Yale Psychiatry Grand Rounds: January 8, 2021

Transcript

• 00:00Um, I'm going to be introducing our grand
• 00:03round speaker in just a minute, but I
• 00:06wanted to make some general comments given.
• 00:08The incredible array of of experiences
• 00:11that we've had in the Department
• 00:14of the past three or four weeks.
• 00:17Obviously we're all shaken by the
• 00:20rioting and in Washington and and the.
• 00:24The message is that the.
• 00:28Rioters sent carrying Confederate flags
• 00:33into the Capitol building and many other.
• 00:40Other kinds of racist imagery to
• 00:43see that in the Capitol building,
• 00:46the place where we all.
• 00:50Believe that our best hopes lie in terms of.
• 00:54Of legislation that can address racism
• 00:57in our society and in disparities.
• 01:01An and. Rights, people's rights,
• 01:04and to see all that happen.
• 01:08All that those images in the
• 01:11Capitol building was just just.
• 01:14Extraordinarily upsetting and.
• 01:18A number of folks,
• 01:19probably on grand rounds today,
• 01:21attending grand rounds today
• 01:23participated in our town Hall
• 01:25meeting yesterday afternoon.
• 01:27And their reactions were really
• 01:31very touching and thought provoking.
• 01:35From from the devastation and fear and anger,
• 01:38an outrage that people were
• 01:41experiencing but also.
• 01:43Some people who felt that these events
• 01:46were yet just another expression of of.
• 01:50Of the paradox in our country of.
• 01:55Of efforts to preserve
• 01:57white dominance and two.
• 02:02In the very structures and institutions
• 02:05that were promoting democracy so.
• 02:07It's clear that there are other at a lot
• 02:10is roiling in our in our community now,
• 02:13and I hope that we will find ways
• 02:15to talk about this in each of
• 02:18the settings in which we work.
• 02:20Because it was clear in that
• 02:22discussion that various groups of
• 02:23staff and trainees and others were
• 02:25feeling very isolated in their
• 02:27distress that they were experiencing
• 02:28in relation to the recent events.
• 02:33The other the other.
• 02:38Experiences that we've had
• 02:40over the last several years.
• 02:42Several weeks excuse me
• 02:43over the last three weeks,
• 02:45we've lost three members of our faculty.
• 02:48Um Nancy Suchman died first.
• 02:51Nancy was an associate professor
• 02:54in our Department are a
• 02:56remarkable person who developed.
• 03:00Psychotherapeutic approaches
• 03:02for addicted mothers.
• 03:05Really remarkably challenging.
• 03:07A space to work clinically,
• 03:10and yet she developed and then validated.
• 03:14With Tom McMahon and others,
• 03:17the Linda Mays,
• 03:19this novel psychotherapy an it
• 03:22was getting traction when she
• 03:26developed a the illness that
• 03:29ultimately took her life and.
• 03:32She died 2 weeks ago at the young age of 63.
• 03:39And then last week.
• 03:41We lost Kathy Carroll.
• 03:44And Kathy.
• 03:47Is one of those unique once
• 03:50in a generation scientists who
• 03:52contributes to transforming a field.
• 03:55In this case the psychotherapy of
• 03:58addiction disorders. Kathy was the
• 04:00Alberty Kent professor of psychiatry.
• 04:03She emerged as a national
• 04:05leader in the context of the.
• 04:08Largest and most elaborate psychotherapy
• 04:11study done in the field of alcohol research,
• 04:14which was called project match.
• 04:17And she continued to be innovator
• 04:20throughout her entire career.
• 04:22Um, she came to Yale in the late 80s.
• 04:29She every grant that she wrote was
• 04:32funded on the 1st submission. And.
• 04:37And. Died after a very brief and
• 04:43unexpected illness at the age of 62.
• 04:46And a terrible, terrible loss for us.
• 04:49Terrible loss for the field.
• 04:53Amen. On Monday. Ron Casey died.
• 04:59Ron is a member of the volunteer faculty.
• 05:04He has been supervising trainees
• 05:06for 40 years in our Department.
• 05:10Was a very respected clinician and had been.
• 05:18Played a very special role
• 05:20in Connecticut as the.
• 05:22As you might say,
• 05:24the consulting psychologist for the
• 05:26Episcopal Church in Connecticut an for the
• 05:30United Church of Christ in Connecticut.
• 05:33So you know 3.
• 05:35Three important losses for our Department
• 05:38in just a very short period of time.
• 05:42That makes us think about.
• 05:45About the fragility of life and the
• 05:48importance of our of our friends,
• 05:50connections to friends and
• 05:52family and colleagues.
• 05:54This is particularly hard after a
• 05:56long year where we lost randumb
• 05:59and at the beginning of February
• 06:01and then Bob Nelson in June.
• 06:03And extraordinary year.
• 06:06Of Of of Loss and.
• 06:14And we hope that 2021 will be much more.
• 06:20Hopeful. A year for us.
• 06:25So let me change the subject.
• 06:28Speaking of longstanding
• 06:29friends and and collaborators,
• 06:31it's it's really my extraordinary
• 06:33pleasure today to introduce our Grand
• 06:36Round Speaker Sally set up for those of
• 06:39you who were a little bit early to the
• 06:42call you heard Sally and I reminiscing
• 06:45about how we first met before, when I,
• 06:48when we were both medical students
• 06:51before we before we came to the
• 06:54psychiatry residency here at Yale.
• 06:56And they were classmates in internship
• 06:59and residency here in psychiatry and
• 07:02joined the faculty at the same time
• 07:05around the same time and and had
• 07:08careers at the VA before Sally went off.
• 07:11To become a very distinctive
• 07:14voice and in American Society,
• 07:17in American psychiatry.
• 07:18Um, Sally was a resident scholar at the
• 07:22American Enterprise Institute and for a
• 07:25long time was a staff psychiatrist at
• 07:29a methadone clinic in Washington DC.
• 07:32As I mentioned,
• 07:33she had been in assistant professor
• 07:35in psychiatry at Yale and remains
• 07:38a lecture in our Department.
• 07:40She was a Robert Wood Johnson
• 07:41policy fellow with the Senate,
• 07:43Labor and Human Resources Committee.
• 07:46As she developed her,
• 07:49careeer continued to focus on public
• 07:53issues and has been very visible
• 07:56commentator on mental health and
• 07:59addiction issues in venues like the
• 08:03New York Times, Wall Street Journal,
• 08:07and another other. Public media.
• 08:12She's written six books.
• 08:16The first drug treatment,
• 08:18the caseworker version, came out in 1999.
• 08:21As she wrote a book about about
• 08:24political correctness,
• 08:26how political correctness
• 08:27is corrupting medicine.
• 08:29One nation under therapy in 2005,
• 08:32the health Disparity Myth 2006,
• 08:34when altruism isn't enough.
• 08:37The case for compensating
• 08:39kidney donors in 2009.
• 08:41And her recent book coauthored
• 08:43with Emory Psychologists got
• 08:45Lowenfeld is called Brainwashed.
• 08:47The seductive appeal of
• 08:49mindless neuroscience.
• 08:51This book was a finalist for the 2013
• 08:54Los Angeles Times book Price and Science.
• 08:57As you can tell from the titles of her book,
• 09:03Sally does not shy away from the
• 09:06most challenging, complicated,
• 09:08and and contentious issues in our field.
• 09:12Um, she has, as I said,
• 09:15been an independent voice.
• 09:19Anne Anne.
• 09:22Provoked thought and discussion in
• 09:24very constructive ways in our field,
• 09:27and we're thrilled Sally to
• 09:29have you back home. Virtually.
• 09:34Two yeah today for for four
• 09:36grand rounds thanks.
• 09:37Thanks for coming.
• 09:39Oh thank you
• 09:40so much and you know I always start
• 09:43writing talks like weeks before and
• 09:46'cause I'm still a pre Med at heart
• 09:49and I remember thinking I you know,
• 09:52I hope Kathy likes this.
• 09:54You know, I've known Kathy Carroll
• 09:57for over 30 years so she was.
• 10:00Such an important.
• 10:02Really important person to me in
• 10:05a wonderful friend and anyway so
• 10:08on to on to Ironton OH so I called
• 10:12this talk my year abroad because
• 10:15to someone like me who's never.
• 10:19I mean, I've never lived in a small
• 10:21town unless they were associated with.
• 10:23I went to Cornell,
• 10:25but with a major University.
• 10:26Otherwise, I've lived in big cities,
• 10:29so small town,
• 10:30consigned to seem like a foreign country,
• 10:32although in other ways it can turn out
• 10:35to be just place with universal ways of life,
• 10:38play out an ice all out of that as well.
• 10:41Well, since 2015 I thought I wanted to go
• 10:45to Apple Acha and see how I could be helpful.
• 10:49My recollection, even though that the opioid.
• 10:53You know crisis had been
• 10:55going on for over a decade.
• 10:58In 2050, yes.
• 10:59Well over a decade.
• 11:00At that time,
• 11:01I think it really burst into
• 11:04public consciousness.
• 11:05For people who lived in areas
• 11:08that weren't that affected in
• 11:10around 2015 during the primary,
• 11:12the presidential primary,
• 11:13I remember when Hillary Clinton went
• 11:15to a town Hall meeting in Manchester,
• 11:18NH, which was very afflicted town,
• 11:20and, you know,
• 11:21was just stunned that people really
• 11:24didn't want to talk about jobs
• 11:26that much or immigration or other
• 11:28things they were focusing on.
• 11:30Opioids an other, I think.
• 11:32Other candidates had that experience
• 11:35as well that she was the only
• 11:38one who came up with a plan.
