 Hi everyone and welcome to the Addiction Recovery Channel. I'm Ed Baker, and I'm your host. Thank you for sharing your time with us today. Today, as our guest, we have Dr. Joseph D'Razio. Dr. D'Razio is an emergency physician, medical toxicologist and addiction medicine specialist at the Lewis Katz School of Medicine at Temple University. He cares for temple patients in a variety of settings, including the emergency department, an inpatient consultative service for addiction medicine and toxicology, the trust clinic, an office-based opioid treatment program, and begin the turn, Temple's low barrier access street side medicine program. Dr. D'Razio is a medical toxicologist for the Poison Control Center at Children's Hospital of Philadelphia and is regarded as a regional expert regarding substance use and substance use disorder treatment in Philadelphia. Thank you, doctor, for being on the show. Thanks for having me. You know, I just like to set the stage by giving you some information about what's happening in Vermont. In Vermont since 2010, we've seen a quintupling of poly-drug overdose death. 2022 was the worst year ever. It seems like every year is the worst year ever. In 2022, we had confirmed 237 accidental poly-drug overdose deaths with 24 penting, so potentially 261 deaths in one year. That's one every 33 hours in this little state. 93% of those deaths involved fentanyl and just under 30% involved xylozine and you know, you've done a lot of research on this. You've got boots on the ground on this in Philadelphia and I would just like, I'd like to hear from you to begin with and then we can zero in on stuff, but to begin with what is your assessment about what's happening in our country with the unregulated drug supply? Well, I think sort of echo exactly what you said there. I think the major drug that we're dealing with is fentanyl as the cause of deaths of overdose. You know, here in Philadelphia, we're seeing the same sort of things. The numbers are sort of on a higher scale, but you know, we're sort of in a bigger big city. But we're seeing the same effects fentanyl as the major drug. You know, more than 90% of overdose deaths are caused by fentanyl here and you know, more than 30% of those opioid overdose deaths are test positive for xylozine and postmortem, so they're being exposed to xylozine also. For the viewing, now my viewing audience is varied. There are some, you know, practitioners, some recovery coaches, some people who are using drugs, families, harm reductionists. You know, can you explain to us, you know, what is xylozine? Why is it being mixed with fentanyl? What is going on? So xylozine is a sedative. It's a veterinary sedative. So it's typically used to sedate animals to do a procedure. You know, if you need a surgical procedure done on a horse, a cat, a dog, they will get xylozine and it puts them to sleep so they can perform that procedure. It has now made its way outside the veterinary supply, or the veterinary supply has made it outside of the veterinary world and is on the streets. And so we first started seeing xylozine in Puerto Rico in the early 2000s and the first hint of it being here in the mainland was in Philadelphia in 2006 and then we saw a rapid increase in 2018 with xylozine. And so why it's in there, I think, is a really good question and I don't think we necessarily have that answer. I think there's a lot of conjecture about what a potential reasons it could be in there. You know, the word on the street is that it gives fentanyl legs and that's the phrase that I hear all the time, you know, that like fentanyl is a really short-acting opioid and xylozine can provide like a longer period of sedation associated with fentanyl use and so there's not nearly as much up and down. I'm not quite sure that's necessarily true, you know, and I'm not quite sure that's the reason why xylozine is in the supply, but it certainly causes a sedative effect. Dr. Richard Rawson, who's a researcher here in Vermont with the University of Vermont, has been active in this field for a long time in addictions and he was wondering, he's hearing from people who use drugs that one of the things that's occurring is because xylozine has a relatively long half-life and fentanyl has a relatively short half-life, some users are experiencing the sedation of xylozine longer than the drug effect of fentanyl and they're coming out of the xylozine sedation in withdrawal from fentanyl. Have you heard? Is that true? Have you heard anything like that? You know, I hear about this a lot from my patients that I'm taking care of. They'll say, you know, I used a bag and it was heavy on the trunk, meaning xylozine, and I woke up three or four hours later. I feel like I got no opioid effect out of it and then I was in withdrawal when I came to. And certainly that goes to that sort of the pharmacokinetics certainly work there, the duration of effect of xylozine is going to be much longer than fentanyl. It really depends on the dose at which you're getting though too, but certainly you can see a scenario in which the xylozine is going to outlast the fentanyl effect, duration of effect, and then people, you know, the opioid portion has worn off and you're just to date from the xylozine. So now we're seeing people with fentanyl addiction and we're seeing people with xylozine addiction running concurrently. Is that what's happening? Well, you know, we're not really seeing anyone that's necessarily using xylozine alone. And actually when I talk to people who are using, they typically say they're trying to avoid xylozine. Like they wish it wasn't in the supply and they really want the opioid effect, not the sedative effect. So we're not necessarily