 about five minutes there's people doing a double turn around thing and we're going to get started. Are you picking up audio now? Are you picking up audio now? Test. Check one, two. Check, check. You hear that? I'll turn it up a little bit. Check, check. Test. Testing, testing. Is that good? Yeah. Okay. Test. Tell me two, and I'll tell you. Test, test. Test, test. It might be just a bad signal. Test, test. I think I'm pretty good. So we are having it recorded and videotaped and it will be available. We'll send it to everyone via link. Make sure that when you sign in you add an email address on there and we'll be able to forward you that so you can have it as well. We will, bathrooms are right here to the, across from the elevator, to the left, to the right, I'm sorry, across from the elevator. And we will be taking a little short break about, just share a little bit about our two speakers. Charles is a licensed chemist. During that time he has worked in residential treatment settings for both adults and adolescents. He worked as a, he worked for the HIT Division for one year and in the remaining nine years for the SHS Institute. Who saw both our speakers last week? Anybody from here? Founder of the Texas Overdose Boxing Initiative, Tony for short, which brings overdose awareness and treatment to the state of Texas. He has worked in the field of harm reduction and public health for over the last 27 years. In bringing prevention and intervention to drug use and the recovery community. He is currently a national trainer and consultant on issues of substance abuse, ranking, HIV, STDs and intervention that developed the development of appropriate responses to the complexities of the patient. He is also a recovery coach and a patient navigator for individuals in the medical care system. He works at a recent associate at Yale University School of Medicine and Public Health and has been the coordinator and project manager of numerous National Institute of Drug Abuse, NIDA. Funded studies including sexual acquisition and transition, he has worked in many states and was part of the New Haven Needle Exchange, the first legal needle exchange in the East Coast for several years. He has worked in connected trainings for corporations and for supportive housing and a national organization that develops supportive housing for persons with history of either addiction or mental illness. He is currently in the board of directors for the National Harm Reduction Coalition. Serving also as a trainer and expert on the advisory board for the North American Serendix Team for the Overdose Prevention Education for Substance Abuse and Mental Health, SAMHSA. He has also served on the community advisory committee and an executive committee at Yale Center for... This kid is pretty scary. So I'm glad everyone here on the status law enforcement treatment is really good. Today we're going to do a little introduction and I'll turn it over to Mark. I want to be up here and do this training with Mark. I met Mark on the East Coast. He was doing a training back when I did Supervisor Street out on his team in Austin and we were able to go to New York to train. That's what we met 20 years ago. He's done a lot of this work in other countries in this country as well. Saved a lot of lives. Today we're going to be talking about some data about the opioid overdose or opioid abuse problem. One thing to know, Mark, is how to collaborate about this. Texas has either very poor data or it doesn't exist. So we'll be talking about some of the cost associated with opioid abuse problems. How to maximize, respond, evaluate... Senate Bill 1462, which has allowed greater access to naloxone. You're going to hear us talk about naloxone. Narcan is the same medication. Narcan is the medication. Naloxone is the generic name. So we're going to talk about that. We'll talk about how to get this medication and how to use it and how to pay for it and all that good stuff. I'm thinking we're in San Antonio. We have some southern folks in the room. Mark's always concerned that people still don't understand what I'm saying because we're from up north. So if there's something I say we don't understand, feel free to raise your hand. Mark will clarify for you. But at this time I'm going to turn it over to Mark and let him do his thing and then we'll go connect. Thank you. And so I'm very passionate about some of the more effective streets around the country and internationally around the epidemic. Each idea is a cultural community where drugs use to ramp it and it certainly was a participating member of that particular community. And so I stand here often times when I hit up a ton of folks. A lot of stuff rushes in at the beginning. But a lot of us as a young lady come with my different ideas. So I vote as best as I possibly can if I find myself emotional when it makes it. Texas Overdose Deloxo Initiative was started as a direct result of a couple of us getting together after I found myself back in Texas or in Texas at the statewide HIV outreach workers. I was asked to come here and do a training for outreach workers. And I came here with about $300 a day. I was on the elevator down to do my training. And the start is that I was playing it all from the way. That had to be the way I was doing it. I was 160 pounds. I was something in. My eyes were thin. I was sick. And I saw Charles