 And welcome to another episode of A Likeable Science here on Think Tech Hawaii. I'm your host, Ethan Allen. As you know, likeable science is all about science that is meaningful, relevant to all of our lives, why we should all pay attention to science, why we should care about science and support science. Today, we're going to be dealing with a subject that really gets right in that beautiful interface. We're going to be talking about addiction, drug abuse, and the work that's being done to help people deal with those issues. And we have Alan Johnson, the president and CEO of Kenamaoka. Well, thank you. Well, thank you. We appreciate this opportunity. Oh, yeah. No, very glad to have you here. This is, you know, it's a big growing problem, right? There are more people now in need of, we're misusing drugs, certainly, and more addictions to more, more compounds coming up all the time, right, that are. Yeah, you know, part of the reform that we did, you know, when we did it in our state, we were doing the reform, which we said, okay, we have to look at chronic illnesses and what the impacts are. And we, like many other states, began looking at, okay, we're treating addiction, but what about misuse? And then, oh my God, that's when the government came out two years ago, it said 93 million people have a misuse or addiction problem. It's almost 30% of our nation, if you count prescription drugs and alcohol. And we said, oh my God, and they don't get any treatment if you're misusing. It's really opened our eyes. This is sort of like a continuum. There are people who don't use it at all. There are people who use it a little bit, very sensible, there are people who sort of misuse, and then there are people who abuse and, and or get addicted to it. Yeah. That's right. So we're not talking about moderation, but we're saying, hey, if you're misusing, you're doing it to the extent that you're hurting your brain and hurting your organs. And that's 30% of our population. And we said, and they tabulated that it was half a trillion dollars a year going to our healthcare. And that's without really knowing all the, yeah, and that's not taking help on the, on the personal suffering and the problems with all your friends and family, trying to help you out and deal with these people, right? Yeah. It affects your emotions, affects your social interactions, but also affects your health and how you, well, your brain operates. So a lot of suffering that's going on, and by extension to the family, too. Yeah. Yeah. And it's, it's a funny interface between sort of personal choice, medical health and legal system, right? I mean, all three of these groups sort of, well, interface on it. I think that there's, you know, at least from the federal government they're saying, we, you know, we've messed up, you know, because we're so fragmented that our criminal justice solutions involving shame and punishment, maybe, you know, if you are a safety issue, yes. But if you're not, maybe that wasn't our best choice. And how do we get medical, physical medical, talk to behavioral health? And that wasn't happening as we get them together, we go, we've got great technology, we've got great solutions. We're just not really working together and implementing them. Yeah. But that's interesting now that that middle ground and misuse is being recognized. And again, this is sort of like the trend in medicine in general these days, right? It's better, you know, an ounce of prevention is worth a pound of cure, right? You're far better sort of stopping the problem before it gets to be too severe, right? Well, we found out is why we were tasked with looking at chronic illness, we found out in the United States that 5% of the people cost 50% of the cost. And we're the most expensive in the world per person with the lowest outcomes of all the advanced nations. And a large part of it is that, hey, we have, we're not taking care of people when they first get sick. Half the population we do, but the other half we don't. And when they say, if we were to take care of everybody, that's way cheaper than not taking care of you and then take care of it with all our wonderful technology that's very expensive. Yes. That book came out from Pearl's book, Mis-Treated recently, that really lays out the whole case on how badly our medical system as a whole is doing. Basically, it's, we face this perfect storm of weird insurance laws and... Our systems are broken, but we undoubtedly have the best medicine in the world, best doctors and even the best behavioral specialists. But how we do it, how we work together, not too good. We don't have the outcomes to show for it, for sure. Excellent. So let's be sure we get some terms out here. So addiction is, I mean, how do you define addiction? Addiction, you know, by the medical field is designed as a chronic relapsing disease, kind of like heart disease and diabetes, but with addiction is that you have an obsessive compulsive need to seek and use drugs, even if there's negative consequences, even if it harms you, you would still obsessively do it. And so something like this can become very, very harmful for you. You're losing a lot of control. You're uncontrollable. Parts of your brain are not functioning, so you lose