• 11:40But in any case, and that's when I decided,
• 11:43well,
• 11:44you know you keep reading
• 11:46about places that don't have.
• 11:48Psychiatrists don't have
• 11:49addiction specialists,
• 11:49don't have people with waivers,
• 11:51and I had all of that, so it took awhile.
• 11:55But I but I finally was able to,
• 11:58you know, find a place that.
• 12:01You could use a psychiatrist.
• 12:03I contacted a friend who had a lot
• 12:06of Ohio connections and he sent me up.
• 12:10Contacted in fact people who who
• 12:13ran so called Community Action
• 12:15organizations and I think there are
• 12:18almost about 50 of those in Ohio.
• 12:20Basically,
• 12:21Community Action organizations
• 12:22were started in the 19 in 1964 like
• 12:26President Johnson is part of the War
• 12:29on Poverty and these were all anti poverty.
• 12:32Agencies they were about 1000 nationwide.
• 12:35Many of them failed,
• 12:37but many of them were going and that was
• 12:40the one and so I went to one in Ironton,
• 12:44OH which was still going and
• 12:46a very successfully they.
• 12:48They ran the Head Start program there,
• 12:51they job placement and weatherization.
• 12:53You know for people who were unable
• 12:56to insulate their homes in the in the
• 12:59winter that kind of thing so that.
• 13:02That's where I went and let
• 13:05me just show you
• 13:07where it is odear. All of a sudden my
• 13:11thing is not working. We were just.
• 13:18OK, we're here. It's OK, you can.
• 13:22You can escape, but if you want
• 13:23and trying it back into it, well,
• 13:25you want to advance it for me.
• 13:27I can do that OK. Pull them up.
• 13:30This audit was just working before. If
• 13:33you hit this, if you hit the hit the key,
• 13:36the slide is let me Orient you a little
• 13:40bit of obviously the Upper North Midwest.
• 13:44Northeast, but the the Red dot
• 13:48is Lawrence County in Ohio in.
• 13:52Southern, southeastern Ohio You'll
• 13:56see that they in Pitts Burg,
• 13:59but Pittsburgh actually should be off more
• 14:02off to the left as part of Philadelphia,
• 14:06Philadelphia, Ohio is right there.
• 14:08I can, under Detroit, under the Erie,
• 14:11Lake Erie and Lawrence County.
• 14:14In which direction resides
• 14:15in the southeast corner, OK?
• 14:19So I just wanted people to
• 14:21get a general sense of.
• 14:22At the air is about 8 hour drive,
• 14:259 hour drive from Washington DC.
• 14:27And then I'm going to drill
• 14:29down a little bit, OK.
• 14:32Now you can see Ohio,
• 14:34Kentucky, and West Virginia.
• 14:35I never heard of Ironton.
• 14:37You can't even see it on this map,
• 14:40but again,
• 14:41it's it's at the tip of Lawrence
• 14:44County and it's right where these
• 14:46three states converge where the
• 14:49Ohio River join in a way kind of
• 14:51guy sex or tries to axe them and.
• 14:56One side is Ohio or again
• 14:59Ironton in particular.
• 15:00The other part of the tristate area
• 15:03in terms of cities is Ashland,
• 15:06Ky, which is in Boyd County and
• 15:09then there is Huntington, WV.
• 15:12OK, can you see that there's a
• 15:15little airplane there 'cause?
• 15:17There is an airport and Huntington WV,
• 15:20though I never heard of Ironton.
• 15:23I certainly heard of Huntington WV because.
• 15:26That was a place that,
• 15:28with Drew national attention in 2016
• 15:31when 26 people overdosed within 4 hours,
• 15:34like two of them Fatal E.
• 15:36Anyway,
• 15:36I was there from 2018 to 2019,
• 15:39and so for a year I prescribed
• 15:42even Orfina nycholat,
• 15:43a group therapy,
• 15:44and I spoke to a lot of people
• 15:47about the town trying to understand
• 15:50the history in the local dynamics.
• 15:53And of course, how the drug situation fit in.
• 15:56I also.
• 15:59Being somewhat from New York.
• 16:01Looked in vain for a good everything
• 16:05bagel couldn't be found.
• 16:06I learned the basics of quilting.
• 16:09Now this slide is accidentaly on purpose.
• 16:14Refer a speaker you know wrong
• 16:16direction because frankly,
• 16:18it's so unlike me.
• 16:19So I thought that was kind of an
• 16:22interesting metaphor for that.
• 16:24And the other thing I did was I
• 16:27went to church affair amount.
• 16:30Now that's not a church in Ironton.
• 16:32That's lavish for Ironton but Ashland,
• 16:35as I mentioned, was nearby and Kentucky.
• 16:38And this is somewhat bigger city, Ohio.
• 16:41Ironton is a 10,000 to about 10,600 people.
• 16:44Ashland has about 20,000 people and.
• 16:48And the reason why I went to church
• 16:50being a Jewish atheist with not
• 16:52the place you'd expect to find
• 16:55me is because everyone I met was
• 16:57this very very religious and two
• 16:59of my best friends taught Sunday
• 17:01school and they were devoted to
• 17:02the church and and really devoted
• 17:04to the poor and devoted.
• 17:06They were wonderful,
• 17:07wonderful people,
• 17:08so I spent a lot of time with them and I'll,
• 17:11and when they'd introduce me to preach,
• 17:13you know, the.
• 17:16Pastor and whatever they always say this
• 17:18is Sally from Washington and they'd say,
• 17:20well, what church do you go to?
• 17:23And I said how the Jewish atheist
• 17:25and they go, oh that's great.
• 17:27They were just very enthusiastic about
• 17:29having anyone show any you know,
• 17:30interest in in what they did
• 17:32and what their life was like.
• 17:34So the other thing I did was I
• 17:36walked a lot because in these small
• 17:39places all you do is drive an you
• 17:41could get a lot of weight so I want
• 17:44like crazy and I would see these.
• 17:46Interesting signs like this one.
• 17:51And I also saw some Confederate flags,
• 17:54which is something you don't see unless
• 17:56you were on the Capitol two days ago anyway,
• 18:00so. That's what I did.
• 18:03OK enough about me.
• 18:04So let me tell you a little bit
• 18:07more about the place because it's a
• 18:10stand in for a lot of rural America.
• 18:13And how the opioid crisis.
• 18:15And now I know it's morphing nationally
• 18:18and especially in Ironton you know into
• 18:21a methamphetamine crisis as as well.
• 18:24I'm also going to draw some lessons,
• 18:27some inspired by my experience,
• 18:29I'm inspired by the data as it's
• 18:32been accumulating over the years
• 18:35specifically about the nature
• 18:37of prescription drug abuse.
• 18:39I'm going to touch on my perspectives
• 18:42on addiction and drug epidemics,
• 18:44and I'm going to end with a
• 18:47reminder that our work in clinical
• 18:50medicine and public health.
• 18:52Is extremely important,
• 18:54but it's also just two dynamics
• 18:58in a huge ecosystem that an
• 19:02ecosystem of forces that has shaped.
• 19:06Vulnerability to drug use and that
• 19:10is relevant to informing remedies
• 19:13so that we all need to.
• 19:16You know humility about that
• 19:18because it's it's bigger than
• 19:20it's bigger than our professions.
• 19:22I think.
• 19:23So I mentioned I worked for the
• 19:27Community Action Organization and
• 19:28this was one of the nicer and more
• 19:32beautiful places in Iron 10 as a 22 room.
• 19:36Building a house that was built
• 19:39in 1850 by this gentleman,
• 19:41whose name is John Campbell Ann.
• 19:44He owned many furnaces.
• 19:46The name Ironton is named for iron
• 19:50and this town was really North of
• 19:53what you think of as deep Apple.
• 19:56ACHA and its main product was iron ore.
• 20:00An Ironton produced some of
• 20:02the best was called Pig Iron,
• 20:03which is just an unrefined.
• 20:05It needs to be smelted.
• 20:08Iron and in in the world at that time,
• 20:12so they say, but definitely in the country.
• 20:15At that time he owned many furnaces.
• 20:18Furnaces, did the smelting,
• 20:20they were all over southern Ohio at the time.
• 20:24He was also an important town leader,
• 20:27and he was also a staunch abolitionist.
• 20:30And what makes that building so
• 20:32wonderfully historic was that his home
• 20:35was a station on the Underground Railroad.
• 20:39And as you saw from the slide,
• 20:42given the proximity of Southern
• 20:44Ohio to Kentucky and Virginia,
• 20:46which were slave states at the time,
• 20:49Virginia hadn't become West Virginia.
• 20:51Then that didn't happen till 1863.
• 20:54That slaves would cross the
• 20:56River and be brought to.
• 20:58He was not the only one,
• 21:00but he was an important station.
• 21:03And then he brought to his house,
• 21:06kept in the.
• 21:09Maybe in the basement for several
• 21:12hours or overnight and then be taken
• 21:16the next day by cold actually was.
• 21:19A band that he would use to
• 21:21move his iron further North.
• 21:23And you know some some
• 21:24slaves just stay in Ohio,
• 21:26but the idea was to get North.
• 21:29To Canada,
• 21:29and if you can remember the first slide,
• 21:32the Lake Erie is the northern
• 21:34border and if you cross that
• 21:36you're you're into Canada.
• 21:38So it was a popular,
• 21:40very prosperous place back then.
• 21:42Every grandparent I talked to in town
• 21:44remembers first person accounts of that
• 21:46went back to the Civil War when Ironton,
• 21:49as I said, was just an enormous producer,
• 21:52and this this is obviously
• 21:54a stylized picture.
• 21:55But if you look on the.
