 Good morning and welcome everyone. I'm Donna Jacob senior vice president at the University of Maryland medical system I want to welcome you all here today for our program not all wounds are visible a community conversation We're speaking today about addiction and substance abuse Perhaps many of you were here in June when we did a day-long program about many or all of the issues in mental health and substance abuse the response to that day was so Great and overwhelming that we've decided on every six-month basis to talk about the issues one by one And today is the first one. We'll talk about again addiction and substance abuse You have in your program and you have in your folders the program for the day We have several topics one is what's addiction and substance abuse and then what are the non-opioid? Addictions that'll be followed by the opioid epidemic what is recovery and then we have a special presentation from one of our Physicians who is the child of two addicted parents. We'll talk about his journeys and his struggles and his triumph I'm going to introduce dr. Brad Schwartz to you now He's going to speak about addiction and substance abuse and particularly about non-opioid addictions dr. Schwartz is the Professor at the University of Maryland in the School of Medicine in emergency medicine and he currently works down at the um capital regional health System in Prince George's County both he and dr. Chris Welsh who is also at the University of Maryland medical system and psychiatry will then take questions following this opening presentation so my name is a Dr. Brad Schwartz I work over at Prince George Hospital Center and I'm an emergency medicine physician So I chose to talk about non-opioid addictions today a couple Non-mainstream medications that you'll hear a lot about over in the news synthetic cannabinoids It's called synthetic marijuana and bath salts not what you pour over into your tongue And so the reason that I thought about to talk about these were two-fold one These are just like our title over here. Not all wounds are visible not all drugs are visible either These are things that we really have a tough time testing for And in addition not all addictions are opiate dependent So as dr. Walsh did a great job talking about most dependence and subsidies comes down to stimulating your dopamine receptors But not all medications do that just directly and a lot of people have addictions to these medications which are Or rather these drugs which are just coming out more recently So we'll talk a little bit more about that So synthetic cannabinoids, they're called, you know, you see them K2 spice They're originally devised by a very well-meaning chemist over the 90s for medical research and unfortunately They got changed over into something else So as of five five years ago mainly ten years ago, you would see these over in head shops over in gas stations They're labeled for not for human consumption, but obviously people were consuming them a lot and They're becoming a significant problem because unlike marijuana which stimulates mostly the cannabinoid receptor CB1 Which is over in the brain causes some relaxation inhibition effects and CB2 receptors which are kind of less important which have some immune modulation response over in the body They stimulated the same receptor, but they just did it so much more so they have much more tight binding Affinity over for this receptor. And so what they caused we didn't know So what we would see patients presenting to over in the emergency department would be patients coming all the way in from agitation seizures fighting to The flip side of that people very sedated Comatose Both causing problems. So agitation, you know requiring police staff being physically assaulting people all the way to the flip side Over people being so sedated where they couldn't breathe on their own a recover bring breathing to we'd have outbreaks of these and they would Usually the state board would let you know that was a significant health problem. There's an outbreak of a certain batch Depending where they were devised over from a chemist in the outside country who devised this formula That they had no idea what it did, but then they released it over to the public So here's sort of a timeline about what happened over maybe the last 10 years It really became prominent over we can blame everything over on the UK to start off with And then over in 2010 you can see it really started to become a problem and the DEA started to use emergency powers to ban synthetic marijuana And they started to play a cat and mouse game where they could only ban it Compound if they knew the chemical structure they'll ban the chemical structure and then the chemist over in China or the UK or here We change the chemical structure and then they would need six months more to figure out what the chemical structure was And then ban that too. So obviously that was a problem and then somewhere around 2012 They said we're just gonna ban these compounds based on what they cost rather than what they look like and as Legislation got better and police enforcement has gotten better these compounds are a lot more rare Over in the public. You really don't see them very much over in gas stations and head shops Because people end up doing jail time for distribution or conservable fines So who's using it so there's an interesting Poll that they do over in University of Michigan. It's called monitoring the future study So every year they'll pull the high school students to see what their drugs of abuse are And as you can see the most common is marijuana Followed by number two over in the misses in 2012 when they took this poll with synthetic marijuana So at that time 8% of patient 8% of students were reporting that they had to leave at least use this once if not more and So you can see a trend change over in 2016 Where over here now you can see that marijuana still about the same and then over Now dropping down to about 4% of synthetic marijuana Our synthetic cannabinoids rather and then over prescription medications surprisingly amphetamines is number one and opiates are number three So What does this mean? Well, it just shows a trend change You know I can hypothesize that this is due to the fact that Legislation and police enforcement got a lot better over for synthetic cannabinoids, which is absolutely a good thing And perhaps that marijuana has become illegalized in more states is becoming more accessible So we talked a little bit about this synthetic cannabinoid effects Which range from the worst being agitation seizures all the way to being comatose and obviously that can be a problem and What we found over in the literature as well is that people can become just like opiates addicted to this medication If they stopped taking it they develop mood swings trouble sleeping And they can even develop tremors And so one of the reasons I bring this to your attention is so we know a little bit more about some atypical Drugs that are being abused and also realize that not everything is opiate that once again that can develop dependency and abuse another Medication that you'll hear a lot about over in the news is a caffeine ounce which are called bath salts now They're marketed over as bath salts, but obviously you're not pouring these over to your tub And these are a lot of the scary stories you'd hear over in the news about people attacking each other biting each other space zombie-like activity really scary stuff And so interestingly these medications were synthesized from a stimulant found the cat plant If anybody saw the war movie black Hawk down That was what the Somalians were chewing when they stage the assault over and the afternoon time And they work as a stimulant and they're often the replacement for ecstasy or cocaine it can be used kind of in any format and The same it will not the same but similar to synthetic cannabinoids. It's addictive and can cause withdrawals depression tremors trouble sleeping So these are some atypical drugs now additional things that dr. Also talked about that can also cause substance abuse and dependency absolutely cocaine When we talk about opiates, I should say that you know These are the medications that like prescription medications We talk about Vicodin oxycodone these include heroin and then the other medications that you'll hear about frequently It's something called fentanyl, which is often way marketed over on the street and now people are mixing over into drugs as well So despite Talking about this the And talking about the non-opien drugs the majority of mortality in the US is due to overdose from opiate medications And dr. Ramesh is going to do a longer talk over about this But just to kind of transition into this for a second If you look at US drug deaths over the last few years or last 10 to 15 years You can see a growing uptrend of opiate deaths and 64,000 sounds like a big number and it is but to put it into context over in the Vietnam War 58,000 people died, so we're already exceeding that in one year and the worst year for motor vehicle accidents, I believe is 1972 And around 42,000 people died so every year more people are dying from opiates than they are dying from car accidents And this is just looking over at drugs involved in overdoses trying to develop them over into class and you can see that the the top three over here being synthetic opiates heroin and Natural and semi synthetic opiates with cocaine and methamphetamine being lower or down So that's not to say that all our efforts need to be devoted to opiates, but this is definitely becoming an epidemic and something that we need to pay more attention to Hopefully bring these numbers down And that's all Thank you We have a microphone here you can consider the questions you want and as well I'm keeping my eye on the iPad come up to the microphone so we can hear you It's a microphone in the center We've got people at other satellites who want to hear your question, too So we need you to come up So let me say this before we start we want to really try to get as many questions as we can questions and answers Because this is a community conversation I remember we've got four other sites where we can't get questions from so please try to keep your questions succinct Person and so nice it depends on the drug But for most people that eventually Their brain function will get back to normal, but it's the idea that they can take a long time Okay, and the other one was I'm looking at the numbers and I'm wondering if person's born and going through seeing drugs in the state community in the 60's and 70's What's that number on the 50's? In terms of compared to the 60's and 70's I can't give you a number for that, but you can see I mean is it higher? What do we it's it's higher now that it wasn't so yeah And then and I think the big difference now here in Maryland and really across the country is that back in the 60's and 70's heroin was almost all Irving in the inner cities and almost all minorities and a lot of people are like why are we now caring that it's middle-class white and that's a whole nother discussion, but But it definitely the big thing over the last 10 or so years is how it's And and we've had a lot of heroin even in you know, I have a newspaper from the mid I think it was 97 about you know heroin in Carroll County So Maryland we've actually had more in the suburbs For longer than most areas of the country, but for a lot of like Appalachia You know New England there are areas of the country that really didn't have it until this last decade And that's a big difference now with the epidemic now compared to the 60's and 70's Thank you There's And Category So we thought that so but I think one of the later speakers also talking about treatments So this comes up all the time, this question, and so the vast, vast majority of people that take buprenorphine, there's also a methadone that is used, the vast majority of people when they're taking it correctly are not getting a hive from it. Puprenorphine actually, it only works partially at the receptors in our brain where opiates work. So most people when they take that they don't feel a high at all. So what it's doing is helping some of those brain changes, which with opiates those changes can take many, many years. There are people that when they've used opiates chronically, it affects their pain threshold. They're always more sensitive to pain after that. So especially with opiates, those medications like methadone and buprenorphine can really be helpful for people. So there's a lot of people that feel you're just replacing one for the other, but going back to the first thing that I talked about, the difference between being physically dependent and addiction, the vast majority of people when they're taking methadone and buprenorphine they are physically dependent, so if they stop it, they'll go through withdrawal, but they're not addicted to it. It's not affecting their life in the negative way that heroin or whatever opiate they were misusing was. Thank you. I'm sorry. Those are some medical terms I left over. What is that? Those just have to do with basically what your pupils are doing when you're taking the medication. So if your pupils get dilated, or if they get constricted with the medication, and then also one has to do with, I believe it's about, with your white blood cells that they get elevated during that. Yeah. Okay. My next question is, for K2, is there a medication besides cancer and therapy, as far as top therapy, is there a medication, detox or something for K2? Burn the bill. I'm not aware of anything. I'm not sure. Yeah. So when the clients that are, when we have someone to come to K2, especially the young people that are coming in with K2 addiction, they are getting into how therapy, but the medication they're getting is amphetamines or something else that's not going to happen to me, so what would be their treatment for them? Just a recent that we're realizing that just like many other medications, if you're on something chronically that you can develop a, you know, abuse habit and addiction to it, and even a dependency, which you can see when people start to get some withdrawal symptoms. So, I think that's an interesting area. We'll see if it continues. Hopefully the abuse will settle off, so we won't need to devise as much strategies towards people rehabilitating from it, but currently there's not much. I agree. And while I'm just sad that part of the problem with the synthetic cannabinoids like that is that people can more easily get psychotic, like hear voices and sometimes that doesn't get better right away. So part of the therapy and the ongoing treatment is to try and tease out, is this something that was just from the medicine or is this somebody that might have, you know, developed some kind of a problem? So part of it is keeping someone engaged in treatment and so that you can just see over time how they do it and if they're getting better or not. So you're suggesting that the therapy for K18 glutamate, especially if the person got psychotic from the K2 use, which happens a lot more than it does, than we see like with plain marijuana or things like that. I have a question here from one of the