 If you could please take your seats, what we're going to do with the question and answer is we have two people in the center aisle. One will be asking you what your question is and making sure that it is concise because we academics like to take long prefaces for our questions to build background and we don't really have time for a lot of that if we're going to have a good question and answer session. So concise questions and often when I go through the cards there's dozens of the same question or variations on the same theme so that will also if you're asked to state your question concisely you may be told that oh we've already got several of those questions asked and then the second person will control the microphone so that frankly we don't ramble on because I have that problem when I have a microphone as you will find out very shortly. But I would like to start the conversation by taking director's privilege and say thank you Dr. Hart and I would love, I would love to have a conversation with you at some point maybe not right now about how the tenure process reinforces the scientific literature and low hanging fruit. What needs to be published are the headline grabbing results because no one wants to publish oh well we did this and didn't find any any difference negative results don't get published as they used to so at some point we should talk about that. And I will also open this up now to the panelists if there are any particular questions that are on your minds. Panelist you got first shot I guess you know this is a bizarre ass thing having these panelists up here and me when you got an audience that came here that should you guys should be the people that are asking yeah all right all right well then we will open it up to the audience right away. I mean if the panelist has some burning issue where particularly when they disagree let's hear it but let's let's give the audience full bullet billing here let's go that means you're on man and let's be concise and let's do it. So Dr. Hart what would you say to your son or daughter if they came up to you and said dad you know I'm thinking about trying methamphetamine. Well I wrote about it it's an alternative on alternate.com so I wrote about a conversation with that I had with my son about drugs and I took him to a party one night picked him up he was about sixteen I guess and I was like damn when I when it was late at night we returned and I thought damn he might have used some drugs and it was one of those things I caught myself going through this nonsense that people say well look for the sides and that sort of thing and I thought that's not not effective and so what I made sure that I do is to make sure I tell them what the real concerns are with their drug use and first of all I'm not going to really think about methamphetamine first that would be ridiculous and irresponsible of me as a parent the drug that they are most likely to have tobacco alcohol marijuana those are the major things that I worry about in this case this stun has asthma and so the first thing we talked about was okay just make sure you have your inhaler make sure you know that I mean we talked about the effects they come to my talk so they know what the major effects are and and know that you're black and so that means that that's the major concern that I have make sure you use the drug in an environment where there is almost no risk of you interacting with the police so we talk about all of those things and and I'm sure but you know I don't want to put his business out which I won't but I'm sure that he has or will use drugs but you know what I am more concerned about how well he is contributing to the society and right now that particular son is 20 and his job for our society is to do well in school in high school almost a straight a student he's in an Ivy League institution doing really well and he might have used drugs but that's not the important thing the important thing is that he's going to contribute to this society that's it you still didn't answer the question though dad I want to use methamphetamine what would you say to that and and the point of the question is what would you say to young people or anybody for that matter dad I want to use more you know I want to use methamphetamine I want to use heroin it's recreational I just want to give it a shot what do you think about that well I think I said that I did answer the question I told you that the drug that he's most likely to use is marijuana alcohol and tobacco I did answer the question but if he wanted to use methamphetamine it will be treated in the same way just like that if he wanted to use heroin it will be treated in the same way drug specific what the real concerns are okay what's the source you wouldn't start using a drug for the first time for example smoking hopefully you start using it orally you certainly wouldn't start with needles if they do then you probably have a parenting problem could I jump in please yeah no no I think it's important to add another element to this so it's not just the physiology that we're talking about or what's in the compound that is in the drug your son has come to you and has said something very important my first response and then I would follow up with what some of Dr. Hart was saying is thank you thank you for telling me you're thinking about this it makes sense that's what's important how many of you can go back to when your kids were really little infants we measured so think about the first one we measured so carefully what we were gonna give them when they were sick because we knew that these substances had beneficial effects and potentially harmful effects if we didn't know what we were doing I mean I must have spilled a dime a tap a dozen times before I got the right dose so the same thing applies here thank you for telling me what are you thinking about why are you thinking about that and and let's see if you're gonna proceed anyway because you're out there in the world my kids are a little younger but not that much I want to arm you with the best possible information