15.6 Overdosed: SOLUTIONS to the current epidemic

[00:00:00] [SPEAKER_02]: Alright, I'm back for the sixth and final installment of my overdose series.

[00:00:05] [SPEAKER_02]: And today we're going to talk about proven and potential solutions to the overwhelmingly

[00:00:10] [SPEAKER_02]: tragic drug epidemic that's ravaging our country, killing hundreds of thousands of people every

[00:00:16] [SPEAKER_02]: year and debilitating millions more.

[00:00:21] [SPEAKER_00]: Somebody get this guy some help!

[00:00:31] [SPEAKER_02]: Now, some of the proposed solutions have a lot of evidence and logic behind their uses.

[00:00:38] [SPEAKER_02]: But oftentimes social factors and considerations can get in the way of communities accepting

[00:00:45] [SPEAKER_02]: a different way of approaching this problem.

[00:00:48] [SPEAKER_02]: Oftentimes there is a huge stigma that other people or other families struggle with addiction.

[00:00:55] [SPEAKER_02]: And sometimes it takes a direct experience with the loved one dying or becoming functionally

[00:01:03] [SPEAKER_02]: impaired as a result of their addiction to destigmatize it.

[00:01:07] [SPEAKER_02]: People who struggle with addiction ultimately can be viewed as lesser than, limiting the

[00:01:14] [SPEAKER_02]: number and availability of some of the resources that we'll discuss in today's episode.

[00:01:20] [SPEAKER_02]: The reality is that we're all addicted to something, whether it be an illicit drug or substance

[00:01:27] [SPEAKER_02]: like meth, heroin, pain pills that runs the risk of dying with each use.

[00:01:35] [SPEAKER_02]: Or a illicit substance like nicotine or alcohol or benzodiazepines in some states marijuana.

[00:01:43] [SPEAKER_02]: Prescription medication, some people are addicted to their phones and diverting attention away

[00:01:50] [SPEAKER_02]: from their internal experience.

[00:01:53] [SPEAKER_02]: Some people are addicted to power or sex or money or greed.

[00:01:57] [SPEAKER_02]: These are all things that ultimately make us feel better in the moment or in the short term.

[00:02:04] [SPEAKER_02]: But limit our ability to move towards the things that are ultimately meaningful or important

[00:02:12] [SPEAKER_02]: or valued to us in the long term.

[00:02:15] [SPEAKER_02]: All that to say we're way more alike to each other than we are different.

[00:02:23] [SPEAKER_02]: To speak to that fact is the data showing that nicotine and alcohol kill way more

[00:02:29] [SPEAKER_02]: people on an annual basis than the other drugs we've discussed.

[00:02:32] [SPEAKER_02]: Though most of these are chronic deaths from accumulated medical comorbidities and are not

[00:02:39] [SPEAKER_02]: associated with as many years of life loss.

[00:02:42] [SPEAKER_02]: The other drugs in brighter red colors are drugs that can kill instantly via overdose

[00:02:48] [SPEAKER_02]: and have been the focus of this series.

[00:02:54] [SPEAKER_02]: So when I graduated from high school in 2007, I didn't know what was afflicting my classmates.

[00:03:02] [SPEAKER_02]: I was not aware of this problem, but learned through the next decade that I lived near the

[00:03:08] [SPEAKER_02]: epicenter of the drug epidemic.

[00:03:10] [SPEAKER_02]: I saw football players, cross country runners, math leads and advanced program students,

[00:03:17] [SPEAKER_02]: people from different walks of life all getting addicted to opiates primarily and subsequently

[00:03:24] [SPEAKER_02]: other drugs.

[00:03:26] [SPEAKER_02]: This is a problem that as a society we've got to destigmatize.

[00:03:31] [SPEAKER_02]: Naturally more people being affected should lead to more empathy and sympathy for those

[00:03:36] [SPEAKER_02]: afflicted, but hopefully it doesn't take a majority of our nation to suffer the fallout

[00:03:42] [SPEAKER_02]: to have compassion for this population.

[00:03:47] [SPEAKER_00]: One of our basic approaches that we need to adjust in our medical training

[00:03:55] [SPEAKER_02]: and within outpatient services and in the emergency rooms is how we view addiction.

[00:04:03] [SPEAKER_02]: It is a chronic disease.

[00:04:05] [SPEAKER_02]: It needs to be looked at as a chronic disease.

[00:04:08] [SPEAKER_02]: And just like we would do what we could to optimally treat a hypertensive patient with

[00:04:15] [SPEAKER_02]: high blood pressure or a diabetic with high blood sugar, regardless of how compliant they've

[00:04:21] [SPEAKER_02]: been with treatment or how we feel about how they're living their lives and the choices that

[00:04:27] [SPEAKER_02]: they're making, we should be doing the same with addiction.

[00:04:30] [SPEAKER_02]: We need to offer all forms of treatment from primary prevention to tertiary,

[00:04:36] [SPEAKER_02]: take an approach of offering preventive treatment, giving acute treatment, chronic

[00:04:41] [SPEAKER_02]: treatment and also maintenance treatment after the person has achieved meaningful recovery.

[00:04:49] [SPEAKER_00]: Now, words certainly matter in this discussion.

[00:04:54] [SPEAKER_02]: And this piece isn't meant to make people resistant or feel uncomfortable.

[00:04:59] [SPEAKER_02]: It is a way and a slide that is emphasizing the fact that we need to humanize

[00:05:06] [SPEAKER_02]: the struggles that people in the throes of addiction face.

[00:05:11] [SPEAKER_02]: One prime example of that is in the word abuse or drug abuse.

[00:05:17] [SPEAKER_02]: Now, let's take a parallel where the word abuse is used appropriately in reference to domestic

[00:05:23] [SPEAKER_02]: or child abuse.

[00:05:25] [SPEAKER_02]: In those situations, the child, for example, is being abused by an abuser.

[00:05:32] [SPEAKER_02]: And there is a very negative connotation associated with the word abuse.

[00:05:38] [SPEAKER_02]: Now, with drug abuse, if you follow the same line of thinking, it seems that a person

[00:05:43] [SPEAKER_02]: is abusing a given substance and carries with it this connotation of punishment rather than treatment

[00:05:52] [SPEAKER_02]: when in reality, the drug is abusing that person in their health, not the other way around.

[00:06:00] [SPEAKER_02]: Similarly, the term addict dehumanizes somebody.

[00:06:06] [SPEAKER_02]: It insinuates that they are nothing more than their addiction,

[00:06:10] [SPEAKER_02]: throwing out their positive qualities or the negative or traumatic life experiences

[00:06:15] [SPEAKER_02]: that contribute to their struggle with the disease of addiction.

[00:06:20] [SPEAKER_02]: It also indicates some sense of permanence in that condition, that it is static and inherently

[00:06:27] [SPEAKER_02]: part of who they are without a likelihood of change.

[00:06:31] [SPEAKER_02]: So words are critically important in those first few minutes of approaching someone

[00:06:38] [SPEAKER_00]: suffering from an addiction.

[00:06:44] [SPEAKER_02]: So, look, it's hard to get ourselves, much less others, to change their behaviors.

[00:06:53] [SPEAKER_02]: There certainly must be internal motivation on the patient's part and a willingness

[00:07:00] [SPEAKER_02]: to experience some discomfort along the way.

[00:07:04] [SPEAKER_02]: But we cannot just focus on the individual approach.

[00:07:08] [SPEAKER_02]: Our approach to addiction must address all aspects of social, psychological, and biological function.

