 So, this final session this afternoon conference, as we got framing this topic, it was really important to us to talk about, okay, if we can come to some kind of understanding about patterns of use and maybe what addiction is or isn't, what are the options for what do we do? And I think that there are some clear-cut cases where addiction means something and then there's some gray areas. I hope you're starting to see how complex this can kind of be to slice and dice, but this panel is going to try and talk a little bit about what do we do, what are the next steps, what are the insights that we've learned at this conference that might help us move forward, whether it's about the specific use patterns or it's about the person that will come out in the panel discussion. Also as a part of this, it turns out that several of our panelists write for ProTalk, which is a blog on rehabs.com. Now, rehabs.com is a for-profit company that sort of tries to be an internet clearinghouse, and I'm oversimplifying, an internet clearinghouse for treatment programs. They did us a huge favor by sending out a lot of our publicity to their client base, so we want to acknowledge that they were instrumental in getting a lot of our publicity out to an audience that we don't normally reach, so we thank them explicitly for that. And it's now my pleasure to introduce Tom Crady, who is a vice president of the college, and while we normally have faculty who know quite a bit about the speaker's area introduce our guests, we thought it was very fitting that Tom Crady would introduce our panel, since his dissertation was on unwritten normative drinking behaviors, alcohol use, in fraternities. So he knows a little bit about this topic. So Tom? Well, it's my pleasure to introduce our panel today, and I'm going to start with Ann Fletcher, MSRD, who is nationally known award-winning and medical writer, speaker, and consultant on the topic of weight management and lifestyle change, as well as the treatment and recovery of addiction. She spent nearly five years writing a book called Inside Rehab, The Surprising Truth About Addiction and Treatment, and How to Get Help That Works, which was published by Viking in February of 2013, with an accompanying e-book titled, Holistic Rehab Therapies Are Alternative Approaches Helpful, Harmful, or Headgames. Also the offer of a New York Times bestseller, Sober for Good, and currently works as a peer support and family services specialist at Minnesota Alternatives Outpatient Program in Minneapolis, and is also the lead columnist for the online forum pro talk and rehabs.com. Dr. Willen Brink is Director of the Treatment and Recovery Research Division of the National Institute of Alcohol Abuse and Alcoholism National Institutes of Health. Prior to his current appointment, he was Professor of Psychiatry at the University of Minnesota. He is a board certified general psychiatrist with added qualifications and addiction and forensic psychiatry. In his research, he has worked to develop test innovative management strategies for patients with complex addictive problems such as combined mental health and addictive disorders, medically ill heavy drinkers, and homeless public inebrates. He has also played a leading role in developing the evidence-based clinical practice guidelines for treating addictive disorders, and co-led a national initiative to determine the utility and feasibility of implementing practice guidelines in the treatment of addictive disorders within the U.S. Department of Veteran Affairs. In his current position, he works to stimulate new directions and research on treatment and recovery, health services research, and to disseminate new research findings and to facilitate their adoption. Dr. Michael Pantalon is a senior research scientist in the Department of Emergency Medicine, assistant clinical professor in the Department of Psychiatry, and lecturer at Yale University Psychology Department. He is also co-founder of the Center for Progressive Recovery, whose philosophy is that recovery comes within the addicted individual versus outside pressure. Thus, the responsibility to change is placed in the hands of the addicted individual by acknowledging that he is he or she is free to decide whether or not to change, internal locus of control, free to decide why they might want to change, and free to choose how they would like to change. Finally, we have William Cope Myers, who is the Vice President of Public Affairs and Community Relations at the Hazelton Betty Ford Foundation. He has been in the forefront of the national recovery advocacy efforts for more than 20 years. Carrying the message about addiction, treatment, and recovery to public policy, philanthropy. Moyers brings a wealth of professional expertise and an intimate, personal understanding of communities across the nation. He uses his own experiences to highlight the power of both addiction and recovery. Moyers is an author of Broken, My Story of Addiction and Redemption in 2006, a memoir that became a New York Times bestseller, and Now What? An Insider's Guide to Addiction and Recovery 2012. Many of William's nationally syndicated columns were recently compiled in a new e-book entitled Beyond Addiction. Volume one, he has appeared on the Larry King Live, Oprah, and is a regular contributor to Good Morning America. As a former journalist for CNN, his work has been featured in the New York Times, U.S. Today and Newsweek. At this point, I'm going to turn it over to Peg O'Connor, who's going to facilitate the panel. Thank you, Peg. Thank you, Tom. When we conceived this panel, we knew that there would be a set of questions that would continue to pop up. And we've seen the kinds of disagreements we have about trying to figure out what addiction is or when something moves from just drug use into something slightly more problematic. And we knew that it was really important that within all of these conversations that we talk about, so what do we do? So in this panel, we've got four questions that our panelists will address somehow. And within this constellation of questions are the following. What counts as effective treatment, along with the embedded question, what is or what are the goals of treatment? What's working? What's not working? What are the ways we treat, if that's even the right word, people who have mild to moderate substance use disorder? And then four, what insights from the conference might influence clinical practice? Now, they won't take these one at a time, but in their comments, they will address various parts of that. So each will have about five to 10 minutes to to speak. And our order is Anne Fletcher, Mike Panalone, Mark Willenbring, and then William Moyers. And then it will open to conversations between them. But if you are in the audience, you want to write a question and send it up. So we'll have about an hour for that. And then for that last half hour, we'll put the rest of the band back together. The other conference participants will join us for that final half hour. So Anne Fletcher. Hi, I'm going to address the questions or at least some of them in the context of sharing some of the findings from my latest book inside rehab and the research that I did for that. After one of Lindsay Lohan's early rehab visits, it was kind of the early period when Lindsay and Brittany Spears were in and out of rehab. A leading addiction researcher told me that when a People Magazine reporter came to him and said, how can we find out what goes on inside these places in these rehabs? The researcher who happened to be a friend of mine said to me, I have no clue. I thought if these researchers have no clue, the people who are working in this field, nobody seems to know what goes on inside these places. Another prominent treatment researcher, Thomas McClellan, regularly filled me in on his research about gross shortcomings he was finding in addiction facilities that he was studying across the nation. So in 2008, I set out on my own to be kept to what became a five year journey to study our addiction treatment in the United States. Coast to Coast, I visited 15 facilities, everything from celebrity rehabs, famous 12 step residential facilities, programs, outpatient programs that treat indigent people, rural outpatient programs and residential programs. I wanted to get a whole smattering of different types of facilities. The research process included interviewing hundreds of clients and their families who had been through some kind of treatment, as well as many leading experts in the field. In fact, that's how I got to know some of the people on this panel. Before addressing the questions proposed to the panel in the context of my findings, I'll first share a few facts about treatment or reiterate some of what we said earlier, very briefly. Of the more than 21 people in this country with drug and alcohol use disorders, which is the proper term that we now use, we talked about the DSM earlier, how we diagnose substance problems of the 22 million people who have one of these problems, only about one out of 10 receives treatment in this country. While many who need addiction treatment don't receive it, as we said earlier, the truth is that many don't need what we think of as treatment, treatment going to a rehab or an outpatient program. We talked about how drug and alcohol use problems fall on a wide continuum. They can be mild, moderate or severe. Most people with drug and alcohol problems, including those that are severe, get better on their own. Those that are severe are the ones that are more likely to need treatment. But people who either get better on their own by going to a, this is most