by the way society and your teachers and doctors have not done that so we have a lot of catching up to do you know the okay you you mentioned Dr. Hart to call attention to those who provide misinformation and the misinformation for me here is that we know that certain drugs are going to result in addiction potential to a much higher degree and certainly that would be the case with methamphetamine heroin other drugs of that nature we also know that would be part of the education we and I would also we point out that the data doesn't support that we also know that using drugs as a young person increases and in terms of things compared to wait wait wait let me finish that right he's getting ready to say some misinformation right now go on we also know that in using drugs as a young person at a as an adolescent will dramatically increase the risk of addiction and and so by virtue of sharing this information that use somehow is not problematic is misinformation well what what what you just said is somebody who has a little bit of information and misinterpreted or broadly applied the notion that people who start using drugs early and then they're more likely to become addiction addicted that's true but it's not the drug per se there are other things that those young people are engaged in that need to be dealt with even more so than the drug use that's the that's the point and so you didn't get the full education yell in there I I'd take issue with that just I agree with virtually everything you you have said and been saying that much the same for a long time especially when in terms of misinterpretation of scientific studies and the distortion in the literature but the the one cannot ignore for example the genetic vulnerability that's very powerful no no no no what is the evidence I this oh there's okay I mean I don't know a lot of evidence there's a lot of evidence for no that's just simply not true in terms of genetics I'm looking at this well there's there's there's there's tons and tons of evidence and we know that well for example if if you have a family history is for first of all the strong family history is not genetic by the way I didn't say it was but it's here but this is a heritable disorder it's about 60% heritable and about 40% environment what what are you talking about alcohol because alcohol that so that varies widely and that's the only drug that you you have that high number with I mean I'm looking at this evidence now and I am just not convinced because it varies so widely and alcohol is the only one that you have any signal you certainly don't have a signal with cocaine with methamphetamine are none of these other drinkers very hard to know because so few people use those comparatively you certainly do it nicotine the but let me just tell you from a clinical perspective too and one thing I think I think I think it's easy to get into it's all environmental and miss it I think misinterpret what you're saying for example the when I when I have a new heroin addict new patient who comes to me with a heroin addiction well lately they've all been like 20 20 21 22 years old and I ask them the very first time you took an opiate do you remember it and they'll say yeah I had my wisdom teeth taken out and I took a Vicodin I say I will ask him and how did you how did you feel on it and they to us to it to 100% certainty they say every one of them says I loved it and they say it like that I say the same I say the same thing no I love what does that mean okay what it means is that they have a genetic vulnerability and we know what that is we know what that is most people don't like opiate no that's not you know I loved it but I'm not and I'm not being overly deterministic here all I'm saying is that there's a vulnerability there that's very clearly genetic and that's true with no that's not clearly genetic that's not that does not that does not equate to clear genetic information that's not true that's misinformation okay so I believe Mike has I had a thought so somewhere in between here let's let's say that that is evidence of heritability the general rate of addiction or let's just take alcohol 5% 15 15% of alcoholism I think it's well okay let's say 15% oh I'm sorry I was thinking so the general rate of alcoholism or alcohol use disorder is something on the order of 5 to 7% and even if no that's it that's you know you talk about lifetime now or at any given time any given time okay it's about 4% yeah okay we're quibbling between 4 and 15% whatever it is if the heritability studies tell us that you're six times more likely to develop alcoholism yourself if it's in a first-degree relative then do the math it's it is something to be concerned about but it's also not the way that it's portrayed in society as if you have one single drink and your dad is an alcoholic that's it you're going to hit the skids immediately so there is there's a intermediate opinion here we just can't get as as petrified about it as we have been because then we won't have the the conversations that we need to one quick example is if you have a strong family history you want to tell your kids that their reaction to the first time that they drink alcohol maybe that they think they can handle it maybe some of you know this but maybe a lot of you don't and those people will think that they're invulnerable to the effects of alcohol so that's something that you would you would tell them it's it's different for opioids but I think we should be here thinking about what kind of better information we give to our children I'd like to also say that we've been tossing that term addiction around again and we have not clearly defined what that means and that has been a persistent question coming from the audience is what is what is that definition for addiction and what where do you say okay this person has an addiction versus where you say this person just uses where is that line if there is a line when I use the term I'm simply referring to the DSM terminology right it's clear I think we all speak that language okay and for our audience who doesn't