[00:07:17] [SPEAKER_02]: We need to understand the system that promotes addiction and work on every aspect,

[00:07:23] [SPEAKER_02]: from the individual's perspective and what they feel, to the interpersonal impact

[00:07:28] [SPEAKER_02]: and how their addiction affects those people related to an irregular contact with that individual,

[00:07:35] [SPEAKER_02]: positively or negatively.

[00:07:37] [SPEAKER_02]: We need to address the community changes and concessions that must be made to reduce

[00:07:42] [SPEAKER_02]: the taboo surrounding addiction and build these individuals back up,

[00:07:48] [SPEAKER_02]: as well as revamp our societal approaches to addiction,

[00:07:52] [SPEAKER_02]: incentivizing insurance companies to provide more coverage, promoting educational and prevention

[00:07:58] [SPEAKER_02]: programs, and maybe most importantly, change our policies of law enforcement, demonizing drug

[00:08:05] [SPEAKER_02]: use. The most relevant and harmful societal approach, in my opinion, was the quote-unquote

[00:08:12] [SPEAKER_02]: war on drugs, which really represented a war on drug users, incarcerating and punishing those

[00:08:21] [SPEAKER_02]: affected through the 1970s, 80s, 90s, and this still persists today.

[00:08:28] [SPEAKER_02]: We've got to help people reestablish their basic social and psychological needs.

[00:08:35] [SPEAKER_02]: Not just rely on medical or biologic treatment to help them improve.

[00:08:41] [SPEAKER_02]: It simply will not sustain them in their recovery in terms of the masses.

[00:08:47] [SPEAKER_02]: People need to be reintroduced to and feel support from their communities,

[00:08:54] [SPEAKER_02]: and if they don't have one, help them to find a community.

[00:09:00] [SPEAKER_02]: So let's start talking about some specific solutions, and we'll do so starting with

[00:09:08] [SPEAKER_02]: retracing the first wave of this evolution of the epidemic.

[00:09:13] [SPEAKER_02]: So it all started with an increase in the prescribing of addictive substances,

[00:09:18] [SPEAKER_02]: which by the way, we're still prescribing as many or more opiates,

[00:09:24] [SPEAKER_02]: benzos, and stimulants today as we were at the peak of the prescribing epidemic.

[00:09:31] [SPEAKER_02]: So this 2019 University of Michigan study is of 130,000 post-surgical patients

[00:09:39] [SPEAKER_02]: in three countries, the US, Sweden, and Canada.

[00:09:44] [SPEAKER_02]: These are all for minor surgical procedures, and what they show is that American post-surgical

[00:09:51] [SPEAKER_02]: providers are seven times more likely to prescribe an opioid within a week of discharge compared to

[00:09:59] [SPEAKER_02]: Sweden, and our average morphine equivalents that are prescribed after these surgeries are also

[00:10:05] [SPEAKER_02]: significantly higher than both Sweden and Canada. And as you can see, Canada also

[00:10:11] [SPEAKER_02]: is falling into the same trap that the United States has in terms of really relying,

[00:10:17] [SPEAKER_02]: over-relying on medication and not considering that long-term risk, more so just considering the

[00:10:25] [SPEAKER_02]: short-term reduction of pain and symptoms, and likely getting a little bit better patient

[00:10:32] [SPEAKER_02]: satisfaction score because of that short-term reduction or short-term helping the person

[00:10:41] [SPEAKER_02]: get away from that uncomfortable feeling, but again at the expense of long-term recovery and stability.

[00:10:49] [SPEAKER_02]: We in the United States routinely prescribe on average three to four times the recommendations

[00:10:56] [SPEAKER_02]: that you see on the right, which take into account the potential for addiction to develop with an

[00:11:10] [SPEAKER_02]: advanced data set and others is that the one-year and three-year probabilities of continued pain pill

[00:11:18] [SPEAKER_02]: usage among people who had never taken a pain pill until they were prescribed it post-surgically

[00:11:25] [SPEAKER_02]: increases drastically past a short-term five-day outpatient opioid prescription.

[00:11:32] [SPEAKER_02]: The risk of continued use at five days is a little bit less than 10% at one year,

[00:11:38] [SPEAKER_02]: which is still significant in a little bit less than 5% at three years, but for somebody who has

[00:11:44] [SPEAKER_02]: prescribed a 30-day supply, which is the most common prescription link, it reveals a risk of nearly 40%

[00:11:54] [SPEAKER_02]: of continued use at one year, 20% at three years. Even the risks of one year and three-year use

[00:12:02] [SPEAKER_02]: after five days are still 10 and 5%. I must point out again that these medications

[00:12:11] [SPEAKER_02]: desensitize the patient's pain receptors to the perception of pain. When they wear off,

[00:12:17] [SPEAKER_02]: it's like having the numbing medicine at the dentist wear off, a gradual increase in the

[00:12:23] [SPEAKER_02]: perception of pain until that opiate is completely out of the system. Long-term use of opiates

[00:12:30] [SPEAKER_02]: and opioids cause what is called hyperalgesia in the long-term or a increased sensitivity to pain.

[00:12:39] [SPEAKER_02]: They do not continue to work well for most people with chronic pain in the long-term,

[00:12:45] [SPEAKER_02]: similar to most people with chronic anxiety in the long-term on benzos.

[00:12:52] [SPEAKER_02]: They change people's brain to desire more of the addictive drug and alter their behavior

[00:12:59] [SPEAKER_02]: progressively over time. So, opiates are in an important class of medications. Have they

[00:13:09] [SPEAKER_02]: done more harm than good as a whole? I absolutely believe that. But do they have a legitimate medical

[00:13:15] [SPEAKER_02]: purpose? Absolutely. It's really important that we restrict those initial prescriptions to the

[00:13:23] [SPEAKER_02]: minimum amount needed to help post-surgical patients have early mobility to improve

[00:13:31] [SPEAKER_02]: to as close to their presurgical baseline of functioning as possible. These are some very

[00:13:37] [SPEAKER_02]: straightforward examples of ways to talk to patients about these risks and minimize their

[00:13:43] [SPEAKER_02]: risk of cultivating a lifelong addiction after having a minor surgical procedure like a knee

[00:13:49] [SPEAKER_02]: replacement or breast augmentation. So, education is paramount for prevention and to set the next

[00:13:58] [SPEAKER_02]: generation straight in terms of knowing all of the associated risks and the lack of long-term

[00:14:05] [SPEAKER_02]: benefits of these substances. But right now we also have millions of people who are beyond

[00:14:14] [SPEAKER_02]: the prevention stage that need help now. They've moved beyond just prescription pain or anxiety pills

[00:14:21] [SPEAKER_02]: to using illicit substances. And after the emergence of the second wave of the epidemic

[00:14:27] [SPEAKER_02]: involving heroin, a lot of people started using drugs intravenously. Now, what's the definition

[00:14:36] [SPEAKER_02]: of insanity? Well, it's doing the same thing over and over again and expecting different

[00:14:42] [SPEAKER_02]: results. We've got to start doing things differently with how we approach addiction and illicit drug

[00:14:50] [SPEAKER_02]: use, demonizing and incarcerating this population or shaming them into changing or offering an

[00:14:58] [SPEAKER_02]: abstinence only form of treatment. These are clearly not working. So maybe we should try

[00:15:06] [SPEAKER_02]: something different. Maybe we should shift our focus to reducing harm, meeting users where they're at

[00:15:14] [SPEAKER_02]: and clearly showing compassion to this population. First and foremost, we can't help people if

