 Well, welcome back, and Owen Flanigan is going to start us off with a question. So Sheila, thank you so much for a very, very interesting talk, sort of brings out the social dimension of these problems. I was curious just from two things, you were emphasizing being a good consumer, giving some advice about that, which was good. And you were also spent a lot of time on sort of the way in which community, in the case of these prescription drugs, I mean these prescription drugs for non-medical uses works. And I was curious about just the following, you didn't talk about, you didn't use the word addiction almost at all, maybe not at all, I think you didn't, and I'm grateful for that actually. Because we know, I think the audience probably knows too, that at least a lot of the diagnostic manuals no longer use the word addiction much, they use words like substance dependence and substance abuse. But I was curious about what you've learned about the information flow among, say, young people who are taking these medications. What kind of information do they get from their peers about the possibilities of harmful effects from these uses? So for example, sometimes, at least at my university, we hear that amphetamine use is high in exactly the ways you said, children who have been diagnosed with ADD or ADHD get extra, pass it around, it's reciprocated. We don't hear as much about opiates, prescription opiates. I think the alarm bells would go off if we heard more about opiates, and I think the Adderall is sort of allowed to flow. So I'm just curious, A, what is the information flow like, and are there cases where we should be worried more about some of these uses, some drugs that are being used this way versus others? What is this? Okay. That's a lot of questions, but I'll try and address them. One of the things that I was talking about was that, well, as my friend John Morgan used to say, he was a psychopharmacologist, he said, you know, it's all in the dose. One person, you know, the same substance is poisoned at one level, and at another level it does something completely different. I think that the information about, in terms of information networks about drugs, certainly there were some of the people that we interviewed that seemed to know a lot more. Certainly the Internet is a very good source. People do use that. But mostly, you know, I think mostly it's, you know, it's in a social situation, it's at a party, and they say, take this, you'll be up for four hours. You know, they don't talk about, it's not indicated if you have to live or disease, and they don't do those sorts of things. But, you know, they do talk about, they do describe strategies for how, you know, like, don't take your Adderall afternoon before you're not going to go to sleep. So that sort of thing is, of course, is very helpful. In terms of whether Adderall is particularly bad as opposed to Vicodan, which certainly these kids were also using, their sense of when they got in trouble was if they were using Adderall to study, and then they used it to go party, and then they drank so much alcohol that then they had a hangover, they saw that as the worst part of it, in a sense. And it was sort of a cautionary tale. Their friends would tell them, you know, you're using too much. They'd stop hooking them up. And this happens in all forms of drug life. You know, crack sellers won't sell to someone who's pregnant, not all of them, but certainly a good percentage of them. So that drug users do form social bonds, they care about one another, they share information, just like we share recipes and cocktail recipes, and how, you know, never drink beer after liquor, or what is the other way, liquor after beer, or whatever the, those kinds of social norms, strategies, information certainly get shared. Thank you. Questions from the other panelists? I can ask someone, or mention something. I live in the Netherlands, and it's, as people may have heard, there's very different drug policies there. And one famous institution is the Smart Shop. It's called Smart Shops. There are Smart Shops in every town. These are not like the coffee houses. Not where you go and get marijuana, which is legal, by the way. And I mean, like really legal. But in Smart Shops you can go and get a whole variety of substances, many of which have psychedelic properties or relaxing properties. Some of them are pretty powerful. Some of them less so. They're perfectly legal. And it's such an interesting, the different way of distributing drugs, because first of all, people can walk in there and talk to the people behind the counter and ask questions about what does this drug do, how much should I take, and when should I take it, or shouldn't I take it, and they talk about it, and it's really, it's all above board. And I think in many ways it works really well. This is a big debate now about legalization versus decriminalization and the stages in between, and I think this is one of the stages in between that can be very useful. And by the way, you can go into these places and you can put yourself on a voluntary blacklist. Don't let me come in here and get a kratom for, let's see now, oh, I better give myself three months, and they won't. So it's kind of an interesting social. There's harm reduction in practice, right? Well, the thing about all of them, the notion that our young people are exposed to all these various drugs and substances, and they're given no more information, I mean, the information that they're given is most of the time just don't do it. And very little information about how to use it safely or to reduce their harms or any of those sorts of things. It's sort of like if we gave every 14-year-old a car and said, here, we're not going to teach you how to drive it. We're not even going to give you any gas. Just go. So yeah, it seems to me that people do use drugs for what might be seen, or at least from their perspective, reasonable reasons. I mean, it makes sense to do this and, Mike, this context with