at the elevator and he looked at me and said, Man, what do you want to do? He liked a lot of the folks that we worked with. And Charles let me know that he wasn't going to let me down. He wasn't really watching. And I needed help. So I said he could help me. And so that particular trip I ended up in a 90 day treatment center in Austin, Texas. I said, See, I've been a king for many, many years. Almost a decade in between. And I thought I was going to drift again. So when I came to Austin, Texas through the training, I did what I hoped that I would be able to do. And so we got my own treatment. I found myself wondering what my purpose was. Why is it great to have me here? At this particular time. And so Charles and I started to talk about what was going on nationally. I said, It's not been nationally around the 7th century since 1996. Yes, it has been pretty bad since 1996. But what we got here, Charles and I started to talk about what we could do here in the state of Texas when we started to put together some people. And look at the issue. We started doing some outreach in the city of Austin. We started to distribute the locks over in our can. Our outreach program and started to build on the education piece of the 7th century. It has brought us to this particular place where we are traveling in one of the state of Texas right now, educating law enforcement, educating providers, treatment centers, solar houses. Because this is an epidemic that has really crossed some barriers that many have. And so, you know, it's just ironic. And I'll tell this really quick so I can get moving with this. But while I was at Yale University, my one apartment that I had worked on the streets of was kind of the previous 15 years. We had 15 years clean. I had, you know, 11 plus years clean. And we both relapsed. And in 2004, I called this by the debt my office overdosed. And the reason I say that is ironically, I ended up in Austin, Texas, and we call this the Texas Overdose and Lockdown Initiative. My best friend that I found in my office, his name was Tony. So I don't know what the creator is doing, but he's doing something. And so I'm going to go with it for now. I'm going to ask a question, and if you're uncomfortable with it, please do not raise your hand. Who in this room either knows somebody that knows somebody that knows somebody who is overdosed? Those of you who didn't raise your hand, who in this room knows somebody that knows somebody that knows somebody that has previously used opioids, currently using opioids, or may probably in the future use opioids, pain, whatever it may be. Yeah, everybody in this room. So one of the things that we're dealing with, and I'm grateful law enforcement is here, that's probably a rare thing for me to say, but I'm grateful the law enforcement is saying play an integral part in what we're going to talk about throughout this afternoon. Because there has to be a multi-prong approach to us for us to address this appropriately. And we've got to look at this honestly. And so I'm going to say some things in the early course of this that are going to really challenge your beliefs, that are really going to challenge what you have been taught. Let me start by saying that I hate drugs. I hate them. Honestly, God, I hate them. I hate what they did to me. I hate what they did to my family. And I hate what they've done to my community. The community I grew up in is gone. It's completely gone. Either they passed from overdoses or HIV. And much of that is driven by some of the stuff that we'll talk about in the course of this. So when I talk about some of this stuff that challenges you, I don't want you to think that I'm co-signing people's drug use. What I am going to talk to you about is the realities for which we face. Because if we don't start looking at this in a way that is effective, this is not going to change. I was sitting on a panel last week with the FBI and the DEA, also not on the bucket list. And I found myself intrigued by a number of things that was being said in there. One of the things that always fascinates me is when, in particular, frontline law enforcement says, we will not arrest ourselves out of this. And we won't, right? Because if that would have worked, it would have worked 60 years ago, right? And they start talking about treatment. And so now you see all these parry projects that are open up all over the country where law enforcement has become a, because they're in contact with our folks regularly, they have become a conduit to social services, right? And so these are all really important transitions that we're seeing. And so when we have this dialogue today, I want you to be open minded around this. You don't have to necessarily agree with me. I mean, I'm from the East Coast. I try to piss people off. That's what we do. And so, you know, we'll see where this takes us. So a lot of things that we're going to look at in the course of today is the epidemiology and physiology of what this epidemic looks like, okay? We're going to talk and share some information and some resources around overdose prevention and what we can do. You know, I've been involved with public health for almost 30 years now. And I am going to tell you there has never been a simpler public health initiative than the one we're looking at right now. And I say that to say that we continue to put barriers