A microphone right over here thats for the audience qanda. When it gets to that time, i encourage anybody that has a question, whoever you are, to just go up to the microphone there, why not and we will try to get as many questions as possible within the time we have. And with that, im very excited to introduce tonights event. Travis reeder, the author tonight, has channeled a background in philosophy into his current role on the faculty at the john hopkins Berman Institute for bioethics where he serves as the director for the program and also assistant director for education initiatives. As a person leading the program in the field associated with medicine and Public Health, he was obviously be one of the best people to talk to in order to understand what people should know about the current ways of opioid dependencies sweeping across the vast swaths of the american landscape. As you will see in his book, he comes to the topic from his own struggles against that very dependency. After crushing his foot in a motorcycle accident about four years ago now, an injury that almost necessitate amputation, he underwent numerous surgeries to put his body backhe in placea procesprocess an incomprehensibe amounthat an incomprehensibleamn various forms. To manage that, he creates relief in the form he wasor prescribed morphine content and all and more. The question then became of course how do you back away from those doses when the time is right and that is a question that is likely debated among the medical community is. That reader unfortunately came to experience for firsthand to grapple with it as best as he could. With the notes forming while she was still in the hospital documenting the shape of his bodily sensations, the book is an exceptionally vivid account of much debated and widely misunderstood subject matter all the more vital because it is grounded in experiences that we all might undergo some day or might have experienced ourselves. So, with that inn mind please joinrs me in welcoming him to politics and prose. Its a little bit surreal. I spent a couple of years in the dc area. Its been a while so i appreciate you being here with me. Bioethics is a strange sort of field. Those of us who do that are all sorts of disciplinary weirdos, but we all come from distinct disciplines and workt on these urgent pressing issues at hand entirely scholarly way that is s the way that i start my work in bioethics but it turns out if youre interested in the policy regarding the Health Care System, the really good way of the not recommended way of finding out some huge gaps in the American Healthcare system is to become a patient in that system and you will find it very quickly that its quite broken in all sorts of ways, so not the best way to find a Research Program but its the way that i found this Research Program so im going to tellst you some of the stories from some are mine, some are people i love and no and some oregon storie are the r culture and medicine. In 2015, i had just gotten my First Permanent faculty position at Johns Hopkins and my partner had gotten a permanent position as a Research Scientist and we were feeling quite ecstatic, we had a one and a half yearold daughter who is gorgeous and amazing and celebration and all of these i did a really dumb thing and bought the new motorcycle. Ive ridden for a long time but i was like now i can afford a really nice or cycle and on memorial day weekend i took the shiny bike out on a ride and made it about three blocks before a stop sign and tbone at the bike crushing my left foot between the bumper and the motorcycle itself. Im not going to describe the details of my injury and hes not all of your up for that tonight. I wont describe in detail. It in detail. Im going to give you enough of a sense of wh why it would have been next happen. So, basically the first that anconnects shattered and blew ot the inside of my foot and as you heard in the introduction, that would bee in a limb salvage situation, one where the surgeon thinks theyre to b there to bet of amputation of their job is to see if they can salvageo the lad so that is where i found myself in may of 2015 and a story that im going to tell about to kick things off is a particular day that happened it was actually almost a month after the accident i get up into three different hospitals at this point. I was undergoing my fifth major surgery and this was a big reconstructive surgery, so its one where they dealt with the shattered bone but the only way that the doctor could save it as if they found a way to plug the hole. And its something that had never been considered before but not all injuries can be stitched together if you lose a big chunk of flesh you have to do something about that. So there is a very aggressive and ambitious surgery where they made an incision on my left d lg and carved out a bunch of flesh. It is more than just a skin graft. They take skin, muscle, fat and thin they will transplant an artery just in case i ever want to feelve anything in the foot again. It took almost nine hours. Itit involved three different surgical teams had when i woke up, the next morning kind of slowly coming out of the anesthesia, i was in the excruciating pain. Ive been in pain from a and thought i knew about it. I had been under medicated at month. Nce a i now have a new surgical sites, a big one and the original was also expanded into never experienced anything like this in my life. The result of the site was desperate to get relief and i had been hospitalized for several weeks. I had morphine, since all, i was taking things