speak that language can can you give us a brief summary of what that DSM language looks like well so DSM stands for diagnostic and statistical manual of the American Psychiatric Association in it it's currently in its fifth edition and it has a specific diagnostic criteria for every kind of mental and substance use disorder there are 11 criteria and DSM five the early symptoms are impaired control overuse because you set limits and you keep going over them you keep trying to quit or cut down you find it hard to do you spend more time doing it then you wish you'll drink and drive or do other physically hazardous things and and you'll develop preoccupation and desire and craving most people who develop alcohol use disorder only have those external symptoms and it never really seriously causes functional disturbances like job loss or marital problems or that's or serious health problems those things only occur later on sort of in the middle there are developing tolerance where you need a lot more or you develop withdrawal when you when you stop using and the the criteria are basically the same there's 11 of them and and the number of criteria positive pretty well scales with severity and it's the criteria the same for every kind of substance so you need you need two out of 11 to meet the current diagnostic diagnostic and so the current terminology is use disorder so substance use disorder alcohol use disorder opioid use disorder and the thing is is that there's a there's a tremendous range of of drug involvement and a tremendous range of severity and in early stages this is clearly reversible in later stages probably not depending on the drug and drugs do vary a lot in terms of their addiction potential i'll just add that most people don't realize that dr. willin bring referred to a spectrum there's a huge range and they are divided in the dsm according to mild moderate and severe and it's not until you get into the severe category that they're truly considered addiction maybe some people in the moderate category so the more of those criteria that he listed that you meet um the more severe addiction you have fewer criteria then you fall more into the mild and moderate category um most people with substance use disorders fall in the vast majority fall into the mild and moderate category it's the people with the severe disorders who fall into the severe category that the people with a severe in the severe category are the ones who usually wind up in addiction treatment programs and they kind of shape our views of what addiction is it's what we see on tv but they really don't represent the vast majority of people with substance use disorders whether it's drug or alcohol use disorders um in this country probably in the world thank you and almost all of them go away over time uh usually without any kind of specialty treatment thank you in the interest of time we'll take one or maybe two more questions what i'm sorry we have to get to lunch too and we have a program line i know i know guess i'm pretty lucky skip lunch thank you very much for your outstanding talk this morning dr. heart my question addresses a little bit of a twist on what you were trying to say knowing that drug abuse alcohol abuse are overwhelmingly destructive to families even when they occur in small numbers and knowing also that they occur in families that are well to do it does not affect social strata and within the same families like you were saying you'll find one member out of many that may have the problem so why my brother and not me or why one out of 10 children are not the others when they grew up in a very similar environment how do we balance then our resources and society our educational deal with all that with the information that you were trying to get through this morning well you have to understand first of all they don't grow up in the same environment you know i have the two kids i raised and they didn't grow up in the same household one grew up when there was no one there and the other one grew up when there was another kid there they grow up when their parents have developed in certain ways and not other ways and so and then so out the frame when you say drug and alcohol destroys family or have this impact on family i would ask you to change that frame to try and figure out what's really destroying or the what's really bugging the person who has the problem or the problem that's manifesting in this thing that we're calling drug addiction or drug substance use disorder you know for me the most powerful thing for me is that the vast majority of people who use these drugs all of them don't have a problem but some people do and if those people have a problem it seems that we should focus on those people and try to figure out what's going on with those people by giving them very comprehensive assessments to try and figure out what's going on with them as opposed to going to the simple easy frame of blaming that drug or saying that drug is doing this because trust me in my book i write about alcohol related problems other drug related problems and i too thought about thought the drug was the problem i no longer believe that i'm trying to look at what the what really is causing the problem sometimes it might be co-occurring psychiatric illnesses sometimes it might be the person who's having the problem have limited options other options sometimes it might be that there are limited responsibility skills because a lot of these symptoms deal with tempering your behavior in certain domains and they just have problems tempering their behavior in a multiple domains and so those are just a few reasons but that's why we need good therapists to look beyond the drug and look at the person i would also i would also add that children who come from the same family don't come into the world a blank slate um they um they come into the world whether you want to call it a genetic predisposition or whatever they they're they come into the world with different predispositions in my family there is a tendency toward addiction um and some people like