control. Right, yeah. Your whole risk reward system gets thrown real out of whack. And rather whack. And also you have structural changes in your brain. Chemical changes that, you know, become dysfunctional in those brain. And so when you need them most, they're not there to help you. In fact, they hurt you. They work against you. Yeah, yeah. Okay. And I miss you. And the difference of addiction is it's treatable and preventable, but if left on, you know, it's gonna not end good. On the misuse, you know, you're losing a little bit of that control, but you're still keeping some of the control. So the answer for you would be slow down. Where addiction is, you can't, you have to stop. You can't ever use again. But you could slow down, but maybe you need a little help with that. But you're losing some control, and do you know that? We think people don't really know that. Right, right. People, particularly people who are getting these, they're drugs legally, right, like how can I be out of control? I'm continuing to refill my prescriptions using prescribed. Well, the case in point is the opioid crisis that every state, 50 states has a crisis of over-prescribing like 700,000 prescriptions here in Hawaii, 30% of the people using them, and we have 66,000 people on the mainland dying from it. But it's the 50-year-olds and 40-year-olds that started opioids. We never would think, we thought you start young and here you're starting later, and then we find, oh my God, it's really too much for you and you didn't understand that you have a predisposition to addiction, which most people do. Yeah, and that gets us into the next one, talk about, well, are there ways to look at the factors that, you know, people, who's really at risk? Can you tell sort of in advance before people ever start dealing with using drugs, who's at risk for addiction or is there really, are there lifestyle indicators, are there tests to do, any of that stuff? Yes, yeah, there's what they call protective and risk factors. But we now know the genes are about 50% of the issue. And the issue is that we know a lot about genetics and we know a lot about the chemical reactions in the brain, but we don't know exactly on the genes for, you know, why about 25% of the people are going to say, you know, I don't like drinking. It just doesn't do much for me. And 25% of the people go, this is the most amazing thing ever. And then about 50% of us are in-between. We kind of like it, but is it worth the hangover and how much times? And so we manage it. So we don't know why that is that there's those people. If we did, we think we could do a lot. But protective risk factors has been geared towards the kids because usually you started as a teenager. Only recently is it middle class starting at 50 with opioids. Yeah, when you were at a rotary group, you showed a slide that showed how big, sort of, midlife bulge in opioid use with a 50 to 40 to 60 year old was basically being a huge percentage of the people who were really in trouble with it. Yeah, so before we would say, if you're 50 years old, we didn't really see in treatment because you probably started as a teenager or a young 20s. You didn't live till you're 50. Not very many people did. All of a sudden, we're overwhelmed with all these 50 year olds coming in that said, illness, injury, now I have an addiction. I can't stop. Help me. Yeah, that's it. So it's all too easy to do, too, right? You get, yes, you break a pallium or get a bad sprain or whatever. And the companies who manufacture these opioids, in particular, have been quite aggressive about marketing them to doctors, right? Yeah, and not always forthcoming or on either. But that's true, is that, hey, look, it's really good for acute pain. But it's dangerous for chronic pain where you use it over a long period of time. And in fact, it can increase your sensitivity to pain. And your doctor has to make that call, whether that's worth it or not. But you can end up into an addiction easy. Right, yeah. It's a very sophisticated drug. A lot of their doctors all the time. Well, doctor shopping gets pretty common. Getting some from your dentist. And then you're getting from different doctors. And then, of course, you're getting from your friends and family who say, I'm 50, I'm working. Could you help me open up your medicine cabinet? We all got that little stash or emergency use when I'm going to need it the most. Okay, you can have it. So all of that leads to, okay, then I'd be more. And where do I get it? Right, and they start mixing drugs in. And then if I can't get more of the legal stuff, I go off the roots. Yeah, the methamphetamine is really spiked here in Hawaii. We haven't got, we've got some hair and increased, but not like the mainland to get huge heroin and fentanyl. But it looks like they're turning to methamphetamine a lot of folks. But a lot of them are just heavily using alcohol and prescription paints, not a good combination. And then you get, I mean, you've got also these people who are in very diverse life circumstances, right? Some people who are just sort of slid into it very accidentally from, yes, they're a working person. They've been good all their life, basically. Never been in trouble. And suddenly they're in this