treating anyone for addiction to xylozine. You know, certainly we have noticed a lot of talk about xylozine dependence and when people are not using xylozine, they're getting sick. But to my knowledge I'm not quite sure there's a lot of treatment going on for like an addiction to xylozine as in like people having difficulty putting it down. You know, I think I used the wrong incorrect terminology. So we have fentanyl addiction and xylozine dependence. Do we see withdrawal from xylozine? You know, it's a good question because certainly people who are using xylozine will describe that. You know, it's my withdrawal is just not the same anymore. You know, I used to be able just like a couple of days if I were to stop and go through opioid withdrawal but now I'm having anxiety and restlessness that lasts much longer or that. You know, ever since xylozine made it into our supply, my withdrawal just felt different. But you know, the symptoms typically of xylozine withdrawal are like anxiety, dysphoria, restlessness. And as you can see that those are overlapping symptoms with opioid withdrawal. And so sometimes it's really hard to differentiate the two. Is this just really bad opioid withdrawal or is there really such thing as xylozine withdrawal? You know, you certainly can't find it in a textbook. There has not really been much research into this. At least not that I know of. And certainly we need to start looking into the dependence to xylozine. But what we have seen is an ever increasing dose of fentanyl in the community. And so while maybe a couple years ago we were talking about like a milligram of fentanyl. Then it went to two milligrams of fentanyl per bag and now we're dealing with five milligrams of fentanyl per bag in Philadelphia. And so, you know, some part of me thinks that there is xylozine withdrawal. There really is a dependence. But another part of me thinks that it really just could be due to the, you know, the ever rising dose of opioid. Yeah, you know, I visited Kensington in February. And you know, it's interesting that you say people would be trying to avoid xylozine. But I was told that people are also trying to avoid fentanyl. And that there was heroin, you know, a specific brand, a bag with a specific brand. I believe it was Turbo. And that this particular brand included heroin and not fentanyl. And that was selling for like an increased price on the street. Is there any truth to that? Are people looking to get away from both xylozine and fentanyl and purchase heroin? You know, good question. I really don't think you can avoid fentanyl and xylozine if you're consuming bags dope in Philadelphia right now. It seems like, you know, greater than 90% of the bags in drug tracking programs have xylozine in them. And almost all of the bags have fentanyl in them. And if they don't have fentanyl, it's either a nidazine, like a non-fentanyl synthetic opioid or a different fentanyl analog. And really finding heroin in Philadelphia is like a needle in a haystack. I don't think it really exists in significant quantities. And that's not just from like talking to people because I think people just don't know what's in the bags. But actually from drug checking programs. And you know, we're really not seeing much heroin at all. And unfortunately, while people may want to go back to the age of heroin, brown heroin, it's a thing of the past. It's not coming back. You know, the monetary constraints or what is going on with the money making through fentanyl is just never going to allow for the natural product to ever come back again. And also from the user experience, now that we're at these doses of fentanyl that are so high, they could never go back to heroin because heroin just wouldn't ever support their dependence. And they'd actually be sick despite using heroin. Isn't that something that this completely supply-driven phenomenon has changed the nature of drug use and drug addiction in America? That's what I hear over and over again too. It's a supply-side market. It has nothing to do with the end user. It really has everything to do with the people who are selling it. This is what I have and this is where I can make the most money and so I'm going to push this out into the streets. And there's no, if not your typical supply and demand market. Yeah. It just underlines the incredible vulnerability of the population that we're describing. And when I was out there in Kensington because I was with a couple of people who have been working in that particular area for a number of years, they've established the trust of the people like I'm sure you have. So I kind of benefited by that trust. And I was allowed into some abandoned buildings and I spoke with some people. And I saw some things that, you know, frankly, I wish I hadn't seen. You know, the wounds associated with xylazine contamination are mind-boggling and profound. And I wanted you to talk a little bit about that, but first I wanted to ask you a question about it because I've asked a few people this question because it's on my mind. So we know that xylazine causes a soft tissue wounds when you inject it. What about insufflation or snorting it or inhalation, otherwise smoking it? Is there any data on other routes of administration and wounds? No, there really is not much at all. Actually, this is an area that really needs a lot of concentration. We need more research to understand what the cause of xylazine-associated wounds are. You know, is this a site of toxic effect of the drug? Is it a local effect if injected into the skin? You know, I think when I first started understanding xylazine a number of years ago, I would have said that it's associated with intranasal