• 21:58On the left I mean the whole idea was that
• 22:01they were just furnaces belching out smoke,
• 22:03you know 24/7,
• 22:05and it was an enormously productive place.
• 22:08After World War Two,
• 22:10it became a thriving
• 22:11producer of iron casting,
• 22:13which was used mainly in cars at the time,
• 22:17and you can see the in the 50s
• 22:20car off on the on the right,
• 22:22but other plants would make
• 22:24aluminum enough chemicals,
• 22:25fertilizer it.
• 22:26But the economy was really never
• 22:29white hot again after World War One,
• 22:31although in every every war actually
• 22:33was was a real boon to a town like
• 22:37this because they always needed.
• 22:39Ordnance and,
• 22:40and that's what an iron was very important,
• 22:43and obviously making steel.
• 22:44And also as I said,
• 22:46iron itself could be used.
• 22:48So the 40s,
• 22:49fifties and 60s there were
• 22:50were really were great years.
• 22:52People who graduated from high
• 22:54school could always get a good
• 22:56paying job in the factory.
• 22:58These were obviously labor intensive jobs,
• 23:00but they were very financially
• 23:02secure and most mom stayed home
• 23:04with the kids and and middle class
• 23:06life was really vibrant and mean.
• 23:09Here's just one example of.
• 23:11Mrs Statehouse, but they were the downtown.
• 23:14Looked very nice.
• 23:17Then the economy began to
• 23:19realign in the six late 60s and
• 23:22two major factories closed,
• 23:24and that initiated a wave.
• 23:27Of layoffs and plant Closings,
• 23:29and then in the 70s there oil.
• 23:31Have you know,
• 23:32a lot of folks were around them,
• 23:35but it was a time of oil shocks emanating
• 23:38from turmoil in the Middle East.
• 23:41Inflation was really high.
• 23:42Japanese and German carmakers started to be
• 23:45very competitive with the US manufacturers.
• 23:47So from a business standpoint,
• 23:49things were being threatened.
• 23:50The community,
• 23:51however,
• 23:51was still pretty good,
• 23:53and families were largely intact.
• 23:55But then that process you know kept.
• 23:57Kept.
• 24:00The spiral downwards pull of
• 24:02living wage jobs contracted and
• 24:04skilled workers moved out of town,
• 24:06and today there was a real
• 24:09hollowing out of the middle
• 24:11class because of that.
• 24:12By 1980 the place was
• 24:15bankrupt and here are just
• 24:17some. Slides that evoke was kind of decay.
• 24:20These are probably won't call hoppers,
• 24:23and they were filled with fertile.
• 24:25Is that fertilizer that we delivered
• 24:28to barges that were on the Ohio River
• 24:31was the good old days, then there was.
• 24:36And there's this off on the
• 24:38right of the slide. Actually,
• 24:39that's not the front of the building,
• 24:42that's the back of it.
• 24:43But that was just a beautiful.
• 24:45It's called the Grand Army of
• 24:47the Republic Memorial Hall,
• 24:49and it was built in 1892 as a meeting Hall
• 24:52for veterans who fought for the Union.
• 24:54And then it became a City Hall.
• 24:57And then it was a jail.
• 24:59And then it went through
• 25:00various iterations of things.
• 25:02Boy Scout troops would meet there,
• 25:04but in 2014 it was knocked down and.
• 25:06It still looks like this fact.
• 25:08You can see some of them if
• 25:10you look some of those things
• 25:12that are standing up in the.
• 25:15Yard are actually jail of the bars of
• 25:18the jail and then there was this place
• 25:21which makes the Bates Motel look inviting.
• 25:24And then there was the big.
• 25:28Movie theater in town,
• 25:30which was as you you get the
• 25:34idea it it was a thriving,
• 25:36exciting,
• 25:37entertaining place and that
• 25:39went that deteriorated as well.
• 25:41So the social fabric really
• 25:43began to unravel as well,
• 25:46with men not working and families broke
• 25:49down and welfare and disability rules
• 25:53grew and substance abuse escalated.
• 25:56Taking it to the 90s now about any kid
• 25:58who had a shot at the future would just.
• 26:01Pursue it elsewhere so you had a
• 26:05town increasingly dominated by you.
• 26:07Know people who were.
• 26:09You know fairly well offer managing
• 26:12and a town with people who were,
• 26:15you know, and really desperate.
• 26:18Situations the poverty rate there is
• 26:2220 is almost 21% the poverty rate in
• 26:26Ohio is 14% and 13.4% in the nation.
• 26:32The last
• 26:36Department of Ohio Department of
• 26:39Education report card gave the
• 26:41schools there a between AD&C.
• 26:44Android is now is completely normalized,
• 26:46going on his third and
• 26:48sometimes 4th generation.
• 26:49Almost everyone is like 1 degree of
• 26:52separation from someone who has been
• 26:54afflicted at the precise rates of addiction.
• 26:57There were hard to come by.
• 26:59There were certain kinds of number
• 27:01keeping that didn't seem to be done,
• 27:04or I couldn't get access to,
• 27:06but every time I'd ask people.
• 27:08Well, just let your estimate of
• 27:11what's the rate of drug involvement
• 27:13and kept it pretty vague.
• 27:16They would say about one
• 27:18in four to one and three.
• 27:20So my task was to help a brilliant
• 27:23social worker run a group.
• 27:25I haven't run group since my residency days.
• 27:29This was John Herlihy was a social worker.
• 27:33Ran it and I mean he's a dead
• 27:35ringer for Santa Claus and he had
• 27:38you know this twinkly eyed persona.
• 27:40He was just wonderful and you
• 27:43know in some ways I could have
• 27:45been still in DC or New Haven.
• 27:47I mean there are a lot of
• 27:50universals about people who.
• 27:52Find themselves in with drug
• 27:54problems and a lot of the stories.
• 27:57The special part of the story is that.
• 28:00Was the same where why people came
• 28:02in and it's usually the same.
• 28:04You know my wife is gonna leave me.
• 28:07My boss is gonna fire me.
• 28:09My probation officers gonna violate
• 28:11me my my kids hate me anyway.
• 28:13The point is that people are
• 28:17usually pressured to come in.
• 28:19Now the pills were different.
• 28:20That was there was a lot of use of pills
• 28:23and I didn't see that and methadone clinic.
• 28:25I worked in Washington DC and some
• 28:27of the people in Ironton by the time
• 28:30I got there had moved on to heroin.
• 28:32But every now and then a patient would
• 28:35say to John Oh my problems started
• 28:38when I went to the doctor and he gave
• 28:41me Oxycontin an John said to them.
• 28:45He would wink and he'd say, oh,
• 28:48I see so the directions on the prescription,
• 28:50she said, chop and snort.
• 28:53Two times a day, I don't think so now I
• 28:56could never get away with such a thing.
• 29:00I wouldn't even dream of saying it,
• 29:02but he could.
• 29:03He was beloved and they kind
• 29:05of laughed because you know,
• 29:07these folks were in their 20s
• 29:10thirties and 40s.
• 29:11And then I had,
• 29:12you know,
• 29:13I got to know many of them and they
• 29:15were well acquainted with intoxicants
• 29:18before before prescription opioids
• 29:19became part of their repertoire.
• 29:22So what John was really doing was
• 29:24challenging the idea of the accidental.
• 29:27Addict Ann and you know he had to
• 29:31because the idea that the idea that we
• 29:35often see perpetuated in the media is that.
• 29:39The typical.
• 29:42Prescription pill versus addicted
• 29:44to prescription pills or abuse
• 29:46them was otherwise fine.
• 29:48Life was wonderful and then they got
• 29:51some pills for wisdom tooth or broken
• 29:54ankle whatever and then within weeks
• 29:57to months it was life was out of control.
• 30:01I'm not, I can't tell you
• 30:03that's never happened,
• 30:03but it's just not the rule.
• 30:05Even though the media portrayed is an.
• 30:07That's an important misconception because
• 30:09it's led to some unfortunate policy's,
• 30:11and I'm going to get to that
• 30:12in a little while. But first,
• 30:14I just want to present some.
• 30:19Some data about who abuses opioids an
• 30:22and I'm talking bout prescription opioids
• 30:25now and who's at risk for that and I'm
• 30:30sure a lot of you have seen this slide.
• 30:33It's from SAMHSA representing
• 30:352013 to 14 and the most important
• 30:39part is the red part which is.
• 30:42When they asked folks. Who had?
• 30:47Sorry, can't read the part of top because.
• 30:51But when they ask people who had misused
• 30:56prescription opioids within the last year,
• 30:58who did they get their
• 31:01most recent pills from?
• 31:031/5 actually got them from a physician
• 31:07and we even know actually there is very.
• 31:12An interesting book called Drug Dealer,
• 31:15MD by Anna Lemke,
• 31:16who's a psychiatrist at Stanford and
• 31:19she's a whole typology of patients who
• 31:22are basically duping their doctors.
• 31:24And that's my goodness not all of our
• 31:27don't ever get that impression from me,
• 31:31but I my point is that even from
• 31:34that 22.1% some fraction of fat is
• 31:37not even what one might consider up
• 31:40corner quote legitimate chronic pain,
• 31:42patient or pain patient.
• 31:44But that's an important slide because
• 31:48at the very least it tells us the.
• 31:51That the supplies that though the pill
• 31:54supplies that went directly to miss users,
• 31:58were not being sustained by physicians.
• 32:02Now,
• 32:02as I said before,
• 32:04a lot of these folks had significant
• 32:06involvement with other drugs.
• 32:10I've just mentioned Ted Cicero, who's that.
• 32:13Washington University has done
• 32:16some really excellent work in.
• 32:19Descriptive work in the Epidemiology of
• 32:21this population an an over several studies.