[00:15:23] [SPEAKER_02]: they're dead. So continuing to increase access to Narcan or Naloxone in opioid antagonists

[00:15:31] [SPEAKER_02]: that prevents opioids like Oxycontin and Fentanyl from binding to the opiate receptors

[00:15:37] [SPEAKER_02]: and causing the downstream effects like slowing and stopping breathing, leading to death by hypoxia

[00:15:44] [SPEAKER_02]: or not breathing is vitally important. Narcan can be administered intranasally by inserting it

[00:15:52] [SPEAKER_02]: deep into somebody who has overdosed nostril and pushing the lever to hopefully reverse the

[00:15:58] [SPEAKER_02]: overdose. Sometimes due to how powerful and potent fentanyl's effects are, you may need multiple

[00:16:05] [SPEAKER_02]: administrations. The actual dose in each Narcan has increased drastically in the last several

[00:16:11] [SPEAKER_02]: years due to the increased potency of opiates in our environment. Because Narcan kicks fentanyl

[00:16:19] [SPEAKER_02]: off the opiate receptors, don't be surprised if the overdose person comes back to consciousness

[00:16:24] [SPEAKER_02]: and is irritable or angry. The last thing they remember is being high and euphoric.

[00:16:29] [SPEAKER_02]: They didn't consciously experience the slowing or even stopping of their breathing.

[00:16:36] [SPEAKER_02]: Next thing you know, you're waking them up and they're thrown immediately into opioid withdrawal.

[00:16:42] [SPEAKER_02]: These reversal agents that don't produce any sort of euphoric effects need to be much more

[00:16:49] [SPEAKER_02]: widely available in gas stations, convenience stores, obviously in pharmacies and health centers,

[00:16:56] [SPEAKER_02]: etc., etc. At an extremely cheap if not free cost, I always tell my patients who don't struggle

[00:17:04] [SPEAKER_02]: with addiction, pick up a two pack of Narcan because it would be a shame to have the chance

[00:17:10] [SPEAKER_02]: to save somebody's life but not have the reversal agent on hand. Okay so before we get to some

[00:17:17] [SPEAKER_02]: a little bit more polarizing issues, let's discuss another one that's pretty uniformly agreed upon

[00:17:23] [SPEAKER_02]: as a protective measure in treating addictions and so important with the amount of contamination

[00:17:30] [SPEAKER_02]: in our drug supply. That's the use of FT-Ss or fentanyl test strips. So these are

[00:17:39] [SPEAKER_02]: straightforward right? Person, people who are using any substance because of the amount of

[00:17:45] [SPEAKER_02]: contamination in every illicit drug can use this to decipher beforehand if there's any fentanyl in it

[00:17:55] [SPEAKER_02]: which is the main cause of people dying in overdoses. So there was a study of 93 young persons

[00:18:05] [SPEAKER_02]: who inject drugs that were given fentanyl test strips in Rhode Island. They had 81 that returned

[00:18:12] [SPEAKER_02]: for follow-up and of those 81 62 had used at least one fentanyl test strip with half of them finding

[00:18:21] [SPEAKER_02]: fentanyl in their drug supply at least once. Of all 81 participants that used fentanyl test strips,

[00:18:30] [SPEAKER_02]: 79 out of 81 or 98 percent of them reported competence in their ability to use them

[00:18:37] [SPEAKER_02]: and 77 or 95 percent wanted to use them in the future. Another North Carolina study found similar

[00:18:46] [SPEAKER_02]: results with 81 percent of 125 people who inject drugs being willing to use fentanyl test strips.

[00:18:54] [SPEAKER_02]: 43 percent of them reported positive changes in their drug use and 77 percent felt an increased

[00:19:01] [SPEAKER_02]: sense of safety by using them. Now if you are using drugs intravenously and in one scenario

[00:19:11] [SPEAKER_02]: you're chased down, arrested, and taken to jail for using a drug where you may go into

[00:19:18] [SPEAKER_02]: floor drug withdrawal even when you're not harming anybody but yourself versus the second

[00:19:25] [SPEAKER_02]: scenario where a nice person goes out of their way to help you reduce risk associated with drug

[00:19:33] [SPEAKER_02]: use. They show compassion instead of judgment and being derogatory and dehumanizing. Which

[00:19:42] [SPEAKER_02]: one do you think is more likely to lead to your recovery? Look I'm not saying that everybody

[00:19:49] [SPEAKER_02]: struggling with addiction can be helped but I think it is my job, it is our job to try to help

[00:19:57] [SPEAKER_02]: everybody. But this is just such a common sense and simple way of reducing harm in this population.

[00:20:05] [SPEAKER_02]: All right now let's stir up some controversy and talk about a couple other harm reduction measures,

[00:20:12] [SPEAKER_02]: needle exchange programs and overdose protection centers also known as supervised

[00:20:18] [SPEAKER_02]: injection sites or facilities. According to 2022 CDC data on syringe services programs

[00:20:29] [SPEAKER_02]: as well as a 2014 international journal of epidemiology article on rates of HIV transmission

[00:20:37] [SPEAKER_02]: as well as another 2017 HIV prevention study these needle exchange programs where somebody

[00:20:46] [SPEAKER_02]: injecting drugs can go and give their old needles, all their their used needles as well as get new

[00:20:56] [SPEAKER_02]: fresh unused needles led to a nearly 50% local reduction in HIV transmission. We'll look at

[00:21:05] [SPEAKER_02]: Portugal's situation in a little bit, a country that has legalized and regulated decriminalize all drugs

[00:21:13] [SPEAKER_02]: and how that has impacted a huge reduction in Portugal's HIV transmission. But not only does

[00:21:22] [SPEAKER_02]: this create a clear and logical way to reduce the transmission of infectious viruses like HIV

[00:21:30] [SPEAKER_02]: and hepatitis C, it also brings users in contact with health care workers and public health workers

[00:21:38] [SPEAKER_02]: on a regular basis. They can hand out education on how to further reduce harm, they can provide

[00:21:46] [SPEAKER_02]: access to adequate medical care, they can give condoms other forms of STD and pregnancy

[00:21:52] [SPEAKER_02]: prevention out, they can recommend again medical assessments when needed but

[00:22:01] [SPEAKER_02]: every time that somebody interacts with these systems or programs it's another chance for them

[00:22:08] [SPEAKER_02]: to be convinced to seek out more intensive treatment for their addiction. Now this harm

[00:22:17] [SPEAKER_02]: reduction strategy, supervised injection sites overdose prevention centers probably sounds a

[00:22:23] [SPEAKER_02]: little bit better. It really gets people up in arms but it has evidence of being more effective

[00:22:30] [SPEAKER_02]: in the long-term reduction of harm and overall illicit drug use. OPCs which were initially

[00:22:38] [SPEAKER_02]: called supervised injection sites or facilities can be really helpful in our fight against

[00:22:46] [SPEAKER_02]: this drug epidemic. This picture that you see here is one of two recently opened overdose protection

[00:22:54] [SPEAKER_02]: centers in New York City by a nonprofit organization called On Point. It allows people to use their

[00:23:02] [SPEAKER_02]: drugs using a checklist to notify the available providers of what they're using in case they

[00:23:08] [SPEAKER_02]: have complications. It represents an alternative to using on the street, the sidewalk between

[00:23:15] [SPEAKER_02]: cars under a bridge in other unsafe areas and it also allows somebody to use and not break my

[00:23:23] [SPEAKER_02]: number one rule of safer drug use. Don't use drugs alone. These OPCs or supervised injection sites

[00:23:32] [SPEAKER_02]: have existed around the world for a long time. Several past studies have shown that they improve

[00:23:38] [SPEAKER_02]: local outcomes. They reduce local overdose deaths, they reduce health care costs,

[00:23:44] [SPEAKER_02]: they reduce the use of emergency rooms and subsequent hospital stays, reduce public drug use,

[00:23:50] [SPEAKER_02]: infectious diseases from non-sterile needles, reduce the amount of unused syringes or used

[00:23:56] [SPEAKER_02]: syringes that could litter and theoretically infect a non-user not paying attention that

[00:24:03] [SPEAKER_02]: takes a wrong step probably while entranced by their device on their way to work, on their way to dinner.