satellite locations before you start. And it's one percentage of the patients that are using these drugs also have a diagnosed mental illness. So we don't really know, but pretty much every study shows that if somebody has a substance use problem they're much more likely to have another mental illness and vice versa. So, but the numbers vary all over the place and by diagnosis people with schizophrenia more than 50% will often have substance abuse problems, PTSD, 50, 60, 70% so it really depends on the diagnosis. But probably in general you're talking at least 30 to 50%. We do have some information based on research that we did here at the University of Maryland Medical System which is related and that is for a sample size out of West Baltimore. People with chronic disease or several chronic diseases, 3, 4, 5, 6 chronic diseases in some instances 91% of the sample that we looked at also had either mental health or substance abuse or both 91% which makes getting treatment that much more difficult for that somatic or medical condition. And also important that when you're getting substance abuse treatment that people are also looking at your mental health and vice versa that just to do one or the other for many people isn't enough. That question was from Charles Richard. Yes. Thank you both for the presentation. So I had a question about some statistics relating to the Nature and Nature question for Dr. Walsh. So I've always thought that it was, I know that the debate has kind of been out for a while. I've been not speaking. And so you're saying that 60% genetic and 40% environmental, I was thinking that the statistics are pretty close. So kind of similar to 50-50. I was just wondering if you could kind of talk about how recent those statistics were sort of calculated and kind of how they came to those conclusions and if you could sort of speak to kind of whether those, whether that kind of was, I don't know, close. But whether you thought that was sort of close enough, how close that was kind of, whether you thought that that could close enough to 50-50 or how you could speculate as to whether that might be kind of still out in Europeans. Yeah. So that number comes from trying to synthesize all different substances. A lot of research has been done on alcohol, but other substances as well. And it's all different types of like truly genetic, you know, looking at different, you know, genes and things, but also some countries do, like in Sweden, they have a really good registry of everyone that's born and they've actually done studies with identical twins where one ends up staying with the family and one gets adopted out. So you have the same genetics, but a different environment in which you're raised. And so all those different kind of studies, when you kind of pull them together, it shows that, you know, kind of in general addictions about 60% genetic. But it's going to vary by substance. It varies because that environmental part, you know, so right now in different, you know, opiates go up and down, you know, over the decades in the U.S., say. Now opiates are much more available. So that changes the environmental piece. So again, it varies somewhat. But I think it makes sense because I definitely see patients who, you know, didn't have any parents with addiction. And then I've also seen young people who had a lot of addiction in their family. And for, you know, whatever reasons they do not develop addiction. So it's just important to remember that it's not like some things where you really are pretty, if your parents have it, you're pretty much definitely going to inherit it. It's just important that we recognize that people inherit a piece of, you know, that makes it more likely for them. But they're definitely not going to inherit it, you know, definitely as a disease the way that some diseases are. Yeah, I guess why you're clapping. And again, I think later people are going to talk about prevention things. But it makes it, if you can identify high-risk people and you don't just, like, give them, you know, a 15-minute talk about it, you really kind of intervene. And, you know, the problem is a lot of the interventions that are necessary. It costs a lot of money and organization. But if you can do that and really work on the whole idea of resilience, of finding out, you know, like the children of people with addiction, you know, working with their strengths and trying to help them so that they don't get sucked into it. But it, you know, it's good because a big piece of it is not genetic. It means that you can do things like that and they can help someone not develop the disease. Yes. Well, my question kind of tied into the previous question and delivering the disease. Because I know that we invest a lot of money into intervention and effort into intervention frequently. But I was just wondering if all those faculty listed what could we do as a preventive measure, you know, so that we could stop seeing some of this fraud and see a decrease with this field of information that we have going forward. I mean, that's a whole several-day conference you could do. But because it's not, you know, it'd be nice. It was a simple thing. It's just, you know, having Dergo in the school and give some talks. And that mostly affects the kids who are least at risk to begin with. So you can, you know, do things like trying to intervene with the kids at highest risk. But that, again, that's very costly time and manpower. But even the bigger issues of, you know, what do we do to help West Baltimore where, you know, so many people have the problem. It's great to open community centers and do different things. And that's going to help some people. But there need to be larger systemic changes to really kind of help with the prevention and it's more of its core. Good morning. My question is pertaining to a female that is pregnant. So in the last 10 years, you see the whole place taking effect and how it's affecting the mother. And what is the challenge for the next 10 years? What substance do you see? Is it nicotine, heroin? What substance do you see in the future and currently that's going to keep rolling over? In general or with pregnant? Both. So pretty much the same. Unfortunately, the opioid epidemic, I don't think is going away soon. And I think we're still going to be struggling with this. I don't know how much in 10 years, but certainly for a number of years. And that's going to affect women and pregnant women as well as we focus so much because this epidemic is so big now and so many people are dying from it. But alcohol, nicotine, cocaine is making a resurgence here in Maryland. But they're really important and they're certainly important for pregnancy. Alcohol and nicotine especially are big issues that really have not gotten, they're not any better than they were. They're just kind of eclipsed now by the opioid epidemic. Hi, thank you for being here today. My question relates also to the genetic or the generational as well as the environmental. So since we're treating and approaching this as a disease, my question becomes from the environmental standpoint I can understand or my perception is that it's either peer pressure or there's a performance, an institution, so to speak, for coping mechanisms in some respect. From the generational side, when we look at this as a disease, are we saying that at some point a person who's predisposed by genetics will start seeking out something to satisfy something in them? Or is it also a factor of the environmental where that actually triggers that? So hopefully I'm making that clear. Yeah, I think there may be a small percentage that whatever the genetic component that they may start seeking, but probably more often it's just if it's available or you know what we've seen in the most recent piece of this epidemic is people who have an injury and they get put on a pain medicine and some people hate morphine, it makes them sick and they don't want to take any more than absolutely necessary. Someone else who's kind of genetically predisposed, they take it and it's helping their pain but it's also triggering that part of their brain. So it's probably more often that you're more prone to when it comes your way in your environment for different reasons. But there may be some people that are actually, there's something that kind of feels missing and they actually start seeking other things to kind of fill that void. Just to perhaps transition into one further comment with that. So some people are worried about should we not be prescribing pain medications upfront to people? Does that increase your likelihood to become dependent if you're first introduced to it? A lot of the literature shows that slightly but it's more, you develop a dependency when you have longer term use. So there's been a lot of questions about as doctors are we over prescribing pain medication and a lot of the news over the 90s, which I'm sure Dr. Amesh will talk about, about a push towards getting people to pain free. And unfortunately a lot of these answers are not just medical but also cultural. And that's something that we're going to struggle with the society to figure out as well as physicians as a cultural together to figure out where does our happy place stand in treating people for pain but not over treating people for pain. Let's thank Dr. Welsh and Dr. Schwartz for their presentation. As we welcome Dr. Amesh to come forward, let me just make a couple of comments. We're now going to speak about the opioid epidemic in particular. Someone asked about the numbers, where are the numbers? There was an increase of 66% in opioid and addiction deaths in Maryland in 2016 over 2015 to a total of 2,000 deaths. So you can understand the magnitude of the explosion. And let me also comment, almost all of the hospitals in Baltimore City are right now engaged in doing a community health survey. And as part of that, we surveyed about 4,700 people in Baltimore City and asked them, what's the number one health problem that you or your family struggle with? And the answer was addiction and substance abuse this year. Three years ago that wasn't the answer. The answer was cardiac issues, diabetes, etc. So you can see that just in that short time frame, we've got a changed focus. Dr. Amesh is the department chair of psychiatry at the University of Maryland Capital Region Health, serving both Prince George's Hospital and Laurel Hospital. And welcome. Okay. I think this is the topic of the hour. I'll try to address those a lot of interesting questions there. I'll try to address some of the questions in my presentation also. I have a lot of slides. Some of them were covered in the previous topic, so I'll skip some of those and I'll go a little fast and make sure that there's enough time for questions from you all. So first, opioids. What are these? Opioids are drugs they are derived from the opium, the natural opium in the seeds. The natural derivatives are the morphine and the codeine. The semi-synthetic derivatives are the oxycodone, hydrocodone. The fully synthetic drugs are the fentanyl. Actually, they are more powerful than morphine. And the illicit drugs are the heroin. So when somebody talks about opiates, these are all the common drugs that they're talking about. So Dr. Welch did address the next thing that opiates bind to receptors in the brain in the spinal cord, and that's how they relieve the pain. But they also bind to the dopamine. They increase the release of the dopamine, causing a sense of euphoria or a high. So how did we get here? My talk, I'm going to divide into how we got to where we are right now. What's the current status? Where are we? What is being done systemically? Your question about what is being done systemically by the government and the state legislature. And then a few slides on opiate addiction and treatment. So Dr. Schwartz did mention about this being a cultural thing. We did grow up in U.S. for pain, take a headache, take a trial and all, if you have a fever, take a ibuprofen, what not. But these pain treatments were mostly restricted to acute pain and not chronic pain until 1930s or so. So what changed all this was a letter that's published in the famous New England Journal of Medicine that's considered the number one medical journal recognized by everybody. And the letter in 1970s that came from the Boston Medical Center, they did a case study analysis on 12,000 patients that were hospitalized in a controlled sitting and they found that opiate addiction was not a big issue. The letter states we conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction. So basically they said we don't see much addiction in patients who are being treated on opiates. So this was what changed everything. Then the pain movement kind of gained more momentum. There were a lot of lobbying efforts. There were American Pain Society, the American Academy of Anesthesiologists, and then the pharmaceutical industry. So there were a lot of lobbying efforts for relief of pain. And the cancer treatment, people talked about using it in cancer and there were a lot of research, literature support to that and then they talked about using it for other chronic pain. So in 1993 there was a famous article in New York Times by a famous psychiatrist talking about how the growing literature shows that these drugs can be used for a long time with few side effects and that addiction and abuse are not a problem. So then the push was to add the pain assessment as a fifth vital sign. We do the vital signs, the blood pressure, the pulse and all those things. The fifth vital sign was supposed to be pain assessment. Of course we want patients to be comfortable. We want them to not be hurting. So there was a big push and anybody who says they have pain, they have to be medicated. I go to nursing homes. I see there if a patient complains of pain and they are not medicated, the nursing home gets dinged for it. So the pain treatment was pushed and even if a patient is in mild pain, they were given a lot of pain medications. So during the next decade, as I said, the anesthesiologist and the pain people and then the pharmaceutical companies, they came out with a lot of drugs. If you see all those drugs came between 1990 to 2000s. And if you see how much profit they made, so I'll just give a couple of examples. Just in two years Johnson and Johnson made 4 billion in Doragizic patch. In 2015 Forbes released that oxycontin made 35 billion since 1995. In a span of 20 years they made 35 billion profit. So there was a big market here and there was a big push. So also it was not just pharmaceutical industries, there were a lot of pain clinics. They called them as pill mills. And they sprung open everywhere and they were just easy to obtain. The patients had very easy access to get pain medications, prescription pain medications. So in DEA they released a report in 2004 where they said the patients were sitting in a crowded waiting room for an hour. They were just examined in a very short period of time. They did not get much attention. And average if you see there they got three different opiate prescriptions. A muscle relaxant and an anti-anxiety drug after a short visit. So this is one of the slides to show how the pill mills