use, inhalational use and injection. But over the years, just talking to people more and more, it seems like that it's more associated with injection drug use. And so, and this is also not just talking to people who are using substance, but like looking at the variation and differences or geographical differences. You know, certainly we know that on the West Coast, there's a lot more smoking offense than there is injection drug use and talking to people who are treating opioid use disorder on the West Coast. They, you know, they're never seeing wounds. And we sort of have this concentrated group of people in Philadelphia that are engaging with injection drug use behavior that we're seeing the wounds. And it's not just like someone who uses here and there. This is typically a person who is associated with severe heavy fentanyl injection drug use. Yeah, and I had spoken with a few. I met one young man who had lost a foot to amputation. I met a couple of other young women who had xylazine sores. And you know, interesting and I'm happy to tell you that the two women that I talked to, I had very positive things to say about the medical care that they were getting. And specifically that they weren't, they didn't feel like they were judged. They didn't feel like they were looked at in a punitive way and they were, they were welcome. And I really, I really, it was just wonderful to hear that. So, you know, thank you for the work that you're doing there. No, they're just to sort of speak to that. There are some amazing groups that have their boots on the ground in Philadelphia and Kensington and specifically prevention point is doing a lot of care. Savage sisters is another non for profit that's helping. You know, there are a lot of these programs in Philadelphia that are helping people who are living on the streets who are engaging with injection drug use in particular fentanyl who have these wounds. And you know, I'm not quite sure where we'd be without them. Yeah, exactly. My sentiment exactly. And you know, it's the same here in Vermont. We have coaching, we have volunteers, we have 12 step programs, we have recovery centers, we have the medical profession. You know, we have harm reduction. I mean, we're all out. There's been a robust response in Vermont. We're doing everything we can and that really kind of to me just throws light on the severity of what we're dealing with. Because even with a robust response still the numbers of deaths climb each year more each year more. Which brings me to another question from Dr. Ross and Dr. Ross and wondered if if he cited some some drugs that have infiltrated America for good and then some that have come and gone. And he wondered, do we think that xylozine is something that is going to be here indefinitely or will it pass on to some next thing? Do we have any idea about that or any way to kind of make a guess about that? No, but I can give you some of my opinions. I think xylozine is here to stay. I think it's only going to get worse. I don't think we have seen the peak of this disorder or this epidemic just yet. I think with a recent switch from a veterinary pharmaceutical supply to an illicit powder supply just like fentanyl, the monetary forces in there are just really going to just point toward it's only going to continue to increase. Well, you know, so then I'll go into this segment now. I had planned to go into it a little bit later, but this is really the time to do it. With that in mind, a rising number of loved ones taken from us yearly. I just read some data from Nuravalkov. The figure for 2021 was over 109,000 people. The figure from October 21 to October 22, which is the latest figure, was over 107,000 people. Now, all of those are not opioids, but unless I'm mistaken, more than two-thirds are. It's up, it's around 70% are opioids. So we're looking at it like a tsunami of death and all our responses are inadequate. So what, what comes to mind for me and what I've been focusing on is really two things. One is overdose prevention centers or systems of overdose prevention centers. And then the second is safer supply. Do you have, do you have opinions on, on both those interventions? Yeah, I think, you know, over and over again, we focus politically on like prohibition, right? And that just does not seem to work. And the more regulations, the more scheduling, the more border patrol activity we sort of concentrate on, we just keep seeing increasing, increasing number of overdose deaths. So there's like the overdose death crisis. And I think prohibition is not going to fix the overdose death crisis. And what we really need is a safe supply or a safe way for people that are going to use. And overdose prevention centers are like, you know, are a great example of a harm reduction manner of preventing those overdose deaths. We're providing a safe supply, especially for people with the severe use that despite multiple attempts at treatment, I've just have never been able to get into recovery. We're going to keep those people alive until, you know, better treatments are available to help them achieve recovery. And a safe supply seems to be like a step towards that. For the viewing audience that may not be familiar with that term, would you explain what safe or safer supply is? I think just simply a supply that people, a supply of opioids that people can use that they know, know the dose. They know that it's pure, that they know that it is not contaminated with lots of other substances. So people can meter a dose so they know what they can expect. And so they're not getting, you know, randomly large doses in other days, really small doses. And, you know, the variability in the supply and the contaminants in