brought their gifts and their NOTE Confidence: 0.7940616 01:11:38.619 --> 01:11:41.219 cold pizza and and all that and but NOTE Confidence: 0.7940616 01:11:41.301 --> 01:11:43.779 the doctors like sure will use it NOTE Confidence: 0.7940616 01:11:43.779 --> 01:11:46.685 because this is what we do we just NOTE Confidence: 0.7940616 01:11:46.685 --> 01:11:48.520 prescribed for noncancer chronic pain. NOTE Confidence: 0.7940616 01:11:48.520 --> 01:11:51.327 We've been doing it forever and they NOTE Confidence: 0.7940616 01:11:51.327 --> 01:11:54.776 were pushing on an open door which is books. NOTE Confidence: 0.7940616 01:11:54.780 --> 01:11:56.748 Which is very different. NOTE Confidence: 0.7940616 01:11:56.748 --> 01:12:02.160 Gosh, sorry guys, I'll just keep talking. NOTE Confidence: 0.7940616 01:12:02.160 --> 01:12:03.848 So in other words, NOTE Confidence: 0.7940616 01:12:03.848 --> 01:12:06.380 unlike doctors who were in more NOTE Confidence: 0.7940616 01:12:06.473 --> 01:12:09.311 urban areas or in smaller towns NOTE Confidence: 0.7940616 01:12:09.311 --> 01:12:12.140 like that had University Hospitals, NOTE Confidence: 0.7940616 01:12:12.140 --> 01:12:13.526 or you know, NOTE Confidence: 0.7940616 01:12:13.526 --> 01:12:16.298 or hospitals that depend on federal NOTE Confidence: 0.7940616 01:12:16.298 --> 01:12:19.735 dollars which were most these doctors were, NOTE Confidence: 0.7940616 01:12:19.740 --> 01:12:21.162 you know, really, NOTE Confidence: 0.7940616 01:12:21.162 --> 01:12:22.110 you know, NOTE Confidence: 0.79998904 01:12:22.110 --> 01:12:24.804 insulated. So and it they their NOTE Confidence: 0.79998904 01:12:24.804 --> 01:12:27.912 view of prescribing did not have to NOTE Confidence: 0.79998904 01:12:27.912 --> 01:12:30.360 be changed now and Oxycontin when NOTE Confidence: 0.79998904 01:12:30.360 --> 01:12:33.308 they started prescribing Oxycontin. NOTE Confidence: 0.79998904 01:12:33.310 --> 01:12:35.410 It clearly destabilized the situation NOTE Confidence: 0.79998904 01:12:35.410 --> 01:12:38.020 tremendously because a lot of people, NOTE Confidence: 0.79998904 01:12:38.020 --> 01:12:40.160 I mean, uh, some percentage. NOTE Confidence: 0.79998904 01:12:40.160 --> 01:12:44.440 Again, I wish I could give you a number, but. NOTE Confidence: 0.78335834 01:12:46.960 --> 01:12:48.464 But folks who used, NOTE Confidence: 0.78335834 01:12:48.464 --> 01:12:51.859 you know Tylox and Tylenol and Oxy oxycodone. NOTE Confidence: 0.78335834 01:12:51.860 --> 01:12:54.709 You know where they even chew that. NOTE Confidence: 0.78335834 01:12:54.710 --> 01:12:57.158 And they had their own little NOTE Confidence: 0.78335834 01:12:57.158 --> 01:12:59.606 barter systems for drugs, you know, NOTE Confidence: 0.78335834 01:12:59.606 --> 01:13:02.054 will give you so many Percocet. NOTE Confidence: 0.78335834 01:13:02.060 --> 01:13:07.084 For, you know, get gasoline or whatever that. NOTE Confidence: 0.78335834 01:13:07.090 --> 01:13:08.354 They the Oxy cotton, NOTE Confidence: 0.78335834 01:13:08.354 --> 01:13:11.441 was so potent that when because, as you know, NOTE Confidence: 0.78335834 01:13:11.441 --> 01:13:15.819 you have to pack a lot into a long release. NOTE Confidence: 0.78335834 01:13:15.820 --> 01:13:17.808 Formulation that it's just NOTE Confidence: 0.78335834 01:13:17.808 --> 01:13:19.796 people who were managed, NOTE Confidence: 0.78335834 01:13:19.800 --> 01:13:21.792 basically