• 32:25He's reported that between 70 and 90% of
• 32:28people who come in for treatment for.
• 32:33Scription use disorder had
• 32:34used at least one another,
• 32:36not opioid drug in the months before cocaine.
• 32:40Methamphetamine hallucinogens Ben,
• 32:41so this kind of thing,
• 32:43and if you look at tox screens,
• 32:46you'll see that there is also a big range,
• 32:49but seems at the bottom.
• 32:51The bottom part of the
• 32:53range is 60% of people who.
• 32:58Have toxicology screens at after overdose.
• 33:0060% have more than one drug and then
• 33:04there was one study from for that.
• 33:08Follow data from from Florida
• 33:10and 90% so 9 out of 10 people who
• 33:14died of a with an opioid.
• 33:17Related death had other drugs
• 33:19in their talk screens as well,
• 33:22so this suggests that people who develop
• 33:25significant problems with prescription pills.
• 33:28Raffin experienced users and.
• 33:32And that's important to know.
• 33:34Now you could say that,
• 33:37well, maybe you know.
• 33:39Going back to that pie chart,
• 33:42you know well,
• 33:44maybe they maybe they sustained
• 33:46their use this way,
• 33:48but maybe they were mostly initiated into
• 33:52prescription problems through their doctor.
• 33:54But I think that it's mitigated.
• 33:57Interpretation is mitigated against by the
• 34:00by data on the addictiveness among patients.
• 34:05Excuse me,
• 34:06the addictiveness of prescription
• 34:08opioids prescription pain relievers
• 34:11among patients for whom those
• 34:13pain relievers are prescribed so.
• 34:15This is data from.
• 34:19Um, that's Ted Cicero's group,
• 34:21too.
• 34:22I think he's not the first author
• 34:25where 7000 people looked at
• 34:28their prescriptions and the key.
• 34:31Figure there is .3% developed opioid
• 34:34use and addiction within a year after
• 34:38receiving at least one prescription.
• 34:40Another study, this one from Harvard.
• 34:43Published in the British Medical
• 34:46Journal is consistent with that .6.
• 34:49Let's under 1% for over half
• 34:52a million people.
• 34:53Privately insured.
• 34:54Misses some brat study is
• 34:57definitely about acute pain,
• 34:59and the survey above probably combines
• 35:03acute and chronic prescribing.
• 35:06So that's important and I think I
• 35:08think the public would be pretty
• 35:11surprised to see those relatively
• 35:13low numbers now when you.
• 35:17Drill down on chronic pain
• 35:19things get a little different.
• 35:21There's much, much more of a range.
• 35:23For example, the Edlin study for
• 35:26the Research Triangle showed up.
• 35:28A range of .12 to 6.1 in a half
• 35:32a million patients. That's big.
• 35:37But then the Cochrane Library,
• 35:38which as you know is a very respected
• 35:42international database and they do reviews.
• 35:44They found that less again back to under
• 35:471% developed signs of opioid abuse.
• 35:49Then there is the third study I'm mentioning.
• 35:52These are all representative,
• 35:54so an and I'm happy to provide people
• 35:57with much more of a bibliography
• 35:59if they if they want anyway,
• 36:02an article in the New England Journal
• 36:04of Medicine by VAALCO Anne McLellan.
• 36:07Again, rates averaging less than 8%.
• 36:11But that's a range up to 8% AMI 8% is.
• 36:16You know it's not trivial,
• 36:18So what is that about?
• 36:20Why?
• 36:21Why does that range exist an
• 36:24and there's a study from.
• 36:27Out of the University of
• 36:29Miami by David Fishbrain,
• 36:31which sheds a lot of light on this question,
• 36:34his group did a review of 24 studies
• 36:37of this is chronic pain of patients
• 36:40prescribed opioids and and he did
• 36:43find a relatively low rate of 3.27%.
• 36:46But then when he separated out the
• 36:49four studies that had specifically
• 36:51excluded patients with previous or
• 36:53current history of addiction or abuse,
• 36:56it dropped significantly.
• 36:57And in fact,
• 36:59the Cochrane report specifically
• 37:01says that their reported low rates.
• 37:05Remember that was .27 should not
• 37:07be generalized to an unselected
• 37:10population or to individuals taking
• 37:13opioids without supervision,
• 37:15because the conference study,
• 37:17I think also weeded out.
• 37:22We did out studies that had that that had
• 37:27included people with these histories of.
• 37:31Substance abuse, and that's really really
• 37:34important because there is an abundance
• 37:37of data confirming that patients with
• 37:40prior addiction to alcohol or drugs or
• 37:43people who are experiencing depression
• 37:45are those who will report taking an extra
• 37:49pain reliever to manage stress with.
• 37:52These are the folks who are much more
• 37:56likely to progress on to addiction.
• 38:00And This is why it's so important.
• 38:02Of course, for doctors before they
• 38:03prescribe any addictive medicine,
• 38:05not just opioids,
• 38:05but as to what gather a very decent,
• 38:08you know, a very detailed.
• 38:10Information on their prior experience
• 38:11with substance use, current consumption,
• 38:13and how they've managed.
• 38:14If they've been on no prescription
• 38:16opioids in the past,
• 38:18how they manage them and since
• 38:19primary care doctors you know we're
• 38:21doing much of this prescribing.
• 38:26It's fairly evident that they I mean
• 38:28there everyone is busy and pressured,
• 38:30and but that they probably we
• 38:33doctors in general probably didn't
• 38:34do their as much diligence as they
• 38:37should have in terms of screening.
• 38:39People who are at risk and
• 38:42now there all kinds of of.
• 38:45Instruments to screen for that kind of thing,
• 38:47and in fact there are a number of
• 38:49surveys of primary care doctors
• 38:51where the majority of them say when
• 38:53we're very uneasy with treating pain,
• 38:56we don't know how,
• 38:57and also that they don't know how to
• 39:00treat addiction that might develop.
• 39:02Now people. Do you have vulnerabilities?
• 39:05It doesn't mean that doctors
• 39:07should avoid prescribing for them,
• 39:08but they obviously have to
• 39:10monitor them a lot more carefully.
• 39:13You should also,
• 39:14in addition to looking for these
• 39:16more kind of conventional point
• 39:19details of history,
• 39:20they really have to appraise the
• 39:24patients current well being because.
• 39:27You know there are situations.
• 39:33Is it? There are definitely
• 39:36situations in which.
• 39:38You know in which people might
• 39:40go might begin their problems
• 39:41with drugs or with with opioid
• 39:44prescription opioids through a doctor,
• 39:45but the kind of situation
• 39:47is often one where I mean,
• 39:49here's a sort of a classic,
• 39:51and then I saw this in Ironton
• 39:53where a young guy really was
• 39:55captain of the football team.
• 39:57Had a period have a great life he was.
• 40:01Got a football scholarship to Ohio
• 40:03State and then he was in a car
• 40:06accident and it ruined his throwing
• 40:08arm and basically his whole future
• 40:11just collapsed before his eyes and
• 40:13you can imagine a young boy like this
• 40:16was just utterly devastated and he
• 40:19was prescribed opioids because he
• 40:21had his surgery and it was a painful
• 40:24condition but but those opioids
• 40:26helped a lot more than his shoulder pain.
• 40:29I mean they really helped
• 40:31his psychic pain as well.
• 40:33And that put him at significant risk.
• 40:35The fact that the fact that this accident
• 40:38was so traumatic to him was a real risk.
• 40:42So it's very important that we
• 40:45think about always think about.
• 40:47Opioid abuse and addiction.
• 40:49As a product of the person and the
• 40:53context and drug availability.
• 40:55Drug availability,
• 40:56but exposure itself is probably
• 40:59never sufficient and this matter
• 41:02is this accidental addict image
• 41:04does matter because it led to
• 41:08an exaggerated impression of the
• 41:10addictiveness of opioid medications and.
• 41:14And that led to a fairly
• 41:17indiscriminate crackdown.
• 41:18Now there's no question that doctors
• 41:21prescribed these medications too liberally.
• 41:23Most people needed just several days.
• 41:26Some people probably didn't
• 41:28need anything except Tylenol,
• 41:30extra strength, etc is pretty darn good.
• 41:33Anna hot water bottle.
• 41:36So I've certainly stipulate that.
• 41:39And of course,
• 41:41doctors started treating pain more
• 41:43aggressively because they had
• 41:45undertreated pain through most
• 41:46of the Sixties, 70s, and 80s.
• 41:50And as.
• 41:52As we all know,
• 41:53in the late 90s and early 2000s the
• 41:56Joint Commission was encouraging doctors
• 41:58to to pay more attention to pain relief.
• 42:02They didn't necessarily.
• 42:04They didn't specifically mention opioids,
• 42:06but the doctors had to be
• 42:08much more responsive.
• 42:10Medicare and Medicaid would
• 42:11actually have patients,
• 42:13would fill out patient satisfaction
• 42:15surveys and one of the items was
• 42:18was your pain rate cared for, and.
• 42:21So that it is patient, said no.
• 42:24There was some pressures and
• 42:26brought to bear on those physicians
• 42:28or their health care system.
• 42:30So that was more pressure.
• 42:31There was a whole 5th vital sign
• 42:34of the Smiley faces and you know,
• 42:36you know the drill state boards were
• 42:39much more were encouraging and also
• 42:41holding doctors harmless if they prescribed.
• 42:43If it appeared that they were prescribing
• 42:46high doses and we know where this all went,
• 42:49it overshot.
• 42:50And then in 2000.
• 42:5311 Doctors started to reduce.
• 42:59The amount of opioid prescriptions they were.
• 43:03Handing out an that
• 43:04discontinuation goes on today.