people, get better on their own by going to a private therapist or expert, or by attending support meetings. Support meetings could be AA, smart recovery, they could be some kind of a church group. There are many, many, many different ways to recover from a drug or alcohol problem. And by the way, AA is not treatment. AA is informal, it's an informal support group. It's not considered treatment. Of those who do go to addiction treatment, far more do it far, far more, I don't have the numbers right in front of me, but far, far more do it in outpatient than inpatient settings, despite the fact that the knee jerk reaction of most people when somebody has a problem is, oh, you got to send them to rehab. This is perpetuated by television shows, this is what we see all the time when somebody has a drug or alcohol problem. And the research suggests that overall outcomes are not better for residential or often the two terms are used synonymously, residential inpatient treatment than they are for outpatient treatment. Turning back now to my book research findings, which uncovered many things that aren't working in treatment, including both residential and outpatient settings, I'm going to refer to them as shortcomings. I'm also going to reveal areas for more effective treatment that could help more people. I'll also share too that I've seen some signs that things are beginning to change since the book was published. The first shortcoming, I'm just going to address three major areas. The first shortcoming is that addiction treatment in this country tends to be one size fits all. The more options we have, the more people could be helped. Remember I said that about one out of 10 people with a substance use disorder gets help in this country. So what are some examples of one size fits all treatment? We predominantly have group treatment in this country. Dr. Thomas McClellan, who is the co-founder of the very prominent treatment research institute, which is affiliated with Penn in Philadelphia, is known for saying, if you go to just about any addiction program in this country, the major activity is group. If that doesn't work, they'll say try group. And when all else fails, they'll suggest group. At residential rehab, these are from the rehabs I visited where some I stayed for five days to a week. And I have to give tremendous credit for these programs to let a stranger, a writer come in and stay amongst their midst and sit in on treatment with their clients. I give them tremendous credit for allowing me to do this. At residential rehab, there's some type of group counseling, education, lecture, or other group activity, about eight hours a day at many places. This doesn't include meals. Individual counseling can easily be five hours a week or less. Outpatient. Outpatient model in this country is typically three hours of group treatment three times a week, sometimes with no individual counseling at all at some places. Despite its widespread use, and there can be great value in group therapy, but despite its widespread use, it has not been well researched, and we know relatively little about its effectiveness for treating substance use disorders. There's no evidence that it's critical to the recovery process, despite what Dr. Drew has said on TV, you have to have group treatment to get well from addiction. There's no evidence of that. And of the many people I interviewed, some of them said I could never speak in a group. I could never speak up in an AA meeting. Some of them said I wasn't able to get well until I found an individual therapist who was willing to work with me alone. Another example of one-size-fits-all treatment is what I call AA ubiquity. Seven out of, there had been some very distorted in a negative way, and negative to AA, figures that had been going around because of some popular books in this country. This is the best I could come up with. Seven to eight out of 10 programs in the U.S. are based, it's hard to find data on this, but about seven to eight out of 10 programs, treatment programs in the U.S., involve the 12 steps of AA in some fashion. But studies suggest that the dropout rates are quite high. One review of the literature suggested that between six to eight out of 10 people with severe alcohol problems who are encouraged to attend AA while in treatment will stop attending AA in less than one year. Now, that doesn't tell us anything about the people who will drop out, and they may come back again. But the dropout rates are fairly high. Again, if we offered more options and we told them about more options in treatment, it's believed that more people would be helped. What would boost the efficacy of treatment? Choices and flexibility. This is a quote from a major government publication. Motivation for participating in treatment is heightened by giving clients choices regarding treatment goals and types of services needed. Offering a menu of options increases treatment effectiveness. Clients often have a really good sense of what helps them. Many people have been through treatment time and time again, and they have a pretty good idea of what's going to be effective and what's not for them. But they're often told things like your own best thinking got you here. When in fact they have a pretty good idea from their past experiences that that kind of treatment hurt me in the past. And this would help me a lot better. Most addiction treat the second major area of shortcomings, I said I would address three, is the second one is that there's a huge gap between science and practice. Most, we know about science-based practices that have been shown to be to increase the effect, to produce better outcomes in addiction treatment. I believe Dr. Willenbring will be talking about some of these. Most addiction treatment programs say that they're using effective scientific approaches shown to be effective in scientific studies, and they are to a certain extent, but they're often not using them in ways that they were shown to be effective in scientific studies. One researcher went into programs, typical treatment programs, and she found that often what went on in those programs, she defined it as chat. There was not a lot of evidence-based treatment going on. She said that it was so rare as to be almost undetectable. Another example of the gap between science and practice, we have medications, numerous medications, that can help people with alcohol problems, but only about 25% of facilities, treatment facilities, reported that they offered any of them in the latest survey of treatment programs in the U.S. Although we know that long-term use of medication, such as methadone and suboxone, lowered death and relapse rates substantially for people addicted to prescription pills and heroin, they are grossly underused in this country. Third major shortcoming, the things that we think should protect us in this country don't. Licensing and certification of programs provide no guarantees. The made accrediting bodies for rehabs don't assure that science-based care is offered. Being state licensed, some of the major accrediting bodies for addiction treatment programs are major, mainly quality control measures, they don't assure that they're using science-based treatment. Finally, often people in this field are inadequately trained. There was a major study that was done by a group called Casa Colombia. They surveyed the state of addiction treatment in many, many different areas a couple of years ago, all across the country, and they looked at the qualifications for becoming an addiction counselor. Addiction counselors provide most of the treatment in addiction programs. They found that six states have no degree requirements for becoming an addiction counselor. Twenty-four required only a high school equivalency or an associate's degree. This is really disturbing given the complexity of treating substance use disorders and the fact that more than half of people with a substance use disorder have another co-occurring mental health problem. One expert said to me in few other fields, do we play some of the most difficult and complicated patients in the health care system with some of the least trained folks among us? What we need to make this better is to require better and more training, at least a master's degree for people in the field, as it is for any other mental health problem. So the other thing too is that we need therapists with empathy and respect, not telling people that we know what's best for you but people who will meet you where you are and what you're ready for in treatment. Thank you. Mike Pantalone. Thank you all for being here. I appreciate your concern about this topic and thank you to my panelists for their passion in the area and for all the presenters. I think it's fantastic that we have this many people here who are concerned about the topic of addiction, problematic substance use, whatever you want to call the condition. And I am thrilled to be here. I want to thank Gustavus for inviting me to this very important and frankly magnificent conference. It's been wonderful. So my aim today is to tell you that in no uncertain terms we have a science of the treatment of addiction. It is not a perfect science nor is any other but we do know a good many things about what constitutes effective treatment. We know what outcomes we get from certain treatments and even if they're not as effective as we'd like them to be we know what their effectiveness is and as a scientist, a therapist, an educator that is critically important to me and I think it is probably very important to you. So while I ended a fantastic job of setting up what isn't working and what we need in there, I'm