were advertised. And if you have 75 dollars you get a visit there. So then the pill mills actually they were in Florida for some reason. Florida was a state where this was very, very epidemic. That's how it started in 2009. Nine out of ten counties where the top ranked prescribing oxycontin in the US. Nine out of ten counties were in Florida. And 98 out of the top 100 prescribing physicians were in Florida. The people who prescribed more prescriptions, the opiate prescriptions, 98 of them out of the 100 were in Florida. There were 1,500 pain clinics open during that same time. And there were 12,000 deaths between the periods 2003 to 2009. There were 12,000 deaths just in Florida. And for some reason Florida was the country to be the hub. Again Baltimore here is also nationally ranked in terms of opiate use. We are among the top ten cities in US for opiate use. If you see the prescription rates, if you take a ten year sample from 2010, the prescription rate almost jumped more than double. It was 14.7 there. Sorry. Oops. Okay. It was 14.7 there and went to 32 in a span of ten years. This is 14.7 out of 100,000 population, 14.7 prescriptions. The cause for alarm, how did this all create an alarm? What happened? They looked at a lot of studies. The DEA was monitoring and they looked at a lot of studies. The prescription rate as you see there, for each of the drugs, it jumped for morphine 100 percent, for hydromarphone 300 percent, for oxycodone 346 percent. That's just out of, it's very high within the span of ten years, five years. Here it's five years. And the other data, someone was asking about pregnancy. Here within, if you see between 2003 to 2013, 2003 there are 5000 births of babies that are born to opiate dependent moms. But in 2013 there were 27,000, almost more than five times. So these were all the things that raised the red flag and caused alarm. So the epidemic today is, this is how many people are dying. From 2000 to 2015, there's 35 deaths, or 35 almost, from any opiate out of 100,000. How do I put it in number? This is all the stats I want you to look at. Two million people are addicted in 2016 alone. Two million people were addicted. Out of which are, for each of the two million, there are 11.5 million people who are misusing the prescriptions, prescription pain medicines. Roughly half of heroin users start out from prescription pain medicines. And over 0.3% are using heroin in 2016, which is about 100,000 people. The deaths, the reason they call it opiate epidemic is because of death rate. There's 200 deaths overall so far in US. And the death rates are climbing each year. 2015, it was 52,000. 2016, it's 64,000 last year. 64,000 people, just like Dr. Schwartz was saying, to put it in context, is that more people died from more than car accidents or in wars. That's a lot of people dying. Daily death rate is like 90 people. More than 90 people are dying on a daily basis. As we talk, each day 90 people are dying from overdose. Some more stats. 78.5 billion per year is the economic burden to US. That includes the healthcare cost, lost productivity, addiction treatment, legal cost and so on. One-third of the people start misusing when they prescribe for chronic pain and you have the other data. I can go on giving data. The data are alarming. So the prevalence is not just in US, it's worldwide. It's not only in developed countries like Canada, Britain, Spain, Australia, but also in other countries like Saudi Arabia, Lebanon, China. It's prevalent everywhere. It can become pandemic if it is not controlled soon. Talking about US, 80% of global supply is consumed in US. And if you want to look at US, which states are consuming more, West Virginia is number one. So if you are a practitioner, if you are treating any patients here, you ask them where they are getting the drugs from, West Virginia. Number two, then followed by Pennsylvania and New Hampshire and other states. And if you look at the prevalence, it started out in the 60s, 70s in the cities, but now it's mostly in the rural areas. It's among Caucasian patients. It's among working class patients. It's not in city. Now, city is there, but the prevalence is high in the rural areas and among working class patients. Okay, now my second part of the talk. What is being done? What's the government doing? 2010, FIDs started cracking down on the pharmacist prescribers. 2010, they passed the act take back or drug disposal programs where the pharmacies are allowed to accept the excess supplies from the household and long-term care facilities and things like that. 2016, Surgeon General Vivek Moti described the extent of the problem and gave a speech and a thing. I think in 2016, same year Obama signed a comprehensive addiction and recovery act and allocated about several millions, I don't have the exact figure, several millions of dollars for research and treatment. In 2016, Governor Hogan declared a state of emergency. In Maryland, 2000 people died last year. Out of the 64,000, 2000 died in Maryland. Maryland's a small state and we can't have this many deaths in Maryland. And this year, our President Trump declared on August 10th national emergency. So, what else is being done? Prescription Drug Monitoring Program. It's a PDMP, we call it. It's now mandatory. Everyone has to sign. If the position prescribers who don't sign into it, they don't get the control drug prescription license renewed. So, all states are required to do this. And all the pharmacies are also required to be registered. They collect and distribute the data. And more states now are restricting the prescriptions to a maximum of seven days. Seven days is the maximum you could get, the prescriptions. Maryland is a little different. I'll come to it next. Maryland is, again, they had to be registered by mid-2018. You have to query into this database. You have to look into the database before you write a new prescription for each patient. And for chronic prescriptions, you have to look into the database every 90 days, every three months. And you have to document why you are using it for long periods of time. You have to say the dosage is the least minimal dosage that you're using. You have to document a lot and you have to substantiate proof of what you're doing and show evidence-based medicine, basically. So now, addiction. Now I am coming to the treatment side. So that's what's being done by the government to crack down on the use and to limit the prescriptions. So now talk about addictions. I'll skip this slide. I think Dr. Welch covered this very well. He talked about the distinction between dependency and addiction, and he talked about tolerance and withdrawals. So I'm going to skip this slide. I want to just mention this slide, one thing alone. Naloxone, which is Narcan, is now available very easily. You can get it if for targeted population. If you go into the emergency room and if they deem you as a high-risk opiate user, they will give you naloxone nasal spray or injections to take home. So just to prevent the death, because the key is you've got to use it really quick before you don't want to wait until the patient comes. So the families are being educated on how to use it and it's now available free of cost to eligible patients in the emergency room and all the hospitals are now being equipped with this. So what are all the warning signs? They talked about the previous two speakers, talked about the withdrawal symptoms and things like that. Just on opiate, what are all the warning signs for opiate addiction, opiate use? They get a sense of elation, euphoria. Sometimes they can be confused, drowsy. They are not able to concentrate. Their appearance changes. They are more isolated. They are more secretive. Their pupils are constricted. This is what Neos is that other speakers are referring to. If you see a pinpoint pupil, that's a classic sign of opiate overdose. And their breathing flows, they are constipated. Just think if they are high on opiates, their secretion all dries up. So you have urinary retention, you have constipation, you have blurred vision. So you have all those secretions dry up. And if you are withdrawing, it's the opposite. The other signs, they are doctor shopping. They have financial problems. They are dramatically changing moods, social behavior changes. Now the withdrawals, as I said, there's more secretion. So there's diarrhea, there's vomiting, there's sweating. And they are irritable. They have insomnia. Their blood pressure pulse goes up. So those are all the signs of someone is going through a withdrawal from opiate. This is specific for opiate. Some treatments. There was a question about treatment with Biprenorphine. Dr. Welch addressed it. It's partial agonist. Yes, we started out using Clonidin, which only treated the physical symptoms. It treated the high blood pressure. It treated the pulse rate. It treated the physical withdrawal symptoms. It didn't really treat the mental cravings and things like that. So then we started using methadone. Methadone was the gold standard treatment for a while until people somewhat started using, abusing the methadone too. They found ways of abusing it. So then came also methadone was only available in the clinics. And you had to go daily or you'll only be getting a prescription maximum of three days to one week after you have been in the program for a long time. So it was not available easily for treatment. So then came Biprenorphine, which is actually now the gold standard of treatment. As he said, unlike methadone, Biprenorphine is a partial agonist. What that means, what the term means is it doesn't give the fully effect of the opiate stimulation. Agonist means stimulating. It's not stimulating the receptors fully. It's partially. And it partially blocks. The beauty is, if you try to take any other opiates on top of it, you go into a drawl because it's blocked all the opiate receptors in your brain. So you can't take any other opiates. So it curbs that. And to answer your question, why can't they abuse this? There is a ceiling effect with Biprenorphine. You can abuse it to a little bit. But if you take more than a certain dose range, 32 milligrams, then you don't get any more effects. It doesn't impair your functioning. It doesn't get you addicted, like Dr. Welch said. It does make you dependent. And when you stop, you do go into a drawl sometimes. But it helps you be functional, helps you be productive, and helps keep you stay away from the opiate drugs that you would otherwise be using. Then there's pro-Biphenous, nothing but Biprenorphine. Now for patients who need long treatment, it's an implant in the forearm or in the arm here. It's a minor surgical procedure. You implant the drug there and stays in your system for six months or so. So you don't have to go to the office often to get the treatment. Now the Biprenorphine is available as an outpatient treatment. You don't have to go to a clinic. It's always an outpatient treatment. And a lot of prescribers are trained to use this. So a person who is licensed, you could get it, internist, psychiatrist, anyone. Addiction is not only just medications. Medications are a tool, but the main treatment is counseling. Individual groups, NAAA meetings. So you need to combine them with counseling for the best results. The treatment settings vary from outpatient to partial day intensive and to the inpatient treatment. I think I went over a little bit over my time. I'll stop here and I'll take any questions. Coming forward to the mic they are. My question is, is there a research or study that is being done for the opiate detox? Because as a counselor, I understand the suboxone with the non-oxalone and all that in it. Now the NACTA, NARCAM, the NARCAM brings them out of the overdose, right? Is there a research that's being done that instead of, okay, methadone and suboxone both has a little bit of opiate for the receptors of their brain, correct? Got it. So is there a research being done where there's medication for detox of opiate use without the opiate in it? Yes, there is research being done. But we don't have anything that's at least in a stage three or something. It's all in the preliminary stages. Right now the ones we have are the ones that contain the opiates or some form of stimulation of opiate receptors. We don't have anything that is not opiate that's at least in the last phase of trials. There is a lot of drugs that's being researched, but nothing promising yet. My next question is for, I thought the lady was going to ask that question, for the women that are pregnant and opiate addicts that are trying to get opiate and them having them on methadone for the babies, is there a better way besides giving them methadone? Because then their baby is already addicted to the heroin and then when they come out there, they get to the methadone, which the babies have to be, I'm not mistaken, they have to be on it for a while. So isn't that predetermined effect of that child growing up being a heroin addict or an addict period or a person that's misusing drugs? Methadone is a methadone and subatex without the naloxone is a preferred drug in their pregnant woman. It's better to have them on these drugs rather than have them abuse the street drugs if they can abstain from using the drugs without any treatment. If they are not heavy users and if they can abstain with counseling alone, we try that first. We don't go and put everyone on Biprenop and R methadone. But the focus is if they are heavy users and they cannot abstain, it's better to be on methadone. But the child is getting some methadone, some opiate through the womb. The child will go through some withdrawal at the time when it was born, but the child doesn't have to be maintained or given any treatment. The withdrawal symptoms in the child is usually more of irritability and crying for periods of time and it should pass on its own. Dr. Ramesh, thank you for your presentation. So you go back to your office and you're there in the phone rings. And hi, this is President Trump. I heard about your wonderful presentation today. What three things should I do to help improve this situation? And while you're thinking through that answer, receptionist comes in and says, Dr. Governor Hogan on line two, and you put President Trump on hold and Governor Hogan says, Dr. Ramesh, I heard about your great presentation. What three things as governors should I do to make this problem better? What three things, and they could be the same, would you say to President Trump, and what three things would you say to Governor Hogan? Thank you. That's an interesting question. I think I need a little more time to answer the question. But things that come right off my mind that I would recommend that they do is not only just curb the prescription that's given, but more education, more system-wide education and dissemination of information about the risks of using OPH and how it could be avoided, and more education basically is what comes to mind, number one. So when you educate them more, when you have educated public, when you have educated customer, your job is half done. Go ahead. Two. Okay. Number two is to do more money into research and come up with better treatments, models, and drugs to kind of target