managing their addiction, NOTE Confidence: 0.78335834 01:13:21.792 --> 01:13:26.764 so to speak, to these other heavy use of NOTE Confidence: 0.78335834 01:13:26.764 --> 01:13:31.019 opioids and other drugs just completely. NOTE Confidence: 0.78335834 01:13:31.020 --> 01:13:33.710 Were transformed into, you know, NOTE Confidence: 0.78335834 01:13:33.710 --> 01:13:36.812 heavy heavy addicts and they've moved NOTE Confidence: 0.78335834 01:13:36.812 --> 01:13:40.149 to an injection and so Oxycontin. NOTE Confidence: 0.78335834 01:13:40.150 --> 01:13:43.372 I'm not trying to downplay its NOTE Confidence: 0.78335834 01:13:43.372 --> 01:13:45.520 affect on those communities, NOTE Confidence: 0.78335834 01:13:45.520 --> 01:13:49.248 but its introduction was. NOTE Confidence: 0.78335834 01:13:49.250 --> 01:13:51.788 It was a very different picture NOTE Confidence: 0.78335834 01:13:51.788 --> 01:13:53.057 and and neither. NOTE Confidence: 0.8554463 01:13:55.310 --> 01:13:57.610 You know federal guidelines or NOTE Confidence: 0.8554463 01:13:57.610 --> 01:13:59.450 prescrip or professional guidelines, NOTE Confidence: 0.8554463 01:13:59.450 --> 01:14:01.730 encouraging more prescribing or the NOTE Confidence: 0.8554463 01:14:01.730 --> 01:14:04.510 introduction of you know this again, NOTE Confidence: 0.8554463 01:14:04.510 --> 01:14:08.126 this idea that we have to treat chronic NOTE Confidence: 0.8554463 01:14:08.126 --> 01:14:11.077 non cancer pain more aggressively that NOTE Confidence: 0.8554463 01:14:11.077 --> 01:14:15.550 that that was not that was not a big force. NOTE Confidence: 0.8554463 01:14:15.550 --> 01:14:18.622 Now in there in terms of the addiction NOTE Confidence: 0.8554463 01:14:18.622 --> 01:14:22.335 it's just that the drug was incredibly NOTE Confidence: 0.8554463 01:14:22.335 --> 01:14:24.890 destabilizing, but it was a. NOTE Confidence: 0.8554463 01:14:24.890 --> 01:14:26.915 A whole, as I say, NOTE Confidence: 0.8554463 01:14:26.915 --> 01:14:28.295 attitude towards these medications, NOTE Confidence: 0.8554463 01:14:28.300 --> 01:14:30.364 which was very different than in NOTE Confidence: 0.8554463 01:14:30.364 --> 01:14:32.738 big cities where a lot of work NOTE Confidence: 0.8554463 01:14:32.738 --> 01:14:34.908 had to be done to change attitudes NOTE Confidence: 0.8554463 01:14:34.978 --> 01:14:36.259 towards using those NOTE Confidence: 0.8094859 01:14:36.260 --> 01:14:38.336 meds so early there there are. NOTE Confidence: 0.8094859 01:14:38.340 --> 01:14:40.070 We're running out of time, NOTE Confidence: 0.8094859 01:14:40.070 --> 01:14:42.394 but there are a couple of two NOTE Confidence: 0.8094859 01:14:42.394 --> 01:14:43.822 people have asked questions NOTE Confidence: 0.8094859 01:14:43.822 --> 01:14:46.300 who would like to to ask them? NOTE Confidence: 0.8094859 01:14:46.300 --> 01:14:48.028 Maybe brief answers for them. NOTE Confidence: 0.8094859 01:14:48.030 --> 01:14:49.760 Showing Anderson has a question. NOTE Confidence: 0.8094859 01:14:49.760 --> 01:14:52.830 Yeah, my name is Sean. NOTE Confidence: 0.8094859 01:14:52.830 --> 01:14:55.056 Appreciate you coming to talk NOTE Confidence: 0.8094859 01:14:55.056 --> 01:14:56.841 about the opioid epidemic. NOTE Confidence: 0.8094859 01:14:56.841 --> 01:15:00.449 I'm from Mississippi and have a lot of NOTE Confidence: 0.8094859 01:15:00.449 --> 01:15:03.070 interface with rural communities and I NOTE Confidence: 