not going to repeat that. I mean that's often what I speak to audiences about. What I'd like to do is to pick it up from there. It's such a great setup for me and to give you the highlights in three arenas of what I think anyone should know if they really want to help a friend or family member with an addiction. Does that sound good? How many of you care about someone with an addiction? So what are these treatments that are scientifically supported? Two general categories, psychotherapy and medications. I don't want to get too technical or get into the descriptions of the therapies but it's too rare that general audiences such as yourselves and probably their professionals in the audience as well know what these actual therapies are. So forgive me but I'm going to give you the technical names so that you can google them, search them and grill providers about them until you are certain that they actually provide these because this is your best fighting chance to help your loved one get good treatment. And by the way Anna's right, you don't necessarily or immediately or even ever necessarily have to go to rehab in order to get well. It does help a great many people who are very medically compromised and who cannot string together even a few hours of not using to have a conversation with someone but by and large intensive outpatient treatment works just as well if it has evidence based treatments in it and it's about a tenth of the cost. So the psychotherapies are cognitive behavioral therapy where we teach people how to regulate their emotions, how to change your environment so it doesn't produce more cravings than what their brain is already doing. Cognitive behavioral therapy helps people understand that they are not powerless, that they have power to control their surroundings, their thoughts, their feelings, and their behaviors to an extent but often that extent allows them the ability to either cut down or stop using. Motivational enhancement therapy is the opposite of what you typically think of when you think of talking to someone with an addiction. You know, anyone ever heard of tough love here, right? Okay, tough love is the opposite of motivational enhancement therapy. Tough love is saying you better, you ought to, you have to, please do it for me or else. Whereas motivational enhancement therapy says let's meet you where you're at. What are the things that are going wrong for you? If someone is a willing, addicted person and then partially unwilling where's the piece of this that you don't like? Let's start there and does not demand anything. It says to the person, tell me what upset you have with your drinking or your drug use. Why might you want to change? Non-confrontational, so cognitive behavioral therapy, motivational enhancement therapy, and to be fair there is something called 12-step facilitation. It is a professional individual, one-on-one psychotherapy that a former U of M grad developed who's a colleague of mine at Yale that has been shown in some studies to be effective. Unfortunately, virtually none of the rehabs that practice a 12-step based approach use 12-step facilitation. But if you find a therapist in your community or a clinic that does that and they adhere to that model, that can also be an effective option. In terms of, we'll talk about how to get people into treatment in the second point, but in terms of medications, how many of you have heard of the medication suboxone? How about methadone? How about naltrexone? All right. Acamprosate? Topomax. Okay. Those are our medications to treat addiction and I urge you, we're not going to spend the time here, I urge you to get over the idea that you cannot or should not treat one addiction, an addiction with a drug. It just does not hold water. The evidence is clear. A combination of scientifically supported psychotherapies like the ones I mentioned, and there are a few more, but those are the highlights, and a medication can not only help someone recover, but can save them from overdose death. I mean, I'm sure you've heard about opioid related overdose deaths, the rates of quadruples in 2002 and 2013. I think that's what's bringing us closer to evidence-based treatment of addiction, because we're going to keep losing our children if we don't get the facts, if we don't pressure our clinicians, our community, our politicians, our payers to support truly scientifically supported treatment. My second point is that which most of our society thinks will get someone into treatment, actually does not work very well. In fairness, it hasn't been studied much, but the results we have so far are not very not very positive, and the alternatives work a lot better, not perfectly, but how many of you have heard of interventions or have seen it on TV, right? You circle, you surprise and circle your loved one, and you confront them with the things that they've done when they've been drinking or using drugs in order to cajole, force, convince, coerce them into treatment. Usually there's a van waiting outside, okay? That's traditional interventions. The science shows very clearly that those people who go through that go at a rate of 20%. 20% of people get in the van. You might think, okay, I'll take my chances with that, but keep in mind that 80% of those 20% leave the rehab before the 28 days are up. Now the rate is substantially reduced. If you compare it to something called CRAFT, C-R-A-F-T, it's an acronym, Community Reinforcement Approach and Family Training, but just remember CRAFT because if the person you're talking to doesn't know what it stands for, hang up, okay? CRAFT gets people into treatment at a rate of 64%. Again, not perfect, we're still working on it, but what we're learning is that the strategies that give you that increase of engagement and treatment run almost completely counter the tough love confrontational approach. I have to admit those are highly satisfying approaches, right? Think of someone you're upset with and you unload on them, right? Isn't that a little satisfying for the moment? But how does the relationship go after that? Okay, so there is a pull to it, but I like to say tough love makes love tough, and if you don't get them on that time, if they're not one of that rare 20%, then you're out and you may not be able to speak to that person about their addiction again. So the more motivational approaches, CRAFT, talking to people about what dissatisfies them about their drug use ultimately does far better to get them into treatment. I do research and work in the emergency room at Yelena Haven Hospital and we have a clinical team and we have research to show that when you do a 5 to 10 minute intervention that completely takes out anything confrontational, luxury, didactic, telling and selling, all you need to do is ask a few poignant questions about why this person might self-elect to try some treatment, outpatient treatment. We get those folks into treatment at a rate of 65% in the emergency room, most of whom didn't even come in because of an addiction or substance related issue. They look at me and they say I broke my arm, why am I talking to the shrink? Well they squirt high on our questionnaires and so we can get people into treatment with that approach. So the last thing is that because the one size fits all doesn't work in treatment, it also doesn't work in terms of social support. I have no illusion that one session a week or even three hours a day for three days a week in an intensive outpatient setting is going to be enough for your loved ones. They need your involvement and if that's tough, as it can be sometimes, they need social support day to day. We have a fantastic option that is available 24-7 and that is AANNA. Unfortunately many people as Ann was saying don't don't go there. Now in fairness they were there when psychologists, psychiatrists, physicians and lots of society didn't care to deal with the substance using person and for that I give them great credit and I've known people who have recovered that way but we need another social support option. That's why I train people to be recovery coaches, people who are informed about the science that I'm telling you about who can help you and your loved ones find the best treatment and motivate your loved ones to stick with it and make the best use of it. So my mission is effective help for all and I'm hoping that we conveyed some of that information to you today. So thank you. Mark Willenbring. Thank you. My pleasure to be here. I feel a great honor just to be part of this and to be able to see in person one of my great heroes Eric Nestler, I'm sorry Eric Nestler, Eric Candell, Carl Hart and it's a great privilege. I'm going to concentrate on future directions and by the way so one of the things I wanted to mention is that the introduction was from my previous job. So I was at the National Institute on Alcohol Abuse and Alcoholism between 2004 and 2010. Before that I was a professor of psychiatry at the University of Minnesota doing research, teaching and running an addiction treatment program and developing programs. I spent most of my career in academia and government and when I left NIH, let me just say it went from the standpoint or viewpoint of NIH, when I first got there I sat back and said well what's the mission? What's the mission of the National Institutes of Health? Well it's to improve the health of the country. So I sat around with my staff there I said well as a result of the research wonderful research has been funded here. Are community treatment outcomes any better than they were 50 years ago? No. Was the prevalence of alcohol dependence any lower than it was 30, 40, 50 years ago? No. Have we