this epidemic. And number three, I would say, is to curb the availability. The deaths are happening not because they are abusing heroin. All these heroin are laced with fentanyl and fentanyl is cheap and that's what's causing the death. So how do we limit the traffic? How do we limit the supply? How do we curb the availability of these drugs would be my thing that I think of. But if you give me a time, I could come with something better. We have a few questions from U.M. St. Joseph's Hospital. So I'll ask two and then we'll proceed here. The first one is how do we best reassure parents who have a child that has a medical condition and that they don't want the child to become addicted on pain medications or there's a family history of addiction and they don't want the child to be addicted to pain medications. What do you say to them and then are there any statistics to talk about this issue? I don't have the statistics but definitely talking to the child and just like now in the high school they talk about, they have a mandatory sex education kind of thing. If you talk to the child about the ill effects of opiates and just drugs in general, not just opiates, drugs in general, share with them what's happening nationwide and be more of a friend if it is high school and things like that, be more of a friend, have an open conversation, be open to talking to them and not be punitive and be restrictive. But if you have open dialogue conversations and talk to them, I think we could address this problem better. That goes without saying for any psychotic problems too. If you talk to your kids and help educate them and be a friend and listen to them, I think we can address the problem better. But I don't have a statistics to talk about. It is highly prevalent in the adolescent. In the high school, college kids, it is highly prevalent in the opiates. The second question is, are there any public training programs on Narcan use? There are a number of CPR students who are asking how they can find them and how they can help. I think the second person there is also part of my group in there. I think I met you there in the Maryland Hospital Administration. All the hospitals are now really dealing with this issue, talking about how to make the Narcan available and how to educate the public. There have been a lot of programs they are discussing. So in the near future, the near next few months, because there is a mandate now starting January 2018, all the hospitals have to have a plan of how they are going to tackle this opiate crisis and patients when they come into the opiate problems, how they are going to tackle it. And one other thing is the Narcan, how is it going to be dispensed, how people are going to be educated. So there should be a lot of educational theories that should be coming out. I missed something you could add, the second person in the line. Good morning. Can you talk a little bit more about the implant? I have not heard of that before. Is it the criteria for using it? Is it covered by Medicaid? That is apparently very new. Can you talk a little bit more about that? And also if there are clinics that are using it, can you share that information? Probiphane is a Biprenorphine long-acting version. It is recently approved. I do not think it is covered by Medicaid. It is an expensive drug. As I said, it lasts for six months. It is done even by private doctors in their clinics. It does not have to be a surgeon. One can go through a training and get the certification and do it. So I do not know in Baltimore, I am from the Montgomery PG County area. I do not know here if the University of Maryland has it. Maybe Dr. Weintraub, the next speaker, can answer the question. But in PG Montgomery County, a lot of private practitioners, they do give this drug. And you can go to the Internet, Probiphane. They have the pharmaceutical company as a website. And you can see who are all the doctors who are certified to prescribe this drug. Thank you, Dr. Ramesh. So regarding the question about getting certified or getting a certificate to administer Narcan, so I took class probably three years ago. That was free in Baltimore City. I can get you the information on the break. Perhaps you can communicate it to those interested online and also to the class. I do not know. It was through Baltimore City. Was it the health department? The health department, yeah. Most of the health departments are doing it. It is valid for two years. You get the card as well as a prescription written by a nurse practitioner for Narcan as well as some kind of kit, I think. You fill the prescription and you don't have to be a health care provider. You just go through the three-hour training. It's good for two years and then you can refill it for free or we get a new card by just contacting them so I can get you the information. So my question is regarding, so it's regarding whether you can kind of speak to whether you think it would be helpful. Is there a sort of promise in reducing the stigma and whether you think that might be helpful or I guess whether there's future promise as kind of the opioid epidemic increases and kind of whether you think that people coming out, particularly with celebrities. I'm thinking about this because there's this really great documentary. I don't know if you've seen it, Dr. Omesha, but it's called The Anonymous People and it sort of talks about how there was a lot of progress right before the 1990s, before the Bush administration when they started really cracking down really when it became about cocaine and there was no tolerance. But before this, a lot of people started coming out in celebrities and talking about their addiction, particularly alcohol, and they saw a lot of progress with politicians, particularly because politicians and celebrities started coming out and talking about their problems and there were some policies, a pretty big policy coming out that came out to help a lot of substance abuse programs, I think. And so with Marilyn Monroe and Elvis and all those things, but even now with Houston and Heath Ledger and Anna Nicole Smith and these recent things, these are ways, when people come out, these are ways to kind of help people, but it's interesting that celebrities, sometimes celebrities, they're not, they're sort of criticized. Like Whitney Houston, she had all this addiction stuff in the media, but they never talked about who's getting her help. All they did was really criticize her and show all these pictures of her looking pretty terrible. So I think that there's, I guess my question is, whether you think there's sort of promise or even maybe some potential for these in the future, something like what happened right before the 1990s, for this to encourage people to not be at this point, this document was anonymous people. So for this to be an opportunity for people to maybe come out and be encouraged and reduce the stigma, because I think there's promise in that for education and people to not be stigmatized I agree 100%. I think that's a great idea, especially when celebrities and politicians, they talk about it, it becomes a big news media and more people watch it and you can get more advertisement than coming from them in terms of educating the public. And there was, as she said, there's more criticism and that's why people don't come out, but if they do come out, it will be a wonderful thing and I 100% agree. If you give me a fourth size, maybe that might have been a fourth size recommendation. I agree. So here are the blessings of technology. I'm getting notes from people in our other locations and one answer was this about the Narcan training. Every health department in the state is providing Narcan training. So that answer goes out, I think it was St. Joseph's, Southern Maryland for everyone. Okay, one other question, two other questions from St. Joseph, if you don't mind. What are the effects of opioids on young adults who have ADHD? I don't know if there is any study that looking at specifically patients with ADHD and opiates, I could go and look, that probably is. But to my knowledge, if you are addicted to one substance, and you tend to get addicted to other drugs, so if you're addicted to stimulants, the medications that are being used for ADHD, there is a likely chance that you could get addicted to other drugs. But people who are not addicted, but who have just ADHD, how likely are they to use opiates? Generally speaking, the psychiatric diagnosis, they all have comorbid conditions, we call it. So they do have generally other diagnoses that go. There's not, there are very few patients who have just ADHD alone. They tend to have multiple other problems. And one of the common comorbid conditions is substance abuse, not just opiates, any drugs. So the prevalence is definitely high. I don't have the rate incidence, but I don't know of any particular study that's looking at ADHD and opiate. One additional question from St. Joseph, and that is, what are the consequences of not checking the prescription dispensary monitoring program, and how is this going to be monitored and valued? So starting 2018, the prescription drug monitoring program, if you don't check, I think you have the consequences, your CDS license, you could lose it, the controlled drug substance license, you could lose it. So you are required to check, and the monitoring agency, I think it's called CRISP. It's a network that connects the hospitals, outpatient doctors and everything. So they monitor, and they have a grant from the government to do this. And I think that's the way they monitor it. Very good. Good morning. I really don't have a question. I have part of a story of my life that I want to share. Is this possible, or I might have a question. Well, if it's brief, go right ahead. Okay. I've cleaned 34 years. I used to use drugs for 10 years. When I first started getting clean, I tried to get on the methadone program. They told me I didn't have enough drugs. So I just put myself into it. I don't think the programs, the methadone program, doesn't work if it's not in the person. If the person is not ready, you can give them all the drugs they want. It's not going to work. Me, I've been cleaning 34 years. There was November 23rd. And I'm proud of myself. I'm going to reach out to people. I want to get on programs to reach out to people. It can be done. It can be done without drugs. But it's got to be the mental part of you wanting to do this. Thank you for sharing that. Dr. Amesh, can you comment as well about peer recovery specialists? Yes. That's what I was going to say. I really thank you for coming up to the podium and sharing your story. The best, I have been to many hospitals and the programs. The best counselors are the ones who have recovered themselves and they come and talk about the drug use and how to stay off of them. And it's more effective when people like the gentleman here comes up and talks to other people and shares their stories and talks about, hey, this is possible. You can do this. And the counselors, the peer reviewers, the counselors in these programs are the greatest counselors that I have ever seen. Is there a website where you can look? Because I've been looking at positions that are looking for peer recovery person in an emergency ward. And I've been looking. You have to take so many classes of classes. I don't know what the website you have to go through to look for. I don't know the website. Is anybody in the audience? Do you have a website for? No. You gave. Okay, great. I got two things. One is to piggyback on what the young lady said about the Noxilon training. Back then, the cars we were given, it was for us to train people into using it. Nowadays, because of the epidemic of hurl and overdoses, you don't have to do training anymore. You can go to the emergency room. And especially people who are hurling users go to the emergency room. They will give them a packet of the Noxilon to carry around. Or you can go to Central, I know this for sure, that the Central Library in Baltimore City or on Cathedral Street does training. I don't know if the days are still the same, but I know it was Wednesdays and Thursdays in the evening. They also have free trainings. So you can get Noxilon anywhere now because of the hurl and epidemic. That was just piggyback on that. My question is... Thanks for sharing that information. Well, hold on and let the person behind you ask a question. If it comes back, great. It's happened to all of us. And if it hasn't happened to you, because you're young, it's coming. First of all, thank you for having this discussion. I work with youth from ages six to 18. My interest is, what do we have for prevention? I mean, all this is all well and good. This costs a lot of money. And to me, it's about how do we get them to not start? And what's out there now? What's coming down the pike other than we got another treatment facility for $30,000 a month? What are we doing about that? To stop it now so that we don't devastate another whole three or four generations of kids? What are we doing with that? There is not much being done now. There is some prevention classes, education and things like that being done in clinics where the treatments are happening. But a systemic nationwide or on a bigger level, I have not heard of something that's being done or initiatives being taken. Maybe they are in the pipeline and they are not just heard of it. But I'm sure that it should be coming. But I don't know of anything that's big, at least in Maryland. Mr. President, I would encourage the gentleman to go to the Hilton Foundation website. They are the whole priority of the Hilton Foundation. The Hilton Foundation in the Basin, California is at all times a pile of stuff. I'll be talking to you in a minute to talk a little bit later about that. The Hilton Foundation has used us to do a major effort for about two years. It's already been based up. And we're starting to get interested. No, no, no. I'm glad. I'm glad. There's a lot of pockets all over the nation, but nothing major on a big scale. But I'm glad you shared that. We're going to take these last two questions. Is it a good idea for children, young adults and children to be taught how to use Noxilon to start it now? Is that a good idea? And if it is, is there a pilot or training out for them? As far as I know, there is no training out for the children's adolescence. And I'm not sure if it is maybe adolescence. Maybe it's something that you should think about. But children, I don't think it's a good, great idea. But you got children with parents. Overdose them in front of them. What are you supposed to do? What I mean by children is a young children. I'm talking about teenagers and things like that. Children, young children. But it says something to think about. Something to raise with the health department. My next question is heroin addicts, they're already addicted, right? When they go to the core current mental health, they're also prescribing addictive medication. Isn't there other medications that they can be taken besides like Vicodin and all that stuff that is addictive for the mental health problem to keep, the behavior is not changing. So if you take me from one addiction to another, my behavior