and i asked for more and they didnt give it to me so i asked a little bit louder and they still didnt give it to me then i started to get a little frustrated. I dont remember this perfectly, but i imagine i stopped being quite as compliant as a patient i used to be and i ask people a little bit more aggressive wait until finally as they check this out they finally did rounds on me and very inpatient she finally gets to my room and im digging for more pain meds and she says youve repeated it and its been noted i will discuss it with my team and she and her flock moveout. I have no idea what had happened at that moment. I was ashamed because she escorted me and im a good kid. I knew enough to be ashamed in your school did but i didnt quite get it. I was, sized at least a little bit high and i didnt get it so it took me a little while to pull myself together and i would lay to take the lea be the leadd what happened. I have been treated like a drug seeker which is insane, lets be clear because i had my fifth major surgery but the fact was even in that situation, i just wanted them a little too badly. I said someones alarm bells off. So thats the first thing i want to tell you about. Its the middle of june and i have to recover somehow and you will hear a lot about my partner throughout the rest of the talk but she had to hold the house together and so this is one day i was by myself and i was freaking out ive got to pull myself together. I put this on afterwards but it seemed to matter to me that the doctor i asked for was the one doctor is called the doctor instead of mr. He was a younger guy that wanted to spend more time with me and ask about my research. Thats the one i wanted and i got him. I said you have to fix this and he said i will. My surgeon will fix you up and he kept his word that they called a Pain Management consoles and Pain Management consoles came to my room and fixed me. They gave me lots of the good stuff angood stuffand i was so. I faded into oblivion for my rest of my ten days of hospitalization and i remember it being hard in the way the whole couple of this was hard but it was fine. They hooked me up. Okay, so the description of this as i gave it to you sounds like i was treated badly and then well, i was like a drug seeker with suspicion and then i was given what i needed, pain relief. But i havent looked through the whole story yet because team that gave me all this medication started a train up a station oun that they had no intention of looking over. I never saw my Pain Management doctor again, and eventually the experience that came to define this entire trauma was not excruciating pain or getting my foot blown apart, it wasnt the months and years of physical therapy and learning to walk again, it is what happened next which is with your site eventuah what i had to go off the pain meds that they gave me a bunch of the seemingly unlimited supply and it was only when i checked in with the surgeon two two months after the accident he said this h is not good, its te for you to get off of the medicine now, alsalso not his pm though. Time for you to get off of the meds but someone elses job so he sent me to a surgeon and that the surgeon says scheuer you are ready to get off the meds the customer does and in a month you will be off of them, drop one dose each week. Im not going to give you the long version of what comes next but i wrote th the book so i wouldnt have to stay in public anymore. I also gave a talk if you want some gruesome details in 14 minutes, you can watch that with the short versiobutthe short vee was terrible. It was spectacularly bad. I spent four years researching this and i can tell you this is how it is supposed to be done and i am not an m. D. By the way. For weak tabor on a seven to eight 170milligram equivalent is phenomenally bad and sent me into aen withdrawal and every dy of the four weeks was the worst day of my life and the sick joke of tapering opioids which i hope that nobody in this room knows but im sure some of you do statistically speaking, it is the further you get into the process, the worse it gets. If somebody gives you a standard dose reduction like a quarter each week or if they are smart and get a 10 reduction in each week, thats 10 or quarter as you get through the process becomes a bigger percentage of the dose you are taking into the severity of symptoms is linked to the percentage of each week. One week i thought i was miserable because that is i had no idea what was coming. I was sick and i thought im not going tomac this for a month, then i dropped another dose into the seconded week scrutiny becae you get all the symptoms. Ithese symptoms. If youve ever watched the movie or seen tv, it looks like that but they are not done before a commercial break. They must every second of every minute and you stop being able to sleep so they must 24 hours a day and you shake and sweat and get goosebumps and cant sleep and you are just miserable. Eand the second week for me i started to cry and become depressed because withdrawal is the opposite of the drugs affect and one of the affect is euphoria so the withdrawal gives you dysphoria. I didnt know any of this at the time so all i can think is im dying slowly, excruciatingly. I go through this more and more. I asked doctorsnd for help, my partner startsta calling everyby and nobody will hope us. None of the doctors to prescribe the medicine, none of the surgeon, none of the people that were the descriptions, none of the nurse practitioners, none of that general practitioners that lived in the area that we got a hold