spot. But you've got other people too who have been, for various reasons, vagrants out on the street, homeless, in trouble on and off. And they start using particularly some of the things like the methamphetamine, right? And they get, I mean, oftentimes it seems people speak of them going sort of psychotic. That's true, but the majority of people probably start with something less intensive. And usually they say half are because they want to feel good. And so if you're talking about misuse, it's alcohol and prescription drugs. So that's kind of where they start. And if you're a kid, it's marijuana. Today it's really huge problems with marijuana with kids and they're having troubles with it. So they start there. And they say half use it to feel good and half use it to feel better. So traumas, things not working well at home, puberty, grief, moving, bullying, all that type of stuff. It takes away those feelings. The other half are saying, oh, this feels really good. Let's do more of it. So those are kind of the two approaches that come at it. So it's about 50-50. So then it leads to bad cases if you don't manage it well. Right, right. And then when you get addiction, you can't manage it at all. It's unmanageable. A lot of people say, well, it's low morale. Or what's your morality? What's your willpower? It's not, once you reach a disease, brain disease, it's uncontrollable. Right, right. Your brain is sending you signals saying, give me more of this, give me more of this. And even when it's having very bad effects physiologically on you, on your whole body, on your brain, on your life, right? Yeah, we like to say that, hey, if you're starting off, you're getting kind of a whisper to use more. And then all of a sudden it turns to a loud voice. And when you get addiction, it's somebody with a bullhorn screaming in your ear. And there's nothing you can do but hear that pounding, driving, screaming. People who get a whisper, they don't understand the pounding, driving, screaming in that all you can do is try to take care of that. Right, yeah, yeah. It becomes sort of an urgency to it. I must deal with this in the moment right now because that's the only thing that matters to me. Yeah, and we do know that the brain that stops working was, besides the reward functions of it that wants you to do it, how you deal with stress and it creates anxiety, but it's also cognitive understanding. You don't know how to analyze, evaluate, solve problems, and you lose your impulse control. You can't control your behaviors and you can't control your emotions. So you put the lock of, you know, your judgments in play, you put all that together, you're in trouble. Yeah, so again, it sounds like, as with so many things, we should probably be doing much more in the early end educating kids about that and helping kids understand their own thought processes and how they think when they get impulses to do something, how they should evaluate those impulses before acting on them, right? Yeah, I think that, and that's, so that area in the adolescent brain does not develop very good, how you analyze and impulse control. The other parts are working, but that part doesn't work. And I think we need to get the message to them if you start using marijuana or alcohol, you may arrest the development of your brain and you may never get it back. So if you're alcohol or marijuana as an adult, especially marijuana, you're going to get it all back if you know over some years, but maybe not as a kid. So we've got to get better messages out there. Yeah, yeah, the prefrontal lobes of the brain where you're really, which really are the judgment that's the last part of the brain to develop often times not into late teens and into the 20s. Yeah, they were adult at 23, they're saying, yeah, very good, yeah. So it's, so those impairments, we got to get that message after the kids. Yeah, so this is the 14 year olds or 12 year olds don't start, you know, and understand this is probably something I need to be, to be very cautious about. And we don't want to have scare messages. We don't want to say we're talking about occasional once in a while, you know, we're talking about, you know, how much is too much, you know, and then you're doing, but surprisingly, how much or too much is not very much? Yeah, of course, that's been the whole issue with marijuana, right? It used to be when back in the day, a low percentage of THC, what, 10%, 5%, I mean, it was really low and now they've got stuff that's just phenomenal. Yeah, they say it's like 300 times more powerful if you get the high grade stuff that, cool, that's, before we would say we didn't see addiction on marijuana, but now it's the third leading addiction in Hawaii for adults, you know, meth, alcohol, and then marijuana. Those are the big three. And so people are coming forward and we're shocked, like, oh, why, you know, but it's been for about 10 years. It's really surprising. Interesting. So we've talked about the sort of the downsides of this and how it all occurs. When we come back, but we're gonna take a short break first, we're gonna look at sort of the upside. You guys at Hina Maoka are doing what you found, what the evidence that it works for is and all that, but we'll do that after the