• 43:06Now this raises a very interesting question.
• 43:08I don't know the answer to is.
• 43:11How much of a reduction in
• 43:13prescribing opioids is enough,
• 43:15but because it's been projected
• 43:17that at the end of this month
• 43:19it might be back to 2000 levels.
• 43:22The year 2000 levels,
• 43:23which is an interesting question,
• 43:25but the important point
• 43:27is now that opioids were.
• 43:31Declining and and that was
• 43:33probably good because they were,
• 43:36as I said, they were overprescribed,
• 43:39but unfortunately that was done with
• 43:42a machete and not a scalpel, and.
• 43:47Which is to say that people who
• 43:51really needed pain opioids for.
• 43:53Chronic pain were often denied them
• 43:56and this situation really increased
• 43:58dramatically after 2016 when the CDC
• 44:02produced its guidelines from for primary
• 44:05care doctors for prescribing opioids,
• 44:07and I'll tell you,
• 44:09I thought those guidelines
• 44:11were they weren't bad.
• 44:13I thought they were fine.
• 44:16They urged going, you know,
• 44:19start low, go slow.
• 44:22Weighing the costs of the
• 44:24benefits of the medications,
• 44:26but in retrospect it was a disaster that
• 44:29they suggested 90 morphine milligram
• 44:31equivalents as as a guard rail.
• 44:34You really should be cautious about going
• 44:37over 90 morphine milligram equivalents.
• 44:40That really wasn't based on any data
• 44:43and the people who were on the task
• 44:46force who included that caution were
• 44:48the first to admit it and they were
• 44:51also the CDC that these are guidelines.
• 44:54Guidelines aren't mandates from
• 44:55the federal government, but.
• 44:57It was taken as if it was the 90
• 45:00morphine milligram of threshold,
• 45:03honestly was understood.
• 45:06So in such a widespread fashion,
• 45:08as if it were written on tablets
• 45:11and handed down from Mount Sinai,
• 45:13and there became just a rash of
• 45:16tapering people from high doses,
• 45:18some perhaps didn't need it,
• 45:20I will grant you that,
• 45:22but many did, tapering them,
• 45:24which is traumatic in terms
• 45:26of precipitating withdrawal,
• 45:27because some of them did it very,
• 45:30very quickly.
• 45:31There was a study from Vermont
• 45:34Medicaid where the average.
• 45:36Time to withdraw was one day and and so
• 45:39some would have their doses lowered.
• 45:42Others would have would
• 45:43have them discontinued,
• 45:45and then they're developed a whole
• 45:47population of people that some have
• 45:50called pain refugees where their doctors.
• 45:52Wouldn't treat them anymore.
• 45:54Some of those doctors were
• 45:56heartbroken because they thought
• 45:57the government was outlawing this,
• 45:59and others were.
• 46:00From what I gathered,
• 46:02unfortunately pretty insensitive to it.
• 46:03There is a lot of talk that about
• 46:06from patient sitting there that their
• 46:08doctor was never really wanted to keep
• 46:11them on opioids in the 1st place,
• 46:14so this was an excuse, but in any case,
• 46:17whatever the motivation the
• 46:19patients were suffering.
• 46:20Terribly and.
• 46:23This is just one survey that
• 46:25was done by pain News Network,
• 46:28which is also an advocacy group,
• 46:30and you know, admittedly this is not a.
• 46:33This was just a survey.
• 46:35It isn't. It wasn't a.
• 46:38It was a scientifically conducted,
• 46:40so to speak, but you can see the trends,
• 46:43my pain and quality of life is worse,
• 46:46you know, like.
• 46:48Spot 4 out of five and I'm no
• 46:50longer prescribed medication
• 46:52are prescribed a lower dose.
• 46:54These are in the yellow highlighted
• 46:56and people were in enormous distress.
• 46:59A colleague to colleagues of mine
• 47:01are keeping a registry of people who
• 47:04committed suicide because of this,
• 47:06and then there was pushed back.
• 47:09This is just one example,
• 47:11best darn analysis and pain psychologist
• 47:14at Stanford and and they were
• 47:16actually 100 signatures on this too.
• 47:19Call attention to this problem of tapering
• 47:23people indiscriminately and quickly.
• 47:25They were also please from Human Rights
• 47:28Watch from the American Medical Association,
• 47:32the American Cancer Society all
• 47:35addressing the CDC and said, please,
• 47:38please would you clarify what you
• 47:41really meant in the guidelines because?
• 47:469090 morphine milligram equivalents is
• 47:48for some people with chronic pain is
• 47:51just you know not enough and to the
• 47:53CDC's credit they did clarify that in
• 47:56an article in the New England Journal
• 47:59in April of 2019 and that now they are.
• 48:03Actually convened another task force with,
• 48:05I think, a totally new complement of experts,
• 48:07and there can be there convened
• 48:10there working on it.
• 48:11I'm fairly certain that any kind
• 48:14of threshold won't won't be in it.
• 48:16But anyway, that's that is.
• 48:18That's why the points that I wanted
• 48:21to bring up is that we have to be
• 48:25very cognizant of who's at risk.
• 48:27And we know that the majority of
• 48:30people who abuse of prescription pills
• 48:32were never patients to begin with,
• 48:35but patients who did among the patients.
• 48:39Who received opioids and develop
• 48:41problems had had risk factors and
• 48:45that because we had a really.
• 48:50Sloppy and heavy handed
• 48:52approach to the overprescribing
• 48:54which was really ended up.
• 48:56I think hurting a lot of chronic
• 49:00pain patients now that part is.
• 49:03The universal story.
• 49:07There's an interesting I see.
• 49:08My time is getting a little short so.
• 49:13No, it's not. I'm good.
• 49:15OK, I'm going to talk till about 10.
• 49:1910 yeah, 11:15.
• 49:24On second thought, it is getting a little
• 49:27short, so I'm going to move on too.
• 49:31My other point, which is to emphasize
• 49:35how to how complicated the story
• 49:40of addiction these addiction.
• 49:44And epidemics are when my
• 49:46people have said we haven't.
• 49:48We haven't overdose epidemic
• 49:50and I think now that is true.
• 49:53What I mean to say was always true,
• 49:56but but I, I'm fairly,
• 49:58I think, data kind of.
• 50:01Persuasive that more not many
• 50:03more people are using drugs.
• 50:04It's just that we've gotten to a
• 50:07stage where the drugs people are
• 50:09using and I'm referring now to heroin
• 50:11and fentanyl are much more lethal,
• 50:13so you're all familiar.
• 50:15I'm sure with this slide.
• 50:18We see it in your dreams and it
• 50:21illustrates what the CDC is called.
• 50:23So the three waves.
• 50:26Portrait of The of the opioid crisis.
• 50:31And you see that this slide starts in 1999.
• 50:35I've other slides that go back to 1990
• 50:37and you already see opioid starting to rise,
• 50:41and that's because of the effort to to
• 50:44compensate for the undertreatment of
• 50:46pain or whatever it's been called an opiate,
• 50:50the OPO phobia.
• 50:51That term was coined in 1983,
• 50:53and the doctors are trying to compensate
• 50:56now and not just cancer patients,
• 50:58but with people with non cancer chronic pain.
• 51:02That was a that was a very important
• 51:05population that had definitely been
• 51:07undertreated for pain and then started.
• 51:09As I said in the 90s and it
• 51:12gained and gained more momentum.
• 51:15Oxycontin came along in 1996.
• 51:18Out of focus is on 1996,
• 51:20but but the trend was going
• 51:23up way before then.
• 51:25Um, and so that was wave one Anas.
• 51:28I've showed you that other slide prescribing
• 51:32actually started to go down in 2011.
• 51:35Then wave two which started around 2010,
• 51:39was growth of heroin.
• 51:43And that's because it was filling
• 51:46a vacuum that was vacated by
• 51:49pills which were becoming.
• 51:52Less and less available in around 2010 was
• 51:55was really a convergence of a lot of things.
• 51:58Pill Mills.
• 51:59There was a really concerted
• 52:00effort to crackdown on pill Mills,
• 52:03and those are bogus doctors offices.
• 52:05Basically that barely did.
• 52:06If they even did a physical exam,
• 52:09they may have done it
• 52:11once when you walked in,
• 52:12but after that they would just
• 52:15hand out the pills, cash for pills.
• 52:18Sometimes Medicaid for pills.
• 52:21There was a reformulation of
• 52:24Oxycontin so that it could not
• 52:27as easily be crushed and snorted.
• 52:29Physician at the PD MPs which have
• 52:32been around for decades but really
• 52:34became much more aggressive to
• 52:36monitor doctor shopping and states
• 52:38were also starting to put limits,
• 52:40especially on prescribing for acute pain.
• 52:43You know Jay limits this kind of thing.
• 52:46And that allowed the creative
• 52:48vacuum that allowed heroin to
• 52:50come in back back in Ironton.
• 52:51Heroin had never been around in Apple Acha.
• 52:54It was rare and largely
• 52:56because they had pills.
• 52:57Then wave three start about 2014.
• 53:00That was fentanyl,
• 53:01and all know how potent that is,
• 53:04100 times as potent as morphine,
• 53:0750 times as potent as heroin and.
• 53:12And we know now.
• 53:13Actually in the next slide that just look
• 53:16at the red an they don't even have meth.
• 53:19Yeah, wrath, the red and the purple.
• 53:22Pink show that meth,
• 53:24methamphetamine and cocaine is
• 53:25really on the rise and unfortunately
• 53:28fentanyl's often sprinkled on those
• 53:30preparations and people overdose
• 53:32from that because typically cocaine.
• 53:35Certainly an methamphetamine stimulus.
• 53:37Don't have the overdose.