is not changing. Isn't there another way or is there something being done where as though, if you're coming as a heroin addict and you're my mental health therapist and you get, is there other medications that it can be given without having addictive consequences? So there are non-opiate pain medicines for patients who need treatment, pain treatment. But the thing is they are not as potent. So patients, when they come for opiate medications, they usually have tried several of them. But yeah, considering the mental health, it's advisable for patients with or without mental health to not use those medications. And doctors do try. And there's a push to not use it now with all these regulations. So there are non-opiate prescriptions available. Hi, thank you for the information that you presented. One of the challenges that I have is understanding where we start really dealing with the ethical and systemic issues around substance abuse, mental health, because when we come, one thing that becomes pretty apparent when we come to forums like this is that we have a lot of empirical evidence, but we don't necessarily have systems to support either prevention, preemption, or full recovery for many people. So where do we begin that conversation? Because there are ethical issues here, clearly, because we're dealing now with treating and helping individuals who in many cases trusted the medical professional that prescribed these medications, and now the onus is on this generation and the next generation, and however many generations it takes. So when do we start having that discussion upfront instead of waiting for the train to run us over? And why aren't we having more of those discussions when we're doing the research and putting people in these situations? I agree. The ethical discussions has to be upfront. It has to be in the start of the treatment and the first encounter. And there's being more done now and with the customer's clients being more educated, that's happening more and more, and they are being more aware, and there's actually more of a discussion these days than one of, okay, what do I do and just tell me what do I need to do? There's more of a discussion between the patients, doctors, patients, treatment providers, and about these ethical discussions. There's actually separate committee. If you go to all these conferences, the ASM and the APA and other things, there's separate conference just to talk on these ethical issues with substance abuse in psychiatry and how do we tackle all these ethical challenges and there's a lot of them. So there's more focus being done on that and I think it's happening more and more. I agree it could happen. It should happen even more than what's happening now, but I think we are getting there. Ladies and gentlemen, please join me in thanking Dr. Amesh for this very brilliant presentation. Thank you. Okay, because we've had a good, robust conversation, we are a little bit behind. That's all right. We're going to take maybe a seven-minute break given that bio break or there's more food outside. As you do that, please do visit the vendors and service professionals who are outside. We have AA of Baltimore, the Maryland Addiction Recovery Center, the Maryland Office of the Attorney General and the Health Education and Advocacy Unit, the UMS, the University of Maryland Medical System Health Plans, the University of Maryland Midtown Behavioral Health Center, the Recovery Centers of America and then part of the School of Medicine Department of Psychiatry. So take a moment and visit them at one of our satellite locations. They, too, have service providers that are on hand. Come back in about seven minutes so we can resume this program. Thank you. All right, we're ready to resume, everyone. We're going to pick up now with our next speaker who is going to talk about recovery. This is Dr. Eric Weintraub. And I need to say a special thank you to him because he is the person within the University of Maryland system who helped us put today's program together and decide what we should do. I'm very grateful about that. And he's also made himself abundantly present when the media have asked to hear what we're doing and help us communicate this out to the community. So very grateful to you for that. Dr. Weintraub is a board certified addiction psychiatrist here at the University of Maryland and he works right across the street at the University of Maryland Medical Center. Thank you, Don. I welcome everyone to... Okay. What I wanted to do was talk a little bit, not only about recovery but about treatment as well because they're so interlinked and just bring up some topics that I think we need to discuss. I really heard some great questions the last hour that I think bring up a lot of the issues that we're dealing with. I know Dr. Remisch talked about the opioid epidemic. So my background is I've been working in the city of Baltimore for the last approximately 20 years working with people with opiate dependence and other substance abuse issues. And in the more recent five years I've been actually working in rural areas as well as the opioid epidemic has spread to other areas. So before we get into recovery I just wanted to talk about treatment because there's a couple... There's many different levels of care if you look up and I had a couple slides that are not included here that I may be able to get to you later but ASAM has levels of care and different types of treatment that range from simple outpatient counseling to intensive medical detoxification. So one of the things that we're always doing with patients is trying to determine what level of care they need. And I think one of the issues that we have, I think one of the gentlemen in fact who's working with the adolescents talked about the amount of money that we spend on inpatient treatment. So I think what we really need to do is look at patients individually make a determination of where they need to go for treatment and then send them to that appropriate level of care. There's a tendency to oversell I think inpatient treatment as a cure-all and families hear that, families have individuals or sons, daughters that are really struggling in life and they're kind of sold, I wouldn't say a bill of goods but they're told you send your kid with us for 30 days everything's going to be okay they come out and things are not necessarily okay and this pattern repeats itself over and over. There's lots of good outpatient treatment out there and people can do really well in outpatient treatment. So I think just as a clinicians and community members you really need to question what your son or daughter or family member or friend is getting when they're referred for treatment. Other issues that have to do with treatment are there's different types of treatment like I said there's counseling there's 12 step programs there's medication assisted treatment there's family treatment many of our patients need dual diagnosis treatment because they've been traumatized they might have mental health disorders we also know that many of our patients especially those that are injection drug users and people that have severe alcoholism have a lot of medical problems so trying to co-link medical treatment with substance abuse treatment is really important. One of the and I think what we need to understand is that we need to meet patients where they are and not have them fit into what they think they need and I think that's really critically important so these are all tools in our toolbox so medications can be helpful for some patients 12 step programs can be helpful for some patients and sometimes people need a combination of treatments I think what we find most frustrating is that programs have a certain set of expectations for patients and we have to come to group three hours a day, four days a week and everybody needs to go to those groups or you can't be in the program and we know that certain people are working they go to school, they have other lives and when we get into talking about recovery those are critical parts of getting better and there is no one size that fits all we know that so we really need to look at each patient try to individualize treatment try to see where they are and I really can be upsetting for me when I hear somebody say well this is the way I did it this is the way you have to do it well that's just not true we have scientific based treatments what work for somebody in this audience may not work for somebody else we have to be culturally sensitive and really attuned to what each individual needs and that's our job as clinicians to try to help figure that out we're not always going to get it right the first time but we do know somebody had talked about stigma before I think before we can fight stigma in the community we have to fight it within our own substance abuse treatment community we still have people that are denying that evidence based treatments are effective so we know that for opiate dependence methadone and buprenorphine are effective treatments there's a ton of science on it and yet I still have patients that say that this person or that person in this program won't accept me because I'm on medications I think that's an individual decision between a patient and its physician it's not for everybody but we need to understand that some people need different things than other people again there's a couple other issues I just wanted to talk about real quickly before we open it up for questions one is again motivational interviewing stages of change everybody's at a different stage if you haven't read about it there's a nice concept to think about some people are pre-contemplative when we meet them that means they're not even thinking about treatment some people are thinking about treatment called contemplative some people are ready for action some people are in the maintenance phase where they've already figured it out our job is not to go from stage one to stage four I mean if you think you're going to go into the meet with somebody that's actively using, that's pre-contemplative and have him turn around and say thank you, you've helped me see the light we know that's probably not going to be the case but if we can leave the room and see that they're thinking well maybe I'll think about getting treatment that's a success and I think that's kind of what we need to do is sort of push people towards recovery sometimes it's a long process every once in a while somebody will have an eye-opening experience they'll have a car accident they'll be diagnosed with a serious illness and they'll come out of it but in general that's not what we see and I know we have some of our peer recovery coaches here from the emergency room and they probably see that every day and they see people that come back and come back another thing that I find it's very important that we're working towards but we don't have is immediate access to treatment I think that's just a huge issue for us we're working on things like in the emergency room being able to start people on medication getting treatment in the ER when you think about it let's take heroin for example somebody's using heroin six or eight times a day and you give an appointment in four days the guy could be somewhere in East Baltimore he could be anywhere trying to chase those drugs if he says I'm ready for treatment now hey he may not be but we gotta give him a chance we have to be able to open the door so people can have immediate access to treatment Maryland's working on that we're not there but I think that's a really important thing I talked about the medication issue I think we need to come together and understand there is not one way I'm repeating myself that medications can be an important component for recovery for not only people with alcohol use disorders but with opiate use disorders even Hazelton that was the initial accident space treatment program was switched over and said people can be in recovery if they're taking medications being on a medication does not mean you're addicted to another drug addiction is the behaviors that are related to chasing a drug so if you're preoccupied with finding cocaine 24 hours a day and it dominates your life that's addiction if you're taking a medication like buprenorphine once a day and you're able to work and take care of your family and not think about drugs that's not addiction not in my mind anyway the last thing I just want to talk about with treatment is harm reduction so this is another very controversial topic some people believe it's abstinence or bust I think we're in the process of understanding that's not always going to be the case that sometimes we're going to see people that want to just reduce consumption and there's some literature that that can be affected with certain types of people that drink that they are able to reduce their drinking to a level that allows them to function and not engage in risky behavior so I think we need to be patient with patients there's a thought sometimes in treatment programs that I've seen that if you don't get it right right away they kick you out of treatment there's no other medical condition when somebody's doing poorly that we kick them out of treatment if you're a diabetic and you go off your diet and stop your medications and your blood sugar goes up to 400 they don't say well you can't come back you're out they work with you, they counsel you they try to improve their treatment intervention but with in substance abuse it happens you test positive you're gone and I don't think that's a really accurate way of dealing with patients that have a medical illness and a brain that's been impacted by years and years of drug use other, so it was interesting a couple years ago we went to Amsterdam to visit and see what they were doing in Holland because they're a little bit more progressive I mean some people may not agree with what they're doing but we visited a safe consumption site which they're talking about now and having in the United States a lot of people would say well that's just enabling people to use you could argue about that but the way they see it is very different they see that these people are using this allows us to have them use in a safe place where it's not impacting the community where we can prevent overdose they've never had one overdose stuff in a safe consumption site and the goal is in those sites is that you're trying to work on getting somebody into treatment that they're not giving up on the person the goal is yeah we don't want this to be this way we want you to get help and treatment and so that's another thing that we're talking about in this country right now we don't have any I think there may be one in Seattle and they're talking about having one in Baltimore but again you bring that up it causes all sorts of controversy and people get upset so in talking about recovery so I think we're pretty good at treatment we have an idea we want to get people in we want to get them to reduce or stop their drug use but I think and again for the people here in recovery they can speak to this as well that's not enough that's the beginning so my experience in working in the field is there are a group of people that when they stop using they just