[00:24:09] [SPEAKER_02]: These facilities also provide testing for the drugs prior to use and ensure clean needle use

[00:24:15] [SPEAKER_02]: and appropriate skin cleaning prior to the injection reducing theoretically the risk of

[00:24:20] [SPEAKER_02]: endocarditis or heart infection. These sites have shown promising results in major metropolitan

[00:24:29] [SPEAKER_02]: areas for nearly 25 years with Vancouver Canada's insight, one of the first in the world when they

[00:24:40] [SPEAKER_02]: opened in 2003 showing a 35% reduction in fatal overdose rate over four years in areas within

[00:24:48] [SPEAKER_02]: a quarter mile of the site compared to a 9% reduction over the same time period in the rest

[00:24:54] [SPEAKER_02]: of Vancouver. In Sydney, Australia at one of their supervised injection facilities the number

[00:25:02] [SPEAKER_02]: of monthly ambulance calls related to overdose decreased by 80%. Importantly, none of the studies

[00:25:10] [SPEAKER_02]: in a major systematic review of these centers showed any overdose deaths. San Francisco facility

[00:25:17] [SPEAKER_02]: that was open for a little less than a year until unwarranted public backlash shut it down

[00:25:24] [SPEAKER_02]: showed that over 10,000 drug injections only 33 opioid related overdoses occurred on site.

[00:25:31] [SPEAKER_02]: All of those were reversed with naloxone or Narcan with nobody dying and nobody even having

[00:25:38] [SPEAKER_02]: to be transferred to a medical facility. Contrary to critics beliefs there were not

[00:25:44] [SPEAKER_02]: increases in crime there was not increases in total number of persons using drugs or in drug

[00:25:51] [SPEAKER_02]: use related public nuisances. There were positive associations of visiting the site with a 1.4

[00:26:00] [SPEAKER_02]: to 1.7 times increased likelihood of the person using entering a detox program or an addiction

[00:26:06] [SPEAKER_02]: treatment program compared with those who use drugs but visited overdose protection centers

[00:26:13] [SPEAKER_02]: infrequently or not at all. In the bottom line is we don't view things like dialysis

[00:26:21] [SPEAKER_02]: which is essentially an external kidney that people rely on when their kidneys fail.

[00:26:28] [SPEAKER_02]: We don't view dialysis the same way as addiction even though that condition

[00:26:33] [SPEAKER_02]: like most other major medical conditions and complications oftentimes have a component

[00:26:39] [SPEAKER_02]: or sometimes are directly tied to poor lifestyle choices. We don't restrict treatment we don't shut

[00:26:46] [SPEAKER_02]: down dialysis centers because patients are not abiding by their doctor's diet and activity

[00:26:52] [SPEAKER_02]: recommendations or medic or not taking their medications nor do we do that with other chronic

[00:26:57] [SPEAKER_02]: diseases why should addiction be any different? Next on the list of harm reduction measures is

[00:27:06] [SPEAKER_02]: another hot topic the use of MAT or medication assisted treatment. So while vivitrol or naltrexone

[00:27:16] [SPEAKER_02]: which is a monthly injectable version of naloxone or Narcan is a very viable and an ideal MAT option

[00:27:25] [SPEAKER_02]: for opioid use disorder that severely limits the potential for fatal overdose

[00:27:32] [SPEAKER_02]: most opioid users know that it will send them into withdrawal they may not be willing to engage with

[00:27:38] [SPEAKER_02]: treatment via this route. Vivitrol or naltrexone is a direct opiate antagonist it will kick off

[00:27:47] [SPEAKER_02]: other opiates occupying those opiate receptors and send the person into withdrawal. Again very

[00:27:54] [SPEAKER_02]: very safe there's no opiate in it it's an ideal option but it may not be something that the patient

[00:28:03] [SPEAKER_02]: is willing to do and that's where other medication assisted treatment options come into the fold.

[00:28:10] [SPEAKER_02]: The most well-known historical opioid MAT is methadone however i'm not a huge fan in i'll

[00:28:19] [SPEAKER_02]: tell you why methadone is what's called a full agonist at the opiate receptors people regularly

[00:28:27] [SPEAKER_02]: fatally overdose on methadone by itself with more than 55 000 deaths between 2007 and 2021

[00:28:37] [SPEAKER_02]: according to an addiction research retrospective administrative data study in england and wales

[00:28:44] [SPEAKER_02]: assessing nearly 20 million MAT prescriptions of methadone or buprenorphine aka suboxone or one of the

[00:28:53] [SPEAKER_02]: two components of suboxone um it's so 20 million MAT prescriptions and 2400 deaths in a six-year

[00:29:03] [SPEAKER_02]: period between 2007 and 2012 there were 2366 methadone related deaths in only 52 buprenorphine

[00:29:14] [SPEAKER_02]: related deaths now there was a lot more people on methadone than buprenorphine but still the

[00:29:20] [SPEAKER_02]: relative risk of death on those medications was six times higher with methadone than it was

[00:29:28] [SPEAKER_02]: buprenorphine methadone may be more effective at keeping patients in treatment potentially because

[00:29:35] [SPEAKER_02]: buprenorphine has what's called a sealing effect which we'll discuss in a second but i think the

[00:29:40] [SPEAKER_02]: risk overall is much higher with methadone and buprenorphine is in my opinion the much safer

[00:29:47] [SPEAKER_02]: option or better said suboxone the combination of buprenorphine and naloxone is a much better

[00:29:55] [SPEAKER_02]: option in a marion county indiana study which includes indianapolis of nearly 2400 overdose

[00:30:05] [SPEAKER_02]: deaths only 55 involved buprenorphine and of those 51 of them had heavy involvement of other

[00:30:14] [SPEAKER_02]: illicit drugs and remember benzo diazepines are one way that buprenorphine can kill people

[00:30:22] [SPEAKER_02]: if it is combined with a benzo the four other deaths were attributed to buprenorphine

[00:30:30] [SPEAKER_02]: and liver failure or diabetic ketoacidosis benzos were present in 24 of the 55 buprenorphine

[00:30:39] [SPEAKER_02]: related deaths and fentanyl in 51 of them and this is the reason why suboxone is safer

[00:30:48] [SPEAKER_02]: um buprenorphine is a unique opiate because it's what's called a partial agonist at the

[00:30:57] [SPEAKER_02]: opiate receptors uh what that means is it limits its ability to cause respiratory depression

[00:31:05] [SPEAKER_02]: again that may go out the window when it's combined with a benzo but therefore the overdose

[00:31:10] [SPEAKER_02]: on buprenorphine by itself will not stop someone's breathing because of this sealing effect

[00:31:17] [SPEAKER_02]: uh only occupying at most a little bit more than 80 percent of opiate receptors

[00:31:23] [SPEAKER_02]: and blocking the others from being bound by fentanyl and other opiates therefore they won't