• 53:39Potential that opioids too.
• 53:41And as I mentioned before,
• 53:43these are opioids that are
• 53:45usually almost in when they're in.
• 53:47Overdose are almost always
• 53:49combined with something else.
• 53:51When I mentioned before,
• 53:52the tox screen showed 60 to 90% of other
• 53:56drugs that didn't even include alcohol.
• 53:58So OK, then fentanyl to cough,
• 54:01and that is really been a disaster.
• 54:04The pandemic, of course,
• 54:05worsened everything people using alone,
• 54:07so that if they do. Overdose.
• 54:10There's no one there to give them
• 54:13Narcan or take them to an ER.
• 54:15The pandemic disrupted trafficking
• 54:17routes so people were buying from now on.
• 54:21Reliable usual sources and they
• 54:23had less access to treatment.
• 54:25Then.
• 54:25Of course there was just more
• 54:28hardship in general, so to the
• 54:30extent that and I think a massive extent,
• 54:33that addiction is basically a
• 54:36form of self medication.
• 54:37There was a lot more to medicate
• 54:40in terms of social isolation.
• 54:42Death of.
• 54:43Friends and family.
• 54:45Maybe job loss.
• 54:47So economic pressure.
• 54:49Now the deaths were increasing
• 54:51even before the pandemic,
• 54:53but the latest data show that from
• 54:56March to May of 2020 twenty the
• 54:591st two months of the pandemic,
• 55:01there was needing steeper
• 55:03acceleration and death,
• 55:04so that's a big problem in what's called the
• 55:07other epidemic or the forgotten epidemic?
• 55:10You know,
• 55:12in the context of covid.
• 55:15So I'm going to wrap up.
• 55:19We've hopefully leave a lot of
• 55:21time for Q&A because I do have
• 55:23kind of a story about Apple Watch.
• 55:24I want to get to,
• 55:26but I'll fit that into the Q&A.
• 55:27Make sure I finish the formal talk on time.
• 55:40Give us a good enough answer,
• 55:43like for example the accidental addict too.
• 55:47Some find it is it's it's a.
• 55:51Although it's disturbing.
• 55:53It's a clean narrative.
• 55:55You know. People were fine,
• 55:57then they were essentially contaminated
• 55:59by their physician who was either,
• 56:01you know, well meaning slash,
• 56:04duped by a drug Rep into prescribing opioids.
• 56:07And and that was the
• 56:09beginning of of a disaster,
• 56:11and we've seen that you know.
• 56:14Again, I I can't say there's that there
• 56:17aren't people who whose lives are
• 56:19wonderful and content and they don't
• 56:22unravel when given a prescription.
• 56:24But that's not the usual story
• 56:26an even when that happens,
• 56:28I'm fairly confident that
• 56:30if you scratch the surface,
• 56:32you'll see that especially
• 56:34visiting a young person,
• 56:35you find someone who is struggling with.
• 56:39You know all kinds of teenage angst,
• 56:42and in fact I did interview a
• 56:44patient once who broke a tooth,
• 56:47but his doctor gave him opioids.
• 56:49He was.
• 56:5117 and he was new that,
• 56:53you know he's probably gay,
• 56:55but he was terrified of revealing
• 56:57that to his parents,
• 56:58and it really weighed on him and became
• 57:00so oppressive to him psychologically
• 57:02that these medications actually
• 57:04relieved that that stress for him,
• 57:06and he kept taking them and taking them.
• 57:10I think we like a 90 morphine
• 57:13milligram equivalent.
• 57:14Threshold is convenient, but it's more.
• 57:17There's more to the story than that.
• 57:19I think we like a one
• 57:23casualty picture which is.
• 57:25And we should worry about people
• 57:27who became addicted and we should,
• 57:29of course, because they are suffering.
• 57:31But you know what about
• 57:32the chronic pain patients?
• 57:33I mean, this is a tradeoff.
• 57:35I think you can.
• 57:36I think we can do both without question.
• 57:39I think we can.
• 57:41Treat people for pain in a
• 57:44rational way while.
• 57:46Protecting people who are
• 57:47vulnerable from addiction.
• 57:48I think we can do that at the same time,
• 57:51and we're going to get much better
• 57:53at it and we're getting better at it.
• 57:56But I think we like one villain
• 57:59and Big Pharma is the villain here.
• 58:02And of course there are tons
• 58:04of lawsuits going on,
• 58:05and massive multidistrict litigation
• 58:07which is thrown off by the pandemic
• 58:10but is definitely on track.
• 58:11I'm not exonerating them, there was heavy,
• 58:14overly aggressive marketing,
• 58:15no question about that,
• 58:17but the drug companies were
• 58:18part of a big web drug.
• 58:21Distributors were in that web,
• 58:23drug distributor is a company,
• 58:24and they're like really low on
• 58:27the four high on the Fortune 500.
• 58:29Some of the biggest ones, McKesson.
• 58:32Whatever their normal sleep,
• 58:34profitable companies,
• 58:35there big industries and they what
• 58:37they do is basically transport
• 58:39the drugs from the medications
• 58:41from the manufacturers warehouse
• 58:43to hospitals and pharmacies.
• 58:45They are bound by law to
• 58:48report suspicious orders.
• 58:49In other words of if if a pharmacy the
• 58:53pharmacy works with the distributor
• 58:55and says we need this much Oxycontin,
• 58:58we need this much value.
• 59:01We need this.
• 59:02There supposed to report it if that
• 59:06looks off and. There were
• 59:09significant many instances,
• 59:10and there's been lawsuits.
• 59:14Many lawsuits and ongoing
• 59:16lawsuits where they did not.
• 59:18They weren't as conscientious
• 59:19as they should have been.
• 59:21the DEA missed many of these
• 59:23suspicious orders because all of those
• 59:26reports would also go to the DEA.
• 59:28We may have.
• 59:29You may have read last week
• 59:31that Walgreens is is being sued
• 59:34by the federal government for
• 59:36filling fraudulent prescriptions.
• 59:38Again, not every Walgreens,
• 59:40but enough that this is a
• 59:42problem at CVS in the past,
• 59:44has been sued for such things
• 59:45by if I add staff another factor
• 59:48and I'm going through them,
• 59:50I'm wrapping up and I'm going
• 59:52through a list of factors just
• 59:54to show how complicated this is.
• 59:56Medicare and Medicaid expanded
• 59:58their coverage of. A vote.
• 01:00:01Yards,
• 01:00:01you know on patent opioids so
• 01:00:04much that 60% of all opioids
• 01:00:07were paid for by the government.
• 01:00:10From 2001 to 2000.
• 01:00:1410 That's up from 17% before then, and.
• 01:00:20Out of pocket prices dropped 81%,
• 01:00:22so that's a lot.
• 01:00:24I'm almost finished with my
• 01:00:27list of people or.
• 01:00:29Figures that need to be calculated.
• 01:00:31In this understanding this,
• 01:00:33this or this large ecosystem
• 01:00:35of this web doctors for both
• 01:00:37pressured and inexperienced,
• 01:00:39but they were always the gatekeepers
• 01:00:41and these drugs were always
• 01:00:43scheduled to except Hydra codon
• 01:00:45which was scheduled 3 until 2014,
• 01:00:48but Oxycontin was always scheduled to.
• 01:00:51Then there were the neighbors who
• 01:00:53sold pills to their neighbors.
• 01:00:54I work with a nurse who actually holds
• 01:00:57those people more accountable than anything.
• 01:00:59And then Lastly of course
• 01:01:01there are the people.
• 01:01:02The demand that came from the patients.
• 01:01:05Now I could I've been to a place
• 01:01:07where you see how difficult
• 01:01:09and depressing and life can be.
• 01:01:11And as I said before,
• 01:01:13I'm a great believer in the self
• 01:01:15medication theory of addiction.
• 01:01:17I mean people use drugs for reasons.
• 01:01:20But they use them and that demand
• 01:01:22dynamic is very important.
• 01:01:24So I want to end on a happy note if
• 01:01:27you aren't all too distressed by now,
• 01:01:30which is.
• 01:01:32That in Iron 10 there is still a great.
• 01:01:37Spirit of tradition.
• 01:01:38This was a dog at the Memorial Day Parade,
• 01:01:41which is.
• 01:01:42I haven't checked,
• 01:01:43but I'm going to leave Ironton colleagues.
• 01:01:46It's the longest running.
• 01:01:48Memorial Day Parade in the
• 01:01:51country since 1868 and this is.
• 01:01:55Great fact that it was even
• 01:01:57held during the 1918 pandemic.
• 01:01:59Not sure if that ended up being
• 01:02:02a super spreader event or not,
• 01:02:04but the 1918 pandemic was attended
• 01:02:06by veterans of the Civil War
• 01:02:09in the Spanish American War.
• 01:02:10They were there.
• 01:02:12I met wonderful people,
• 01:02:13a lot of a lot of individuals,
• 01:02:16local entrepreneurs.
• 01:02:17Or, you know, just trying to.
• 01:02:19He opened up Mr Fisher, right.
• 01:02:22Richard Fisher opened a coffee shop,
• 01:02:24a very, very artisanal coffee shop,
• 01:02:27which wasn't what you'd find there.
• 01:02:29But he was very enthusiastic.
• 01:02:31He's retired,
• 01:02:32and this is what he wanted to do,
• 01:02:35and he was a former chemist.
• 01:02:37So even though the name of
• 01:02:39his store is the
• 01:02:40Ironton Coffee,
• 01:02:41a lab that iron was Effie in his news,
• 01:02:45you may be able to see here.
• 01:02:47He'd have open night and.