0.8094859 01:15:03.070 --> 01:15:07.258 had more of a comment than a question so. NOTE Confidence: 0.8094859 01:15:07.258 --> 01:15:09.900 I wanted to make a comment about NOTE Confidence: 0.8094859 01:15:09.900 --> 01:15:11.930 kind of how we talk about rural NOTE Confidence: 0.8094859 01:15:11.930 --> 01:15:13.670 populations and how we use the NOTE Confidence: 0.8094859 01:15:13.670 --> 01:15:15.410 ways we describe them to make NOTE Confidence: 0.8094859 01:15:15.410 --> 01:15:17.440 our point too often when we come NOTE Confidence: 0.8094859 01:15:17.440 --> 01:15:19.470 out of our ivory towers in poker, NOTE Confidence: 0.8094859 01:15:19.470 --> 01:15:20.920 head out the window. It's NOTE Confidence: 0.84208554 01:15:20.920 --> 01:15:22.370 easy to view these communities NOTE Confidence: 0.84208554 01:15:22.370 --> 01:15:24.690 kind of like a zoo and I think NOTE Confidence: 0.84208554 01:15:24.690 --> 01:15:26.430 some of some of the initial NOTE Confidence: 0.84208554 01:15:26.430 --> 01:15:28.170 part of the PowerPoint kind of NOTE Confidence: 0.84208554 01:15:28.170 --> 01:15:29.910 utilized that perspective, not in it. NOTE Confidence: 0.84208554 01:15:29.910 --> 01:15:32.408 Correct me if I'm wrong. NOTE Confidence: 0.84208554 01:15:32.410 --> 01:15:35.406 But to me, and in some ways, NOTE Confidence: 0.84208554 01:15:35.410 --> 01:15:37.120 it seemed that, um, NOTE Confidence: 0.84208554 01:15:37.120 --> 01:15:40.669 that you might have been using the. NOTE Confidence: 0.84208554 01:15:40.670 --> 01:15:42.536 Kind of dehumanizing or mocking NOTE Confidence: 0.84208554 01:15:42.536 --> 01:15:44.773 the rural population of Ohio to NOTE Confidence: 0.84208554 01:15:44.773 --> 01:15:46.638 emphasize your thesis that patients NOTE Confidence: 0.84208554 01:15:46.640 --> 01:15:48.506 are more responsible for their NOTE Confidence: 0.84208554 01:15:48.506 --> 01:15:50.372 illness than we previously thought, NOTE Confidence: 0.84208554 01:15:50.372 --> 01:15:52.979 and I was just just wanted to NOTE Confidence: 0.85208446 01:15:52.980 --> 01:15:55.218 get your perspective on the view NOTE Confidence: 0.85208446 01:15:55.220 --> 01:15:58.850 that I took away from that. NOTE Confidence: 0.85208446 01:15:58.850 --> 01:16:00.335 Do you think that people NOTE Confidence: 0.85208446 01:16:00.335 --> 01:16:01.820 of course have a role? NOTE Confidence: 0.85208446 01:16:01.820 --> 01:16:03.899 That's what we do in drug treatment. NOTE Confidence: 0.85208446 01:16:03.900 --> 01:16:05.979 We show them what that role was, NOTE Confidence: 0.85208446 01:16:05.980 --> 01:16:08.950 so let me not not in any kind of a, NOTE Confidence: 0.85208446 01:16:08.950 --> 01:16:12.400 you know, a blaming or. NOTE Confidence: 0.85208446 01:16:12.400 --> 01:16:13.106 Discouraging way, NOTE Confidence: 0.85208446 01:16:13.106 --> 01:16:15.930 but that's that's really the key to go. NOTE Confidence: 0.85208446 01:16:15.930 --> 01:16:18.048 After you've stabilized people on it. NOTE Confidence: 0.85208446 01:16:18.050 --> 01:16:19.434 We're talking bout opioids. NOTE Confidence: 0.85208446 01:16:19.434 --> 01:16:20.818 Maybe after you've stabilized NOTE Confidence: 0.85208446 01:16:20.818 --> 01:16:22.638 them on methadone or people, NOTE Confidence: 0.85208446 01:16:22.640 --> 01:16:23.813 morphine or whatever, NOTE Confidence: 0.85208446 01:16:23.813 --> 01:16:26.550 which is often the first move people NOTE