in the way for every very simple preventing deaths and diseases and we put more barriers in the way than knock them down. Low threshold stuff works really well. We're going to discuss the attitudes towards drug use and drug users, right? Because it's important. That's who we're talking about. We'll look at the Texas data. We'll look at the national data. We'll talk about 1462 and what it looks like. And then we'll look at some of the training Charles will go through the different forms of naloxone and arcan that we have available. And then we're going to talk about access to that medication to the communities from which we serve. So lots of money, folks. So the cost associated with opioid overdoses is about $21 billion a year. It's a lot of money, right? And quite honestly, all the indicators, I should maybe the dictators too, but all the indicators right now are showing that this is not getting better it's getting worse, right? And so those numbers are going to increase. We look at the overnight health care costs for somebody who shows up in an emergency department on a national level. Texas is a little bit lower cost wise, but you'll also see why this is a big issue. Is that me? What am I doing? So always most important to me is always the most important to me is that yet it financially is incredibly expensive, but the amount of human lives that this is taking at the rate it's taking them and the communities that it's affecting is enormous. A lot of hands went up for overdoses, right? And so I think people are intimately involved with how this affects not only the individual, but the family members, the community, the psyche of people that these individuals hang out with, friends, colleagues. This is tragic what's going on. If you look at the numbers nationally last year, it's around 48,000 people overdosed. The human life costs, as I stated earlier, is continuing to grow. And I think it's interesting, when we look at some of the Texas stuff, is that when we hear even the media talk about overdoses in this particular state, we often hear and see what they portray as where the real problem is. And you see them doing really good pieces on street outreach here in San Antonio, a Fox 29 last night, did a really good piece on Sean Baker and CHCS's efforts to look at this issue. But they always go to the street, right? Well, in Texas, this epidemic is still driven really highly by prescription pain medications, right? And although the heroin and the synthetic opiates that are coming in are starting to be much more influential in these numbers, it still is a large majority of these are still prescription pain medications. So be aware of that. When you look at the number that it costs for us to put somebody for an overnight stay as a result of an overdose into the hospital, it's about $36,000 a night, okay? And the average stay is about 3.8 nights, right? For an overdose. It's a lot of money for one individual, right? And so these are numbers that by doing pretty simple education and access to medication and other alternatives can dramatically cut down the cost of this. The other thing is, is that we live in a state where we have the second, well, we have the most uninsured individuals in the country, right? Between 17 and 20% of the individuals in our state are uninsured, right? We do not have Medicaid expansion here. Much of the money that is recouped by the hospitals through what we call an 1115 waiver. That waiver is getting ready to go away in August. I mean, in September. And as a result, many of these hospitals that would be willing to admit people for an episode like this may not be able to do it as a result of what it's going to cost them because they can't recoup it, right? And so, you know, we need to look at some alternatives around this and some ways to keep people safer if there's an episode around overdoses occurring in their communities. Untrue to what the national maps and what Charles talked about earlier around data collection in the state of Texas is really poor, right? And really inaccurate in a lot of ways, I'm sure. And the reason I say that 254 counties, 254 medical examiners, you do not have to be a medical person in the state of Texas to be a medical examiner. And so when some of these incidences happen, the numbers that get back to the individuals that collect these type numbers are often inaccurate, right? And so, but if you look at the national data that the CDC and HRSA and many of the other top-notch, you know, Feds that look at health consequences and indicators, Texas is number two in the United States for healthcare costs associated with opioid abuse, right? So, the other thing is that we have four of the top 25 cities in the United States for prescription opioid abuse. Four of the top 25. And so you can't tell me that there's not an opioid problem or that maybe that the data that shows up around fatal overdoses is a little bit skewed, right? Because those numbers don't add up with what the numbers show. But when we're talking legislatively, what folks want to see is they want to see that light up before we actually do anything. My plea to people is let's do something before it lights up. It just is really good public health, right? And so when we look at the amount of people that are dying, we can see from 2003 to 2014. Sure, Texas lights up. The Southwest lights up, right? But