improved? Has this research improved the health and welfare of the people of the country? No. Not only that but it became very clear to me one of the main reasons for that because the research that's been funded by the National Institutes of Alcohol Abuse and Alcoholism and on Drug Abuse has produced some of the most pristine neuroscience epidemiological data treatment research but I realized especially from that vantage point that in the substance use treatment field we did not have a vehicle for getting those new treatments new ideas to the people who paid for the research that our treatment system is not based on science it was founded and formed in about 1950 to 55 and no matter what the marketing the only thing that's changed from what I can tell is the marketing but the substance of the treatment hasn't changed and it's not really treatment rehab is the kind of treatment you do when you don't have a real treatment and so we used to treat breast cancer with prayer too but we don't do that anymore and we shouldn't be doing that with addiction anymore either not that I have anything against prayer but it's not a medical treatment or a psychological or behavioral treatment. Anyway in contrast to my colleagues in the Heart and Lung and Blood Institute when they publish a big study about a new approach to treating high blood pressure cardiologists and other physicians read those articles they go to professional meetings and they hear about the new research and they change their practice Bertrand Russell once said in a famous debate when the facts change I change my mind what do you do sir and in the rehab field when the facts change and they have changed a lot the minds have not changed so when we publish studies in our field nobody who's running these centers reads them and if it counters what they already know they discount them so when I left NIH I thought well I could go back to some other academic institution and do more research and watch that sit on the shelf and collect dust along with all the last 40 50 years of research or I could try to change the system and so that's what I've been doing now for the last five years I formed a company called Altair with a clinic a demonstration project that to show how to do 21st century addiction treatment it's located in St. Paul and for the last three years we've been basically inventing the model no one's done this before and it takes about three years to do it you can't compress it I've done this a number of times and we're pretty much done with that now and we've got proof of concept for a number of things and I'll tell you a little bit more about that in a minute in terms of what what we're finding so I'm just going to very briefly cover how well does the current system work what what does work and dr. panel on is really pretty much gone over that as as Anne Fletcher and so I won't spend a lot of time on that how well does it work do people have access to up-to-date treatment how do we get 21st treatment to more people and how will research help us improve treatment one of the things I was really struck with with this recent big rally in Washington about addiction and the emphasis was on sort of coming out okay I'm a recovering addict when we're we're strong and we you know and so forth and I think that's fine what really bothered me though was that there wasn't any emphasis on the need to fund more research it's just about having more rehab that's really a problem in our field we don't have an advocacy organization that advocates for research funds so the advocacy organizations for heart disease breast cancer Alzheimer's disease autism what are they always clamoring for more funding by NIH to do more research nobody in our field speaks up for that they say we already know what to do and we don't need more research to show that but we don't know that so the current system has about a ten percent market penetration about ten percent of people with substance use disorders will access that treatment system rehab basically and most people who go to rehab almost all of them are forced to go rehab the rehab industry is dependent upon the criminal justice system for the majority of its referrals the second most common is an employer mandate and the third is what I would call a family mandate but nobody goes to rehab because they want to because it's a it's an obnoxious treatment it's expensive disruptive stigmatizing and old-fashioned it's an anachronism and it doesn't work any better than seeing a counselor once a week for 12 weeks there's no choice people don't have a choice one woman a few a few months ago there was an article in the Atlantic Monthly in which all tier clinic was was featured and since then the call you know been phone's been ringing off the hook half the calls from are from out of state but one woman came to me and here's the interesting thing is eighty five percent of them have been people on the very mild to at most moderate end of alcohol use disorders these are people who are functional but they're distressed they these are people who get up and go to work in the morning they're fine their colleagues have you know don't know anything about their struggle with drinking they they pick up the kids after school they take them home they help with their homework give them dinner put them to bed and then they go and they drink their two bottles of wine or their pint of whiskey and they do that every night even though they don't really want to and they don't like it and they're distressed they're not seeking they're not seeking treatment because they don't want it they're not seeking treatment because it's not available to them in a form that's acceptable to them so eighty five percent of the people have come as a result of this article have been people like that early intervention so we're getting much deeper penetration into the affected population just the same as with and eventually treatment's going to all be I mean the alcohol and opiate treatment is going to be primarily done in primary care just like it is now with depression and but one woman said to me I've been looking for help since the 1960s and all I could find was 12-step rehab until this clinic opened it's not that people don't want help so people need a choice there's inadequate informed consent it's the only place in health care where you can routinely lie to patients where you can routinely fail to disclose what the scientific evidence is for the effectiveness of different types of treatments and what the alternative treatments are and get by with it any physician who practiced like that would be out of business in about three months so people who are heroin addicts go to re abstinence based rehab they're taken off the they're withdrawn from the opiates they lose their tolerance they're told if they work a program an abstinence based program it'll work there's not one study in the world that shows that while there's massive amounts of research demonstrating that maintenance on a drug called suboxone or on methadone is very very effective and very cost effective but people aren't told that and they and these mostly young people now go out and they've lost their tolerance and the first time that they use they use the same amount they were using before and they die of an overdose this has happened over and over and over because they were lied to in rehab the expectations are unrealistic if you come to me and you've got asthma and i prescribe some inhalers would you expect that would either one of us expect you would never ever have another asthma attack the rest of your life and if you if it did if you did it would be a total failure that's the expectation now here's the worst thing of all this is the only industry i know that has been so successful at blaming their customers for the failure of their treatment and that puts a horrible stigma because recur it takes the average alcohol dependent person five to ten years to stop in this country and they do it through multiple quick attempts and multiple recurrences that's why at altar we say we don't just call addiction a disease we treat it like one rehab is like sending a diabetic person to a spa teaching and diet and exercise and then saying go to support group for whatever you do don't take insulin now the one final thing the one final thing i'm going to say is that in terms of the future i just wanted to mention what needs to happen and is going to happen eventually is that substance use treatment needs to be mainstreamed into health care across health care completely most of it can be done in primary care we need a robust medically based or medically anchored specialty treatment i mean a counselor with a g ed preaching a for four weeks is not a backup for a physician and so we really need to reorganize care we really need to rethink who provides care and when and how medications are going to become increasingly important that's why the neuroscience research is so important uh there are new behavioral treatments that are going to go directly to implicit cognition that are going to be much more powerful than what we're using now most therapy will be provided psychotherapy on the web and so those are some of the future directions and i think these there's a lot for the use of technology as well but i think the future is bright but we need to make we the important thing is we have to make treatment available accessible affordable and attractive that's it thank you William Moyers well somebody's got to go last i'm honored and i'm uh i'm honored to be here and i have to admit to you i'm a bit perplexed too i'm honored by the invitation to take part in this prestigious conference at this