of the ones that popped up on google that we just called because we were desperate, none of them would see us. Im going to do now is create a small selection of the book and this is a story during week number four and i just want to give you a sense of what this is like. My beautiful, wonderful baby daughter gets left out of a lot of the story and that is part of the pain. I simply wasnt present, so i barely remember her being there at all. I know she was managing child care and bchildcare and be runne house and occasionally crawling on me on the couch while she sat on ths the ottoman jus bottom as away watching so she could jump up and grab her if she got too close to myoo foot. Most of what i remember, solitude and pain. I do however remember one particular day it changed the view of what i wante wanted a halfyearold daughter was capable of. I made it ther whole day without crying and without the depression crushing and. I dared to hold this meant i was turning a corner and maybe i was going to get some of my life back and then around four or 5 00 i felt a tall tale whaling chest and darkness are darkness circling. It causewere going. It caused panic and then despair. I blurted out i almost made it today. Im so sorry i had to call you. I started to think i could survive this but i cant. This will never get better. Im so broken. Im just so broken. How can anybody possibly recover from this. She was already driving home. You will survive this, she said. Your home hormones and brain will get better. Just hold on. Im about to pick up baby girl and then we will be home to take care of you. I said okay and hung up. When they pulled up outside i tried toir stop crying. I do my best not to let her see me like that. But it was no use. The harder i tried the more more exclusivity came and i eventually just gave up. She enters the house like a Freight Train in this day was no exception when the door open she burst into the living room her lungt the top of until she saw me. She stopped in her face turned serious. She slowly walked over to where i was on the couch and i cried to her im so sorry i hope you wont remember this. She didnt seem upset about. She seemed in control. I was lying on my side about eye level with her. She walked into her face was inches away from nine with her deep dark eyes she got from her mom and she asked you crying . Yes, i told her. But it will be okay. I didnt believe it if i was trying my best to be strong for my daughter. Then she did something i didnt understand and will never forget. She put her tiny hands on my cheeks and held my face firmly while she looked at me and she kissed my eyes one at a time. Id never seen her do anything like that before and i could hardly believe it. Maybe she learned it had daycare or one of her helpers kissed her after she fell down one time. Or maybe it was an incredible and pathetic and tuitio intuitiy little girl. Whatever the explanation, i grabbed her w and hug her as tightly as i ever have and i told her she just hoped that he get through oneer more night. That wasnt a fun time in my life, not great. That was during week number four. The end of the story, i made it out. Heres something really important to know. I didnt make it out because the system helped me out or because im strong or pulled myself up by my bootstraps, i was a wreck and i made it out because i was lucky, i had an incredible support system and because i wanted to be a dad to my one and a half year old again and a partner in my house and a faculty member at Johns Hopkins and i had the Family Support to carry me through when i was unable to do it myself. But i did make it out. I gave up at the end actually. I filled a prescription because i was done but i managed to sleep a that night for the first time in three nights and that was to crack when i woke up in the morning i knew i could make it out. And in the wake of that, i was grateful at first because i thought i was going to di die inside and into the night was angry because i thought the Healthcare System is the reason i thought i was going to die. And then i was deeply, deeply confused and frustrated as the more i thought about it the more i thought how in the world did we get to a place we are so bad at Pain Medicine that no one failed me in one particular way that an entire group of doctors bandaged his ditch together my foot withhe wifi dont forget failed me in multiple ways that were sometimeson in tension with one another. I was withheld medication when i needed it because the it might e been a drug seeker and then i was medicated in a careless way that led to this m profound suffering that could hav could y led it to be going back on the meds and by the way something nice overtime when i was going through withdrawal if i go back on the meds i will never come off of them because i will never go through this again. So how in the world do we get here and get so messed up. Im a researcher said thats what ive done the last four years. I used to work on ais bunch of other stuff. I dont do that anymore. I think about americas Healthcare System and by the way we arepi not the only ones t turns out other people are just as messed up we are just number one in this instance. So, there is a lesson in the book i cant give you the full version now but history teaches us a lot about this one of the reasons is there is a pendulum when it comes to opioid attitudes and it swings back and forth. A lot longer than we think. About 150 years. Starting with the invention of morphine and heroin into the hypodermic needle. We swing back and forth, so how is the Pain