we're still not aggressively going after this the way we need to. And so we're looking at 120, 930 people dying every day from overdoses. It's a lot of folks, man. It's a lot of families affected. That's a lot of communities affected, right? And if it was this happening, where a plane was going down every four days, we would shut down the air. Nobody would be flying, right? And yet, because oftentimes the stigma associated with substance use, in particular, hair around or opioids, people kind of go, well, maybe not. And I'm just going to be honest. You know, I started doing overdose prevention work in the mid-90s. And we were reading, when I was at the University, we were reading some of the medical examiner's data around deaths of overdoses in the inner cities that I worked in, New York, Newark, some of the other bigger Jersey cities, Bridgeport, Connecticut, Hartford, Connecticut, New Haven, things, places like that. And interested enough, in 1996, the New York Times came out with a front-page article that said, four suburban Fairfield County teenagers died from overdose. I was like, well, that's interesting, front-page. I said, wow, what's that all about? And so when we looked into it, who knows what Purdue Pharmaceutical is? Who knows what they do? They introduced OxyContin. They introduced OxyContin, right? And at that time, they had 160 milligram pills. It's crazy. But anyway, so these four kids from suburban Fairfield County, I think the second or third richest county in the country, died, and it's front-page news. And then the communities that I serve and come from don't even get mentioned, right? And so it came really clear, pretty quick, that once some suburban, affluent white kids start dying, people start paying attention, right? And so that's been the trend. Trust me, when I tell you, we sit in this room today because white kids are dying and affluent kids are dying. And that's the truth of the matter. We don't have to like it. It's the truth. So this is an epidemic that's been happening for decades in the inner city, but because now it's transcended into areas that historically it had not been a problem, we will address it. And I say that to say, let's use the momentum we got to make changes for where we can make changes. You know, this whole new care act, who's familiar with the new care act that just got passed, right? And so who works in treatment? If you don't know what the damn care act is, you better learn what it is. So Charles and I came together. We started doing some advocacy and the epidemic continued to get more and more national attention. And Senator Royce West submitted a bill. There was a number of bills submitted around the opioid epidemic and the overdose situation and what was going on. And we'll talk about the Good Samaritan piece in a minute. So we advocated bill 1462, which the governor ended up signing in September, it passed in May of last year, that allowed for third-party prescriptions for naloxone or Narcan. A simple, pretty benign medication that only does one thing, saves lives, period. In that particular bill, it allowed for standing orders to be written by, and in that case, in that particular bill, it actually encouraged state medical people to write a standing order. They chose not to, but what it did allow is any doctor that was willing to do it and to write a script for the whole state around this particular medication could do so. And that's what we have today. And we'll talk more about standing orders and what that looks like. It basically is very similar to what you see around vaccines and immunizations where you can go into a pharmacy. You don't have to go to your private physician. You can go in and tell them that you have an individual that is using opioids or that you're using opioids and that you would like to have this medication. You don't have to go to your doctor's script. There's a script at the pharmacy for this. Starting August 1st, the Texas Pharmacy Association, which has a standing order from Dr. Carlos Tirada, is training all the pharmacists in the state of Texas around how to talk to their customers, how to recognize some of the risk factors around it, and that will be much more readily available. Walgreens has a standing order. CVS has a standing order. I would highly recommend that you call those stores that you may be close to prior to going in. Some are taking longer to put the medication in their stores. It also gives us a little bit of protection from criminal and civil liability. It's one of the things that we would have gotten a little bit more coverage with the Good Samaritan Act, which would allow people to be called 911 with limited liability medically and criminally. There are many reasons that people don't call 911, and we'll look at that. Charles will talk more about that in a little bit. But if you look at not only law enforcement, not only all the health providers in this country, all the people that really kind of drive some of the policies, they're calling this the epidemic of our generation. It's pretty scary to me with all the other stuff that is going on. So that number of 48,000 people dying from an overdose last year is horrific enough. They're estimating between 58,000 and 62,000 this year. And so this is not going anywhere. And we'll talk a lot about the influx and why Texas is so vulnerable, okay? Not only because of