Confidence: 0.85208446 01:16:26.620 --> 01:16:29.204 have to stand still if they're going to NOTE Confidence: 0.85208446 01:16:29.204 --> 01:16:31.575 start to get better and treatment then NOTE Confidence: 0.85208446 01:16:31.575 --> 01:16:34.642 then so much of the work is showing them. NOTE Confidence: 0.85208446 01:16:34.642 --> 01:16:37.110 You know, that's not blaming the victim, NOTE Confidence: 0.85208446 01:16:37.110 --> 01:16:39.228 it's showing them how they have. NOTE Confidence: 0.85208446 01:16:39.230 --> 01:16:40.325 You know this, NOTE Confidence: 0.85208446 01:16:40.325 --> 01:16:42.880 that's what relapse prevention is all about. NOTE Confidence: 0.85208446 01:16:42.880 --> 01:16:46.549 Is is understanding? NOTE Confidence: 0.85208446 01:16:46.550 --> 01:16:47.898 The vulnerabilities which can NOTE Confidence: 0.85208446 01:16:47.898 --> 01:16:49.924 take the form of, you know, NOTE Confidence: 0.85208446 01:16:49.924 --> 01:16:51.609 choose the most you know, NOTE Confidence: 0.85208446 01:16:51.610 --> 01:16:53.290 conditioned cues kind of way. NOTE Confidence: 0.85208446 01:16:53.290 --> 01:16:54.241 What else is, NOTE Confidence: 0.85208446 01:16:54.241 --> 01:16:56.143 you know how they can fill NOTE Confidence: 0.85208446 01:16:56.143 --> 01:16:58.007 what they perceived to be. NOTE Confidence: 0.85208446 01:16:58.010 --> 01:17:00.698 Some of the deaf deficits in their life. NOTE Confidence: 0.85208446 01:17:00.700 --> 01:17:01.364 That is, NOTE Confidence: 0.85208446 01:17:01.364 --> 01:17:03.356 with them to feel so distraught NOTE Confidence: 0.85208446 01:17:03.356 --> 01:17:05.756 that they they often turn to drugs. NOTE Confidence: 0.85208446 01:17:05.760 --> 01:17:07.748 So you know if we treat it NOTE Confidence: 0.85208446 01:17:07.748 --> 01:17:09.800 like it's a formal disease, NOTE Confidence: 0.85208446 01:17:09.800 --> 01:17:12.496 where you know if you had an ammonia, NOTE Confidence: 0.85208446 01:17:12.500 --> 01:17:13.844 I could treat it. NOTE Confidence: 0.85208446 01:17:13.844 --> 01:17:16.378 If you're in a coma, it's it's. NOTE Confidence: 0.85208446 01:17:16.378 --> 01:17:17.650 Not like that. NOTE Confidence: 0.85208446 01:17:17.650 --> 01:17:19.006 It's much more interactive, NOTE Confidence: 0.85208446 01:17:19.006 --> 01:17:21.694 so so I think that talking about the NOTE Confidence: 0.85208446 01:17:21.694 --> 01:17:23.759 extent to which people play a role NOTE Confidence: 0.85208446 01:17:23.759 --> 01:17:26.190 in their circumstances is essential. NOTE Confidence: 0.763014 01:17:27.460 --> 01:17:29.090 Time for one last quick NOTE Confidence: 0.763014 01:17:29.090 --> 01:17:30.394 question from Joe Ficos. NOTE Confidence: 0.7300118 01:17:32.680 --> 01:17:35.676 I'm really relieved how Joe could you NOTE Confidence: 0.7300118 01:17:35.680 --> 01:17:39.096 speak up or get closer to your microphone. NOTE Confidence: 0.7947140625 01:17:40.400 --> 01:17:43.024 It's loud enough. I just barely. NOTE Confidence: 0.7947140625 01:17:43.024 --> 01:17:46.496 I think I just had IT working on this today. NOTE Confidence: 0.7947140625 01:17:46.500 --> 01:17:49.730 I think things went badly. NOTE Confidence: 0.7947140625 01:17:49.730 --> 01:17:51.218 Doctor Patel, can you hear me? NOTE Confidence: 0.7947140625 01:17:51.220 --> 01:17:53.508 I can hear you. NOTE Confidence: 0.7947140625 01:17:53.510 --> 01:17:55.792 I was I was actually relieved by NOTE