And august we have printed calendars by the information desk. Everything thats been confirmed to ththe last three months you l find there. If you havent already purchased two nights but i would encourage you to do so. There are a bunch behind the registers for sale and there will be a signing afterwards write here at this table. So, the line will go down from the register up to here. If you could help by folding up the chairs when the talk is over and leaning them against something solid, that would be great and in the meantime if you could silence your cell phone to keep everybody focused in the room and also you will see there is a camera over a year, cspan is recording of the talk and you dont want to be the person whose phone goes off in the middle of a broadcast. Also for that reason, we have a microphone right over here and that is for the audio qanda when it gets to that time i encourage anybody that has a question whoever you are to just go up to the microphone and line up and we will try to get to as many questions as possible channel a background in philosophy into his current role on the faculty at the Johns Hopkins institute for bioethics as a person who is awaiting a pathbreaking program in the field associated with medicine. As we 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, almost necessitated amputation reader underwent numerous surgeries that put his body back in place and as i managed that they craved relief in the form he was prescribed the question then becomes how do you back away from the doses once the time is right. He was still in the hospital documenting the shape of the bodily sensations readers book is an exceptionally vivid account it is grounded in experiences that we all might undergo some day so with that in mind please join me in welcoming Travis Rieder to politics and prose. [applause] its a little bit surreal i spent several years in the area having done my graduate work at georgetown to be speaking at politics and prose which is such an institution its a great while so i appreciate you being here with me in th these urgent pressing issues and i think very often its in an entirely scholarly way and that is how i started my work in bioethics and it turns out that if you are interested in ethics and policies regarding americas healthcare system, a really good way although not a recommended way of finding out huge gaps you will find it very quickly that its quite broken im going to do tonight is tell you some stories of people i love and know and some stories are those of our culture and medicine. In 2015, i was in a celebratory mood and i got my First Permanent faculty position of George Hopkins and my partner had gotten a permanent position as a researcher scientist and we were feeling quite ecstatic and we had a one and a half yearold daughter who was gorgeous and amazing and in celebration of all of these things i did a geta really dumb thing and bought a new motorcycle. I had read in for a long time but i dislike now i can afford a really nice motorcycle and on memorial day weekend i took the shiny new bike out on a ride and made it about three blocks before going through a stop sign and crushing my left foot between the bumper of the van and motorcycle itself. Im not going to describe the details of my injury in case you are not up for that tonight. Im not describe i could descrin detail. I will give you enough of a sense of why what happened next happened and so basically the first three bones, the first that connects to the ankle shattered and blew a hole in the inside of my foot and as you are heard in the introduction that the end a limb salvage the situation and that is one where the surgeon takes her to be severthere to besevere for the f their job is to see if they can salvage said thats where i found myself in may of 2015 and a story that im going to tell you about to kick things off is a particular day that happened almost a month after the accident. I had been to three different hospitals at this point. I was undergoing my fifth major surgery and this was a big Reconstructive Surgery so this is one where they dealt with the shattered bone, pulled them together as best they can but maybe the doctor was going to save this boosay this but as ifa way to plug the hole. Its something i never considered before having been considered fortunate until then. Not all can be stitched together. If you lose a chunk of flesh, you have to do something about that so there is a very aggressive surgery where they made an incision on my left leg and carved out a bunch of flesh to plug that hole so it is more than just a skin graf graft so y take skin, muscle, fat and then they wont mike rowe surgically transplant the nerve in case i ever want to feel anything in that again. It took almost nine hours. It involved three different surgical teams and when i woke up the next morning kind of fully coming out of anesthesia, i was in excruciating pain. I had been in pain for a month. I had been under medicated at least once during that month and i thought i knew about pain, but now i had a surgical site, a big one and the original surgical site was also expanded. I never experienced anything like this in my life. I was desperate to get relief. I have had morphine, i had until, i asked for more and they wouldnt give it to me. I asked a lot of people a little bit more aggressively until finally when someone was attending the icu as they check this out they are doing the rounds on me and she is very impatient and finally gets to my room and im begging