some of the numbers that you saw around high prescription abuse, but because of the access to really pure clandestine fentanyl that is coming into the state or through the state to other parts of the country are sharing with the sheriff just now. HIDA, which is... they oversee a lot of the high intensity... what's the stand for? High intensity drug trafficking? Yeah, something like that. They watch people bring drugs in and arrest them. And they made a bus a week and a half ago in Atlanta, Georgia, of 100 pounds of pure fentanyl that came through Laredo. And they tracked it to Atlanta, they busted them in Atlanta before it could go off the East Coast. But I say that to say this, because of our location and our borders here, there's no way there's not going to be a fentanyl problem. It's just not possible. You know, as vigilant as law enforcement is around this stuff, they will be the first ones to tell you, stuff gets in, it just does. And so we need to be on top of this because our family members and communities are going to die. We don't want this to start looking like New Hampshire and Rhode Island and Massachusetts and New York and New Jersey. And we have a chance to do something different. So, now the fun part. You guys, are we really not at the end of this? I'm sure of it, which is okay. So we're going to look at who in this room feels they don't have any prejudice or any judgment or any stigma for drug users. Good, so at least I got an honest group here. Because we all have it somewhere somehow, right? And I mean, there's certain things that tweak us in a way that's just really uncomfortable, right? And so we all have stigma and prejudice around this in a lot of ways. I think the greatest barrier that we face today is stigma and misinformation around addiction and what this looks like in many communities. And so when we're talking about the opioid epidemic, there are some things that we're going to need to address and look at and when we're working with people directly that may still be actively using, there are some ways that we're going to need to start talking to them. And so for someone who's been doing this type of work for the past 30 years, I will tell you that this is not easy, what we're getting ready to talk about. So I will say, you know, who knows who Dr. Andrew Weil is? Think, see? I think that probably shows yours and I aged a little bit more than these guys probably. So Dr. Andrew Weil is a natural pathic, he's an MD, but he does a lot of natural pathic stuff. I would highly, highly, highly recommend to everybody in this room to read his book, Chocolate to Morphing. It's a tremendous, really simple, layman's terms, book on the psychoactive ingredients, just nuts the bolts, it really is tremendous. But what Dr. Weil says and what Webster says and what the AMA says is that a drug, right, is any substance that in a small amount produces change in the mind, body or bone, right? Anybody disagree with that? No? Pretty accurate, right? Any substance in a small amount produces change in the mind, body or bone, right? Now, in the communities and if you look at what's going on nationally in our country right now, as sad as that is, people are living in fear and stress and degradation and, you know, all these things are going on, right? And so obviously the drugs you do will affect some of the behaviors that you partake in, right? So I'm not discounting that by any means. But the term drug user will drive a lot of stigma about how we provide services to people, right? It just does. Because there's a lot of fear and misinformation. We don't understand, people don't understand why people do certain behaviors when they're under certain circumstances or under the influence of certain drugs. But I want you to think about why people use drugs. You know, we had the privilege of growing up in an era, many of us, where we often would hear one of the great philosophers of our era, you know, talk about that drugs don't work and just say no. Well-intentioned, right? Pretty interesting coming from a person that, at that point, had been on benzodiazepine for 40 years, but an interesting message, right? And so I say that to say this. Don't ever think that how you get your drugs and how you use your drugs and your socioeconomic status doesn't dictate how you get treated. So many of the folks that we are telling to just say no are folks, Texas, highest uninsured population in the country, who access some of their medications from the street. You don't have to like it, it's true, right? So how you get your drugs, how you use your drugs, dictates how you get services, right? And so if we look at society-wise and in human culture, why do people use drugs? And we see. We use drugs for religious practices, correct? Right? Forever. You know? There is no culture, no demand, that doesn't use a mood or mind-altering substance. Somewhere, somehow. Speaking of Purdue Pharmaceutical, we had the opportunity when I was at Yale to be asked by them to go up to a place called Washington County, Maine. Familiar with it at all? So Washington County, anybody know about Washington County, Maine? First most northeast part of the United States, where the sun comes up in the U.S., okay? A lot of stoop labor, a lot of manual labor, fishing, diving for each sea or a chance. Rough folks, man. And we were asked to go to Appalachia. Rough