who I am, et cetera. But we don't facilitate safe drug use. Well, we don't actually, the National Institute of Drug Abuse to this day doesn't recognize controlled drug use or that people can use in ways that they're comfortable with. It's not life-destroying. They still have a job. They still take care of their family, all those sorts of things. We can't even acknowledge that, which makes all of it very difficult. Yeah, we haven't talked about this here, but it's pretty well known in the addiction literature that most people who take drugs do not get addicted. Exactly. And that is also the case with, quote, addictive drugs. Most people try it, and they say, well, OK, whatever. And go on with their life. But when you stab all drug use as evil or wrong or bad or unacceptable, then there's no possibility for information exchange. Sheila, but don't you think your presentation kind of plays into that a little bit? Particularly when you think about your comments about the doctors, the bottom line is that most doctors are doing the best they can. I know. And there will be people who try to get over on them. Right. If I didn't give that, that's exactly. I mean, that's what I was talking about with the scripts. I mean, the actual ways to talk to them and fool them. But I worry about the way the presentation kind of focused on the physicians because, like I said, most are doing the best they can. And in mostly any endeavor in which you have humans, you will have deviant behaviors. Yes. But we act as if the prescriptions is some unique behavior, when in fact it's not. Particularly as we think about opiates in the country, it's true when you look at some indicators. If you look at, I think, the past year use of opio as you see an increase. But if you look at the past month use of opiates, you actually see a decrease. So you don't, and then if you start to look at the numbers of new users, they're usually younger people. And then when you start to look at the people who are dying from opiate overdose, they're the older people. There are a lot of disassociation or a lot of numbers that don't go together. But we talk about these things like they're all the same. But my concern is that if we play into this sort of narrative and without acknowledging that, for example, physicians have a difficult job in that they want to make sure that they treat their patient well. And by the same token, they're trying to be responsible. So I just would ask to be careful. Let me extend your critique because I think that, I mean, the other thing that I could have talked about if I had, was the fact that when we get down on physicians for their prescribing practices, particularly in the pain management arena, we then set ourselves up for them under prescribing. Right. And people being, so I completely, and if I, in my presentation, emphasize it too much, it's a very good point. And yeah, so yeah, so beating up on the physicians is probably not a really good idea. I think I was more impressed with the strategies that they used to get the doctors to prescribe them. Not that the, I mean, there were pill doctors that they went to and get anything they wanted. Those are criminals, those are different people. But the doctors like at the student health centers and they're pretty wise or two. But the, you know, the regular doctor that they'd go to, yeah, they were fooling them. They were working out a way to present themselves in a way so that the doctor would believe them and prescribe to them. So that, I should have, that was really what my emphasis was, but you're absolutely right. We pick on the doctors, we're all gonna, all us old people that need the payments are gonna pay. One question or one theme that comes up in many of the questions has to do with this notion of whiteness and the connection of whiteness to socioeconomic status. And the questions are asking for an elaboration or amplification of what you mean by whiteness and questions about whether when you look at certain drugs, are you saying that, well, white people use these sorts of drugs, African-Americans use those sorts of drugs and a very open-ended question. Well, the first part of, the reason that I talk about whiteness in the way that I do is because I think that in particularly, I don't know if, the field I know best is ethnicity and drug use, but is that we tend to talk about white, I mean, white equals normal and everybody else is in comparison to what we're doing. So, you agree with that? So, you know, it's the hegemonic ideals about how you should live your life are emanate from white people. They're the people that sort of set the stage and make the laws and do all those sorts of things. Now the next part, I lost the next part of your question. I think that the assumption that whiteness is only connected to greater socioeconomic status. Well, it mostly is. Mostly. But the other piece, the piece that I think that is equally important, and I'm sorry if I didn't emphasize it, was I wasn't talking about who used the drugs. I was talking about what we as a culture and society believe about it. Early on, drugs get associated with particular social groups and ethnicities. And when that happens, irrespective of who ends up eventually using these drugs, they have a certain sort of social life, political life that sort of frames how we intervene, what kind of laws we pass. There's, I mean, there's many examples. Certainly the differences between powder cocaine and crack cocaine sentencing had a lot to do with who was perceived publicly in the public of using those drugs. And so that's what I mean. That's the way I'm using whiteness. What I'm saying is we have to look, we can't ignore the privilege that is attached to whiteness. And I think that's difficult for white people to hear, but that's too bad. I think it's more difficult for black people to hear. Another theme that emerged from the questions from the audience had to do with your word to high school students. And the interpretation perhaps, do you have