kind of get it they get a job their workers and they get back and re-engage with their family and things go you know much other than when they come and see and say they're doing okay but there's another large group of patients that that doesn't happen for so three months in they may not be using but they still may have medical problems they may have mental health problems they may not have a stable place to live they may not have a job they may not be connected to the community and so they're still struggling with a lot of issues that could be triggers for them to start using again so if you say to me you know I'm clean I'm not using anymore so what what's next for me so I think what's happened is we started to take a broader look at what recovery really is it's not just abstinence and we know again that some people that are abstinent are not in recovery they're two different things they may not be using and I'm going to go through some of the slides now as defined by SAMHSA there's a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential so this is something we do sort of in the maintenance phase and people aren't using the discussion should be not just about drug use anymore it should be about what are you doing with your life how do you spend your free time where do you live how are you reconnecting with your family are you taking care of your children those are all huge parts of recovery and the four dimensions of recovery is defined by SAMHSA health, home, purpose and community so it's amazing when we see people that are just getting well what they notice about their health so just one typical example is dental health they have a lot of patients that come in and all of a sudden they think the treatments are causing all their dental problems when they probably haven't been to a dentist in like 10 years and they haven't flossed their teeth in 10 years so I think people start to notice they start getting tested for infectious diseases like hepatitis and HIV so health is a huge problem for these patients we need to get them connected to medical care many of our patients especially in this area have been traumatized by there's sexual trauma there's violence that a lot of our patients have experienced a lot of our patients have experienced extreme losses it's amazing to me to see the resilience that many of our patients have that you talk to somebody and they've lost more than one child they've lost spouses and to be able to overcome that so we talked a little bit about that then home I mean this seems pretty simplistic but it's amazing again especially for peer recovery coaches that work in the ED that how many people we see that don't have a place to live and to get well without having a place to live is not easy so and there seems to be a lack of empathy even among health care providers about that so we have people coming to the emergency department I have lots of residents and physicians that will say well the guy's here just because he's homeless well that's an important thing it may not be a reason to come to the emergency room but it's a critical aspect of somebody's life I just say have you ever not had a place to live I mean a place to stay at night and to try to have them think about what the ramifications of that are the purpose so I think and it's more than just stopping drugs what are people going to do with their lives it doesn't mean they need to become professionals but a lot of people reconnect with their families they take care of loved ones they watch their children they take care of an elderly relative but these are important meaningful activities that give people purpose and meaning in life and that are really important for someone self-worth in recovery reconnecting with AA or 12 step programs are a great place and great way to reconnect with the community sometimes I think that's one of the most important aspects of the 12 step programs is providing a social base for people being around people that don't use but also there's churches and or your job there's all sorts of ways that people can reconnect with the community and then SAMHSA also came up with 10 guiding principles of recovery that were hopeful that people can get better I was actually talking to somebody the other day about am I hopeful and I am hopeful that we can get our way out of this because I see people at the grassroots level get better I think the best way for us to Dr. Welsh who came back and I have talked about this the best way to educate trainees actually talk to people with addiction that are doing well I think that's because I think people still see people addicts and not human beings and when you get to know people they're just like you or me they have the same wishes and wants and desires they want to be able to have relationships and meaningful work and when you see somebody doing well it's just that's what convinces me and makes me hopeful that if we get our ducks in order that we can really make a difference in this epidemic let me go back here so then we talked about there are many pathways it's individually driven as we spoke about before not us mandating this is the way it has to be done because that's the way our program is set up that's the way I did it that's the one that gets me the most this is the way I did it so that you have to do it the same way we use peers our patients now they can share their experiences and help them walk through the process I think having recreational is mentioned but I thought where do you go where do you have fun, where do you hang out we've actually talked about trying to have those kind of facilities in our own programs I was talking to an old patient of mine today who goes down to the senior citizen center and plays pool with his buddies he's got a place to go these are important things that we address trauma is really critical as I mentioned before we have a large amount of our patients who have experienced significant trauma over the years and we just respect our patients as individuals and I think that will give them a better chance of achieving a meaningful recovery that's really pretty much what I had if anybody had any questions let's sit down Dr. Weintraub, I'd like to thank you for your service my name is Garrett, I'm a peer recovery Cropes Across the Street in Emergency and and I have to share this with you coming in I was one of the guys abstinence or bust when I came into this process that's what I did and Dr. Weintraub and everybody well there's different ways so it's been a year now and I've seen it come to life so now I'm open minded with this new thing for me I've been cleaning a little over 10 years a young lady came in yesterday I want to share this with you guys real quickly she had been in the emergency room over a hundred times since January she came in and well we like to think as a peer recovery coach as we just like simply plant and seed when they come in are you ready today? You know I'm not ready today so over the hundred times of her coming in we planted a lot of seeds you're telling a great story I want you to face the mic so that our satellite locations will hear you hello satellite so she came in after four months of being clean and she wrecked the emergency room everybody was just WOW I mean they were just taking it back this woman came in she knew all of the ambulance drivers they were coming up hey how you doing it was just such a beautiful thing and she was the one that you know just couldn't stop you know we got a box or whatever now she's absent you know so it's like wow so today I'm open minded you can come in a hundred times you can come in 150 times I'm going to treat you like it's your first time a hundred times and for the life finally came on for me so with that being said thank you Dr. thank you Gary for sharing that I wanted to say thank you for not just the information but your compassion is palpable so your care for the human being I'm one of those people that also believes that you have to deal with the whole person you can't just deal with what they're manifesting or what their particular challenge or issue might be definitely I appreciate that and how you presented that one of the things that I think we face though when we talk about particularly with substance abuse and to me it's kind of they're still a value based judgment attached to that you talk about someone who perhaps has diabetes and how that person doesn't necessarily go through the same perception of someone who has a substance abuse issue or challenge or disease might have or disorder might have because I think at some level we still ascribe responsibility for that to that person so we say well you could if you wanted to when in fact a lot of the data that's being presented says no they can't so at some level we have to as whatever as clinicians as counselors whatever our role is we have to take responsibility for how we're perceiving not just putting everything the onus on the person because if we're truly caring about them then we want them to be whole and we're giving what we have to make them that way rather than blaming them for their condition so I guess in my the question that I would have for you is as you go through your processes of treatment and relating to patients do you and it sounds like you do but I don't want to presume do you educate and do you teach holistically or do you more or less case by case let's talk about the living circumstance the other point is all things being equal what you're saying is perfect but it still goes back to an issue that was raised earlier which is access because on every level of this regardless of what person walks in the door the question that has to be asked is not only is there a service or a support system but do they have access and how are those things being addressed globally globally thank you well thank you for those comments so I got three different responses one is I was trained to see patients or treat patients with a biopsychosocial model kind of approach it's been popular for many years I don't know if we still see it that way so I know that just treating an illness without looking at the psychosocial issues is not going to be effective so that's kind of the initial way I see somebody and talk to them and try to now clearly access to resources is a problem I don't have housing to give to people I can refer them to resources I know those things are critical not being able to have a place to live or food or support sometimes that gradually comes with recovery as people rebuild their lives but sometimes people need that right away so I think we probably need to do a better job of integrating all of our resources and so that's and I don't have the immediate answer to that we're always thinking about the stigma part I think is something that we work with every day and we work with that with I think well I'm not clinical side of this as much I found that even within certain pharmacists certain providers within our own institution that people have these feelings about substances people that use substances they're frustrated and I think one of the reasons I've always thought was they don't see people get better sometimes so I'll give you an example in the emergency room as Garrett was saying they've seen that same person a hundred times I get to see people get better so I'm more hopeful and optimistic so I think it was great that they got to see this person come back in but this is going to be a constant I don't know battle to the right word but we have to be out there advocating and educating people that it's going to turn around immediately but I think we're slowly and gradually making progress and it can be frustrating even for me sometimes it's discouraging when I hear certain things from the same people so we just got to stick together and keep telling people to get better and be optimistic about our patients we have a couple of questions from Prince George's County one is what programs like AA and NA good models to address today's crisis I think NA and AA do a lot of really good things and I think it's I hear people say it's termed out tool in the toolbox I don't think by itself it's a good treatment for opiate dependence without other tools I think it's been pretty clearly shown that the majority of people with opiate dependence are on medications but I think NA and AA are great for great treatment of certain people who well with that alone depending on what their problem is for some people it's a great adjunct I think it's a great way of socializing for people in recovery so if you have somebody that's been using everyday for 10 years and they quit on Thursday what are they going to do on Friday night because all their friends use so you go to AA meetings and they're not sponsored so I think it has a place but it's not a soul way of treating our way out of the epidemic there's a second question here that says some community providers state that they're seeing growth in the new addictions among their patient populations such as K2 which we talked about earlier and counselors are not sure how to manage them so is there exploration of new evidence based models that can be used in the community for ongoing support such as we see with chronic diseases in self-management or to effectively educate individuals families, community providers on how to recognize and address risk factors related to the opioid and other new addictions that's a pretty broad question so we started with K2 so K2 is an issue we you know I'm not sure what the actual question was about that wait one was just how do you manage people with these new addictions and then what evidence based models are out there to help so we're trying to we are just finding out about K2 there's a lot of new synthetic cannabinoids that are out there they're all a little bit different I work in the psychiatric emergency room so I see the end result of people using cannabinoids and becoming psychotic and agitated I don't think there's really evidence based treatment programs just for K2 we're just trying to even right this point identify what they do how they work and which ones are the ones that are causing some of these problems as far we do have evidence based practices for the treatment of opioid addiction which include medication assisted treatment which is a combination of medications methadone, buprenorphine and naltrexone with psychosocial interventions so we have pretty solid evidence that this works the primary outcome measures are decreased opiate use and increased engagement in treatment and we also see decreased transmission of infectious diseases decreased criminal activity decreased overdoses so yeah we do have I mean that is the evidence based treatment for opiate defendants and we're trying to find out new medications people are working on vaccines but right now those are the three FDA approved medications thank you hey digna how you doing let's see I'm a nurse practitioner mental health and I work at department of general services for 8 years and I work at central booking which has been with 9 out of 10 people that I see they have addiction for the substance addiction and the company for mental health assessment and I know that in multiple mental health systems unified over a year ago I just don't