the supply is what typically kills people. And so if there was a safe supply, they knew what was the dose, they knew the dose that they were getting, and knew what was in it, then overdose deaths would drop tremendously. You know, we have, I'm fairly certain you're familiar with it, we have On Point, New York City in Harlem and Washington Heights in New York. And then we have two sites getting ready to open in Rhode Island. It seems that the sites in New York unequivocally have remarkable data coming in all the time. Hundreds and hundreds of overdoses are reversed. I think maybe between five and ten times they had to call emergency services. Incredibly high cost savings to the city in terms of law enforcement, sanitation, you know, different types of very costly services that have to be provided. With data like that, do you have any kind of feeling about, you know, America is coming to a place where we can finally begin to embrace overdose prevention centers? Yeah, I think I just wish we were able to sort of keep this in a medical conversation and take the overdose prevention sites out of a political conversation. But unfortunately, this is like highly controversial sort of stuff, and so it gets highly politicized. But certainly from like a science research and medical treatment perspective, you know, it reduces, you know, the needles on the street. It reduces, you know, open air use where people are just on the sidewalk using and everyone is there to see it. It's reducing overdose deaths. You know, all of this stuff would look like we're saving lives from a public health standpoint. And, you know, to compliment that in the traditional harm reduction approach, people using drugs go to overdose prevention centers and they're welcome as, you know, worthy people with dignity. You know, worthy of being paid attention to and, you know, getting to know each other. This relationship, you know, offered to them. It's a safe place. And this particular population that we're talking about, and you know better than I do because you work with them every Wednesday, they're probably the most unsafe population in America. Besides being unhoused and unfed, they're addicted to drugs that are contaminated with poison. I don't think you can get more at risk than that. Now, this particular population also, unfortunately, tragically has to face stigma. And one of the places that I know of where there is no stigma is in the harm reduction world. So bringing these people in and allowing them to take drugs, helping them, basically teaching them to take drugs safely, it seems to be the epitome of meeting someone where they are. And that, you can't, you can't fake that. And for this population, and many of them have been persecuted, prosecuted, stigmatized, punished, rejected, traumatized, this particular population, the harm reduction world is probably the only place they can engage. And it's overdose prevention centers, and we have, we have harm reduction centers in Vermont, don't get me wrong. They're not overdose prevention centers, and they do exactly what I'm saying. They engage people. But an overdose prevention center seems to me to be the next logical step in this, in this evolution. I just want to echo those, those thoughts there, Ed. And you know, this is why I really, I really like the term comprehensive user engagement site. That was, that's somewhere along the evolution of the name. We've landed on overdose prevention sites, but really overdose prevention sites can be so much more than just preventing an overdose. You know, if you add medical care and recovery services to a site like that, you, you improve the health of people who are using substances. And you know, you know, one day where I'm not interested in recovery, I'm, I show up there and I meet Joe and I say, you know, like, and Joe was there and nice to me and doesn't treat me in a stigmatized manner. And I get, I create a relationship. And then, you know, in due time, when I'm ready for recovery, I now have, I have the trust of Joe to help me get into recovery. And if it all is engaged there, people know where to go for that care. So, yeah. Yeah. And in New York, I've spoken with a couple of times with the people from New York, Klan C in particular. And, you know, they have a barber. They have washers and dryers. They have showers. You know, so people can come in the coffee. People can come in, you know, can, can get a couple of other needs met, can feel safe. And even, even if they're just going there for that, I just want a cup of coffee and I want a haircut. Fine. You know, and if that's why you're coming, come and let's engage you because you may come here for other more profound reasons going forward. So, yes. Like wound care, HIV care, hepatitis C care. Yeah. Those are all really important things. Yeah. You know, so I'm just really glad we're on the same page and the more we can hear people like you, you know, speaking out about this, the more likely we are to turn this corner at some point. What do you, do you have any opinion about the reluctance? This seems to be, it's lessening now. There are more, we seem to be reaching like a little bit of a tipping point where you'll hear more and more people speaking out, you know, calling out for change, you know, citing the science of overdose prevention centers or what did you call it comprehensive? I like that. What was that? Comprehensive user engagement sites. Comprehensive user engagement sites. You'll hear more and more people about speaking out, but what do you think it is that keeps people with scientific minds, people with medical minds, people with wealth of experience, what is keeping the majority of them silent? I don't