for more Pain Medicine and she says yes, you have a repeated request that has been noted. I will discuss it with my team and she and her flock go out. I had no idea what happened at that moment it was she had escorted me and im a good kid. I knew enough to be ashamed that i didnt quite get it. I was traumatized, at least a little bit high and it took me a while to kind of pull myself together. I would later be told exactly what happened with suspicion i had been treated as a drug speaker which is insane lets be clear because i had pins sticking out of my feet and i had my fifth major surgery but the fact was even in that situation, i just wanted the medicine a little too badly. That is the first thing i want to sell you about. In the middle of june and i had recovered somehow and you will hear a lot about my partner, throughout the rest of this talk she had to hold the house together and this is one day that i was by myself and i was freaking out. So i had to kind of pull myself together and i told my privilege together. I put this on afterwards but it seemed to matter to me the doctor that i asked for is the one who called me doctor rieder instead of mr. Rieder. He spent a little more time with me and asked me about my research. My attending surgeon will fix you up and he kept his word and his attending called a Pain Management consult and they came to my room and fixed me. They gave me lots of good stuff and i was so, so grateful i faded into oblivion for the rest of my ten days of hospitalization and i remember it being hard in the way that the whole couple of months was hard but it was fine. They hooked me up. So the description of this day as i just gave it to you sounds like i was treated badly like a drug speaker with suspicion and then i was given what i needed, pain relief. But i havent told you the whole story yet because this team that gave me all this medication, they started a train out of the station that they had no intention of looking over. They were not going to drive this any further. Eventually the experience that came to define this entire drama wasnt excruciating pain and it wasnt getting my foot blown apart. Its what happened next which is i was told i had to go off the Pain Medicines. They gave me a bunch and escalating doses seemingly unlimited supply of and it is only when i check in with the surgeon two months after the accident he says this is not good. Its time for you to get off of the medicine now. Also not his problem. He sent me to the surgeon who have taken over the prescriptions and that surgeon said sure if you are ready to get off of the medicine cut your dose into four and in a month you will be off of them, taper down each week. Im not going to give you the long version of what comes next. A big part of why i wrote this because i didnt have to stay in the public anymore. I gave a tabletalk if you want the details but the short version that advice was terrible. It was spectacularly bad. If you want to know some concrete stuff i can tell you how this is supposed to be done and i am not an m. D. By the way but on the 170 equivalents if was phenomenally bad and every day of that for weeks was the worst day of my life. And the sick joke of tapering off of opioids which i hope that nobody in this room knows but i guess some of you do statistically speaking it is that the further you get into the process, the worse it gets if somebody gives you a standard dose reduction or even if they are smarter and give you a 10 , to 10 or quarter as you get through the process becomes a bigger percentage of the dosage that you are taking and the severity of the withdrawal symptom so one week i thought i was miserable but that is because i have no idea what was coming. I thought im not going to make this for a month and then i dropped another dose into the second week scared me. They look like that but they are not done for commercial break and you stopped being able to sp so the last 24 hours a day. And you shake and sweat and get goosebumps and cant sleep if you are just miserable. The second week i started crying and became depressed. It is the opposite of the drugs affects and one of the effects is euphoria so the withdrawal gives you dysphoria. I didnt know this at the time my partner started calling everybody and nobody would help us. None of those that wrote the prescriptions were for nurse practitioners, none of the general practitioners in the dc Baltimore Area that we got ahead of. The ones that popped up that he called because we were despera desperate. But im going to do now is read a small selection of this book. This is a story during week number four of the Opioid Withdrawal and i just want to give you a sense of what this is like in a way i wont be able to do unless they make myself do it. 