Medicine so broken . Because we are displayin made t. We prescribe really aggressively and here is the key may be prescribing progressively would have been okay if we did it according to any Evidence Base that we didnt and heres the scary part, a whole bunch of doctors still dont. But now we are terrified of opioids because we read the newspaper and what is happening is they are killing a bunch of people so they are telling doctors to stop killing people so we are squeezing the supply and now we are hurting patients in another fun way. We are failing in multiple ways and thatt is crazy. So the next section im going to read is trying to figure out a little bit of just how bad we are at a justin and how much we have to improve before we do anything like responsible prescribing of opioids. This is about my mom in about two years after ive gone through my own, and my mom had to have both her knees replaced. This is an excruciatingly painful surgery. She and i knew she was going to need a lot of pain medication. She was terrified and i was terrified because i had just gone throughgh this, so by theni had exploited all of my access. I knew people in the new people, i had worldclass orthopedic surgeons advising me, and i took all that and applied it to my moms case and said here is the lesson me and my friends and my team have drawn up. I dont care what your surgeons say we are going to take ownership of this because i dont trust doctors anymore. And so, we made a plan and we stuck to it. My mom is an absolute boss and she did what she felt like she needed to do and it was hard to watch and very painful but in about two weeks she was also the medication more or less intoik e third week she needed and occasional nighttime dose but after shesh was a little more coherent and in less pain i texted and said can you count how many you have left because prescribedhe was 120. When i found out i said you are not going to need to do this for pills a day for 30 days. Bad news is that that is. But i was interested to know how much, so she answers me and texted a little while i have 73 of 120 remaining. She is well under half what she had been prescribed. I should have been surprised by this point i had begun to see the data on over prescribing for surgery. Practitioners are starting to examine the prescribing practices publishing the average prescription for a given procedure and then attempting to find out howcr many pills a patient actually ends up taking. Results like this are not uncommon. A particularly striking result published by a group of researchers at the university of michigan looked at a particular procedure, gallbladder removal and found the average postoperative prescription was about 250 milligrams measured in morphine equivalent for the sake of standardization. When thehe researchers intervied patients to discover the average amount taken with 30 milligrams. As a result they included an educational component and informed them they would need only a few pills a handful of days and they shouldnt take them unless they really needed them. In the months following the implementation of the guidelines the average amount dropped from 250 to 75 milligrams with no increase. Just because they are seen as necessary in cases of surgery doesnt mean we cant make real progress. Being exposed to opioids at all but one thaputs one at risk ande suggests it increases to a remarkable degree as a result we simply cannot justify sending more opioid out into the world that are needed we cant allow doctors to write prescriptions for 120 pills when 60 will do. So i get to this point in my research and one of the things im g realizing is we need a discussion about responsible opioid prescribing and esresponsibilities to sustain. We need a discussion about appropriateness and responsibility because the conversation is happening out during the pendulum swing is either drugs for everybody because they have to be given or drugs for nobody because these are evil black magic. But those are not supported by the evidence and it turns out some response for some amount of time and we should responsibly use them in those cases the way. That sounds like a plausible do you need a phd to say that, appearance late someone does have to say that so this is about responsible prescribing and the other thing i found interesting goes back to my experience and it wasnt just about theu number, the number ws almost certainly a problem and gotreason is because i pants off heres an unlimited amount of pills and by the way you will be in excruciating pain. Watch the clock and stay ahead of the pain. I like clockwork. What happens become tolerant to them. If you were looking for the same amount of pain w relief you have to take more to achieve that response. So i kept upping the dose. So there were no problems with the amounts. Havhad i known what i know now,y hope is i would have tried to decrease the dose a lot sooner, way off the benefits of the pain relief against the risk of future suffering. So theres a lot happening here. There is also this management problem if a physician or nurse or physicians assistant who could write education isnt looking at you while you go through this, no one is going to be there to help you when things start to go y off the rails. If no one sees it as their job, you might be in trouble when you try to get off of them. Responsible prescribing is harder than we think. You cant just do all or nothing. The nuance is horrid and we dont like to do this we have to think a lot about what it means to have clinicians prescribe the right number in the right