brief break here. When we come back, here on Likeable Science with Alan Johnson. I'm Jay Feidel, Think Tech. Think Tech loves energy. I'm the host of Mina, Marco, and Me, which is Mina Morita, former chair of the PUC, former legislator, and Energy Dynamics, a consulting organization in energy. Marco Mangostorf is the CEO of Provision Solar in Hilo. Every two weeks, we talk about energy. Everything about energy. Come around and watch us. We're on at noon, on Mondays, every two weeks on Think Tech. Aloha. Hello, everyone. I'm DeSoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech, Hawaii, every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech, Hawaii. Yeah, and welcome to Likeable Science, back to Likeable Science, I should say. Here we're talking here on Think Tech, Hawaii with Alan Johnson, the CEO and president of Hinomauka, recovery center, I guess, you call it? Yes, sir. And we've been talking, we spent the first half of the show discussing what addiction was, how people fall into it, the different sort of paths they fall into, the dangers of it, the damages it can do. But your business is really all about helping people who have gone into it, addictive or now even working with people who are just misusing as we were talking about, right? I know, it seems like a dark subject, but we're about hoping opportunities. Positive message is saying, hey, you know, it is treatable. There's not curable if you have addiction, but misuse is you can slow down, but an addiction is treatable and we can work with you and you can have a wonderful life, maybe not using, but a life of abstinence, but it really can do help. So what are the basic principles of your treatment? So underlying ideas. You know, it depends on the continuum you spoke about. If you're misusing, you're gonna get a lot of motivational type work. If you're, now you're going too far and you need short term, now you need the beginning stages of addiction, you're gonna get this outpatient, but then if you're getting really serious, you need residential, you probably have comorbidity issues, diabetes, depression, and you gotta treat the whole thing. And then you need to be removed from your environment because you gotta relearn all those things. So what happened is you lose your memory, so you learn, you don't know how to do social skills anymore, you don't know how to do evaluation and decision making anymore, you gotta relearn that. So the recent, the research, brain research really helped us to improve our therapies because now we're focusing on changes in attitudes and behaviors and coping skills and how do you address triggers, rolling that. So there's a lot of work like that. Yeah, because this whole triggering business is really bad, right? Somebody may be doing okay and then something happens, they either see a bottle of their favorite booze or smell that, you know, a smell of good marijuana or whatever and... Once you get to the addiction, these cravings, you stop using, those cravings go on for years. Years and years, so they diminish, but sometimes they go away and they come back really strong and then go away, but come back less strong. So you need the support system, but you need these coping skills, how to do it, and you need a practice to relearn your, okay, here's our problem solved, but here's how I cope if something triggers those cravings again, and you understand it's a short duration. So a lot of that happens. Yeah, again, this is sort of getting back to what I was saying earlier about, you really need to educate, we should be educating kids from a fairly young age about being aware of how they think and what's going on in their brains in terms of, when you feel this way, like, step back for a moment and think, why am I feeling like I should go out and do this? What keeping that decision making going so you don't have no control over your impulses, and also the other part is the emotions. You lose the touch over control of your emotions, so we want to help you deal with your emotions with positive ways and begin to learn how to process your emotions, so you go to school, you don't learn that, you don't learn, grandma died, how do I deal with that? You don't learn any of that. There's some, I change schools and one kid does that well and the other kid doesn't, how are you processing that and what kind of support systems do they have? Yeah, and schools typically don't teach a lot of emotional management, emotional management, and people learn very different things, different families, family backgrounds, give very different messages about that, right? Culture and ethnicity, all that has a different way of expressing, so maybe not trying to change that, but how within your culture would you do a healthy expression of working with your emotions that comes out in a good way that helps you, not hinders you, and we're not very good at that, and so we often end up hindering, not helping. Sure, sure, because you can't just ignore the emotion and suppress it and not express it. Suppressing is the worst, but expressing it really badly, why now, I got too good for you. You have to find that happy medium where you express enough that people can see and hear, you're paying, you're frustration, what have you, right? Yeah, so