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. Crawling on me on the couch while she sat on the ottoman just inches away watching so she could jump up and grab her if she got too close to my foot. Most of what i remember, solitude and pain. I do, however, remember one particular day that changed my view of what my daughter was capable of. I have made it the whole day over god im so sorry. Im so sorry that 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 me home. Yohe will survive this, she sai. I said okay and hung up. When the car pulled up outside of the window behind my spot on the couch i tried to stop crying so i do my best not to let her see me like that. But it was no use. She enters the house like a Freight Train into this day was no exception. When the door open she burst into the living room singing at the top of her lungs until she saw me. She stopped babbling and her face turned serious as she walked over to where i was laying on the couch i said i am so sorry. I hope you will not remember this. She didnt seem upset though. She seemed in control. I was lying on my side on the couch about eye level with her. She walked into her face was inches away examining me with her deep dark brown eyes that she got from her mom if she asked are you crying yes, i told her. It will be okay. I didnt believe it, but i was trying my best to be strong for my daughter. And then she did something that i didnt understand and i will never forget. She put her little hands on my cheeks and held my face firmly while she looked at me and then she kissed my eyes one at a time. I had never seen her do anything like that before and i could hardly believe it. Maybe she learned about at daycare. Maybe one of the helpers kissed her eyes after she fell down one time or maybe it was just an incredible empathetic intuition by my little girl. Whatever the explanation, i grabbed her and hugged her as tightly as i ever have. And i told her that she just helps me get through one more night. So it wasnt a fun time in my life, not great. The end of the story was a happy one for me. I didnt make it out because im strong and pulled myself up by my bootstraps. I was a wreck. I needed out because i was lucky and in an incredible support system and because i wanted to be a benefit to my one and half yeahalfyearold againahalf yeara functioning partner in my house and i had the Family Support to kerry me through when i was completely unable to do it myself. But i did make it out. For weeks without. I gave up at the end actually. I filled a prescription and managed to sleep that night for the first time in three nights if i didnt take any and when i woke up in the morning i knew that i could make it out. In the wake of that, i was grateful at first because i thought i was going to die and i didnt than i was angry because i thought the reason was the reason. Then i was deeply confused and frustrated because the more thai thought about it the more i thought how do we get to a place that we are so bad in Pain Medicine at opioids but no one failed me in one particular way that an entire group of worldclass doctors failed me in multiple ma ways. I was withheld medication when i needed it because they may have been a drug seeker and then i was medicated in a careless way that led to this profound suffering that so easily could have led to be going back on the beds. By the way something nice at all the time 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. We are not the only ones it turns out a bunch of other people were just as messed up as we were in this instance. One of the reasons we are so messed up as there is a pendulum when it comes to opioid attitudes and it swings back and forth and its done it a lot longer than we think. About 150 years starting with the invention of orpheum and heroine and hypodermic needle and we swing back and forth between the radical embrace so how are we in this data place how is Pain Medicine so broken, because we are made to swing for ten, 15 years depending on the narrative they prescribe really aggressively. Here is the scary part now we are terrified because read the newspaper about something they are killing a bunch of people. The next section im going to read is trying to figure out a little bit just how bad we are in Pain Medicine and how much we have to improve before we do anything like responsible prescribing opioids. She knew and i knew i was going to need a lot of pain medication. She was terrified and i was terrified because i had just gone through this so then i had exploited all of my access. I had worldclass orthopedic surgeons and pain documents advising the. I took that and applied it answered here is the lesson. I dont care what your surgeon says, we are going to take ownership of this because i dont trust doctors anymore. We stuck to it and my mom is an absolute boss. It was very hard to watch and very painful but in about two weeks she was off of medication more or less and she occasionally needed a night time does. Bad news is what that is. I was interested to know how much. I should have been surprised by this point i had begun to see the data on overprescribing and practitioners in all different fields are starting to examine the prescribing practices for the average for a given procedure and then attempting to find out how many pills patients actually end up taking. These results are not uncommon. Particularly striking result was published by a group of researchers at the university of michigan. The studies looked at a particular procedure, gallbladder removal and found that the average postoperative description for the surgery was about 250 milligrams measured in morphine equivalent for the sake of standardization. When the researchers entered into the average amount taken with 30 milligrams. As a result of the group produced a guideline that included an educational component and informed patients they would need only a few bills for a handful of days and they shouldnt take them unless they really needed them. In the months following the implementation of the guideline of thguidelines, the average amt of opioids prescribed dropped from 250 to 75 milligrams. There was no increase in the refill requests. Just because they were seen as necessary in cases of surgery it doesnt mean we cant make very real