important institute of higher learning with a room and an agenda filled with experts with lots of credentials after their names and in some cases before their names so i'm honored and i'm but i'm also a little bit perplexed too i have to be honest with you because i'm not really sure what i can add to what you've already been talking about for the two days or really add much more or detract from what our other experts here in this panel with me have already talked to you about the topic of our panel is what exploring different treatment options and to that topic all i can say is yes or absolutely or if i really want to get into it of course and if i really want to extrapolate and get into the detail of what it means to explore different treatment options i could include this when it comes to substance use disorders a chronic illness we all know that there is no cure for this illness at least not yet and despite the research of many people trying to find that cure we know there is no cure for this chronic disease but there is a solution which means what that treatment can and does work there are many pathways to recovery and there are millions of people who are in recovery from addiction right now even though among those millions of people their definition of their own recovery may differ or be similar to mine and others there are millions of people in recovery from that seemingly hopeless condition including some in this room today like me i can confidently state these points that i just talked to you about even though i'm not a doctor i'm not a researcher i'm not a scientist i'm not an msw i'm not an ladc i'm not a phd all i got is a ba in journalism washington lee university class of 1981 but i can speak to you confidently i can speak to you confidently and in conjunction with this esteemed panel and the others that you've heard from because i benefited from treatment i am a prime example of the power of addiction the effectiveness of treatment and the promise and the possibility of recovery because in 1994 i got well after four treatments in five years between 1989 and 1994 yes this is what a chronic alcoholic and a drug addict looks like these four treatments at the time between 89 and 94 were grounded in what we now would say is the traditional abstinence-based model that included yes it included the 12-step approach to not treatment but the 12-step approach to recovery i even had two treatments at hazelnut where i work followed by three years of abstinence between 1991 and 1994 note i said abstinence because i think it's important to the conversation we're having here into the conversation we'll take back to our communities that we talk about the fact that abstinence at least as it relates to my biased perspective is not recovery as i would come to understand it but at least during those three years between 91 and 94 i didn't use mood or mind altering substances and so during those three years in the early 90s i functioned pretty well i became a husband a father of two boys i worked as a journalist at cnn i bought a house i paid my taxes and generally i behaved but i didn't recover i didn't recover between 1991 and 94 even though i did not use substances which means that i didn't take care of myself by taking care of my chronic disease which means what well it means that i relapsed on crack cocaine and malt liquor then i had two more treatments at a facility in atlanta that was much like at the time much like the approach that hazelnut was taking and it was at fourth one which ironically started for me on the morning of october the 12th of 1994 a couple of days from now it was at fourth treatment where i finally learned to take personal responsibility by picking up the tools that i had been given by the counselors the docs my therapist my recovery group and other things picking up those tools and beginning to work my own program of recovery by managing my chronic illness keeping it in remission and doing so for a long time now a lot as we've heard today and as an talks about in her book as you've heard from the other panelists today a lot has changed in 21 years for one thing i'm a lot older but seriously what's changed is how we as a field and i use that term in the broadest of sense how we as a field have come to understand addiction for the illness that it is and to come to understand it for the illness that it isn't how we treat it bringing to bear the best of what was the best of what is the best of those things in medicine in pharmacology research into the brain the dynamics of gynet of genetics and yes i will argue that genetics does play a factor the role of mental illness and maybe most of all recognizing all these decades after i last went to treatment recognizing that treatment isn't the end of addiction or it may be the end of addiction but it's merely the beginning it's the merely the beginning of a process called recovery and interestingly and notably enough recovery that has come to embrace a term that didn't even exist when i went to treatment in 89 or 91 or two times in 94 and that's the term recovery management that is what really matters all of those factors coming together to help us improve on what has worked to get rid of what hasn't worked and to give our patients and our clients a better chance by the way i have to echo something that dr willembring said which i think is so critical which is that we have got to mainstream addiction treatment and recovery into the health care continuum and i think one of the most i think one of the most important ways we have to do that for the benefit of our patients and our clients and their families is to take it back down to the community level where most people have to return to after they go to treatment they have to return to their communities i can think of nobody who's got that model down better than a friend of mine who is actually in the audience today i think he's still here is kevin kerby here kevin are you here i can't there you are back there kevin kerby you um founded a face it together a national organization in sew falls south dakota that is taking this paradigm that we talk about is it relates to addiction treatment and mainstreaming it not just into health care and into the community i think that is the future of treatment however we practice treatment in this country thank you kevin kerby for what you're doing that's all that really matters is that we take all the things that we know and bring them to bear in a system if you will that works best and meets the needs of the patients and the clients as and and others have said where they are in that moment it matters that we keep our perspective it doesn't matter what our perspective or our expertise or our biases all that really matters is that we strive to get better at what we do by identifying the complexities of this illness and i would argue that they perhaps are more complex than they ever have been and that we apply apply proven some would say evidence-based approaches to the treatment of it and that most of all we do this with the dignity and the respect that is deserved of our patients and our clients that is all that really matters isn't it i didn't come here this afternoon and i'm grateful for the opportunity to be here i didn't come here today to to debate or defend or attack one pathway of treatment over another i'm here today to be part of the better understanding and to solve this substance use disorders addiction whatever you want to call it it is an illness that we like to think of at least i like to think of as a rubik's cube and yesterday when i was thinking about being here today with all these experts who know a lot more about this than i do i thought about this disease as a rubik's cube and i put i put rubik's cube into google search to try to find out what the solution to this puzzle was i don't try to do this puzzle because it frustrates me when i put it into google up popped the official rubik's cube page and it said this and i quote it took urno rubik the inventor of the rubik's cube one month to learn how to do a rubik's cube some people started thinking about how to complete the rubik's cube back in the 1980s and in 40 years have gotten a little further than one side if you want to learn how to solve the rubik's cube look no further this webpage promised getting help with solving the rubik's cube is not cheating there are 42 quintillion possibilities but only one correct solution well fortunately for all of us here today and for those who suffer with this illness there are not 42 quintillion possibilities for getting help and fortunately for us and for them there isn't one correct solution there are many i was reminded of this three days ago right now when i was in on the national mall in washington dc when thousands of people turned out to the unite to face addiction it was a rally and a concert featuring among others steven tyler of aro smith joe wall should the eagles sheryl crow and even i got to speak from the stage and i didn't have to sing looking out over that sea of thousands of people and dr willing bring mentioned the recovery advocacy that's going on in this field looking out over that sea of of recovering people on sunday i was reminded that while we all have the same illness we have found many different ways pathways to the solution and by the way dr willing bring on that stage that day were members of all the national government representing their causes and their interests and the only point i will disagree with you on in your presentation today is that when we were all up on that stage among the many things we advocated for was the fact that we need more research for prevention treatment