Confidence: 0.7947140625 01:17:55.792 --> 01:17:57.686 the substance of your presentation NOTE Confidence: 0.7947140625 01:17:57.686 --> 01:17:59.786 after reading the title because NOTE Confidence: 0.7947140625 01:17:59.786 --> 01:18:02.250 I thought the view from abroad, NOTE Confidence: 0.7947140625 01:18:02.250 --> 01:18:03.642 the reference to abroad, NOTE Confidence: 0.7947140625 01:18:03.642 --> 01:18:06.430 that kind of echoing like Sean Patterson, NOTE Confidence: 0.7947140625 01:18:06.430 --> 01:18:08.782 was saying, I think speaks to some NOTE Confidence: 0.7947140625 01:18:08.782 --> 01:18:11.370 sort of at least implicit bias, NOTE Confidence: 0.7947140625 01:18:11.370 --> 01:18:13.270 East Coast or what not. NOTE Confidence: 0.7947140625 01:18:13.270 --> 01:18:14.245 And you didn't. NOTE Confidence: 0.7947140625 01:18:14.245 --> 01:18:17.030 I think you sounded very warm and sympathetic NOTE Confidence: 0.7947140625 01:18:17.030 --> 01:18:20.110 toward the folks from Ironton and region, NOTE Confidence: 0.7947140625 01:18:20.110 --> 01:18:23.620 but I wonder how they would feel if they. NOTE Confidence: 0.7947140625 01:18:23.620 --> 01:18:25.408 New York entitling the presentation that, NOTE Confidence: 0.7947140625 01:18:25.410 --> 01:18:27.210 oh, they showed us to them. NOTE Confidence: 0.7947140625 01:18:27.210 --> 01:18:29.838 They're fine with it. NOTE Confidence: 0.7947140625 01:18:29.840 --> 01:18:31.370 As an air of condescension, NOTE Confidence: 0.7947140625 01:18:31.370 --> 01:18:33.505 to refer to, small town did well. NOTE Confidence: 0.7947140625 01:18:33.510 --> 01:18:35.358 I think. I think only people NOTE Confidence: 0.7947140625 01:18:35.358 --> 01:18:37.489 in big towns see it that way. NOTE Confidence: 0.7947140625 01:18:37.490 --> 01:18:38.456 People in liberal, NOTE Confidence: 0.7947140625 01:18:38.456 --> 01:18:39.744 your major liberal universities NOTE Confidence: 0.7947140625 01:18:39.744 --> 01:18:41.770 and to see it that way anyway. NOTE Confidence: 0.7947140625 01:18:41.770 --> 01:18:43.919 But there's a lot of different variation. NOTE Confidence: 0.7947140625 01:18:43.920 --> 01:18:45.756 But to answer your question, no. NOTE Confidence: 0.7947140625 01:18:45.756 --> 01:18:46.980 In fact I wrote. NOTE Confidence: 0.7947140625 01:18:46.980 --> 01:18:49.115 I wrote a big article about them. NOTE Confidence: 0.7947140625 01:18:49.120 --> 01:18:51.311 I mean, I can make it available NOTE Confidence: 0.7947140625 01:18:51.311 --> 01:18:53.398 to folks who want to see it, NOTE Confidence: 0.7947140625 01:18:53.400 --> 01:18:55.535 and I had them read it first, NOTE Confidence: 0.7947140625 01:18:55.540 --> 01:18:57.228 and you know, they. NOTE Confidence: 0.7947140625 01:18:57.228 --> 01:19:00.750 I mean certainly and I said you could. NOTE Confidence: 0.7947140625 01:19:00.750 --> 01:19:03.621 I can take your name out or you know NOTE Confidence: 0.7947140625 01:19:03.621 --> 01:19:06.815 if if there's anything that you find, NOTE Confidence: 0.7947140625 01:19:06.820 --> 01:19:09.226 but it's interesting what this is NOTE Confidence: 0.7947140625 01:19:09.226 --> 01:19:11.954 echoing a little bit in some ways NOTE Confidence: 0.7947140625 01:19:11.954 --> 01:19:14.397 is the reaction to JD Vances book, NOTE Confidence: 0.7947140625 01:19:14.400 --> 01:19:16.290 which it was quite unpopular NOTE Confidence: 0.7947140625 01:19:16.290 --> 01:19:17.424 down