• 01:02:50Even the Ronay Theater now has
• 01:02:52shows and they had a Frank Sinatra
• 01:02:55retrospective and there is a bike
• 01:02:57path and an there's there's some
• 01:02:59enthusiasm I'm not going to be naive.
• 01:03:02I mean, it's still a struggle
• 01:03:04in place of the pandemic.
• 01:03:06Certainly hasn't helped but but it's
• 01:03:08it is very gratifying to see how
• 01:03:10people try to save their small towns.
• 01:03:13And this is happening all over America,
• 01:03:15so we'll just end with a picture of
• 01:03:18this is a picture of the train tracks.
• 01:03:21In downtown Ironton and what you see in.
• 01:03:26The background is a wall.
• 01:03:28That's the floodwall in the Ohio
• 01:03:30River is on the other side,
• 01:03:32and it could be a picturesque place
• 01:03:34that plays place with great people who
• 01:03:37are very enthusiastic and sadly a place
• 01:03:39with a lot of people who are still.
• 01:03:42So. So thank you very much.
• 01:03:46Sally, thanks so much.
• 01:03:48If you could end your screen sharing,
• 01:03:51you'll be able to see the attendees
• 01:03:55better and they'll be able
• 01:03:57to you. I I. OK wait, why is it?
• 01:04:05I don't have her over the top of
• 01:04:08your screen. Maybe that green.
• 01:04:10Yep. Manual CA stock share.
• 01:04:14So I would suggest this OK so
• 01:04:17people can raise questions by
• 01:04:20writing something in the chat,
• 01:04:22or you can wave your hand furiously
• 01:04:25like this and will try to keep
• 01:04:28track of you. On the screen.
• 01:04:33I notice that there is the hand raise.
• 01:04:35Oh, I guess the hand raising.
• 01:04:38It's the hand raising some can
• 01:04:40use the hand raising thing,
• 01:04:41but I can't on my screen.
• 01:04:43So, um.
• 01:04:47So the quick first question is
• 01:04:49Mary's research team is working
• 01:04:51on a systematic review of all
• 01:04:53published substance abuse treatment.
• 01:04:54One of the surprise finding is that
• 01:04:57none of the articles in our final
• 01:04:59review are from rural settings.
• 01:05:01Is it possible that the research on
• 01:05:03the method of 1st Entry into drug
• 01:05:05misuse in our addiction does not
• 01:05:07represent rural or suburban populations
• 01:05:10where demographics might be different?
• 01:05:13Yeah, I think that I
• 01:05:15think there's still more.
• 01:05:16I don't think I know.
• 01:05:18You look at CDC data.
• 01:05:20There's still more pill use and more to
• 01:05:23prescribing in that part of the country.
• 01:05:26I fairly I wouldn't be surprised.
• 01:05:28I mean in fact hit Cicero did work on.
• 01:05:31He was the one who did that.
• 01:05:34Almost Seminole study.
• 01:05:35Now looking at people who
• 01:05:38came into treatment and how.
• 01:05:40You know there was a change over the
• 01:05:43years where in his first sample,
• 01:05:45which I think was in 2000 or
• 01:05:48the paper came out in 2014.
• 01:05:50The sample was done obviously
• 01:05:52years before that.
• 01:05:53The drug that people started on
• 01:05:55in there they were initiated
• 01:05:57through pills as opposed to heroin.
• 01:05:59That was,
• 01:06:00I think for about four and five
• 01:06:03actually reported pills as how
• 01:06:05they initiated their opioid use.
• 01:06:08And years later he went back and followed.
• 01:06:10That up, I think three or four years later,
• 01:06:13and found that a much higher percentage
• 01:06:16now are starting with heroin,
• 01:06:17not pills.
• 01:06:18But I would imagine if you
• 01:06:20did that in rural area,
• 01:06:22you might find still a higher percentage
• 01:06:24of people initiating with with pills
• 01:06:26that actually gets me into the now.
• 01:06:28I don't see any other.
• 01:06:30Am I missing him?
• 01:06:31'cause I don't see any other questions.
• 01:06:34I don't see any at the moment,
• 01:06:36but great perfect because
• 01:06:38that is a perfect segue.
• 01:06:39Into the part of the talk that I put
• 01:06:43outside just in this interest of time,
• 01:06:45which is to say that there really was a very,
• 01:06:49very big difference in the
• 01:06:52culture of prescribing opioids in.
• 01:06:54Apple,
• 01:06:55ACHA and especially central Appalachia.
• 01:06:57When you say central,
• 01:06:59that's like Deep Apple at Eastern Kentucky,
• 01:07:02an southwestern Virginia and
• 01:07:04almost all of West Virginia,
• 01:07:07and these are places where mining
• 01:07:10was a major major industry.
• 01:07:14And this is an area where prescribing
• 01:07:19pills of opioids had always
• 01:07:22always been heavy because of.
• 01:07:26Because of the labor, because mining was a.
• 01:07:31Incredibly,
• 01:07:32I mean when you read about when
• 01:07:34you when I have 'cause I as I
• 01:07:37said coming from Queens,
• 01:07:39NY I don't know about mining but I
• 01:07:42do have to take a crash course in it
• 01:07:45and it now it's a lot of its surface mining.
• 01:07:49It's not quite as brutal, but it was.
• 01:07:52It was just help.
• 01:07:54If you did underground mining often the
• 01:07:57coal seams were at four was called low,
• 01:07:59low, low cold,
• 01:08:01but there was four feet.
• 01:08:034 feet of head way to do your.
• 01:08:07To do your work you can you can just everyday
• 01:08:11for 1012 hour weekday but for 10 hours a day.
• 01:08:15I mean you can only fathom how that
• 01:08:17destroyed peoples bodies and most were
• 01:08:20retired by the time well retired by
• 01:08:22the time they were, you know 40 or 50.
• 01:08:25But The thing is that is before the 60s these
• 01:08:29folks lived on coal camps and a coal camp.
• 01:08:32You may have heard of them.
• 01:08:34I've sold my soul to the company store,
• 01:08:37but coal camps really were
• 01:08:39totalizing institutions.
• 01:08:40And you lived in a coal camp.
• 01:08:42Your kids went to school that the
• 01:08:45that the coal company built you went
• 01:08:47to church is at the coal company ran.
• 01:08:50They had their own police force
• 01:08:52so they could.
• 01:08:53Partly I think put down unionizing and they.
• 01:08:57They were very, very.
• 01:09:03Just strict taskmasters to say the least,
• 01:09:05so that that if a man couldn't work.
• 01:09:09He was basically his house was taken away.
• 01:09:11I mean the house was given to him by the
• 01:09:14cold in a company and the store you had to
• 01:09:17buy everything in the coal company store.
• 01:09:19You weren't even paid in money.
• 01:09:21You were paid in script.
• 01:09:23So you had to exchange it and the
• 01:09:25exchange rates were really curious.
• 01:09:27But people a lot of people
• 01:09:28wanted to use Sears catalogs.
• 01:09:30They couldn't do that 'cause they
• 01:09:32didn't have cash and they could
• 01:09:34have gotten these products cheaper.
• 01:09:35So anyway, the point is you were.
• 01:09:37I mean you can hear stories about.
• 01:09:40Good times in coal camps.
• 01:09:42There's a lot of camaraderie
• 01:09:44and very tight communities.
• 01:09:46As you can imagine,
• 01:09:47but they were so dependent on this work
• 01:09:50and if they couldn't work they would.
• 01:09:53They would basically be thrown off
• 01:09:56the island and so Cole camp doctors
• 01:09:59would prescribe generously for.
• 01:10:01It's not cancer chronic pain,
• 01:10:03so they were like NFL coaches.
• 01:10:05You know,
• 01:10:06strength coaches here is your steroid.
• 01:10:09Get out there and do it.
• 01:10:11Where are they?
• 01:10:12Opioids?
• 01:10:13I mean you people had to work so that
• 01:10:16began a culture of low threshold for
• 01:10:19prescribing that that still exists.
• 01:10:22You know today and so that that
• 01:10:25in small the small isolated towns
• 01:10:27they didn't know about the JCH oh,
• 01:10:31you know?
• 01:10:31In terms of treating pain,
• 01:10:33you know the pain movement,
• 01:10:35the effort to prescribe more
• 01:10:36generously than as I said,
• 01:10:38really started in the mid 80s,
• 01:10:39but really gain traction in the late
• 01:10:4290s and mid to late 90s early 2000s.
• 01:10:45Why these folks weren't aware of it?
• 01:10:48If they were,
• 01:10:50it wouldn't matter because they
• 01:10:52wouldn't have changed their prescribing
• 01:10:54habits and so when Oxycontin came to
• 01:10:58town an it came to town in forest,
• 01:11:00it's well documented that produce sent
• 01:11:03now five times the number of drug
• 01:11:07reps you know to that town to some of
• 01:11:10these small towns and they they did
• 01:11:13to other similarly sized places because.
• 01:11:16They went where there was so much
• 01:11:18prescribing and specifically
• 01:11:20of its former drug,
• 01:11:21which was Ms Contin morphine sulfate,
• 01:11:23continuous and.
• 01:11:25Because places like Kentucky
• 01:11:27and West Virginia were high
• 01:11:28prescribers of long acting morphine.
• 01:11:30So they went there to sell
• 01:11:32the same product effectively.
• 01:11:34But Oxycontin and yeah you know
• 01:11:36they brought their gifts and their
• 01:11:39cold pizza and and all that and but
• 01:11:41the doctors like sure will use it
• 01:11:44because this is what we do we just
• 01:11:47prescribed for noncancer chronic pain.
• 01:11:49We've been doing it forever and they
• 01:11:51were pushing on an open door which is books.
• 01:11:55Which is very different.