this sense of inevitability that students are going to do it, so therefore do it at once. And several of the cards that I have here in front of me. I knew this wouldn't go. You knew this would come to you. It wasn't going to be easy, no. So in talking about why aren't we teaching more refusal skills, for example, or the just say no approach has been held up and we can argue about its effectiveness or how ineffective it was. I mean, is there anything in what you're saying that students might interpret as an encouragement of taking drugs rather than an acknowledgement of when we look at the numbers, it seems as if students are doing this and in light of that then. Okay. I think that what I said, or at least what I tried to say, was that in talking about this, is that certainly there are many teenagers that go through the journey from teenagehood to 30 and never touch a drug and they may be dodging bullets. They may be dodging bullets. I mean, that, you know, they could come their way. And I certainly think that I would hope that people waited as long as, I mean, I think Dr. Kendall talked about the fact that the younger that you start using drugs, your risk probability goes up and up and up. There's some stuff even about marijuana use that's, and I don't know, there's only been one or two studies about its effect on the so-called developing brain. I'm very cynical about whether that's gonna prove out as we continue doing this kind of research. What I'm saying is that we need to develop harm reduction for our young people, not just for the people who are in drug treatment or already, you know, adults with long relationships with drugs. I think we need to help our young people who some percentage of them, looks like maybe 30% of them are going to use drugs. And I think we have to first acknowledge that there's that interest out there. And second, talk to them honestly, not just say no, but just say K-N-O-W. We have to tell them the truth, the truth as we know it about drugs. What is the truth? The truth as we know it today. No, but what is the truth? I mean, this is where you have the real discussion. Right, exactly. But we can, yeah, well, I'm not, yes, I shouldn't use the word truth, you're right. Truth is the wrong word to use. But we do know some things about drugs that we could share. And one of the things we know is that mixing drugs, particularly when you're a young person, is very dangerous. There is never an overdose, particularly under 35 where alcohol is not involved. But we don't have to speculate. Denise showed some data, showed that young people start smoking marijuana at about 16 and a half, right? Right. That's the major one, what tobacco is like earlier. So we don't have to speculate. If we think about, if we want to protect young people, we want to know about marijuana. What are the potential, we want to know about tobacco. What are the potential harms of tobacco? And teach how to keep people safe, given that we know young people are doing this. Right. So we think about marijuana. Major concerns with marijuana, particularly of young people. We worry that young people may take too much initially. And if you do, you might get extremely anxious, paranoid. So how do you teach people to decrease the anxiety, the paranoia and that sort of thing? While standing on that very, very precarious bridge between it's okay that you use this, we... First of all, nobody's encouraging people to use drugs. I mean, that's, we are beyond that. I'm not, I'm not. I think I started out by saying you'd be better off leaving it alone, if you, you know. But we know that's not realistic for many young people. Why do we know that? I mean, I agree with Professor Hart. The whole discussion is this, if it's a good thing to take drugs, we just have to measure the amount of quantity. I don't think cigarette smoking is good for anybody. I can tell you as a physician, you know, if my kids ever started to smoke cigarettes, I would discourage them. Show them these statistics. Why, give me a discussion of a drug you'd encourage your child to have. What would you go to them and say this? I'm really not talking about encouragement. And what I'm talking about is harm reduction. What I'm saying is... Could you explain what harm reduction is? Some of our audience might not know what that orientation... What harm reduction says, what harm reduction says, is that when you come across someone who is using drugs or having problems with drugs, you meet them where they are. You help them to reduce the harms of their drug use. You talk to them about making changes in their lives. You don't immediately say to them, you can never use any more drugs and you must be abstinent tomorrow. You say, I will help you where you are basically. That's a very bastardized definition of harm reduction. What I want us to think about is just what Carl was talking about, is how do we talk about it? But I don't think just saying to people, don't use drugs, you should never use drugs, you should never use drugs while we're all not smoking anymore, thank God, but drinking wine and taking all kinds of drugs, where if you watch TV at night, every third commercial is about some drug that you should be taking. So I think it's very disingenuous to not acknowledge the fact that drugs are pretty exciting, interesting things and that young people, particularly those, and that are going to be interested in trying them. And if that's the case, I gave them what I thought was my best advice, which is do one at a time. Because we don't know everything about the bad effects. That's one thing we're pretty clear about though. I think the evidence is in, that if you mix alcohol with the benzos, with heroin, with those drugs, that you're greatly increasing your risk of overdose. And the evidence too is that if you mix alcohol with a stimulant, you can offset the negative effects either. So I mean... Yeah, exactly, yeah. So the point I was trying to make is that if we are really concerned about young people's