there actually. NOTE Confidence: 0.7947140625 01:19:17.430 --> 01:19:19.320 And because you know they NOTE Confidence: 0.7947140625 01:19:19.320 --> 01:19:20.454 felt hillbilly Elegy. NOTE Confidence: 0.7947140625 01:19:20.460 --> 01:19:21.124 Of course, NOTE Confidence: 0.7947140625 01:19:21.124 --> 01:19:23.116 I'm talking about because they felt NOTE Confidence: 0.7947140625 01:19:23.116 --> 01:19:25.388 that he was somehow stereotyping, NOTE Confidence: 0.7947140625 01:19:25.390 --> 01:19:28.090 you know, the the the. NOTE Confidence: 0.7947140625 01:19:28.090 --> 01:19:29.966 Communities, but I mean, NOTE Confidence: 0.7947140625 01:19:29.966 --> 01:19:33.436 my view is that his that was NOTE Confidence: 0.7947140625 01:19:33.436 --> 01:19:35.089 his experience and. NOTE Confidence: 0.7947140625 01:19:35.090 --> 01:19:36.446 And I've, you know, NOTE Confidence: 0.7947140625 01:19:36.446 --> 01:19:38.924 heard him speak about that in in NOTE Confidence: 0.7947140625 01:19:38.924 --> 01:19:41.528 response to people accusing him of that. NOTE Confidence: 0.7947140625 01:19:41.530 --> 01:19:42.160 In fact, NOTE Confidence: 0.7947140625 01:19:42.160 --> 01:19:44.680 there's a there was a whole book of NOTE Confidence: 0.7947140625 01:19:44.753 --> 01:19:47.255 an anthology that was published to, NOTE Confidence: 0.7947140625 01:19:47.260 --> 01:19:48.688 essentially port portray a NOTE Confidence: 0.7947140625 01:19:48.688 --> 01:19:50.473 different aspect of Apple Acha, NOTE Confidence: 0.7947140625 01:19:50.480 --> 01:19:52.622 but one that was much more NOTE Confidence: 0.7947140625 01:19:52.622 --> 01:19:54.420 vibrant and people who are, NOTE Confidence: 0.7947140625 01:19:54.420 --> 01:19:55.254 you know, NOTE Confidence: 0.7947140625 01:19:55.254 --> 01:19:57.339 hardworking and very devoted to NOTE Confidence: 0.7947140625 01:19:57.339 --> 01:19:59.245 the communities and all this NOTE Confidence: 0.7947140625 01:19:59.245 --> 01:20:00.710 and and he was happy. NOTE Confidence: 0.7947140625 01:20:00.710 --> 01:20:02.480 To it, knowledge is thrilled that, NOTE Confidence: 0.7947140625 01:20:02.480 --> 01:20:02.775 yeah, NOTE Confidence: 0.7947140625 01:20:02.775 --> 01:20:04.250 that's just that's another facet NOTE Confidence: 0.7947140625 01:20:04.250 --> 01:20:05.430 of life down there, NOTE Confidence: 0.7947140625 01:20:05.430 --> 01:20:07.790 but his experience was what he wrote about. NOTE Confidence: 0.8660906 01:20:09.800 --> 01:20:11.168 It's interesting their number NOTE Confidence: 0.8660906 01:20:11.168 --> 01:20:13.220 of comments about this kind of NOTE Confidence: 0.8660906 01:20:13.286 --> 01:20:14.994 general theme in in the in the NOTE Confidence: 0.8660906 01:20:15.000 --> 01:20:17.754 comments, and I wish I could get to them. NOTE Confidence: 0.8660906 01:20:17.760 --> 01:20:19.590 I touch something here and I've NOTE Confidence: 0.8660906 01:20:19.590 --> 01:20:21.428 just been abandoned. I've been I've NOTE Confidence: 0.8660906 01:20:21.428 --> 01:20:22.958 been excommunicated from the thing. NOTE Confidence: 0.8377605 01:20:25.570 --> 01:20:28.180 We don't have time for those right right? NOTE Confidence: 0.8377605 01:20:28.180 --> 01:20:30.784 I'm afraid we're out of time, but yeah, NOTE Confidence: 0.8377605 01:20:30.784 --> 01:20:34.910 well, anyone can contact me. Yeah. NOTE Confidence: 0.75034976 01:20:36.110 --> 01:20:38.880 Alright, well Sally, thank you.