[00:31:30] [SPEAKER_02]: die from just their medication assisted treatment alone and if they slip up and use something

[00:31:37] [SPEAKER_02]: like oxy cotton or heroin or fentanyl uh or has something with fentanyl in it it will not have

[00:31:43] [SPEAKER_02]: an effect because it's blocked out and then those other opiates are eliminated without the person

[00:31:49] [SPEAKER_02]: feeling the high from it or more importantly running the risk of dying from it the inactive

[00:31:55] [SPEAKER_02]: naloxone component is only in there if the person tries to melt the drug down and inject it

[00:32:02] [SPEAKER_02]: activating the opioid antagonist portion uh of naloxone now as with everything on this

[00:32:09] [SPEAKER_02]: podcast i try to appreciate the nuance and offer both sides to the stories i tell so there is a dark

[00:32:17] [SPEAKER_02]: side to suboxone for one because it binds so strongly to the opiate receptors and doesn't

[00:32:25] [SPEAKER_02]: allow fentanyl and other synthetic opioids to bind even when it is inactivating in opiate

[00:32:31] [SPEAKER_02]: receptor uh this means that suboxone has a nasty withdrawal similar to the stickier a band-aid

[00:32:38] [SPEAKER_02]: is and the longer it's been attached to your skin the more it's going to hurt when you pull off

[00:32:43] [SPEAKER_02]: so coming off of suboxone has to be done carefully and ideally slowly over time but

[00:32:52] [SPEAKER_02]: the risk of dying for semi-injecting drugs or using fentanyl is extremely high

[00:32:57] [SPEAKER_02]: coming out of a treatment program so this medicine certainly has utility

[00:33:04] [SPEAKER_02]: but the other factor that goes into this conversation is to have an appreciation for

[00:33:11] [SPEAKER_02]: how a business person in the business side of suboxone can operate at many of these recovery

[00:33:18] [SPEAKER_02]: facilities there is a lot of money and a consistent monthly patient population to be had in the

[00:33:26] [SPEAKER_02]: field of addiction you are replacing one addictive substance with a much safer

[00:33:32] [SPEAKER_02]: but still somewhat addictive substance and mandating that the person be seen every two to

[00:33:39] [SPEAKER_02]: four weeks to continue treatment again that is not so bad in the short term but maybe several

[00:33:45] [SPEAKER_02]: months to years out it may be best to give the person options um to come off of that medication

[00:33:53] [SPEAKER_02]: but it that may not be for everybody either so there are financial incentives to keep people

[00:33:58] [SPEAKER_02]: on MAT for as long as possible and there's researchers directly profiting from more

[00:34:05] [SPEAKER_02]: people being maintained on higher dosages of suboxone this graph shows why I have some skepticism

[00:34:12] [SPEAKER_02]: about the routine recommendations and medication regimens that I've seen keeping patients on 16

[00:34:19] [SPEAKER_02]: and sometimes even 24 milligrams of buprenorphine while this graph is not uniform to every

[00:34:26] [SPEAKER_02]: opioid user it provides a guideline for how much protection you get at each dose of suboxone

[00:34:33] [SPEAKER_02]: and reveals that doses of 8 to 10 milligrams are pretty close to as protective against overdose

[00:34:41] [SPEAKER_02]: as doses of 12 to 32 milligrams unfortunately with suboxone that benefit maxes out around 12 to

[00:34:50] [SPEAKER_02]: 16 milligrams of a total daily dose but the side effects most relevantly sedation and constipation

[00:34:58] [SPEAKER_02]: continue to increase as the dosage increases so no more protection but increased side effects

[00:35:06] [SPEAKER_02]: to me the question is not suboxone or no suboxone it is how long should somebody be on

[00:35:15] [SPEAKER_02]: suboxone again if they're not willing to go the vivitrol or the now trek zone route

[00:35:21] [SPEAKER_02]: the answer is nuance so the risk of death in those discontinuing their suboxone within three months

[00:35:29] [SPEAKER_02]: is reportedly pretty high nearly three to six times the risk of those remaining on suboxone

[00:35:35] [SPEAKER_02]: which makes sense based on how it works and the risk of fatal overdose without it but there

[00:35:41] [SPEAKER_02]: is not good and clear literature on longer term risks and or how to best taper and maintain sobriety

[00:35:50] [SPEAKER_02]: it's very reasonable to keep somebody on suboxone for three to six months especially if they were

[00:35:57] [SPEAKER_02]: previously injecting heroin or fentanyl directly into their bloodstream and this measure can be

[00:36:03] [SPEAKER_02]: very effective at reducing harm ideally we would get more people to transition to the long

[00:36:09] [SPEAKER_02]: acting antagonist vivitrol but this is not highly desirable to patients who must go through the

[00:36:15] [SPEAKER_02]: withdrawal process in order to take vivitrol there's also a significant protective effect of

[00:36:21] [SPEAKER_02]: buprenorphin at lower doses prolonged tapers after long periods of sobriety with re-initiation

[00:36:28] [SPEAKER_02]: or re-increase of the dose if the patient uses are very reasonable options i would never

[00:36:35] [SPEAKER_02]: force somebody off of their suboxone or try to pigeonhole them into one form of treatment

[00:36:40] [SPEAKER_02]: but the reality is that this is a 14 plus billion dollar market globally and keeping people in

[00:36:48] [SPEAKER_02]: supportive community and social programs without suboxone is not nearly as lucrative as with

[00:36:55] [SPEAKER_02]: as with most things in american medicine we've got to prioritize the patient's progress

[00:37:03] [SPEAKER_02]: over the financial incentives of the company or companies that create and distribute these tools

[00:37:10] [SPEAKER_02]: and we've got to individualize our treatment to each specific patient taking into account

[00:37:18] [SPEAKER_02]: their goals of treatment in summary suboxone is a novel and very safe mat option that is

[00:37:27] [SPEAKER_02]: important in preventing people from dying while in the especially the initial

[00:37:31] [SPEAKER_02]: throws of addiction and recovery it's not a zero risk but it is so much damn safer than methadone

[00:37:38] [SPEAKER_02]: and if people are diverting it to the street which has been a thing that i've heard several

[00:37:43] [SPEAKER_02]: times in the last decade about suboxone who cares it blocks the effects of stronger opioids

[00:37:50] [SPEAKER_02]: like fentanyl it may be saving lives whether it's prescribed or not and by the way

[00:37:58] [SPEAKER_02]: people who use or inject drugs the vast majority of them know what the effects of suboxone are

[00:38:06] [SPEAKER_02]: based on illicit users reports they're typically trying to self-treat and maybe

[00:38:12] [SPEAKER_02]: they're not willing and i don't blame them to engage or intersect with the health care system

[00:38:17] [SPEAKER_02]: for some of the reasons that i've mentioned before on this podcast and in the last couple of slides

[00:38:22] [SPEAKER_02]: they maybe fear the system will take advantage of their strife people need to be given options

[00:38:29] [SPEAKER_02]: suboxone is not without risks and it's not without business persons including the us government

[00:38:36] [SPEAKER_02]: having a stake in suboxone and providers with ulterior motives promoting routine visits to

[00:38:44] [SPEAKER_02]: clinics that kind of start to look awfully similar to the oxy cotton pill mills that started this mess

[00:38:52] [SPEAKER_02]: in the first place patients who decide to start on suboxone should be given options at every encounter

[00:38:59] [SPEAKER_02]: it should be a shared decision-making process and like with most psychiatric drugs there should be