progress. Being exposed at all is a risk. The evidence suggests the length of exposure increases to a remarkable degree and as a result we cannot justify sending more opioids out into the world and are needed. We cant allow doctors to write prescriptions for 120 pills when 60 will do it for 313 to five will do. I get to this point in my research and one of the things i am realizing is we need a discussion about responsible prescribing and responsibility, hammer, nail. We needed a discussion about the appropriateness and responsibility because the competition that is happening during this pendulum swing is either drugs for everybody because they have pain and drugs to be given or drugs for nobody because these are evil black magic. But those are both insane positions. They are completely unsupported by the evidence. It turns out some respond to you for some amount of time it sounds plausible but do you need a phd to say that, apparently someone does have to say that. So this is about responsible prescribing and one thing that t kind of interesting go back to my experience and it wasnt just about the number. The number was almost certainly a problem and the reason is because i got a hands off by the way you will be in excruciating pain watch the clock and stay ahead of the pain every four hours is like clockwork happens when you take opioids come you get a tolerance to them, a physiological response. You will need more to achieve the response. I just kept upping the dose and there were problems with the amount. Had i known what i know now, my hope is i would have tried to decrease the dose of a sooner and waved the benefits of pain relief. Theres alsthere is also a manat problem if a physician or nurse or pa someone with the right education isnt looking at you while you go through this no one is going to be able to help you when things go off the rails. To say life is better on the pill. Quick shot of the research its harder than we think its going to take a lot of work. Unfortunately, nuance is hard and we dont like to do with so we havthat sowe have to think at what it means to have clinicians described the right number of pills in the right circumstance for the right amount of time with the right kind of oversight. What would be 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, we solved that. There is a big problem with that. Solving Pain Medicine wont solve the Opioid Crisis and that is the one thing i want to take five minutes worth about. There is a really intuitive narrative and it goes like this. Is cushioned opioids apply and caused a lot of problems in the 1990s so from 1999 to 2010, prescription opioids increased by 400 . And at that exact same time Overdose Deaths from prescription opioids went up 400 . Its a really bad trendlines is a narrative backed up by all the stuff we can talk about with pharmaceutical efforts, different lobbying efforts, medicine, money and the idea you can prescribe without consequence that we have a 400 increase in Overdose Deaths and the idea is to supply with the problem, cut off supply and fix the problem. That was never going to work because it misunderstands a whole bunch of things into the nature of dependence and addiction into the complicated nature of the crisis as it turns into Something Else so we started squeezing the supply 2012 and 2010 and it didnt solve the epidemic. It made it worse. At the same time we did start to decrease the number of prescription opioid deaths of a heroine Overdose Deaths went through the roof. We drove a whole bunch of people to heroine. To make it more and more deadly because you can get more and more for the same amount. And so it is increasingly laced with. We use it to tranquilize elephants and other large mammals. Its being laced with heroine. We should never have tried it. This applies in the case failed in the case of prescriptions and already failed in the case of illicit drugs. That is the war on drugs. We are going to need a lot more than just cutting supplies so the last third of the book is investigating with the solutions might look like. There is at least four categories of things. It looks like when you flood a country it can cause a lot of harm. If you havent read dreamland that is one spreading across the country but also prescription opioids when they are unregulated and handed out without any oversights of the supply is good to be part of the problem but we might also ask about demand and why are so Many Americans taking drugs that sounds like an important question to ask. Can we help people and make them not want to take drugs so much if you provide healthcare and education and give people more prospect, might they look less for pain relief because heroine and prescription opioids are used for some of the pain and it doesnt have to be physical it can be emotional. So, supply demand. We also have to treat the 2. 