and recovery management at the end of of the mall event and at the end of this day this is all that what this is all that matters at this nobel conference we we are the lucky ones we are the ones who help people get well we are the ones who got well and it is our responsibility to change the terms of the debate for the sake of those who still suffer for the sake of those who are not here today thank you all so we've got probably about 10 minutes before we'll ask our other conference participants to come up and join us so this time is just for us and i open it up to you to respond to one another however you'd like there's no order here so if someone is ready to go well i'd like to just say that where i i just had the last word there so to speak but where i think we really need to move the conversation and it's going to take the other experts on the panel and all of you out there is while we're paying attention to the importance of treatment we've got to figure out how we measure the importance of treatment and the effectiveness what is good recovery i mean bill wilson who was a co-founder of alcoholics anonymous may have been clean from alcohol for 35 years but he smoked himself to death and so he was under the influence of a substance even though he was in recovery and had founded a movement that has benefited lots of people so i guess the question i have for the for the for the rest of the panelists is when are we going to start to pay attention to how we measure the outcomes that are as important to effective treatment as anything else you know i think if i may i i think there's actually excellent consensus now about how to measure outcomes i mean we primarily measure substance use outcomes the kind of more subtle qualities of life for example are are extremely difficult to to measure and whether someone is satisfied with their life or what whether they find meaning or or that kind of a thing what we can measure that is kind of a proxy for that is function so employment are they you know are they married are they able to have a relationship you know are they are they are they functioning at a good level in you know those are the so it's a combination of substance use uh and how much and how often and and if there are if they still meet criteria for a disorder in other words if their substance use is still causing impairment or distress and then finally these these measures of of function such as well Freud said you know the purpose of life was to love and to work and and that's kind of what we're talking about here but well I would add that client-centered outcomes I think should be paramount I mean you decided when abstinence was not enough and you needed to focus on recovery that was a personal definition I think we owe our clients our patients whatever you you call them the respect of having them tell you what is a good outcome outcome for them and similarly just as you said abstinence does not necessarily confer recovery you don't necessarily need to stop using everything and all of it in order to improve your life some people would have been thrilled with getting married having a house having a kid and I think that needs to be part of the the discussion here we can't wait till somebody achieves complete abstinence our definition of a good treatment outcome until we allow them to start working on their lives I think that is a very important point well and you mentioning Bill Wilson was also a miserably unhappy person and a lot of that was probably biological we didn't he from from what I know he suffered from horrible depression we didn't have medications that we have now to deal with that and he was you know apparently much of the time he was writing the big book he was sobbing his way through it his secretary would walk in and find him with his head down on his desk and it emphasized to me and I think you alluded to it once in your talk but the the incredible importance of treating co-occurring mental health disorders at the same time the thinking for a long time and still is at many treatment facilities we have to deal with a substance use disorder as the primary disorder then we'll deal with a co-occurring disorder I mean obviously you can't work with somebody who's drunk coming into your office every week but you know you can treat both disorders at the same time whichever one takes precedence at the time generally is the one that it switches which the one that you deal with first but they can be dealt with concurrently and that's called integrated treatment and that's the current approach that is considered to be progressive but we've got to deal with both at the same time and on that point when I went to treatment in Hazel in 1989 I came out to Minnesota from New York because I had obviously caused a lot of problems back there and and I needed to go to a good place and we found this place called Hazel and at the time I've all I didn't know it then about 10 percent of the patients who came to what we then called residential treatment or inpatient treatment presented with mental health issues or mental illness today it's about 85 percent and some of that has to do with the fact that we're better at diagnosing it but a lot of it also has to do with the fact that people are coming to treatment who are a lot sicker than they might have been in the old days when AA might have been a way that people could get into a recovery process without being treated for it it's not like that anymore one thing I mean you're right about who goes to rehab but that's true for every disorder so the people who are in people who have asthma who are you know who are some people have a little bit of asthma they go to the drug store and gets some primary teen mist and they're fine then there's the next group that doesn't work so they go to their doctor they get some prescription inhalers they do fine then there's a group that has to take prednisone steroids and then they get steroid dependent and they get really sick then there's a group that's hospitalized and then there's a group on the in the ICU on a ventilator so people in rehab in many ways are like the someone with asthma in the ICU on a ventilator and whereas most people in the community don't have anywhere near the same severity of disorder or all the co-existing disorders so there is a bit of what we call the clinician's illusion here it has to do with and research has been a the researchers have made the same mistake by focusing on what we call convenience samples people in rehab right or in hospitals they're focusing on the sickest five or 10 percent and it's only until only more recently that we really understood the extent of it for example 75 percent that's 72 percent but about three quarters of people who have an episode of alcohol dependence in this country have a single episode that lasts three or four years on average and then it goes away and it never comes back the most common treatment outcome or most common outcome rather 20 years after treatment is what we now call non-abstinent recovery that's about 40 percent of people who are drinking not very much not very often they have no alcohol related problems then the next most common category is abstinent recovery at about a third there's about a quarter who are much better but still have episodes of drinking and then fewer than 10 percent still have active alcohol dependence so the long term for every the only thing the only substance use disorder where the long term outcome is not good it is a heroin addiction heroin addiction has a 50 percent mortality rate between 25 and 55 if you if it's not treated appropriately right well with all due respect I think you know as important as it is to define the outcomes our group here our audience is here to figure out what kind of treatment what constitutes good treatment and I think you know we have a little bit of a division about evidence-based treatment versus treatment that is not studied where there is no known effectiveness and while I respect the fact that many have come to places like Hazel Lynn and have done well that's one metric that's one way of looking at it your asthma example every level of care has FDA approval has knowledge bases has physicians who know this is what the evidence says do people treat off-label do they do their own thing yes but we have in every other medical condition a knowledge base that is based on empirical evidence it doesn't mean that the only things that we study are the only things that work but how about moving on and throwing away the old to use your term or the unstudied you know when I was at when I was working in the VA for a while I was the first co-editor of the VA and Department of Defense practice evidence based practice guideline for the management of substance use disorders what was really interesting about that they use a very rigorous process across all disorders and what emerged from that that was really interesting is that the evidence base across the continuum in substance use disorders is far stronger than in most areas of medicine and people don't believe that people don't understand that I don't think this audience would believe that the outcomes for substance abuse treatment are on par with asthma, diabetes and hypertension that's actually better and better and better ironically the compliance rates are better the only reason we have such poor outcomes with opioid dependent people and again this speaks to the issue with opioid overdose deaths is that there is the poorest access to the medications that work for that problem in that area because people have very heated beliefs not science but beliefs about the medications that are prescribed for those so