[00:39:06] [SPEAKER_02]: long-term taper options when they start feeling more comfortable in their addictions

[00:39:11] [SPEAKER_02]: and they should be counseled to not just abruptly stop taking suboxone go into severe withdrawal

[00:39:20] [SPEAKER_02]: and then much more likely at that stage to seek out an illicit opiate

[00:39:28] [SPEAKER_02]: so i had to put a couple of slides on this this is one of my pet peeves in psychiatry

[00:39:37] [SPEAKER_02]: and especially in addiction treatment probably the reason why i'm having a hard time remaining employed

[00:39:44] [SPEAKER_02]: at multiple different profit for-profit addiction facilities or companies it's my reticence to

[00:39:52] [SPEAKER_02]: engage in polypharmacy and maybe my outright attacks on how polypharmacy is not helping our patients

[00:40:00] [SPEAKER_02]: more simply stated i'm not trying to replace an addiction to illicit substances with an addiction

[00:40:08] [SPEAKER_02]: to a bunch of prescribed substances so at many of these addiction treatment facilities especially

[00:40:15] [SPEAKER_02]: seemingly in my area patients have many withdrawal related complaints and the answer

[00:40:23] [SPEAKER_02]: too often is to medicate away every aspect of withdrawal again we've got to ride a moderate

[00:40:34] [SPEAKER_02]: line with this um the this doesn't allow the patient to experience some of the needed discomfort

[00:40:43] [SPEAKER_02]: of withdrawal which should be emphasized as an important part of the healing process

[00:40:49] [SPEAKER_02]: but it also puts them directly in danger sometimes in more danger acutely than the

[00:40:55] [SPEAKER_02]: illicit drug did regularly patients are met at the door of the treatment facility with a long

[00:41:01] [SPEAKER_02]: list of withdrawal medications paired with any home medications that looks to be a mile long

[00:41:08] [SPEAKER_02]: i shit you not i have seen dozens of patients with psych only prescription drug regimens

[00:41:16] [SPEAKER_02]: including 10 different psychotropic medications this is not effective treatment there are all

[00:41:25] [SPEAKER_02]: kinds of articles research and information about the harms of polypharmacy in general

[00:41:32] [SPEAKER_02]: which are magnified in the population using illicit substances you can be the best

[00:41:39] [SPEAKER_02]: pharmacologist the best psychopharmacologist in the world and there's no way you can understand

[00:41:46] [SPEAKER_02]: and predict every different drug-drug interaction when you start getting into that many medications

[00:41:56] [SPEAKER_02]: this is an actual medication regimen that i came into one day while working in southern

[00:42:03] [SPEAKER_02]: indiana at a facility that provides addiction treatment inpatient i wish i could say this was

[00:42:11] [SPEAKER_02]: the exception but it seemed that 20 to 40 percent of the patient population was coming in on at

[00:42:18] [SPEAKER_02]: least five psychiatric medications uh or was was by the time their discharge was on at least

[00:42:25] [SPEAKER_02]: five psychiatric medications on admission there was what i call idiot medicine idiot

[00:42:31] [SPEAKER_02]: addiction medicine idiot psychiatry whatever you want to call it being practiced where lazy

[00:42:36] [SPEAKER_02]: practitioners followed company guidelines or policy when they got an admission call starting

[00:42:42] [SPEAKER_02]: every prn or as needed medication without even looking at the characteristics of each individual

[00:42:50] [SPEAKER_02]: admission i'm talking about starting uh ibuprofen on somebody with kidney failure or or non

[00:42:57] [SPEAKER_02]: not a fully functioning kidney i'm talking about somebody who's got liver enzymes severely elevated

[00:43:04] [SPEAKER_02]: and starting them on Tylenol for pain relief just clicking a button instead of looking at

[00:43:11] [SPEAKER_02]: the characteristics of each individual admission including their age in medical comorbidities

[00:43:18] [SPEAKER_02]: whether they're actually taking the medications they say they're taking by looking at a pharmacy

[00:43:23] [SPEAKER_02]: fill record um looking at what drugs elicit drugs they've recently used and thinking whether or not

[00:43:30] [SPEAKER_02]: any of that is still in their system aka not critically thinking for one second about not

[00:43:38] [SPEAKER_02]: just the short term implications but also the long-term implications of these polypharmacy

[00:43:44] [SPEAKER_02]: regimens one day i came in to find an older woman coming off of fentanyl oxycontin pain pills

[00:43:54] [SPEAKER_02]: containing fentanyl elicitly for less than 24 hours having been given multiple sedative hypnotics

[00:44:02] [SPEAKER_02]: along with multiple other psychotropic drugs and at the time when i saw her at first she was

[00:44:09] [SPEAKER_02]: confined to a wheelchair she was unable to participate in an interview with me her blood

[00:44:14] [SPEAKER_02]: pressures were dropping below 80 she was nodding out um so she actually ended up having to get a

[00:44:23] [SPEAKER_02]: little bit uh extra evaluation um within a few days of significantly reducing this polypharmacy

[00:44:33] [SPEAKER_02]: regimen she was able to participate in the program she was able to walk without any sort of ambulatory

[00:44:41] [SPEAKER_02]: aid she was a completely different person um let's look at one of the reasons why we cannot be so

[00:44:50] [SPEAKER_02]: cavalier in treating every symptom a person struggling with addiction and recovery complains

[00:44:57] [SPEAKER_02]: of while they're in withdrawal and by the way please resist the urge to think that i'm

[00:45:03] [SPEAKER_02]: saying no drugs should be used in treating symptoms of withdrawal i'm just pleading with providers and

[00:45:09] [SPEAKER_02]: companies employing them to think about the potential harm they're doing with these protocols

[00:45:14] [SPEAKER_02]: and procedures that lead to short term um avoidance of discomfort and also probably lead to

[00:45:24] [SPEAKER_02]: improvement in patient satisfaction scores while they're at the facility this is not

[00:45:29] [SPEAKER_02]: at all a comprehensive list of what are called c y p interactions this just shows the ones involving

[00:45:37] [SPEAKER_02]: psychiatric drugs c y p is a set of liver enzymes that helps to metabolize drugs and substances

[00:45:46] [SPEAKER_02]: as you can see there are drugs that inhibit and induce the metabolism of different substrates

[00:45:53] [SPEAKER_02]: if somebody uses fentanyl which is as you can see here metabolized by c y p 3 a 4

[00:46:01] [SPEAKER_02]: and they are also on paxil um or they are on prozac or certain antibiotics or certain

[00:46:09] [SPEAKER_02]: antifungal treatments relatively common for people seeking help with their addictions if they have

[00:46:15] [SPEAKER_02]: any sort of std or i've had multiple patients with fungal infections that may prevent that person's

[00:46:23] [SPEAKER_02]: liver from being able to detoxify the fentanyl and they may also have damage to their liver

[00:46:28] [SPEAKER_02]: coming in already this can lead to a buildup and a much greater risk of death from respiratory

[00:46:34] [SPEAKER_02]: depression alternatively other opiates may build up with co-administration of more commonly

[00:46:40] [SPEAKER_02]: known meds like again prozac well butrin or bupropion hydroxazine or visteril often used to treat

[00:46:49] [SPEAKER_02]: acute anxiety or antivirals like retonavir and hiv treatment which again is much more prevalent

[00:46:57] [SPEAKER_02]: in this community than the general population we cannot help somebody in their recovery if we

[00:47:04] [SPEAKER_02]: kill them via over treatment during their withdrawal now not only does this poly pharmacy