understand it. No, I think it's a generational thing, Ed, and I think it's really amazing that someone with your experience of life is on this side. But, you know, I think there are many people and a generation that came before me that don't really understand this and aren't ready to accept it or engage with it. And so I think just like using the analogy of HIV, I think is super important. You know, when HIV, when we first discovered what HIV was and started treatment for HIV, I think we ran into a lot of the same sort of stigma we see here with opioid use disorder, and it took generations to get to the point where we are now. And losing that stigma, supporting research and treating it just like any other infection or disorder has been really important because getting HIV to the point today where, you know, you're living with HIV, it's not a death sentence, it's been really amazing. And I think it's going to take generations to get to the same point with opioid use disorder. Yeah, I think unfortunately you're right and it's just the human way. You know, as far as I'm concerned, you know, I'm in recovery myself for 38 years. I was an injection drug user. I was unhoused in San Francisco for seven years. I entered into my own personal recovery and my recovery, I have no doubt about it, was abstinence-based, 100%. And I believed in abstinence-based recovery and I still do. But what happened to me, and I became a counselor, I had a 30-year career doing therapy with people with substance use disorder, but gradually my mind began to open, you know, to ways other than abstinence-based, namely harm reduction. And what opened my mind was the reality of death, mounting death within a population of people that couldn't just achieve abstinence. They were going to continue to use. And as a result of stigma driving them away from healthcare systems and addiction driving them toward drug use, they were dying left and right. How can one adhere to an abstinence-based dogma when that is reality? And I've talked to other people, other professionals of my generation who have been around for a while who had that abstinence-based kind of bias who opened their minds. So there are many people today opening their minds and I agree with you though, you know, this is going to be a generational thing. So, you know, I should retire, but this is so exciting that I can't. You know, to not be so pessimistic, looking on the optimistic side, I engage with a lot of medical students today and engaging with them, I have a lot of hope that the next generation gets it. This is going to be their burden, you know, the HIV of their generation. You know, this is the biggest crisis of their lifetime and the horizon looks good because a lot of medical students I engage with understand this and there's a new wave of doctors coming up that are treating people in non-stigmatized ways. They're learning at a very early stage in their career to meet people where they're at and be patient-centered and I think I've got a lot of optimism. That's beautiful to hear. I know the American Society of Addiction Medicine for a long time has been kind of leading the way. I know that there are programs with addiction psychiatrists, addiction, there's certifications in addiction, there's certainly a growing field. Do you do any of that work at your University of Philadelphia Temple? I'm addiction medicine, not to be confused with addiction psychiatry, which there is a huge overlap there, but a lot of the work that I'm doing is through ASAM, which is the Society of Addiction Medicine. And then I work at Lewis Cat School of Medicine at Temple and I engage with a lot of medical students through an addiction medicine interest group and there's lots of interest and there's lots of the next generation of students trying to get involved and to find a cure. You mentioned that it's interesting because recently Noravalkov had a blog very recently about a cure for addiction and it involved ultrasonic brainwaves and different types of brain treatments that were really something that I had never ever thought of. So apparently there's a tremendous amount of funding going into research at this point. Yeah, there is a lot of funding, grant funding out there for addiction research and boy we need it because the options for treatment right now are so limited and for so many people buprenorphine and methadone just don't work for them and we need to have alternative options for people. We've talked about safe supply but I think there are treatments out there, there's medications out there that we need to work on to help treat dependence withdrawal and then addiction. We need, there needs to be a new wave of medications and treatments. And I know there's research going into that but along those lines I know that there is like an antidote for xylazine overdose in animals but that antidote or overdose reversal drug has not, I don't think it's been tested on humans. Is there any hope that in the future we might have an overdose reversal for xylazine that humans can use? You know there certainly is a medication that is used for reversal of xylazine in the veterinary world, medications that tip them is all. But I think probably the bigger question is do we need a reversal agent? You know just like we have a reversal agent for benzodiazepines which is flimazanil, it's not a medication that we use regularly. And actually there's significant harm that is associated with that drug if you're giving it to someone who has benzodiazepine dependence. But the way I look at xylazine is you know it's not causing a significant number of overdose deaths. And we're certainly only seeing it with opioids and opioids are really the major cause of