folks, hard-working folks, stoop labor. A lot of seasonal work. And those two particular entities had the highest rates of fatal overdoses per capita in the United States. Now, Washington County, Maine is very large, right? The county itself is probably the size of Delaware, right? One county. With about 30,000 people in it, and it had the highest rate of fatal overdoses in the United States. And so we were like, okay, they want us to go out and do some street ethnography and do some qualitative and quantitative research on why this was happening. And so when we started doing this, the number one reason people used up there was chronic pain, right? But the number two reason that they used up there and used in Appalachia was boredom. Was boredom, right? And it's true. There are a few things that relieve boredom like narcotics. This is not to encourage it. This is the fact, right? And so who's got anybody under 18 that's our house? I got a 17-year-old. You ever hear the word, but man, I'm so bored. Right? Let it start ringing. Be aware, seriously. Be aware. And in many of the communities that we live and function and work in, you know, I'm almost always amazed at why people are not using and some of the living conditions that they're in. So my coping mechanisms were not that good, obviously, right? I had a huge tragedy in 1978 where I was traumatized by a particular situation that occurred. I found opioids that weekend and it became my coping mechanism for many, many, many years, right? And so when we go into these communities where there's poverty, racism, sexism, degradation, all these things, right, I'm fascinated by the folks that aren't using it. I'm like, wow, they're coping mechanisms. Their connection with their creator is like, wow, it's fascinating, right? But understand that's not everybody and people use because of despair. We use drugs in this country by the way. Talk about opioid abuse. Let me run this one at you. 5% of the world's population, right? Were somewhere around 85% and 90% of the world's consumption of both hydrocodone. Think about that. I mean, that's like crazy, right? And so the things with opioids, by the way, that are really effective is they work not only on the physical pain that they were intended to work on, but they work on spiritual and mental pain as well. And so when you start to see younger and younger people start to use, it's not only because of access and that's part of it for sure, but it's also, think about what's going on in 15-year-old young girls' lives, right? They hate themselves or never pretty enough. And the same with boys, right? Same thing, right? And all of a sudden you get introduced to a particular substance that makes everything, we don't have to like it. I don't know any kid that wakes up in the morning and takes a particular pill out of their mom and dad's medicine cabinet thinking that they're going to get strung out and down the street selling themselves 10 years later, I don't know anybody that starts out like that, but what I do know about with a lot of people is that they are looking for some type of relief. And opioids do that. Retreat diseases, socially interaction, social interaction around substance use in our country is rampant, right? It's rampant. What do we call it? What do we call social interaction around drug use? Happy hour. Happy hour, right? And I say this, don't ever make the mistake of thinking that shooting galleries and crack houses are any different than Malone's in regards to some of the things that... I'm going to be honest with you, I have a 20-plus year history of injection drug use, right? If I could have shot dope in Malone's, I would have. I really would have. But people go where the people that are doing what they're doing are, right? And so when we think about shooting galleries and crack houses and we think it's this horrible place and oftentimes they are, understand that they're not that different than the corner bar. They're really not. So we use for artistic enlightenment, we use to escape, we use for relaxation. We use is what I'm saying. Anybody working with the criminal justice system right now? Working with women? Mostly men, all men? Anybody working with women in the criminal justice system? So 80% of all women incarcerated for nonviolent drug offenses, 80% have a history of sexual violence against them. How many of them ever get the issue of sexual violence addressed by the time they get released? About 2% nationally, right? And so drugs become coping mechanisms for many people. We don't have to like that. That's the reality of what's going on, folks. And until we look at it and stop saying, well, they shouldn't know about it. They shouldn't do that. It's going to stay exactly the same and get worse. And so when we're talking about overdoses and particularly the dressing, are you working with the pre-release or release right now? Are you working with individuals that are being released? Absolutely. So one of the things that you'll find is that we have a really captive audience, a point of contact with people in a very high-risk community, right? Highest risk factor for people that leave jail or drug treatment is what? What is it? Fatal overdoses. Highest fatalities. Highest rate of deaths amongst people that leave prison or drug treatment is fatal overdoses. And yet, when we have them in treatment, we don't talk