[00:47:12] [SPEAKER_02]: approach carry significant short-term risks it's also in direct opposition to one of the fundamental

[00:47:19] [SPEAKER_02]: psychological problems or root cause of addiction the focus on relieving or moving away from

[00:47:27] [SPEAKER_02]: short-term discomfort at the expense of moving towards things that are important

[00:47:31] [SPEAKER_02]: and meaningful to the person in the long term i try to show this to every patient who's in a

[00:47:37] [SPEAKER_02]: position to hear it early in their recovery you can break down this chart the bottom is

[00:47:44] [SPEAKER_02]: the internal experience the top is the external experience moving to the right is things that

[00:47:50] [SPEAKER_02]: the person does behavior wise moving towards what's important to them and moving to the left

[00:47:55] [SPEAKER_02]: is things behavior wise the person does moving away from things that are uncomfortable to them

[00:48:01] [SPEAKER_02]: addiction starts in the bottom left corner it starts with the mind and that animal brain part

[00:48:07] [SPEAKER_02]: of us that makes us experience intrusive thoughts or emotional reactions to things that can be

[00:48:13] [SPEAKER_02]: unpleasant or unwanted we don't have control over making these things go away they insert

[00:48:19] [SPEAKER_02]: into our stream of consciousness without asking this can easily lead to a natural

[00:48:26] [SPEAKER_02]: and reactionary behavior of getting away from that internal discomfort via external means

[00:48:32] [SPEAKER_02]: such as using drugs or alcohol again this is not just limited to drugs and alcohol

[00:48:38] [SPEAKER_02]: this is something we all struggle with to some degree it may be your phone it may be a video

[00:48:44] [SPEAKER_02]: game maybe it's work uh with obviously varying degrees of complications that can occur based

[00:48:51] [SPEAKER_02]: on whatever it is you're using externally to avoid but it is a struggle with our internal experience

[00:49:01] [SPEAKER_02]: or our mind fundamentally we're dealing with the same problem we can find ourselves living

[00:49:07] [SPEAKER_02]: in a cycle of avoidance on the left side of this graph we need to emphasize how to hack into

[00:49:15] [SPEAKER_02]: and better understand our own minds in our approach to addiction taking intrusive thoughts

[00:49:22] [SPEAKER_02]: and emotions and stripping them of their content and instead trying to understand why we have those

[00:49:29] [SPEAKER_02]: thoughts or feelings or emotions what is the intention behind them as opposed to hyper

[00:49:35] [SPEAKER_02]: focusing on what is said or felt to help that more conscious frontal lobe part of us

[00:49:42] [SPEAKER_02]: use those intrusive thoughts feelings and emotions to have a better idea of what is important to me

[00:49:49] [SPEAKER_02]: to us internally what do we value in different facets of life and then and only then use those

[00:49:58] [SPEAKER_02]: values in the bottom right corner to guide our specific goals or actions withdrawal is a micro

[00:50:07] [SPEAKER_02]: cause of that very idea and people fighting addiction need to understand it is a fight we need

[00:50:15] [SPEAKER_02]: to find ways to embrace some short-term discomfort in the journey so that we can promote long-term

[00:50:22] [SPEAKER_02]: stability and meaningful living um so we've got to do a better job of tailoring treatment

[00:50:31] [SPEAKER_02]: to more specific populations within substance use disorders and meeting people where they're at

[00:50:38] [SPEAKER_02]: individualizing treatment there is no one cookie cutter approach to treating addiction it is a super

[00:50:46] [SPEAKER_02]: complex multifactorial disease the person's biologic or genetic profile including underlying

[00:50:54] [SPEAKER_02]: mental illnesses or factors that affect their intellectual functioning or their ability to

[00:50:58] [SPEAKER_02]: communicate effectively it includes past life experiences commonly trauma in the substance

[00:51:05] [SPEAKER_02]: use populations and some of the traumas people can't even imagine what somebody who is struggling

[00:51:13] [SPEAKER_02]: with heroin addiction some of the things that they've been through in life so many of us just

[00:51:18] [SPEAKER_02]: don't get it and we may not even be in the position there and if we had gone through those

[00:51:24] [SPEAKER_02]: same things we're talking about current social influences that have to be taken into account

[00:51:30] [SPEAKER_02]: in formulating treatment plans this chart separates patients struggling with addiction

[00:51:36] [SPEAKER_02]: into three overarching categories those not seeking care with treatment recommendations focusing on

[00:51:43] [SPEAKER_02]: harm reduction and safer use those seeking out care to help reduce their use or find

[00:51:50] [SPEAKER_02]: alternatives to using and active users trying for control via medication assisted treatment

[00:51:57] [SPEAKER_02]: or abstinence there's no stigmatization in this chart for those not wanting to get sober but this

[00:52:04] [SPEAKER_02]: is a great example of treatment meeting users where they're at and taking their treatment goals

[00:52:10] [SPEAKER_02]: into account sometimes users in the throes of addiction and also sometimes just people in

[00:52:17] [SPEAKER_02]: general who have experienced traumatic upbringings or experiences can be rude and downright nasty

[00:52:24] [SPEAKER_02]: our job is to not be offended not take it personally but to find the right column

[00:52:32] [SPEAKER_02]: and try to help them engage in treatment in whatever way they're willing to do so

[00:52:40] [SPEAKER_02]: so these are just a few ways to start to stem the tide of the drug epidemic in this country

[00:52:47] [SPEAKER_02]: ultimately i think these are other critically important aspects of our overall approach

[00:52:53] [SPEAKER_02]: to addiction this series is trying to decrease stigma trying to increase awareness of just how

[00:53:00] [SPEAKER_02]: bad this problem is and also educate users as well as the general public in order to prevent

[00:53:09] [SPEAKER_02]: harm from occurring it's so important that we start holding pharmaceutical companies

[00:53:15] [SPEAKER_02]: distributors pharmacies physicians publicly accountable for their poor financially motivated

[00:53:23] [SPEAKER_02]: choices as too often including with Purdue pharma as well as the makers of ssri antidepressants

[00:53:33] [SPEAKER_02]: these companies when faced with a lawsuit for a bad outcome or outcomes force plaintiffs to sign

[00:53:40] [SPEAKER_02]: nda's or non-disclosure agreements as a prerequisite for getting their settlement money this is done

[00:53:48] [SPEAKER_02]: separate or independently from the legal system it prevents the general public from having access

[00:53:54] [SPEAKER_02]: to the details of those cases if we the american public knew more of the details more people

[00:54:04] [SPEAKER_02]: would be up in arms over these harms related to prescription drugs mental health providers

[00:54:10] [SPEAKER_02]: also cannot do this alone and due to the high incidence of medical problems in this population

[00:54:16] [SPEAKER_02]: there has to be a collaborative care approach involving not just medical care but adequate

[00:54:23] [SPEAKER_02]: in nuanced medical care social and psychological services access to housing work community

[00:54:30] [SPEAKER_02]: all of these things have to come together to give people the best chance at meaningful recovery

[00:54:39] [SPEAKER_02]: so a couple of last thoughts ideas something i personally believe is long overdue if we want

[00:54:49] [SPEAKER_02]: to get a better grasp on this problem is to legalize and regulate all drugs look we're losing this

[00:54:57] [SPEAKER_02]: so-called war on drugs well the private prison system is winning while the american people

[00:55:03] [SPEAKER_02]: take all the losses we're not able to prevent illicit drugs from coming into the country and

[00:55:09] [SPEAKER_02]: we haven't been able to do that effectively for the last 40 years the dare program that i grew up with