6 million that have Substance Abuse disorder already and about one out of ten are getting specialty treatment so we have to do a scale of treatment supply, demand but there is another category if you do all those things there is still the risk that in a country with terribly contaminated heroine that a lot of people are using a lot of people will die before they are ready to treat savini to stay alive longer so they are interested in treatment so there is Harm Reduction as another category and a great slogan is that people dont recover well. You have to keep them alive long enough to go into treatment. Im going to read you a little bit about the Harm Reduction because it might be new to folks here than it would be in other countries. Northside east hastings st. There is a storefront along with many like it. The picture of a hypodermic needle gives the appearance of a medical facility and that continues on the inside. Visitors come through the door with their name at the checkin and wait to be called into the back. Rather than a private room however, there are a dozen stalls each with privacy blinders on each side it isnt the Typical Community clinic. Its primary purpose is reducing the harm that often attend to drug use including things like connecting those with health care, providing treatment information and offering a safe space in communities for people who might struggle to find either. The injection room is staffed by Health Professionals and sterile injecting supplies each visitor offered a clean needle, sterile cooker, filter, water and tourniquet. Everything needed to cook and inject heroine in a safe and supervised environment. Inside in other words it is a safe injection site also sometimes called a supervised drug consumption facility or overdose convention site. Consumers can come here to inject drugs getting the risk of contracting hepatitis c with shared needles and they are surrounded with professionals should be overdose. They are equipped with drug testing strips to test a consumer supply for the deadly powerful sentinel along with the user to decide to increase or decrease. The reversal drug is on hand. Since opening a it is the firstn north america in 2003 they served more than 3. 5 Million People and intervened thousands of overdoses and recorded not a single fatality. To the extent americans are surprised by the Harm Reduction strategies we are a little late to the game. The United States has come around th to the Needle Exchange programs with close to 32017. The number is absolutely dwarfed however by other countries. Australia for instance has more than 3,000, more than ten times the number in america serving a population that is less than one tenth the size. Safe injection sites exist in dozens of cities with more proposed overtime including within the u. S. And the reason is simple. They save lives and prevent suffering. As an added bonus they save money on Health Care System and at the same time improving public order and increasing access through addiction and other Health Services by those that use drugs and by taking it off the streets where it is most harmful than connecting those that use injection drugs for the public facing Healthcare Information fro, Safe Injection Sites are able to do a lot of good and they can prevent disease and no walks in this division can reduce overdoses but the brick and mortar site where people can come to use drugs offers the possibility of connecting them with people and resources rather than driving them into the shadows. After all the harder it is to see the person using drugs the harder it is to save them. If you go down the rabbit hole but very far in becomes difficult to understand many of the current practices. What ive suggested here alongside many that we should take a Harm Reduction approach to the crisis whether you buy into the philosophy of the Harm Reduction the current context justifies the basic strategy we have to find a way to prevent our family members, friends and fellow citizens to recuse from killing them. You may find it is sensible or come to a reluctantly but either way i think you should come to it. Im going to wrap up there so i can hear what you all have to say. I will close by noting i probably made this sound like a really dark book. The country is messed up in a bunch of ways and they are bad Pain Medicine. There is a lot of doubt that they are working very hard to fix this and even if we do to fix it wouldnt fix the broad opiate crisis that you would have thought you would have rating reports from the media. But its going to take a lot more if i want you to believe is on all of those accounts, we need a culture change and all of us can be part of a culture change so why did i write this book . Some people asked if it was dramatic and it was a little. The reason i read it anyway is because if i could get a bunch of doctors and patients, which the two groups include all of us could think better about both sides about the pain and drug crisis that intersect when it comes to opioids that will be worth doing, so i invite you to think about that with me and lets chat a little bit more openly now. Is the policy response so far. More harm than good. We cannot get away from the tension right. Sometimes they are the same room. You get groups from insured and yada yada yada. The risk is coming up with something we believe dodgers will actually follow. And with egg is translated into his hand and its Something Like you get four pills after procedure x and its not delineated to any individualized patients right. So for some people for pills will be absolutely enough so thats all we need the evidence. Thats for some people it will be. Its a decision you would want an educated Healthcare Practitioner to know the evidence of in particular to the patients. Im very grateful enforcement tibetan invited to a bunch of them in the fact that they want this. Gives me some help. Where my sleep my perspective. These tend to be very responsive and i am scared when is it too many people in power want to fix the same. Because my fear is that the response will be, 50 more equivalent is the highest dosage anybody said have. And we have a bunch of patients on 700 equivalent or 1200 