• 01:11:57Gosh, sorry guys, I'll just keep talking.
• 01:12:02So in other words,
• 01:12:04unlike doctors who were in more
• 01:12:06urban areas or in smaller towns
• 01:12:09like that had University Hospitals,
• 01:12:12or you know,
• 01:12:14or hospitals that depend on federal
• 01:12:16dollars which were most these doctors were,
• 01:12:20you know, really,
• 01:12:21you know,
• 01:12:22insulated. So and it they their
• 01:12:25view of prescribing did not have to
• 01:12:28be changed now and Oxycontin when
• 01:12:30they started prescribing Oxycontin.
• 01:12:33It clearly destabilized the situation
• 01:12:35tremendously because a lot of people,
• 01:12:38I mean, uh, some percentage.
• 01:12:40Again, I wish I could give you a number, but.
• 01:12:47But folks who used,
• 01:12:48you know Tylox and Tylenol and Oxy oxycodone.
• 01:12:52You know where they even chew that.
• 01:12:55And they had their own little
• 01:12:57barter systems for drugs, you know,
• 01:13:00will give you so many Percocet.
• 01:13:02For, you know, get gasoline or whatever that.
• 01:13:07They the Oxy cotton,
• 01:13:08was so potent that when because, as you know,
• 01:13:11you have to pack a lot into a long release.
• 01:13:16Formulation that it's just
• 01:13:18people who were managed,
• 01:13:20basically managing their addiction,
• 01:13:22so to speak, to these other heavy use of
• 01:13:27opioids and other drugs just completely.
• 01:13:31Were transformed into, you know,
• 01:13:34heavy heavy addicts and they've moved
• 01:13:37to an injection and so Oxycontin.
• 01:13:40I'm not trying to downplay its
• 01:13:43affect on those communities,
• 01:13:46but its introduction was.
• 01:13:49It was a very different picture
• 01:13:52and and neither.
• 01:13:55You know federal guidelines or
• 01:13:58prescrip or professional guidelines,
• 01:13:59encouraging more prescribing or the
• 01:14:02introduction of you know this again,
• 01:14:05this idea that we have to treat chronic
• 01:14:08non cancer pain more aggressively that
• 01:14:11that that was not that was not a big force.
• 01:14:16Now in there in terms of the addiction
• 01:14:19it's just that the drug was incredibly
• 01:14:22destabilizing, but it was a.
• 01:14:25A whole, as I say,
• 01:14:27attitude towards these medications,
• 01:14:28which was very different than in
• 01:14:30big cities where a lot of work
• 01:14:33had to be done to change attitudes
• 01:14:35towards using those
• 01:14:36meds so early there there are.
• 01:14:38We're running out of time,
• 01:14:40but there are a couple of two
• 01:14:42people have asked questions
• 01:14:44who would like to to ask them?
• 01:14:46Maybe brief answers for them.
• 01:14:48Showing Anderson has a question.
• 01:14:50Yeah, my name is Sean.
• 01:14:53Appreciate you coming to talk
• 01:14:55about the opioid epidemic.
• 01:14:57I'm from Mississippi and have a lot of
• 01:15:00interface with rural communities and I
• 01:15:03had more of a comment than a question so.
• 01:15:07I wanted to make a comment about
• 01:15:10kind of how we talk about rural
• 01:15:12populations and how we use the
• 01:15:14ways we describe them to make
• 01:15:15our point too often when we come
• 01:15:17out of our ivory towers in poker,
• 01:15:19head out the window. It's
• 01:15:21easy to view these communities
• 01:15:22kind of like a zoo and I think
• 01:15:25some of some of the initial
• 01:15:26part of the PowerPoint kind of
• 01:15:28utilized that perspective, not in it.
• 01:15:30Correct me if I'm wrong.
• 01:15:32But to me, and in some ways,
• 01:15:35it seemed that, um,
• 01:15:37that you might have been using the.
• 01:15:41Kind of dehumanizing or mocking
• 01:15:43the rural population of Ohio to
• 01:15:45emphasize your thesis that patients
• 01:15:47are more responsible for their
• 01:15:49illness than we previously thought,
• 01:15:50and I was just just wanted to
• 01:15:53get your perspective on the view
• 01:15:55that I took away from that.
• 01:15:59Do you think that people
• 01:16:00of course have a role?
• 01:16:02That's what we do in drug treatment.
• 01:16:04We show them what that role was,
• 01:16:06so let me not not in any kind of a,
• 01:16:09you know, a blaming or.
• 01:16:12Discouraging way,
• 01:16:13but that's that's really the key to go.
• 01:16:16After you've stabilized people on it.
• 01:16:18We're talking bout opioids.
• 01:16:19Maybe after you've stabilized
• 01:16:21them on methadone or people,
• 01:16:23morphine or whatever,
• 01:16:24which is often the first move people
• 01:16:27have to stand still if they're going to
• 01:16:29start to get better and treatment then
• 01:16:32then so much of the work is showing them.
• 01:16:35You know, that's not blaming the victim,
• 01:16:37it's showing them how they have.
• 01:16:39You know this,
• 01:16:40that's what relapse prevention is all about.
• 01:16:43Is is understanding?
• 01:16:47The vulnerabilities which can
• 01:16:48take the form of, you know,
• 01:16:50choose the most you know,
• 01:16:52conditioned cues kind of way.
• 01:16:53What else is,
• 01:16:54you know how they can fill
• 01:16:56what they perceived to be.
• 01:16:58Some of the deaf deficits in their life.
• 01:17:01That is,
• 01:17:01with them to feel so distraught
• 01:17:03that they they often turn to drugs.
• 01:17:06So you know if we treat it
• 01:17:08like it's a formal disease,
• 01:17:10where you know if you had an ammonia,
• 01:17:13I could treat it.
• 01:17:14If you're in a coma, it's it's.
• 01:17:16Not like that.
• 01:17:18It's much more interactive,
• 01:17:19so so I think that talking about the
• 01:17:22extent to which people play a role
• 01:17:24in their circumstances is essential.
• 01:17:27Time for one last quick
• 01:17:29question from Joe Ficos.
• 01:17:33I'm really relieved how Joe could you
• 01:17:36speak up or get closer to your microphone.
• 01:17:40It's loud enough. I just barely.
• 01:17:43I think I just had IT working on this today.
• 01:17:47I think things went badly.
• 01:17:50Doctor Patel, can you hear me?
• 01:17:51I can hear you.
• 01:17:54I was I was actually relieved by
• 01:17:56the substance of your presentation
• 01:17:58after reading the title because
• 01:18:00I thought the view from abroad,
• 01:18:02the reference to abroad,
• 01:18:04that kind of echoing like Sean Patterson,
• 01:18:06was saying, I think speaks to some
• 01:18:09sort of at least implicit bias,
• 01:18:11East Coast or what not.
• 01:18:13And you didn't.
• 01:18:14I think you sounded very warm and sympathetic
• 01:18:17toward the folks from Ironton and region,
• 01:18:20but I wonder how they would feel if they.
• 01:18:24New York entitling the presentation that,
• 01:18:25oh, they showed us to them.
• 01:18:27They're fine with it.
• 01:18:30As an air of condescension,
• 01:18:31to refer to, small town did well.
• 01:18:34I think. I think only people
• 01:18:35in big towns see it that way.
• 01:18:37People in liberal,
• 01:18:38your major liberal universities
• 01:18:40and to see it that way anyway.
• 01:18:42But there's a lot of different variation.
• 01:18:44But to answer your question, no.
• 01:18:46In fact I wrote.
• 01:18:47I wrote a big article about them.
• 01:18:49I mean, I can make it available
• 01:18:51to folks who want to see it,
• 01:18:53and I had them read it first,
• 01:18:56and you know, they.
• 01:18:57I mean certainly and I said you could.
• 01:19:01I can take your name out or you know
• 01:19:04if if there's anything that you find,
• 01:19:07but it's interesting what this is
• 01:19:09echoing a little bit in some ways
• 01:19:12is the reaction to JD Vances book,
• 01:19:14which it was quite unpopular
• 01:19:16down there actually.
• 01:19:17And because you know they
• 01:19:19felt hillbilly Elegy.
• 01:19:20Of course,
• 01:19:21I'm talking about because they felt
• 01:19:23that he was somehow stereotyping,
• 01:19:25you know, the the the.
• 01:19:28Communities, but I mean,
• 01:19:30my view is that his that was
• 01:19:33his experience and.
• 01:19:35And I've, you know,
• 01:19:36heard him speak about that in in
• 01:19:39response to people accusing him of that.
• 01:19:42In fact,
• 01:19:42there's a there was a whole book of
• 01:19:45an anthology that was published to,
• 01:19:47essentially port portray a
• 01:19:49different aspect of Apple Acha,
• 01:19:50but one that was much more
• 01:19:53vibrant and people who are,
• 01:19:54you know,
• 01:19:55hardworking and very devoted to
• 01:19:57the communities and all this
• 01:19:59and and he was happy.
• 01:20:01To it, knowledge is thrilled that,
• 01:20:02yeah,
• 01:20:03that's just that's another facet
• 01:20:04of life down there,
• 01:20:05but his experience was what he wrote about.
• 01:20:10It's interesting their number
• 01:20:11of comments about this kind of
• 01:20:13general theme in in the in the
• 01:20:15comments, and I wish I could get to them.
• 01:20:18I touch something here and I've
• 01:20:20just been abandoned. I've been I've
• 01:20:21been excommunicated from the thing.
• 01:20:26We don't have time for those right right?
• 01:20:28I'm afraid we're out of time, but yeah,
• 01:20:31well, anyone can contact me. Yeah.
• 01:20:36Alright, well Sally, thank you.