if we had more access we'd have fewer deaths on that note we at Hazel and Betty Ford have had to change our treatment protocols as it relates to opiates and we sort of are damned if we do and damned if we don't because as a traditional apps in this base program we realized that our opiate patients particularly they were doing well in treatment but the moment they were discharged they were dying they were relapsing and dying and so we've changed those protocols to include the use of medication while they're in treatment and then discharging them on those medications in a group setting among other things not just letting them go and saying here's your prescription good luck but when we started to do that and word of that became public an old timer friend of mine who I actually owe part of my life to and saving me back in the early 90s a traditionalist in the recovery program and he works asked me to have coffee with it in St. Paul after he'd read this piece about the fact that Hazel and Betty Ford was using medication and I sat down with him and he said William you're ruining AA and I said well I couldn't do that even if I wanted to but I said what do you mean he says you're discharging people into recovery meetings who are under the influence so I mean you know we look I know how the 12 steps work and they work for a lot of people but at the same time they have been I don't want to say a hindrance but they've been a challenge to move beyond even as we understand more about the nature of this illness and how to treat it you know Carly you can I time us out here I want to quickly and quietly invite our other conference participants to join this conversation I really don't want to stop it so if I could just ask you to come up quietly you'll get mic'd up and we will just continue so audience please be quiet and respectful so back to Mark Willenbrink so Carl Jung once said God save me from the unions and so it's very it's almost universal that when you have charismatic leaders who form an organization whether that's Jesus or Mohamed or the Buddha or Carl Jung or Dr. Bob and you know the followers frequently start to distort and get rigid overly rigid compared to what the you know think of how many people have been killed in the name of Christianity or Islam right of all things but it should be known that AA takes no official position on medications so that's not AA's and there's actually the big book says talk to your doctor about it we should not interfere right so follow the right the actual big book right great right yeah I think it should also be said too that and it's one of the reasons I suggested Michael Dr. Panel on for the panel I it was interesting and it actually is the way I got help for an alcohol problem many years ago I was talking with Dr. McClellan about you know the many different routes to recovery and he's again the co-founder of Treatment Research Institute in Philadelphia and he said we have no idea how much alcohol treatment or or a substance use treatment goes up on behind the closed doors of of an individual therapist and in fact it's probably more than other routes but I don't know that there are any data to support that I don't know if we know I think there have been a few studies that have looked at that but that when people come to me I know when I was interviewed by Jane Brody for the New York Times before I was ready for interviews the book wasn't even done and she said to me okay I have somebody right here right now she was just making up a case and they come to you and they say I got a kid a young adult kid and he needs help and what should I do and I'm like oh my god I'm not ready for interviews and I said well assuming it's not a real severe case where the person needs to go into detox my first bit of advice would be to get an independent assessment try to find somebody in your town who has expertise with drug and alcohol problems who's not affiliated with a specific treatment program so that you get an unbiased assessment of how bad that problem is and get their opinion about whether or not they need to go to a treatment facility yeah granted they may have some investment about admitting that person to their private practice but usually everybody that I know of is already full and you have to wait two months to get an appointment anyway but anyway get an independent assessment and there are I mean I can think of multiple people in Mankato who are in private practice who have expertise with substance use disorders and and co-occurring mental health problems at the same time so there's lots of treatment goes on that way and just to add to that ask them what psychotherapies they practice I'd use Ann's book go to the back there are a list of questions grill them about what approaches they use and then find an addiction psychiatrist who prescribes those medications and William wanted to jump in here he's just to say something and then I'm going to be quiet the rest of the hour I promise oh no please don't but no but here's the thing to Ann's point and this is the great mystery of it all to me who's more of a layman than anybody else here because I don't have their professional expertise like all of you do but and I think the mall experienced three days ago as a microcosm of this bigger great mystery that I'd love to delve into which is the federal government a few years ago did some sort of survey which found that roughly 23 to 25 million people in this country consider themselves to be in recovery from some kind of substance use problem well the 12 step movement says that they have roughly one to two to three million active members in their meetings on the regular basis so the question is where are the rest of us how are we how did we get into this thing and how are we continuing to do it I think that's the great mystery if we can tap those other 22 million people then we'll have all the answers we need to treatment in recovery well they're not in treatment you know very few people are in treatment fewer still get evidence-based treatment so I think that tells us something about what treatment is available to them that they perceive is available to them and what treatment is not yeah I think it's really important to realize that the system will define who the treatment seekers are so if if you have a system like we do now where the vast majority of facilities are focused on very ill you know very complicated and kind of intractable cases then that's who you're going to see and if but it's sort of like we saw with the introduction of Prozac in 1988 with depression where before that I mean if you if you had depression you could go to the state hospital you'd get committed for six to 12 months you'd get electroshock therapy and Thorazine and not many people went they'd spend six months in bed being depressed rather than do that then when Prozac came along and there was a whole constellation I think of factors that created what I call the Prozac moment all of a sudden people could go to their primary care doctor and I think the penetration and the characteristics of the people seeking treatment changed drastically and I'm seeing that now in in my practice because it's attracting all these more functional folks who are completely different and none of them you know most of them have never been to rehab and wouldn't go exact and it wouldn't fit they wouldn't fit wouldn't need it you know Owen did you and I give each other a look that said I've got a question so uh yeah I that was very very informative from the audience thank you all so much I have just a question seek your wisdom on there's been a lot of mention of these sort of co-occurring conditions and the increase in the large number of people who now come in so but this is related to a sort of a separate debate that's going on about the proliferation of mental health mental illness diagnosis in general I mean some people say with DSM4 but especially with DSM5 it is guaranteed that you are in there and I was there in fact my son was one of the very first people to be diagnosed with ADHD and then the floodgates opened and there was a big discussion about the malady called boyhood or whether there's a real thing and we know that the so I guess I just have a question about I mean there's this other issue about inflation of diagnoses of negative mental states or illnesses or problems on the one hand so I worry about a confirmation kind of bias that we're just looking for that always and we of course we'll see that if we look for it and I wonder how you feel about that you know the major mental illnesses haven't changed that I mean depression is on on the rise worldwide the prevalence of depression for reasons the prevalence of depression though or is it the diagnosis criteria no it's it's I think it's true prevalence because the diagnostic criteria really haven't changed studies using different tech you know different approaches have found the same thing but the the major mental illnesses like schizophrenia and bipolar disorder have pretty much the same prevalence around the world so you know which I think where we where it gets fuzzier is with anxiety disorders with ADHD with some of the these on the milder end the more functional end of the spectrum um but the um and certainly the change between DSM4 and DSM5 in subsist use disorder diagnoses increased the proportion of people who met criteria quite dramatically and they did so primarily by picking up what used to be called diagnostic orphans where they would meet one or two criteria for alcohol dependence but not and you needed three so now they're they're picking those up so uh and and and so you have to take those things into into