morphine equivalent. And we have to decide what to do with him. One thing is are being tapered when theyre not ready. I just described a little bit of what withdrawal is like. Doing that somebody when theyre not ready against the will, is torture. The 62nd version, the right way to come off. By and large most people have only been on opioids two to three to four weeks. Things like Knee Replacements and hip replacements. You stay inside two weeks, most people wont experience withdrawal that they will notice. The thing that some people taking withdrawal, they talk about goosebumps and not being able to sleep because theyre jittery. Doctors dont know things like that. They say things like you dont have to worry about it until about a month out. Which is insane because if you are addicted to opioids, thats an bad. This is reciting literature. With the literature mostly you is if you have independence, and dependence is diagnosed we do go into withdrawal by trying to cut off medication, just going slow, will often fix most of most of it for routine most of tabor his. Going slow reducing more no more than 10 percent restarting those per week if that still makes you sick, go 5 percent every two weeks. Theres no reason to go fast if its going to torture you. Invite people wont notice it. Neither really hard cases god forbid, the infection Knee Replacement, reconstruction, or in six weeks for surgery and then three months of opioids, your case is a lot more obligated. Then you really want to paint met in mandan team that is what they are doing. The ones who are more familiar with the tools and the tapering particles. Im telling you for my own experience. And trying to find those people who will take you monetarily hard. I have a phd and my wife has a phd. We spent three weeks calling people and no one would do it for us. That is scary. What is it like for everybody else. Everyone who has less access than us. I am jeffrey and unite communicated. I was taken with your compelling interview. I couldnt stop listening so i wrote to you. Very simply, you and i are part of the same club. I came off of 150 cc. Im wh, 72 years old. The dodgers warned me at my age, recovery is unpredictable. I shattered my collarbone in my scapula, the big one on the shoulder and i have eight fractures off of it in my left side. Taken to confidentiality, i wont identify the hospital but this was between watergate building and and that corner and [laughter] and also the hospital where Ronald Reagan was treated. [laughter] they used a nerve block procedure which was wonderful so and liquid iv, for 24 hours then for ten days ahead manager wires in my body. They were guided by ultrasound the placed medicine right into where the fractures were. I went through six months of recovery. Physical therapy. I had three grades of Pain Medicine. I didnt have a team. An Orthopedic Team and worldclass common team. I was six nights in a trauma. Its a long time to be in a trauma bed then five nights in a in cupid. Im not a dr. Like you are trained in that, but i have a mind of notion, that if he felt the pain, run the risk of reentering these fractures because i had to shut and take care of myself. I stayed off of the Pain Medicine. I never touched the bottle. I have it in my medicine cabinet for my next accident. Nulty how to get rid of that. I tried to basically i dont want Pain Medicine if i can help it. They were asking me how my pink was. A zero to ten i think its a 15. But im 95 percent recovered. I think god i try to avoid the Pain Medicine. So when often asked why did you do any surgery, your injuries were is it too substantial and we were worried about a punctured lung and a massive concussion. The concussion was minor. What i worry about later on is the psychosomatic stuff that will come later. I have my pressure back to. Waking up in the middle of the night and just have accident. I wonder putting in place and maybe dont want to talk is it too much about that what comes later in the thoughts that you cant control at night. There a lot of questions there. Let me talk about a couple. One point that i think is really important is your dodgers mightve messed up when they said heres a bottle even a seat on it. But they might not have. pain is dangerous to. He can keep you from recovery. The real challenge Pain Medicine is hard. This is the secret. Pain medicine is hard and we act like its not. Weve acted like pain is the sort of thing that can be treated by anyone just like an antibiotic can be given out by anyone. One of the reasons is hard is because exactly what you know staying, you worried about dulling pain to the point where you might reinjure yourself. That is a total legitimate worry a dr. Should warn the patient about. You need to experience enough pain that you dont reinjure yourself. But you need to get enough pain relief that you can sleep, and you can rest and get some recovery. Somebody needs to heal and that requires resting. Theres that sweet spots. Thats phenomenally difficult. There is an interesting link between pain and ptsd which is given to your last question. The group of folks that i talked to an epilogue in the final chapter which is the defense and Veterans Center for Pain Medicine. One of the things it became very well known for as they were treating veterans for pain but not just because they were coming back and developing dependence and addiction which a lot of work but because they were coming back really traumatized. They started to think some of them, as they never processed anything. You got