a lot of the things you would learn in treatment I think would have been great for anybody to learn, you know, because you're really developing those things to a little higher degree, all your cognitive ability, your how to deal with stress, your reward system, all that is really valuable. I mean, you suspect if you taught this to five and six-year-old kids, they'd really learn it fundamentally, it integrated in their brains in a much better way. We could, you know, for one of the things we're trying to do to make it better is we're trying to say, let's get behavioral health into primary care, you know, you go see your family doctor, it's their favorite specialist in the room, so you need a little bit of motivation, so there's some great motivational techniques. I mean, doctors tend to say, well, lose weight or slow down on the drinking. We know that it helps a little bit, but for most people, not too good. But if they learn motivational techniques, they could do something more. And then we also love the idea that, hey, if you do need more, then you come back to the doctor who stays with you. It's a relapsing disease, so you're slipping. Maybe if you need a little more, you come see us for a couple of weeks, you know, outpatient a couple of times, and then if you need it again, we're there, and then if you get too carried away with it and you're gonna need us for our outpatient or residential. So I think that's a great news way. That's why the United States have developed those plans right now to do that. Yeah, because we've had this area of fragmented medical system. I mean, it was driven home to me years ago when I switched jobs and had, essentially had to then switch doctors, and it's like, why should I have to switch my doctor, just because I switched my job? I mean, I just spent two years developing a relationship with this doctor. I finally knew them, I trusted them, I liked them, they knew me. We do lose that by switching, unless there's a good reason or you think you need something different. But being with somebody and then having that network of people who are working with you makes a big difference. And if a behavioral health specialist is part of that, great. And you can use these motivational techniques for diabetes, for hypertension, all, you could really make, that's where you make the changes, motivate people to change. Like to change the behaviors. It would really improve primary care. And then we would like primary care to deal with more chronically ill things and not the less minor things. People with less licensure can do with that. So that's what they're doing in other countries that have been really phenomenal. And we think, that's the next step for us here in the United States. Excellent, so they're getting a whole sort of behavioral health workforce that really focuses on this kind of stuff. That we talk to each other. And we share the treatment plan. Because if you're in treatment and we want to know if you're diabetic or you've got this major heart condition and how do we help you if you're in residential? Now we're saying, hey, look, we need payment reform, we need a doctor on site. So that we can handle more complex patients and a nurse. Not a hospital, but a little investment in us. And we've already had pilot projects. We can make a phenomenal difference on outcomes and keep people out of going to the hospitals, which is where all your cost is. Yeah, right, right. Somebody checks into a hospital for a day and there's thousands of dollars, you probably, right? And we have this few number of people but a large number of them are going to the hospital all the time. Yeah, yeah, repeatedly. They're repeatedly. There's millions of dollars. I mean, we spend about nine billion here in healthcare in Hawaii and they say 5% of the people are doing the... If that's true, that percentage, that means about four and a half billion a year we're spending here in Hawaii for to treat a few people who didn't get treatment when they had to onsite of a chronic illness. So some investment and some good ideas really could save a lot of suffering and a lot of money. Yeah, and we really need to do that. We see that in other things besides the health system too. So in a lot of European countries, for instance, in a K-12 schooling, the teacher will move along with a group of kids for three or four or five years. You'll have the same teacher again and again. That's great. It saves a lot of time each year not having to sort of learn the rules again, right? You know as a student what you can and can't get away with, you know? What is and is not expected of you. The teacher doesn't have to learn new names, new personalities, right? They're just watching you grow and working with you and they get some really good outcomes from that. Yeah, I think we could learn a lot from the European countries and also Japan and some of the others. The thing is what we've been very good at is we've been comparing ourselves to other states. Oh, I'm not as bad as that state. And I think when we were the best, that was a good idea. Who is the best of the states? But now that we're in last place, why are we saying I'm better than my teammate who's worse than me but we're all in last place? And we have