about it. I mean, that's crazy. Because we think if we give people information, it's going to push them to use. It clearly states in the literature I read that knowledge ain't going to keep us clean, it's over. So it probably isn't going to make us use either, right? Information gives us the opportunity to respond appropriately. It's not the stuff that makes us use. The stuff that makes us use is the emptiness here, the rest of serenity and discontent. The stuff that makes us not like where we're at and who we are. I mean, information. And yet, we have captive audiences regularly and we don't talk to them. Honestly, you want to know what I think? I think it's incredibly unethical. As service providers, for us not to address this in a manner that's appropriate, there's two things when we get on lock up that we want to do. Two things. And one of them is get high. Most always, if we haven't had some of the stuff worked on inside, address, right? The other thing that happens to us is that we have that mindset, man, I ain't never coming back here. There's no way. I'm never getting locked up again. I'm never going to use again. It always ends me up back here. And I get back on the block, man, and all of a sudden I got a needle in my arm or I'm smoking crack or I'm doing something, right? And I can't figure out how the hell it happened again. And so we'll talk about some ways coming out of treatment, coming out of the system that are really effective and keep them people connected to services, right? So anybody know who Dr. Norman Zinberg is? Dr. Norman Zinberg did a longitudinal, not a study, probably maybe the longest longitudinal study. I think there are maybe the last long longitudinal study that not ever funded. But what Dr. Zinberg was looking at is why is there so many negative consequences to certain behaviors, certain drug use. And what Dr. Zinberg studied over a 40-year period was individuals based on a couple of criteria, right? And those criteria look like this. And by the way, that's a book. And if you want to read something really interesting around what I'm getting ready to tell you, Dr. Norman Zinberg, drug set seven. And so the drug is the pharmacological makeup of the substance that people put in their body, right? Quality of it, the quantity of it, what it's cut with. You know what, there's some law enforcement in here. You can ask law enforcement. Probably as dangerous as the drugs that are on the street gets the cut that's in it. And physiologically, there's no doubt about it, right? When you start putting neat tenderizer or dope, this is not a good idea, physically, right? And it happens all the time. It happens all the time. So the drug is the pharmacological makeup for which people are putting in their system, right? Purity, quantity, quality, all those things. And the set, and the reason Dr. Zinberg looked at this is because of some of the health indicators that show up often with drug users. The set is the individual, so me, you, whoever, right? And their mindset around their drug use and why they're using it. So who can honestly tell me that they've had a real open, honest conversation with one of their clients recently about their active drug use? Who's talked to them about it? Exactly. Because we don't talk to people about their drug use, right? And so as someone who accessed services for many, many decades and tried to, you know, get treatment and receive services, I never, ever had a counselor sit in front of me and say something like, so you've been using it for the last 10 years until you get out of your drug use. No one ever asked that question, right? Ever, right? So do people think drug users are stupid? Honestly, in this room, do you guys think drug users are stupid? You're being fooled if you don't. Seriously, do people in this room think drug users are stupid? That's exactly right. There may be a lot of pain in there, right? There may be some things that ain't real good and real healthy, but they're not stupid, right? The one thing that they will... that they know when they show up in the service provider's office is exactly what you want to hear. They know that. Trust me, to get what they want, they'll tell you what you need to hear. No one ever talks to our people about why is it that they're using it? Why is it that... What benefits do you get out of your drug use? Because I'm here to tell you folks as much as we don't like some of this stuff, they wouldn't be using it if there wasn't some kind of benefit to them. We talk about it in the books that we read, right? We use for the effect produced, right? If the effect produced wasn't learned in some way, somehow, we wouldn't do it, right? And of course, there's always that line that we cross into addiction, right? And that's true, right? But many of the folks that we work with, folks have never been asked about is it that you use? Do you use to stop the voices? Do you use because you're in physical, mental or spiritual pain? Do you use because you want to get high? Because my intervention with somebody is going to look very different if someone says I use because I want to get high. As opposed to the person that says to me, I use because I want to stop the voices. My intervention and messages are very different. Very different. And yet we never ask that question. Never. And so I would encourage you to start being a little