that first shot of morphine in them the second they hit the ground party and their complete late. If it affects her pain, we wont fix their addiction rate, were not going to get a handle on this crazy epidemic of ptsd that we are staying in our soldiers. They have been some really hard work. So if you have us in the. Gif mentoring and escape fire, highly recommended. His long before i interviewed them, they work for this documentary film crew for escape fire. They want a bunch of awards is really striking. You might want to check that out. Anyone else was. You mention some of the practices in other countries like australia and vancouver. The unity jurisdictions that you found that actually getting this right and if so, what explains how they got it right. Are the jurisdictions we learn from. Is the great question. On the same with the caveat that i have it. Have a part of the caveat is that im not an expert everywhere. From what i am told, germany does Pain Medicine very well. The reason that im a little concerned and theres a caveat there is the pendulum swung everywhere. So a lot of the countries that are not dealing with the Drug Overdose crisis never got the kickstart with opioid overprescribing because they dont respond to pain. Not clinically they just dont give medicine for anything. The Knee Replacement surgery, in some countries you dont have the dent they give you ibuprofen afterwards. I watched my mom go through Knee Replacement. I dont want to live someplace where they only give you ibuprofen after that. I learned from some of the horrors from opium. Theyre not bad for less than two weeks. Ive heard that germany does these very well i will say some of the western europe is starting to freak out a little bit. So they had a ranking of countries that are having some trouble off the top of my head dont write this down is americas the worst. We screwed this up tragically. But north america as a whole at everything. The marketing from pharmaceutical companies and the kind of lesson that you absolutely must treat pain with opium regardless of cause, that happening candidate to an canada is only about three years behind us on the Drug Overdose trajectory. Canada is in terrible streets in australia is pretty bad situation. Western europe over a long time people in my circles were seeing how did they escape this. They are starting to get scared because her staying some prescription overdose spikes in their like we cant follow america. Because america is the big man out. We had 70000 people died in 2017, from Drug Overdose. You cant hold in your mind the scale of that is more american that died in the entire vietnam war. We talk about the hiv aids epidemic and it was, more people die from an opioid in 2017, that ever died in the heights and the hiv epidemic in the 90s. So everyone is freaking out because of our visit with demand. I dont know if there are places that have really nailed this. Thats a great question. Owner about methyl neatness clinics and what your research is shown about them and how they didnt work or are still working and the promise is for this making them work for todays problems with the opioids. Is an opioid agonist which is itself an opioid. One of the reasons ways you treat addiction is you put somebody who has an ejection was in a chaotic drug phase, the running liked him because of their addiction, you put them on methadone which is very long halflife and even brain chemistry out. Because thats the way it works, sometimes you are in the media, the drugs like methadone of the one called super motoring slightly different. So partial. Its up with the give people to treat opioid addiction so you hear things like politician said dont like the stuff, is replacing one addiction with another. If they say that they dont understand addiction. Because heres the thing. Addiction is defined by behavioral compulsion. Craving and inability to control ones behavior. Interesting factoid that if you are listening to a story about the professor they got addicted to boys, turns out not. That really profound dependent and chosen a road to addiction, but there is a difference between physiological response and behavioral response. So methadone, great drugs to treat addiction because they replace the dependence that you have the biological dependence with another one that doesnt care take them extract that from the record that treats the cravings and the compulsion even dozen brain chemistry. So when it works it doesnt work for everybody, less people can hold down a job, the os in the morning they take their drink of meth known becomes a liquid forum. If they do well enough long enough, they get to take two days and with them. When it works well, in detroit back. Their mother gannett father get a brother or sister again. It doesnt work for everybody, its a drug pit specific to opioids. Im a huge fan methadone and nephew off again. I used this response, it doesnt replace prediction. But if the next addiction crisis that comes after this month is methamphetamines, and the next one is benzos, methadone its not going to help. Is it just treats opioid addictions not addictions at large. So invest in heck out of it in a race reduces mortality rate by 50 percent which is Gold Standard in public health. But its not a Silver Bullet for the addiction crisis. Anything else. [applause] [applause] copies are at or register if you would like him to sign your books, he will sign to the right of your table and please fold up chairs. Iq
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