circumstances for the right t. Amount of time with the right kind of oversight. What would be really nice at this point is if i said i figured out how to solve Pain Management so that whole thing youve been hearing about in the news that is super scary, we solved that. I fixed Pain Medicine and opioids, which i didnt, but suppose. Theres a big problem with that. It wont solve the crisis and that is o the most thing i wanto say five minutes worth about. Theres a really intuitive narrative and it goes like this. Prescription opioid supply caused a lot of problems starting in the 1990s, so from 1999 to 2010, prescription opioids increased by 400 . I supply was the problem so supply is the answer so cut off supply you fix the problem. That is never going to work because it misunderstands a bunch of things the nature of dependence and addiction, the complicated nature of the crisis as it turns into something else. So we start squeeze the prescription and didnt solve the epidemic. It made it worse. At that same time with those overdose t deaths heroine overdose went through the roof. We drove people to heroine. So those that are making it more and more potent and deadly to get more money for the same amount that is increasingly laced with fentanyl. That is 1500 times more potent tint then more feet morphine read tranquilize sinceui one elephants and with those prescription opioids we never should have tried it with fails to indicate the prescription and also with illicit drugs on the war on drugs. So we will need a lot more than to cut out the supplies of the last third is investigating what the solutions might look like there are at least four categories talking about ssupply, it does matter so if you flood a country with deadly drugs that are unregulated that can cause harm. Thats one of the central lessons why heroine is spreading across the country also prescription opioids that are unregulated. But we could also ask about demand why are so many taking drugs quickset is an important question what makes people not want to takeig them if we provide healthcare and education and give people more maybe they look less for pain relief because heroine and prescription opioids and t fentanylyl and the pain doesnt have to be central or emotional or psychic. So supply and demand also treating those who have Substance Abuse disorder already one out of ten have to get special treatment so we have to do a massive scale up of supply and demandtr treatment but there is another category if you do all of those there fs still the risk in a country with terribly contaminated heroin people will die before they are ready to treat so we need to help people stay alive long enough to getls treatments in the great slogan is they can keep them long alive long enough for treatment so maybe this could be newer to some folks than in other countries, on theyo north side vancouver Downtown Eastside founded along many others like it the picture of a hypodermic needle gives the appearance of a medical facility and that impression continues on the inside visitors come to the door and put their names down and they wait for people to come to the back rather than private rooms it has a dozen stalls with privacy blinders on either side in the desk with a hard plastic chair. Then there is a desk with medical equipment the facility is called insight is not your Typical Community clinic the primary purpose is reducing the harms from injection drug use secondary goals to connect with healthcare and provide treatment and offer a safe space in communities that struggle to find either. The injectionje room is staffed by Health Professionals with sterile supplies clean needle in the water everything to need in a safe and supervised environment. S insight is a safe injection site or Overdose Prevention site. Consumers come here to inject drugs so they dont have to have hiv to shared needles or hepatitis c should they overdose they are surrounded by medical facilities andnd with that allowing the user to decrease their dose. Should theylo overdose anyway the drug is on hand is the first safe injection site and has served more than three. 5 Million People and has intervened in thousands of overdosess but not a single fatality. To the extent americans are surprised by Harm Reduction strategies we are late to the game slowly it has coming around for the Needle Exchange programs the number is dwarfed by other countries. So there are more than 3000 with ten times the number in america serving a population less than one tenth the size. There is only one Needle Exchange program for every 3200 americans who use iv drugs but in australia for every 31 people. Safe injection sites exist all over the world with more proposed because they save lives and and suffering they also save money through decrease burdens on the Health Care System while increasing action for those who are addicted to drugs that takes it off the streets where it is the most harmful and connect with those with the Healthcare Information and save sites that can do good. They canan prevent disease and reverse some overdoses but if a brickandmortar site where people come to use drugs offers the possibility to connect with people and resources rather than driving them further into the shadows. After all the harder it is to see them the harder it is to save them. Although it does become very difficult to understand but what i have been suggesting here with Public Health as we edshould take the Harm Reduction approach whether you buy into the philosophy the current context of crisis justifies the strategy we have to find a way