bit open about your techniques and reaching people. I know that most of the people in this room got into this work for the money. My hope is that you really got into this because you believe that you can make a difference. I'm here to tell you you can. Man, my last treatment provider saved my life. This dude got in my face and let me know he wasn't going nowhere. Man, it's all I needed. I was out of hope. I needed somebody. I needed a jar head to tell me. I'm not going nowhere. I'm not going to watch you die. That turned it for me, folks. Sometimes a kind word is the most valuable thing we ever did. So the pharmacological makeup, the set, why the people are using and trying to get an understanding of what that looks like. And what Dr. Zimberg found out, and the reason that this is pertinent to overdoses is that much of what we teach folks around overdose prevention is oftentimes based on the context in which they use, right? The setting. My drug use looks very different in the middle of Lady Bird Lake as opposed to the middle of South Congress. Looks very different, right? So when we have conversations with people, honest ones, and we talk to them, we don't have to have addresses. Some folks in this room would like some addresses. I'm not good with them. But when we talk to people about where they use, the context in which they use, we need to find out if they're safe, if they're around people. Are there certain amenities there? And what I mean by that is that one of the things that you'll see, not only for privacy reasons, a lot of illicit drug use in particular and Jeffers that are homeless cops will tell you, they go into bathrooms and McDonald's and places like that. There's a lot of reasons they do that, right? There's clean water in there, right? They can lock the door, right? But it's not always a real safe place. So let me give you a little bit of a context surrounding this is that some Charles and I are actively using. And we go down, not really, but hypothetically. We go down to the corner and we cop some heroin, okay? From the same guy, at the same time, it's the same product, okay? So the drug is the same. And we both are copping because we both want to get high, right? Charles takes his drugs, gets it in his seven series beamer, drives out to his million dollar condo, hypothetically. Remember, he works for the state and he was a licensed clinical drug counselor. He's both ways. And he's a musician. And just by the nature, you know, we can make money doing it. So he goes, he drives out into his condo and he gets his condo and he sits down and he turns with Peterson Brothers. You know, Peterson knows Peterson Brothers. Don't tell me they're from San Antonio. Stop it, folks. Wow. You should be ashamed of yourselves. Biggest suffering coming, blues, young boys in the country. He sits down, he relaxes, he gets clean water, right? Throws his feet up, gets his dope, he cooks it up, he relaxes, he ties off. My coast side of people's drug use. People are using, by the way. Do you know that? People are using drugs, all right? He gets his drugs, he fixes them up, he relaxes, he gets a bang back, right? He chills out, he gets high. I go to the same guy for the same reason, but run around the back of the abandoned building behind a dumpster and I'm fixing up my stuff and I'm looking to make sure the police ain't coming, and I'm looking to make sure I don't get robbed or jumped. I may have clean works, I may not. And I'm fixing my stuff up real quick. And then bang, right? Same drug, same set for the most part, except for maybe some biological things that are going on, right? But the context in which I'm using those drugs dramatically increases my risk factor, right? Are people with me on this? Dramatically increases the risk factor, right? Not only for overdoses, because that narcotics can act very different in me than it is for somebody who's chilling, right? Overdose is much higher, endocarditis is much higher, cellulitis is much higher, abscesses are much higher, hygiene's much lower. All these things just associated with where people are using. And so when we talk to people about risk factors, and primarily the work that Charles and I have historically done has been on the streets with drug users. And so when we're talking to individuals, we talk to them about thinking about, you know, you're in active use, you know, you're in Texas, you ain't getting into drug treatment, you're number 50 in the country, so you might as well wipe that out. That was a dig. It is something we need to work on, folks. We're number 50 in the country for access to drug treatment. 50, right? Number two in opioid abuse healthcare costs, number 50 in access to treatment. And so when we talk to people, we actually have them think about where they're using. Are you safe? And are you around people? Are they clean? Is it hygienic? Do you have clean injection equipment? You know? You know, I think that there's really important work that we can do, and then we educate people about what Charles is going to talk about after this break. We educate people about the risk factors around opioid overdoses and what that looks like. Good job. Who'd I make mad? I didn't make nobody mad. Come back tomorrow. So we're going to take a 15-minute break. Folks, is this working? Are you guys here? Yeah. Oh, my God. It took some volume before you came in.