see the sphere of disturbances for both drug diagnosis and you know addiction and mental health I haven't seen it because in both facilities they are treated separate and I'm just I'm challenged with 9 out of 10 people 9 out of 10 people I see they are for the substance abuse and I'm not reading addiction I'm trying to treat mental health but I'm faced with a challenge sometimes I don't know what I'm really doing can you speak about the effect of the unification of both mental health system and is that well I can speak probably better the general question that there is a lot of comorbidity between substance abuse and addiction and we know that in the jails we're not offering a lot of medication assisted treatment unless you've already been started on it so we try to integrate treatments within our programs where I'm a psychiatrist and we have other psychiatrists working in our program so they can provide both mental health and addiction services and I think by taking the addiction component out it's easier to know what mental health issues are there when somebody presents and you learn withdrawal and it's just an act that we're using but many of those patients are going to present with mental health complaints but many of those patients if you can treat their underlying addiction will not have a pre-existing major mental disorder so I think we do really need to integrate treatment I can't really speak to the politics of the combining of Baltimore City's programs and how that's impacted so I don't know where to go with that one I appreciate what you're saying and I think the discussion certainly has a lot of components particularly what the previous practitioner said and then other comments regarding the stigma also access to care really what I see is the kind of great divide between mental health and addiction which really needs to be it really needs to be treated together and I think you also support that idea and you also mentioned this idea of several mentions the idea of access to care and you really think that care should start ideally at the emergency room and I know that that's really what you can do if you're working in the EDR across the street so I was wondering how you think we as providers and you also sort of as a physician and in teaching are you a medical do you work at the School of Medicine so as a professor can really help students learn and also other doctors kind of help with education to them to your coworkers and colleagues and also for other providers and practitioners in terms of educating them to reduce the stigma that we can so that when we are treating and interacting with substance abusers that we can without bias and supportively help direct them to treatment because I know that I've seen a lot of practitioners doctors and other providers sort of really perpetuate the stigma and you know when even in mental health providers I've seen them someone's doctor shopping we as clinicians really should be have adequate skills and also resources to refer them because this is a disease and if we aren't referring them then we are ignoring a medical condition and I've seen this happen so and I've also talked to a lot of patients who feel that not only mental health providers but other regular providers are treating them in a way that makes them feel very stigmatized and sort of ridiculed about their substance abuse so I think there are several ways we can address that one is through the school the professional schools we work with medical students and residents and trying to educate them and talk about stigma Baltimore City we actually have a very good program with the emergency rooms in which I think six of our emergency rooms now have peer recovery coaches and we've also been able to institute initiation of buprenorphine treatment in the emergency rooms as well and part of the process of getting that off the ground was going to the different emergency rooms and talking to their physicians and kind of dealing with some of the issues that you're talking about what them saying possibly well this is just going to bring all these drug addicts to the emergency room we were talking about if you don't treat the underlying addiction you're going to keep coming anyway with abscesses and different medical problems so there's a lot of both education needs to be done in the classroom and in the clinical setting I think people have to see people get better I think that's really important again I don't want to call on our peer recovery coaches but I know their relationship probably with the emergency room has evolved over the one year that they've been there that we kind of just stuck them in the emergency room and said here they are and I think now they're considered valuable members of the team and the nurses and the emergency room I used to believe to kind of protect them the psychiatric emergency room for I think we were the same zone but I think now they're again you can speak to it more than I can they're accepted and considered a valuable part of the team so it's a constant educational we've got to keep educating our clinicians that this is a chronic illness and people can get better and if we ignore it then they're just going to keep coming back to the emergency room chronic illness so we have a question out of St. Joseph's hospital which is how long are people expected to take buprenorphine and are there long term effects? I think they need to take it as long as it's effective and you know you have a collaboration with your physician so it could be for years it could be you know depending on what they how they feel if they want to work with their physician on coming off of it but we don't set a timeframe on it it would be no different than blood pressure medicine or diabetic medication people take it as long as they need it we don't know of any long term negative effects of taking opioids when you're major organ systems so it could be a lifelong treatment if that's sort of the question Hi, thank you so much something that you said while you were speaking was really refreshing and as someone in recovery and someone that worked in the substance abuse treatment you said that doctors in the medical field should have open dialogue with people that are getting better but you know I've kind of had some barriers with that so I just you know I know peer recovery in the emergency room has been really important but what are some of your suggestions for opening that dialogue both with people you know like myself that are in recovery, long term recovery and also you know someone that works in the substance abuse treatment field you know how can we open this dialogue with the medical field I can specifically can you talk about a particular barrier that you might have so that means you as a patient or a clinician trying to talk to a physician about treatment so what you mostly on a personal note like what you said was talking it's important for the medical field and doctors to talk to people that are in recovery you know how can I someone in recovery open that dialogue with you know a doctor and come to them and say you know this is my experience this is what happened and you know I do on a professional level community outreach so you know on another note like how can I open a dialogue with you know people like yourself or other doctors that you know kind of believe that we have something to offer to this and you know how can we open the dialogue yeah I'm not sure I had the answer I know there are there have been extreme an enormous expansion the utilization of peer recovery specialists coaches so there one way would be to guess I guess get into the field and have interactions in that way because you would be working with physicians as far as more of a open dialogue in an educational setting I'm not sure I have the answer to that but it's probably something good to think about and figure out a way where we could have that hard to get docs out of their offices sometimes so Dr. Weintraub someone said earlier thank you for your compassion it is palpable and I've worked with you a long time and it is clear from your work and from your words how you feel about this and how much you really care about your patients and we thank you for your presentation and for that compassion as well a few minutes ago Dr. Weintraub used the term hope when he was standing here at the podium and we have something that I think is very very special and if this isn't a good story for hope I'm not sure what is we have Dr. Jason Ramirez back here who is going to come to speak to you he is an assistant professor in the department of family and community medicine here at the school of medicine he grew up the child of two addicted parents and he is here to share his story I promised you a present as well later he's written a book which is called the hard way a doctor's fight against addiction poverty and depression when you turn in your evaluations and I know you will you will get an autographed copy of his book today so Dr. Ramirez please come his story is very personal very honest and very real thank you hello everyone thank you so when I first got asked to come talk I didn't know actually how to respond my first thought was well why do you want me to come talk you got all these wonderful people to talk about great things and I'm just me then I realized well I wrote a book about it I can't hide it anymore it's a story that I wanted to share for a simple reason to try to give hope and inspiration to people who may be having struggles with life my initial reservations were well everybody has struggles with life I don't know anybody who doesn't struggle with life in some way shape or form then I realized there are things in my life that changed the way I thought of things and allowed me to become who I am today so who am I yes I'm here says I'm a doctor wow that's pretty cool I am the residency program director for the department of family medicine which means I'm in charge of training the residents becoming young family doctors it's pretty cool some people tease me and say I'm the boss I don't know if I like that but because people usually don't like their boss but that's not how it started that's not who I am yes I have a nice home I have a nice car I have a wife and two kids but that's not how it started out as far as I can remember five years old I grew up in a household of addiction my parents both of them were heroin addicts but I didn't know when you're five, six, seven, eight, nine, ten what do you know you see random people coming over your house kind of all fidgety anxious they go into your parents' bedroom they come out 15, 20 minutes later and they're really sleepy I didn't know what was going on thought my parents were pretty popular they had a lot of people coming over then I realized well that's something else is going on why sometimes people come out of the room sometimes people are dragged out of the room thrown into a bathtub water running on them my mom is slapping them to try and get them to wake up a few people I did not wake up unfortunately got to witness that as a young child you know why why was my father in prison a lot why was my mother always having this stereotypical nodding trying to slowly scratch her face a lot of times missing why was my father a lot of times not playing with me instead he's on the floor face planning down always sleeping I didn't understand these things until I got to be a little bit older and how older I'm talking about eight, nine years old but then the why's kept asking I ask why a lot, I still do but why would my mom want to tie a shoelace around her arm why would my father hold a spoon and my mother light a lighter under it and have this weird substance boiling why would they want to stick with it in their arm I just don't get it but they said don't worry about it so I didn't worry about it too much until it started impacting us I was eight when my first sister was born I'm one of four children I'm the oldest and the only boy and I became a parent very quickly my parents were not capable they weren't bad parents I'll stress that a lot I'll get to that at the end they weren't bad parents but they had struggles and they had to them maybe priorities and maybe a strong word but they passed me a lot with the responsibility of caring for my siblings and again it started at eight so yes what eight, nine year olds left alone with a newborn that was me you know from cooking to cleaning to bathing that became my responsibility really really quickly and then the second and then the third sibling came impacted me socially I didn't do anything as a teenager I didn't I did not like summer vacations summer vacations spent 24 seven at the house with the kids I loved my sisters but still I wanted to be a kid and just didn't have that opportunity never got a chance to play sports other than raise the three sisters that I had the the funny thing is when I left for college I was 17 about to be 18 I thought that I was leaving it all behind I was like I done I put in my time you know I struggled and I but I got through it I raised my they were so small but did my part to help raise my sisters and I thought okay I can move on and live my life and I did for a while read a book that changed the direction of my life and autobiography which really was kind of my impetus to say okay maybe I can do it too but when I left I thought okay I'm gonna do this I've done everything on my own in life I'm gonna become a doctor and because I'm I really believe I can help people in a way that is very special and I wanted to be a surgeon at first okay I make mistakes too don't I know some people got that I thought that was really funny actually sorry if there are any surgeons out there but it caught up with me I lived a childhood feeling that I didn't need anybody I was doing everything on my own I didn't have much parental guidance they didn't push education they didn't push anything they just kind of did their thing and I did my thing but it caught up in the form of I started all of a sudden sleeping a lot grades started dropping again couldn't get out of bed don't go to class turn translates into not doing too well fortunately I was able to snap in and out of it in and out of it I keep going in and out of these waves of what now I know is depression that doesn't go away I still struggle today I have a great life but I still have periods of time where depression creeps in but somehow I'd always get picked up life would knock you down and it does many many many different quotes out there about you know it's not how many times you get knocked down it's how many times you get up and I really believe that but life kept knocking me down and for some somehow some way and I don't know that I have the answers to always how I got up but I would get up and I would fight through and make something positive happen but it wasn't without struggles you know the times growing up watching the kids that was all it was my sisters that wouldn't be so bad but it was okay where are we going to live now I mean I thought my parents just liked moving a lot we had apartment after apartment after apartment after apartment wasn't we like to move and it was because we were getting evicted all the time because we weren't