to prevent family members and friends and citizens from having the drug use kill them we may come to a reluctantly. So i t will close by noting that i make it sound like a really dark book that the country is messed up the healthcare bad at medicine. People are working hard to fix this even if wed did it might have been the thought you would have had and that will take more but on all of those counts we need a culture change in all of us can be a part of that. Why did i write the book . Was actually fairly cathartic it wasnt that dramatic but the reason i wrote it anyway is because if i can get a bunch of doctors and patients to think better about both sides of the drug crisis that intersects with opioids that is worth doing so think about that with me. Thank you. I have a comment and a question or 100 questions. I will limit that to one. But the passage that you read about your daughters amazing response to pain was one of the most emotional ive ever heard red at a bookstore that was a wonderful description of an amazing event. So youe. Intrigued me willing to talk about the protocol that should be followed coming off of opioids so im getting any replacement surgery in september so i have skin in the game i can imagine a lot of people have been through Knee Replacement so i should man up and not be concerned so systemically, there are huge lawsuits looming maybe not as big as tobacco but almost as big. So you would think the threat of that legal action would get people together in a room on a macro level to say lets talked about evidencebased whatever. Is that discussion happening in these medical conferencesic quick. Thats a great question. Yes they are happening. But a big part of what i write in the book is that the response to prescription opioids so far has largely done more harm than good. The reason is we cannot get away from the pendulum. Why isnt everybody getting together in the same t room . From insurers in the cdc and fda. The risk comes up that we believe doctors will follow and then translate Something Like four pills after procedureas x that is not delineated to an individualized patient some people four pills are absolutely enough and for some people it wont and that is why we need evidencebased this is why an educated Healthcare Practitioner can respond to the needs of the patient. Yes these discussions are happening. I am very grateful and fortunate to have been invited to a bunch of them and it does give me hop hope. I wear on my sleeve my perspective and they tend to be responsive but i am scared when too many people say lets oufix this because my fear is the response would be yes that is the highest dose anybody should have now its 700 milligrams equivalent now they decide what to do and what is happening now and then i described what withdrawal is like but doing that to somebody when they are not ready against their will is torture. The 62nd version the right way to come off by and large they are on two or 34 weeks like Knee Replacements if you stay inside two weeks most people want experience withdrawal that they notice but those who have been through surgery if you ask what its like its weird i couldnt sleep they do but it was minor because dependence can form in a matter of days but doctors dont know that they say you have to worry about it until a month out which is insane. Once anc few weeks off this is not me providing medical advice but literature. They will tell you if you have a dependence diagnosed going into withdrawal to cut off just going slow will fix most of that do not reduce more than 10 percent a week if that still makes you sick and go 5 percent every two weeks theres no reason to go fast if it will torture you most people will not noticeeerer butd for bid if it is infected they are doing reconstruction and then six months of surgery then your case is more complicated you want to Pain Management team that knows what they are doing or pain Medication Team they are more familiar with the tools. From my own experience from those who know what they are doing willing to take you on eollis hard for by the phd so ds my wife. We are in the dc Baltimore Area we spent three weeks calling people and nobody would do it for us sparkle that is scary. What is it like for everybody else . I was taken with your compelling interview i could not stop listening so i wrote to you so recently coming off and i am 72 the doctors warned me at my age of the recovery is unpredictable i shattered my collarbone and growth fractures down my left side so taken into confidentiality at the hospital this was between the watergate building. [laughter] also the hospital with ronald reagan. As [laughter] the use of the nerve block procedure which was wonderful over 24 hours than for ten days with the wires in my buy it body were guided by ultrasound to the fractures after six months of recovery i have three Pain Medicine i dont have a Pain Management teamdi but worldclass trauma so the simple question was im not a doctor. But the simple minded notion if i control the pain my risk of injury is a re fracture because they had to take care of myself. I stayed off Pain Medicine i never touched it but it still in my medicine cabinet for the next accident. I will tell you how to get rid of that. Basically i dont want Pain Medicine at all if i can help it if they say how is your pain today . On zero through ten i think it is a 15. But im 95 percent recovered. But i try to avoid the Pain Medicine why didnt you do surgery because we were worried about a punctured lung so what i worryt about later like waking up in the middle of