consideration but I I think we're talking mostly about people with pretty severe mental disorders but William Morris what was the statistic you gave well when I was in in 89 1989 it was about one in 10 of the patients who came to our front door presented and today it's 75 to 80 percent I will tell you too that I don't amount of psychologists or psychiatrists so I don't really know if it's better or worse but with the wars in Afghanistan and Iraq of the last 10 to 12 years we're seeing a lot of veterans we're coming back with PTSD and there's no doubt they got PTSD and they're medicating it before they get help with alcohol or other drugs Mark Lewis yeah this is for Dr. Willen bring um I don't think I've ever heard a talk that I agreed with as much and disagreed with as much both a lot of the stuff you say really resonates for me and some of it really doesn't so you you you say things about the rehab industry about how ineffective it is how it sucks how it lies to patients and all that stuff I agree but you want more money for research and we know that most of the research money is spent by NIDA by NIDA by the national by the national drug abuse right and we've been well reliably by a number of people that 90 percent of the research in the world is in drug abuse is is conducted by NIDA and we know that they endorse the disease model of addiction so you want more money to support research which is supports the disease model which is that endorsed by the rehab industry which doesn't work at all they endorse a different disease model the rehab disease model which is more the 12 step disease model is significantly different than the biological psychological social disorder that we're talking about in the DSM so while I know that you you have would take contention with both types it's not a contradiction as I see it I think you're right and that might help solve so obviously the kind of disease model that that William is describing is not the same as the kind that you're describing but but let me just go one more point and then you can answer that as yeah as long as you want that is that you foresee a treatment approach based on community support and and eventually internet-based connection between people and yet you also want it to be dispensed by primary care physicians who from what I understand about the medical practice in the U.S. are charging huge amounts of money that has to then be approved by an insurance industry which doesn't sound anything like the community okay so you know you there's a complex interlocking though I hope of ideas that you had there or addressed first of all I would completely agree with with Dr. Panolone here but in terms of the difference in the disease model I call the old sort of a 12-step disease model the pneumonia model you've got something highly specific you go into the hospital you get highly specific treatment you're cured yeah and what we're really talking about is you know the whole issue of a brain-based behavioral illness or and I know you would object to brain-based but but behavioral illnesses let's say and and and those can be one of the things I didn't have a chance to talk about is we're underusing public health approaches that could probably help many many more people than any kind of treatment you bet yeah and in fact more in fact most of the mortality and premature morbidity in this country comes from people who who drink in a binge fashion but don't have don't meet criteria for a disorder yeah so we have this huge public health problem that would be best addressed with public health mainly mainly like raising taxes on alcoholic beverages so we're we're really ignoring those and and and so but I'm just talking about the the in terms of the medical aspect you know when I was a resident there was an argument between going on between psychoanalysts Mark could I ask you to speak a little more clearly or louder I'm sure I'm sorry oh sure maybe that's better that's better this position so when I was a resident many years ago there was an argument going on at the time between psychoanalysts and psychopharmacologists about treatment of depression and the psychoanalysts argued no you should not give them medication because it will destroy their motivation for examining and resolving their conflicts in psycho psychoanalysis which actually turns out not to be effective for depression but but the it reminds me very much of this dichotomization that we're experiencing here so medications are simply tools that address some aspect of the phenomenology but medication is really only even relevant for opiate addicts and you know for a week or so maybe for for extreme alcoholics I mean no no no no no that's not what the no I mean no well what kind of medication are you going to give coke addicts sex addicts methamphetamine addicts you know okay so the where we have good medications where we have good medications are for alcohol and opioid use disorders and for smoking we don't have good medications now for stimulants of any type and and we for the most part don't have medications for what you you call these you know behavioral compulsions that don't involve substances I'd like to yeah I'd like to bring our focus so that we may address some of the departing college students in high school students the binge drinkers okay so we're here to talk about treatment but that you don't just treat people who are at the far end of the severity spectrum you treat people along the way you may call it prevention but I call it treatment if you have mild asthma or if you're moving towards it there are things you can do binge drinkers are moving towards an alcohol use disorder so for the binge drinkers we're not here to send them to rehab do an intervention or say that they have to completely stop drinking let's meet them where they are and help them to reduce teach your children teach the students here that you know no more than seven drinks a week or more than four on occasion for a woman no more than 14 drinks a week and no more than four on an occasion for a man is what is considered low risk drinking how many people know that when people exceed those limits there are evidence based studied treatments to bring those levels to low risk amounts which then makes it less likely that they end up becoming an alcoholic down the road so there are a range of treatments along this entire spectrum for example the medication El Trexone which basically blunts the effect of alcohol has been shown in in sort of relatively low dose to reduce binge drinking among college students it makes it easier to do yeah so El Trexone has been around for 40 years and the lock zone what 40 50 years and so all this research funding you're basically talking about the physical the problems that have to do with you are these medications there's a psychological overlay hang on there's a psychological overlay if you can help to relieve physical suffering of course that's going to assist a process of psychological adjustment but I mean what other sorts of medications are you looking for given that addiction is primarily a psychological problem well I it's much more complex I think if we've shown anything over the last two days is that we can say it is this one single thing it's a lot of different things that needs a lot of help from multiple angles I think tell me how you all feel about it that the number one problem in terms of addiction is the lack of knowledge and access to evidence-based treatment that is the number one thing if we if you leave here with only one thing from my perspective so with all due respect is that there is much more science on what works out there and that you you gotta grill people in your community to either give it to you or figure it out or find an expert and bring them in your primary care doctor should be able to help you with your kids in terms of substance use problems or addiction and there are good behavioral therapies and and they're best combined or sometimes that's all people need and I really think the future is in much more direct intervention with implicit cognition yes I like that I agree with that a lot so I I'm not a reductionist that way but why should if there is a medication available that makes it easier for people to achieve their goals psychological goals and social goals why should they not have access to that and I'm just saying like mindfulness which is back by the way one of the most effective treatments has been around for 2,500 years so I'm not you know this is not like we don't need I just don't think we need new research into the sorts of things you're talking about as much as we need a real shift a major major 180 degree shift in the way we think about addiction the way we define it and I am going to take a little moderator discretion and say thank you to everyone who has participated in this conference from the organizer Scott Burr our dining service our physical plant who has made this room immaculate to all the multimedia to all the students who have acted as hosts and you're the best and to speak and say thank you from many of my friends who are addicted and I myself am addicted to say it has been incredibly empowering to see this room filled with people who care so thank you thank you and I remind you that if you have a ticket for the banquet that begins at 6 30 Mark Lewis is our banquet speaker his talk will be at 7 30 it'll be streamed so if you don't have a ticket you may watch it in alumni hall in the O.J. Johnson I almost said O.J. Simpson O.J. Johnson I'm sorry and may this conference have planted some seeds as President Bergman said in her opening comments about what we can do so stay well thank you have a good day