[00:55:15] [SPEAKER_02]: bringing cops into schools to try to scare people into not using drugs telling people to just say

[00:55:23] [SPEAKER_02]: no did not work with all kinds well all kinds of evidence most notably the obvious drug

[00:55:30] [SPEAKER_02]: epidemic numbers continuing to rise and become astronomical prove that it didn't work by the way

[00:55:38] [SPEAKER_02]: dare was started in la by darrell gates the chief of police who in 1990 once said casual drug users

[00:55:46] [SPEAKER_02]: should be taken out and shot needless to say this is not a very humane approach it reminds

[00:55:54] [SPEAKER_02]: me of the abstinence only approach to sex education instead of teaching young people

[00:55:59] [SPEAKER_02]: about safe sex that abstinence only approach by the way also didn't work so we're not stopping the

[00:56:06] [SPEAKER_02]: influx we're not curbing the desire for people to experiment or escape to use drugs so to me that

[00:56:14] [SPEAKER_02]: leaves legalizing and regulating drugs that way people can access drugs they are seeking out

[00:56:20] [SPEAKER_02]: without the risk of them being contaminated with fentanyl or other non-desired substances

[00:56:26] [SPEAKER_02]: they can be educated about the drug they're using including its short-term and long-term effects

[00:56:32] [SPEAKER_02]: instead of incarcerated and demonized for daring to go against the abstinence only approach

[00:56:38] [SPEAKER_02]: as you can see with portugal which decriminalize all drugs in 2001 their number of overdose deaths

[00:56:45] [SPEAKER_02]: new hiv diagnoses and people incarcerated for drug related offenses have all dropped drastically

[00:56:53] [SPEAKER_02]: between 1999 and 2017 portugal is now joined by chechia the netherlands and switzerland among a

[00:57:03] [SPEAKER_02]: handful of countries that have decriminalized drug use and possession for personal use and heavily

[00:57:09] [SPEAKER_02]: invested in harm reduction programs and these countries are having consistently good results

[00:57:16] [SPEAKER_02]: now what i will say again appreciating the nuance marijuana provides a little bit of a cautionary

[00:57:24] [SPEAKER_02]: tale about legalization so many of our drugs licit and illicit are adulterated which is a process

[00:57:32] [SPEAKER_02]: that specifically means reducing purity but in this context the natural marijuana plant is

[00:57:39] [SPEAKER_02]: adulterated by taking the psychoactive compound thc which naturally occurs again in the organic

[00:57:47] [SPEAKER_02]: natural plant that grows in nature in one to three percent of non-manipulated marijuana plants

[00:57:56] [SPEAKER_02]: and using that psychoactive vegetative part of the same plant but cultivating excessive and

[00:58:02] [SPEAKER_02]: unnatural amounts taking out that one to three percent and cloning it to create what we see in

[00:58:09] [SPEAKER_02]: our medicinal and recreational marijuana today thc concentrations of 15 to 100 percent by the way

[00:58:18] [SPEAKER_02]: just as a public service announcement to people who smoke weed stop using marijuana vapes they are

[00:58:25] [SPEAKER_02]: on average nearly 100 percent potent they started out in 2005 around five percent potency on average

[00:58:32] [SPEAKER_02]: and it did not take long for the average potency today to approach 100 percent

[00:58:40] [SPEAKER_02]: smoking the same amount of a 100 percent potent substance versus the historically

[00:58:46] [SPEAKER_02]: two percent potent substance simply cannot be good for your brain

[00:58:51] [SPEAKER_02]: and by the way most of the medicinal benefit of marijuana is related to CBD

[00:59:00] [SPEAKER_02]: um look we've got to do something differently with how we treat addiction

[00:59:07] [SPEAKER_02]: we just have to or we won't get out of the rut that we're in currently primarily this novel

[00:59:14] [SPEAKER_02]: approach involves having compassion and providing support for people using drugs trying to

[00:59:20] [SPEAKER_02]: understand why they use drugs before dictating how they need to be treated for it offering several

[00:59:27] [SPEAKER_02]: different treatment options as we do for other chronic diseases that are tailored to the specific

[00:59:32] [SPEAKER_02]: person standing or sitting in front of you and stop letting fear of people who use get in the

[00:59:40] [SPEAKER_02]: way of a treatment that the majority of americans need access to or need to help their loved

[00:59:46] [SPEAKER_02]: ones get access to hopefully this series has been eye-opening and viewers or listeners take away a

[00:59:53] [SPEAKER_02]: better understanding of the overall impact and need for change in addressing the drug epidemic

[00:59:59] [SPEAKER_02]: if not we may see numbers and afflicted persons continue to rise well above the already crazy

[01:00:07] [SPEAKER_02]: numbers we see now with over a hundred thousand people dying in a matter of minutes from

[01:00:13] [SPEAKER_02]: overdoses every year and millions more suffering from long-term complications such as hiv hepatitis c

[01:00:22] [SPEAKER_02]: endocarditis other infections sexually transmitted diseases depression and suicide psychosis and

[01:00:30] [SPEAKER_02]: other worsening mental health problems lung failure liver failure kidney failure heart failure

[01:00:37] [SPEAKER_02]: vascular complications high blood pressure stroke headaches loss of productivity and meaningful

[01:00:44] [SPEAKER_02]: living child abuse and neglect neonatal abstinence syndrome users being separated from their kids

[01:00:52] [SPEAKER_02]: sometimes solely because they failed a drug test kids not having appropriate role models to look

[01:00:58] [SPEAKER_02]: up to and raise them into adulthood overcrowded jails and hospitals domestic violence and

[01:01:05] [SPEAKER_02]: murder violent crimes the list goes on and on and on it's sad but we've got to maintain hope

[01:01:14] [SPEAKER_02]: that we can dig ourselves out of this hole by doing things differently part of that hope

[01:01:21] [SPEAKER_02]: is changing the way that we approach it i hope that you've enjoyed i thank you for watching

[01:01:27] [SPEAKER_02]: and listening to me rant on america's current and ongoing number one public health crisis

[01:01:35] [SPEAKER_02]: the last few slides are an incomplete list of source material for these overdosed powerpoint

[01:01:42] [SPEAKER_02]: presentations i started to give presentations on this nearly 10 years ago and my understanding

[01:01:49] [SPEAKER_02]: and hence the powerpoints have been updated multiple times since then i've several other

[01:01:55] [SPEAKER_02]: sources embedded in my internet browser and if you're interested in having direct access to

[01:02:01] [SPEAKER_02]: all of the data i'm referencing here please reach out directly via renegadepsike at gmail.com

[01:02:08] [SPEAKER_02]: or via the comments section on youtube uh if you have other questions comments concerns

[01:02:14] [SPEAKER_02]: suggestions thanks again for listening um like this video like this series of videos subscribe

[01:02:23] [SPEAKER_02]: all those things that will help to spread the word and promote the message thanks

[01:02:59] [SPEAKER_02]: again for watching and or listening if you're passionate about the subjects that i discuss on

[01:03:05] [SPEAKER_02]: the channel do me a favor and like comment subscribe do whatever you can to make your voice

[01:03:14] [SPEAKER_02]: heard that these are problems that must be addressed in our society if you have any questions

[01:03:21] [SPEAKER_02]: comments or concerns i want to hear them feel free to reach out on social media or email us at

[01:03:29] [SPEAKER_02]: renegadesike at gmail.com and if you'd like to be a guest of the show or you have a connection

[01:03:35] [SPEAKER_02]: to somebody that you think would be a good guess let us know thanks again for listening