overdose death. And actually after reversing opioids if a patient remains sedate from xylazine they usually do pretty well with just supportive care. And so if it's you know someone in the field managing this overdose or someone coming to the emergency department it's typically really just some supportive care managing their airway. And even from the data from overdoses that are associated with xylazine the patients are typically discharged from the emergency department because it's not this prolonged sedation or they don't end up in critical care intensive care units. They typically the drug wears off and they're fine. You know when you mention that again what comes to my mind immediately is over those prevention centers because with xylazine I believe it's called hypoxia. There's a blunted response to hypoxia. In other words the person stops breathing and they don't really care. They're not even aware of it. It's not as with an opioid the mechanism that causes you to breathe shuts down and you just stop breathing. With xylazine you want to keep breathing something gets in the way of your breathing and you're so sedated that you don't do anything about it. So it seems that in an overdose prevention center people in overdose prevention centers could be very quickly trained on how to position a body to keep airways open and perhaps save a life. Whereas people on the street with Narcan may not know about this and getting the information out to them I think it's going to take a while but I also think we need to get this information out to people who are using drugs on the street. You're absolutely correct. I think there's some misinformation out there but it seems like you've been to a couple of my lectures about xylazine. Xylazine does not cause respiratory depression in the sense like opioids do where they slow the respiratory rate down. You know what xylazine does is very similar to what benzodiazepines or alcohol in large quantities would do. It puts you to sleep and if your airway is occluded or you vomit and there's vomit in your mouth and you can't clear your airway. You don't wake up to clear your airway like you would with someone with a sleep apnea. If they're sleeping and including their airway, catechol means wake them up and then they breathe and take a deep breath. Whereas with xylazine it makes you so sleepy you don't wake up to clear your airway to take a deep breath. Getting all this information out and that's part of what this interview will do. This information will get out. People will share this widely and your information that's potentially life-saving will be disseminated. That's the purpose of the addiction recovery channel and I know from your generosity with your time that it's your purpose too. To get this word out there to help people to really understand what we can do about this because we're in this together. I want to thank you. I want to offer you with a deep sense of gratitude for your time today doctor. Do you have anything else you'd like to add today? I think we sort of, with some new information out from ONDCP that xylazine, they're working towards scheduling xylazine. They've announced that is the combination of xylazine and fentanyl is an emerging drug threat. I think it's going to be super helpful in spurring on some research to make sure everyone's aware that this is a dangerous drug and that we need to understand a lot more about it. My concerns are the criminal ramifications of scheduling this drug and just compounding all the problems of drug possession charges out there for people who have a substance use disorder. I'm concerned that it's not going to curtail the drug supply and while that may be what people are intending to do, I think as we move to powder supply for xylazine it's not going to make much of an effect and really it's only going to negatively impact people who are using drugs. Yeah, I sadly agree with you. I think that Dr. Gupta at the RX summit made this announcement and he also, from what I've heard, implied that resources would become available but the definition of resources and the definition of resources for what? Well, it was left a little foggy so no one really knows right now but criminalization, as we've seen since the inception of the war on drugs, does exactly the opposite of anything, anyone would want to accomplish. I agree with you on that. So thank you and I love your enthusiasm about the medical profession and the way the medical profession is moving forward. I love your enthusiasm about committing to this. Even if it takes generations, we're not going to give up, we're not going away, we're not going to stop loving people, we're not going to stop being here for people who need us. Thanks for having me, Ed. To my audience, there's going to be a screen lingering now with 211. 211 is the helpline in Vermont. If you call 211 and hit prompt five, you'll get in touch with a real person who will give you information on harm reduction services, treatment services, recovery center services, a wide, very wide range of services and I want everyone to know that I would never ever recommend something I hadn't tried and I call them today. I call 211 today and I was put in touch with a person and I asked all the questions I wanted to ask about harm reduction, about syringe supply, about wound kits, about fentanyl test strips and I was treated with the utmost respect, the utmost dignity, I didn't even feel a whiff of stigma coming toward me. So this is a safe number for you to call 211. If you need help, immediately call 211 and hit prompt number five and you will be directed toward a resource. So again, thank you doctor and thank you my viewing audience. See you next time.