the best medicine and the best technology. We could take some of their ideas and we could do phenomenally better. I mean we could skyrocket back to the best. If we just plan better. Right, but it's a very large scale, very sort of system-wide problem is a problem. And there's a lot of different factors of economics, sort of the business models are currently being used, the academic structures, the medical insurance companies of course are a big part of it. All these things sort of right now locked into a sort of pattern, right? And you can't change one of them. Well, we began here in Hawaii recently by having all these task forces and I must be on seven task forces now and I'm glad to be invited to them and with hospitals and insurances and other providers and government. And for the first time we're talking to each other. There's a great deal of hope on that. My complaint is we move too slow but we need some activism and more people saying let's do it but it's a good start. Excellent, excellent. That is a hopeful trend. So when you see an individual patient, I mean how do you define success for them? No? Well, it's a chronic relapsing disease so it's not uncommon that you come and do you complete treatment and are you absent when you leave treatment? We talked to these coping skills, how are you a couple of months later? And so we're just learning that now with support from the federal government to help us change its funding. And so they're saying well maybe you should be a case manager, we try to connect you with a primary care doctor so that we know if you're relapsing, we catch you so it's a little bit more not you're out there for a long time and you come back for a lot more. So that's beginning to happen but so we do have follow-ups for six months but a self-report but we're going for by having a doctor and a nurse and we're talking to each other, we went from about 50% completing residential to about the 75% completing. That's really good. Now how many are still there six months? We think a chronic relapsing they're not getting that follow-up, we call you six months and go how are you doing? What did we do for six months? Nothing. Right. So you know. You catch me in a good moment, I'm fine if you catch me in a bad moment. You're really good, even though last week you weren't too good. Or this week you are good but you were great for six months. So that has to improve. So some case management is happening now that we have some expertise on that. So that's just at the beginning stages it developed. That's great that as a sort of a therapeutic specialty you're learning about yourselves, you're learning about better ways to manage your own businesses or to make your treatment more effective and more helpful to people. Well it's kind of like saying, hey we got all the stigma out here and we got the shame and punishment and now let's call it a medical issue and that it's treatable as a medical issue. Now if you were to do that, how would you do that better? And that could lead us to a lot better solutions. Yeah, I mean if you look to really the old model where a lot of illicit drug use was treated strictly as a legal problem more than a medical problem, there was a very weird situation where you had the police on the one side saying, let's enforce this law more tightly and organize crimes. And yes, let's keep it all enforced tightly so we can keep our monogamy on things. And it's like, well the police and organized crime are on the same side. Something wrong with power handling this. I do like that one, the police need to keep us safe no matter what. And if you're misbehaving and we could take away your drug addiction and you would stop misbehaving and we would say you're not really a criminal, you're doing criminal because of your drug addiction versus a criminal who has a drug addiction and you take away the drug addiction now you have a sober criminal. Those are two different people. But for the police they're recognizing that those who have a drug addiction they're reaching out more. Their safety is their priority. But they're reaching out to us to say, can you help us more? So we began those talks just in the last year so we see them as being, look we know we can't arrest ourselves out of this, we need you. That's really refreshing to be, we're at the same table because before we would be at the table and disagree and now we're kind of agreeing. Excellent, that's really valuable because yeah, again it's a sort of systemic view of it and let's get this person, let's get them in help. Excellent. Hey, well this has been great fun and very informative. I've learned a lot and I'm sure all of our viewers out there have learned a lot too. Alan Johnson, the CEO of Hinamauka Recovery Center and people I'm sure can just Google Hinamauka. Hinamauka.org and we do have walk-in clinics where you just show up between nine and two and we'll help you right there screening assessments. So please come and see us and we got multiple sites and at 27 sites so we're all over it. Excellent. So thank you for having me. Thank you for being here and I look forward to your continued success and I hope you will come back and join us next week for another episode of Likeable Science here on Think Tech Hawaii.