paying the rent so from apartment to grandmother's basement to apartment to grandmother's basement to worst times where when I was 19 it was our car five of us in a car those were the pretty rough nights we'd sleep in the car on rest areas on I-95 I was born in Connecticut parents really were running from the law and decided to make an escape it's in the book but we just stopped at rest areas along I-95 my parents would very humbling when you're watching your parents begging for money my mother was very very convincing and we did that all the way down it took a two month period of time to get from Connecticut to Florida but we would just stop panhandle whatever that would call it now ask for money go find whatever major city we were close to go get their heroin and then at night we'd try and find a homeless shelter if we didn't find a homeless shelter that became our car I actually preferred the car homeless shelters to me were always very intimidating and scary as a young child big auditoriums hard gymnasium floors sometimes you got a cot most of the time not but those are the times that they really stuck with you and it didn't end when I left when depression got hold I ended up I'm a doctor I'm a surgical trainee and I couldn't again started my father passed away right before I graduated medical school he contracted hepatitis C from IV drug use also drank very heavily but we two don't go together very well from the liver standpoint and he passed away and I really spun into a major depression where I could not get out of bed my job thought well what's the matter you must be using drugs I'm like well the irony of this whole thing is that I'm not but and I didn't I don't know if I didn't have the insight or what it was I didn't know why I couldn't get up out of bed why I couldn't show up to work I'm not going to have that job very long so I got asked to resign and I resigned but basically didn't have a choice and so now I'm an unemployed doctor living out of my car because that's all I knew I knew how to do that that was taught to me but I didn't know what else I was going to do fortunately I was able to get back into medicine family medicine which I always say family medicine kind of found me more than I found family medicine it's the best thing that's really ever happened from a personal and professional standpoint but I still had a large chip on my shoulder it wasn't and I probably still do if you ask my wife but I just thank you for a couple of chuckles there that's nice unfortunately true but it was still rough because I still felt like okay I didn't need anybody to succeed I still thought oh I was doing all this on my own it took me 44 years however long it's been I'm 44 now but it took me some time to realize and maybe it was writing the book I don't know but reflecting back at the pass and thinking you know I did not do it myself you know what poses the question well how did you do it how did you do it I don't know I don't have the answer to that I do believe certain things I said before my parents were not bad parents they had as we've heard all this morning they had a disease they had a major disease that cost them their lives at a young age I've been without parents for 15 years now again I'm only 44 I told you about my father my mother after being in recovery for a while unfortunately this is nice it's tying in a lot of stuff we talked about this morning but had some problems with chronic headaches went to her family doctor who prescribed oxycodone and that's all it took addicted again back to using lost her lost her husband because of it I took her in moved her into my house because she attempted suicide she didn't succeed the first time she succeeded the second time the second time was by a bottle of medications that were prescribed by Dr. Jason Ramirez I was trying to help her depression help her headaches help her insomnia I thought I was doing the right thing she was a very wise woman she knew what I was giving her she had it in her mind what she was going to do somehow that did not throw me into the major depression that you may think it would have and it ties into again why I think I've been able to overcome a lot of things you know why we talked about 50 roughly genetics environmental statistically I suppose you would think I had environmental I had genetic I had everything you know why I really believe it's not to sound cliche but a lot of who I become and how I've been able to get through things and how other people speaking of parents two parents who have children the parents who have addiction problems again sound however you want it to sound but I really think it's based on love my parents I know for a fact loved us and they tried shielding us they didn't do a very good job but they tried and they weren't there as much as they could have been but they did instill in me anyway family is paramount importance we must love each other we must support each other and that's what I did for my sisters I didn't have three sisters I don't think I'd be standing up here talking about my story I don't know what would have happened but I dedicated my childhood to loving my sisters and raising my sisters in adulthood I had my struggles again overcame them based on on the love of a young woman that is unfortunately not here she's across street working in the ER but my wife who literally entered my apartment one day while I was in bed sleeping because I didn't want to face the world plopped a bottle of antidepressants on the table wrote with a note saying start taking this or we will no longer be now anybody seen my wife she's really really really hot so I took that bottle of medication that day and the rest is history 17 years later but I it's still an issue even today I still have struggles I still think about what my life has been where I've come going I still have problems with again not I can't talk about what it's like to be a have a substance abuse disorder what it's like to struggle with addiction but I know what it can do to the children to the family and know what I'd encourage people to do that either are seeing or counseling families is to remember that you know they for their themselves and their children showing love to their family their children putting that above all else can make big differences and then knowing that they can't they don't have to do it alone when I think it's when I realize that I need to get rid of this I can do it myself mentality I don't need anybody I don't need anybody once I let go of that I accepted that there are people that care about you and that's okay you can let people in it's not working on that a little bit but you can let people in and they can make they can show you that you're cared for and you're loved it really makes a difference so I definitely try and instill that now in people that I see I don't share my personal story very often with patients or anything but I have on a couple occasions one I'll share with you is because I think it was the most beautiful experience I've ever had with a patient long story short she had multiple admissions to the hospital this undefined nausea, vomiting, abdominal pain nobody could figure out a million dollar workup all the specialists you could do all the procedures you could do nothing's wrong nothing's wrong and she literally could not eat and this wasn't made up this is real stuff I would watch her vomit she'd smell food and she'd throw up and I came in the room I sat down I'm like I don't understand what's going on I know you have a heroin abuse history I know you're you've battled that but I knew it wasn't because she had been in the hospital for like a month I'm like could it be withdrawing what's going on I'm like look I don't I'm not going to tell you I know what it's like to be in your shoes but and I shared my background my family background and growing up in a home of addiction and I kid you not she sat up in her bed gave me a hug said thank you for sharing my story I'm hungry normally they're not taking anything by mouth you like start with the clears or something no I gave her the biggest tray of food I possibly could find and she ate the whole thing and I discharged her the next day she was like my fear was I was a I lost my connection to my suboxone and I was fearful that I was going to relapse and go back to heroin and then all these symptoms came about and I came in the hospital and it was simply sharing the story I was in the hospital she was in ironically my wife took her in the ER one time for something totally different and this was a couple years later and she recognized the name badge and she was like your husband saved my life and I was like that's just give me chills right now but it's that's the reason why I've chosen to continue to now start sharing my story is that if I can help and then give inspiration, hope to others and it doesn't have to I thought initially oh the youth I want to help the youth it doesn't have to be it could be anyone of us hopefully somebody in this room can be inspired by my story and I'm nothing special I mean I'm just Jason Ramirez you know grew up in Bristol Connecticut as a youngster Florida as a young man nothing special about me I have all kinds of problems thank you sir appreciate that but I honestly think I'm no different than anybody else and we all have to get through this life and again doing it together is the way we can do it thank you very much so very humble would you say you may not know it but we know it you are a rather you are a very amazing human being and we thank you very much for your story to share it wow gave him chills gave me chills what a special person you are thank you very so much for sharing you are going to help people absolutely you are so I prepped for that question I didn't have to prep but it's a great question the four of us 75% of us beat the odds so I have me my oldest sister who is doing well she is a fitness instructor in Georgia living her life through faith and doing very well no problems my second sister who I just found out this week is expecting her first child so it's exciting I'm going to be an uncle which is awesome she owns a dance studio a Fred Astaire dance studio in Sarasota Florida so she competitively dances ballroom dance she got all the dance genes I have nothing trust me on that one you don't want to see it my fourth the youngest right now I'm pretty sure I should know for sure but pretty sure still in jail in and out of jail in and out of rehabs has fallen you know kind of from time to time with addiction and but last I heard she was in prison in Florida don't really hear from her unless somebody from the law is looking for her or she wants you know wants money and I've heard from her now you can make what you want from now I'm not going to say that I was the one who did anything but I almost feel a little bit of guilt there because when I left she was like home to go to college she was two and I was there for the other two a little bit longer in their lives and when I left for college I mean I left I never really went back my oldest sister would kind of take over and step into my shoes she actually ran away from home and went to people who said hey you want a room of your own you want a TV in your room you want a telephone she was an impressionable young teenager teenage girl she left home and left my two younger sisters behind they consequently cost us five years of not talking to each other but we mean that and do talk from time to time but yeah that's where they are thank you so much I work at University of Maryland alcohol and drug abuse program and I also work with a lot of youth in parenting class who suffer from depression and who come from parents of the same background and besides medication what are some coping skills that maybe younger children can use because we know medication is not just the answer you still have to have coping skills and kind of sometimes I guess if you feel when you're going into that depression or things maybe that younger children can use to get out of it whose parents are still using very good question and this is something I never really knew about or even even as an adult we all realize and appreciate that medications alone versus therapy alone and then the combination is always better it's one we have to as people who have battles with depression this is where I struggled was accepting that I have that problem I mean it took a long long time to realize that okay I have this problem I can't do it on my own and I need help and it's harder for children I think to kind of understand that and that's where I think it's hard to say but the home environment the supporting environment has to if it's there it makes it a lot easier the problem is most of the time it's not and so how do you I don't know how you I don't deal a lot with pediatric psychology but how do you instill that there I think if you can get that message I can get the message out there that that is the most fundamental thing I know you care about your kids I know it I know you have a disease that's limiting you from being the optimal parent that you want to be but showing that support showing that love being there for them reading to them doing their homework just playing with them I have one memory only of me and my father doing anything together it was when I was a teenager we played that's because he bet some guys at work that we could beat him at two on two basketball we did but that's it I don't remember any true times that we you know I can say okay we bonded and I'm let me tell you I have a seven year old son and a three year old daughter I come home I don't care if it's up until 11 o'clock I have to play with them do anything until they go to sleep and then I'm up to one in the morning doing my work but as best as I hope I can do the best I can I will not have them going through childhood and being an adult saying oh I have one memory of playing with my father I cannot I love what I do I love medicine I love teaching but I know where my heart is and it's with those three people that I go home to every night any other questions Dr. Amiris thank you again for sharing such a poignant story ladies and gentlemen we have come to the end of our formal program but I want to invite you once again to visit all of the service providers who are outside at their tables and I also want to say an overall thank you to all of the speakers for today and a special thank you to everyone who helped put today together our community benefit team, our IT team our media folks your efforts are really very greatly appreciated I hope you all will continue to join us as I mentioned at the beginning this is part of our now new series Not All Wounds Are Visible a community conversation on X we started today with addiction and substance abuse following the day long that we did some months ago the next one will be on May 23rd here in the same location and that one will be on depression and anxiety so we hope you'll come back and join us again I hope today has been beneficial to you we really do welcome your comments and those evaluations Dr. Amiris will be outside by his book table and make sure you turn those in and get a copy of the book on your exit thank you so much for joining us today