drug use, we acknowledge the fact that we know that young people start using certain drugs at a certain point. And we target our education accordingly. That's the point. The point is if we're worried about young people primarily using tobacco, alcohol, and marijuana, that's where most of our education should be. Right, exactly. And they don't really, yeah, exactly. That's really true. And I think it's very important when, I mean, some of the dare programs that started in kindergarten talking to kids about drugs were ridiculous. These kids didn't even know what drugs were. However, I think in kindergarten, in your science class, you could teach children not to take medications that were not to take medications without an adult. I mean, that's... And it also, it's like, there's also the part where you sort of silo the drug information. You know, it should just be a part of your science class. It shouldn't, you shouldn't have, okay, now we're gonna talk about drugs. I mean, we should incorporate it into... And because drugs are so interesting, I think we can really do some really engaging things with kids if we incorporate it that way. And as we start, as we think about the drug education and sort of program, the thing that people must remember, particularly as we think about drug use by young people, particularly young, very young kids, parents still have the parent. Right. You know, oftentimes, when it's... Yeah. Oftentimes when we have drug use, drug use occurring at very early stages, drug use is not the biggest problem. There are supervision problems and a wide range of problems, and it just becomes easy to point to the drug use as the problem. But you can almost be assured that there are larger problems going on. And so be clear about what your target is. I like that idea, that is the role of the parents in this, because I think they're very important. I wanna ask you people, because I have no facts, this may be complete bullshit on my part. There is a Jewish myth that I don't think anyone has ever obtained empirical evidence for. You know, it's a Passover Seder. There are four glasses of wine. You don't have to complete all four, but you have to touch all four. And so kids see at the Seder, their parents are drinking, and they're permitted to have a little bit. And I'm told as a result of the fact that they learn this in a parental and a social context in a, you know, way that you don't find serious alcoholism among Jews. Is that true? That's true. I think the big studies were Italians versus the Irish. I mean, there are some studies. That's at least my knowledge. At least that's what I've written in my textbook. Yeah, so. I can't go to Ohio so much. Actually, I'm something of an authority on this part. Actually, this is again about parental role and the social dynamics. There's actually in George Valiant's work on the natural history of alcoholism, he indicates that unlike a lot of sort of street lore, there's no personality types, temperamental types, et cetera, that predict alcohol use. But there are ethnic, and it almost, and so then when people go in and look at the sort of various ethnicities, the one variable that he thinks is important in explaining Irish excess is that there's jokes about adult alcoholism that are permitted, sort of about, you know, isn't it funny that Uncle Shlomo ran into the garage last night and he's on the wagon again? That kind of humor, it tends to sort of encourage, it looks like children in certain ethnic groups to think, oh, it's not so bad if I behave like so and so. So it's interesting, I think these, these are clearly- And also doing it in a social context. That's a cultural thing, not evidence. Yes, true. Well, right. It becomes a broader sense. You know, doing it in a family context has different meaning. Yeah. But I think one issue that is really coming up, particularly with the number of psychiatrists I've met here, is that, and this again goes back to your point, at the heart, and that is, parents may be overlooking real problems their kids have and part of the reason they may turn to drugs and be very much influenced by their peers, although every adolescent is influenced by their peers, is because they're trying to solve some problems. So being more sensitive to your children's issues and learning how to be sensitive to it may also be an important part of this. But don't you think that's true across the life course? That essentially people that get in real trouble with drugs are what the treatment feels called dual diagnosis. I mean, most of the drug use that is going on is self-medicating. People are trying to figure out how to make it through the day. These are the substances that are available to them. So that's why it's always confused to me. I mean, I understand how the politics of it, but why we have a mental health system, a drug treatment system, and a primary care system when the folks we're trying to intervene with need to be in all three of those places at the same time. That's absolutely right. You know, I mean... And the idea of overcoming the stigma of seeing as a kind just. I mean, you have no stigma about seeing the internist. What's the problem of seeing as a kind just? And I would just like to say that these final comments are actually a wonderful preview of some of the issues that will come up tomorrow in the treatment panel at three o'clock in the afternoon. Before I send you all away and thank our panelists, I want to remind you of the opening at the Hillster Museum at six o'clock, during which there will be a dance performance. At 6.30 in here, we have what we've called the front line triage panel. So people whose professional work has them encountering people struggling with drug use or addiction. And at eight o'clock, we have music in the Christ Chapel. So it is a full evening. Have yourselves a good supper, and I hopefully will see many of you right around six o'clock. So please join me in thanking Professor Murphy and all of our panelists. Nice job with the clip.