the night if you are putting in place of what comes later. Wow. There are a lot of questions in their. One thats important your doctors might have missed appears a bottle even though you dont want it but they may not have because pain is dangerous also from recovery. So the real challenge. Pain medicine part we act like pain can be treated just like antibiotics. One of the reasons from what you are saying worried about dulling the pain to the point a wyou could injure yourself thats what we warn the patient about. So to experience enough pain so that you dont re injure yourself if you get enough painse relief that you can get into recovery so your body can heal and that requires resting and there is a sweet spot. Interestingly there is a link between pain with ptsd getting to the last question the group that i talk to in the epilogue at the center for integrated Pain Medicine what they were well known for is treating i veterans for pain but not because they had a clandestine addiction which they were but because they were traumatized some of the traumas they never processedou anything because they would shove morphine into them and they are completely on cloud nine all the way back through walter reed through germany so their conclusion was we cannot fix that dependency and addiction rate we will not get a handle on this with the ptsd we are seeing with the soldiers. If you havent seen safe fire i highly recommend it. Long before interview them they worked with a film crew that is striking. To make you mention the practices in other countries like australia areli there any jurisdictions you have found that are getting this right . And if so what explains how and are they ones we can learn from quick. Thats a great question. With a caveat i havent but im not also not an expert on everywhere. So from what im told germany has done it pretty well. The reason there is a caveat is the pendulum has swung everywhere. A lot of the countries that are not dealing with a Drug Overdose crisis never got the kickstart with overprescribing to dull the pain. So that Knee Replacement surgery some will give you ibuprofen afterwards. I watch my mom go through a Knee Replacement i dont want to go somewhere that gives you ibuprofen. They are notu black magic there is good use for small doses less than two weeks. I have heard germany does it well also western europe so ranking the countries that are having trouble but america is the worst we screwed it upic tragically but north america as a whole god everything so from pharmaceutical companies, the lesson regardless of the cause that also happened in canada so they switched over to fentanyl early so canada is in terrible straight so is australia but western europe who for a long time people said how did they escape this are starting to get scared now they are seeing prescription overdose they cannot follow americaan because we are the bogeyman because people died from Drug Overdose if you cannot open your mind to the scale of that more americans dying than the entire vietnam war. Talkd about a hivaids epidemic more people died from opioids the never at the height of aids in the nineties. Everybody is freaking out because we are the bogeyman but i dont knoww if they have really nailed this. Thats a great question. With the maintenance clinics and how they didnt work or they are still working and the promise to make them work for todays problems and ideas. Methadone is an agonist which means its also an opioid one way to treat the disorder or the addiction take somebody who has the addiction that is burning their life down because of the addiction put them on the veryut long halflife to alter the brain chemistry because of that sometimes you will hear that drugs like methadone that you ogive it to people to treat addiction politicians will say i dont like this it replaces one addiction with another because if you say that you dont understandnd addiction addiction is defined by behavioral compulsion cravings and inability to control. So interesting with the professor thats addicted to opioids going into withdrawal maybe was on a road trip and he vowed never to come off but othere is a difference with behavioral response so methadone is a great drug to treat addiction but do they replace the dependenceede that biological dependence with another streaks the cravings andvi compulsions that doesnt work for everybody but lets people get their life back and hold down a job it comes in liquid form after long enough they could take it home with them. They are your father or mother or sister again. It doesnt work for everybody. And its a drug that is specific to opioids im a huge fan of methadone to say it doesnt replace addiction with addiction that is a stigma but the next edition crisis is methamphetamines that will not help. So i think we should invest in the heck out of it reducing mortality by 50 percent which is a Gold Standard in public s health but it is not a Silver Bullet for the addiction. [applause] thank you. [inaudible conversations] all of the authors could push through whatever barriers they had to look openly and honestly about their struggles so as you mentioned an honest account of grief and their loss this is not in him an uplifting book. The reality is i have to arm them not simply with a set of skills and intellectual tools that allow them to flourish in schools with ethics and values but also a way to make sense of the hostility that they encounter every day and people at times whose responsibility is to treat them as community members. All modicum of decency they call him far worse things