opioids and some people don't some people like alcohol and some people don't i have one kid who when he went through that stage where kids experiment with drugs he said to me my kids are pretty open gee you know i went through that thing where we went to parties and kids tried this pill and that pill and i really tried to like opioids and i didn't they just didn't do a thing for me i have another kid who liked them so you know it and that's in the same family so part of that is what whether you want to call that genetic predisposition um that is something biological see i worry about us talking about genetics we talk about genetics as if it's the waste basket of things we don't understand and and and so if we're going to talk about genetics please have some evidence that when whenever you say well this we know that this is a genetics uh factor or function have some evidence to show that that that's what i would encourage i think i think there's there's a lot of evidence uh if you look at uh you know a genetic epidemiologist and and so forth uh there there's certainly just as good evidence uh that uh addiction and other substance use disorders are about uh as heritable as heart disease or asthma and but you know the the genetics are so complex because as you know we're talking about hundreds of genes not at least and so it's not a single gene or two and uh that all contribute to the variability and actually most of the genetic vulnerability to mental health and substance use disorders including personality disorders is shared it's common and so it's environmental factors plus some specific genetic traits that help shape which direction they'll it'll go in and then finally to say environment is not to say non-genetic correct because the the the the number one environmental trigger uh is early childhood neglect and um and that that we now know causes epigenetic changes in gene expression particularly related to anxiety and that's been conclusively demonstrated in rodents uh and i i i also agree that you can't go from you know rodent models to humans very easily but i think the evidence is very strong it's a strong that is for any other illness except simple uh illnesses like Parkinson's or or hunt against career but but in terms of these common complex disorders the evidence is is at least as strong as it is for any of them so next year i will have a new book out and this conversation i want you all to look at the evidence and then you decide let's let's co-write it um can we have the next question please um i'm from jamesville high school and i want to know do you promote drug use when it's used correctly and if so will this leave more people vulnerable to addiction i'm sorry what was that um do i promote drug use do you promote drug use when it's used correctly if so will this leave more people vulnerable to addiction do i promote drug use if used correctly of course not i mean i i i i'm an educator i i promote people being educated informed in whatever activities they engage and so when people frame the discussion in terms of promoting drug use the goal is to shut down the discussion or the goal is not i i find it low level i find it actually beneath me when people ask am i promoting drug use it's like do you promote automobile driving yeah of course i don't promote automobile driving or riding in an airplane all of these activities are potentially dangerous but i do want people to whoever engages in those in that in those activities to be safe as possible um i have better things to do than promote drug use thank you i enjoyed um dr murphy's talk yesterday and you're a talk this spring dr heart and it would be interesting to the two of you drawing some connections between the prescription drug misuse you talked about and the um biases in the drug addiction research industry is it okay we will talk i promise no i appreciate your comment um and i think that what dr heart has done for all of us this morning is for us to really rethink um a lot of what we thought we have thought about drugs to to to put all that put all of our sort of shared notions of what a drug user looks like what a what a drug user acts like um and uh and and you know look at look at it a lot in a lot deeper fashion uh the other thing that that that i think dr heart did very well was to talk about our funding sources um one of the reasons we have the information that we have and we have and other information that we really could really need we don't have is because the politics of what research questions get funded okay so some of our laps are it's not just bias in the sense of the way we interpret our findings we don't even ask questions we don't ask the we don't ask for questions about okay if 80 of the people that are using these particular drugs don't get in trouble with those drugs how do they do that how is it that they're able to do that for many of you this is incredulous i mean you there's actually drug users in the world that go to college that become president how do they do that and obviously there's a lot of people that are doing that and to put a fine point on that historically in the 1700s in this country in the 1800s we had a lot of morphine morphine people opium lotinum tincture was really readily available and was sort of a panacea um so historically speaking we have lots of evidence that people people manage very well right you know the the national institute on drug abuse is is really best thought of as an arm of the office of national drug control policy uh because they essentially dictate what can and cannot be and and their explicit goal as dr heart pointed out is to is is to find out that there's something wrong with you know these drugs are bad to use as drug war propaganda that's why we don't have any that's why the evidence base for medical marijuana for example is so poor because neither would you know would never fund would never allow any research like that to be done um and and so the the um so there is a tremendous amount of distortion for political ends uh of of what gets funded and what gets emphasized and I think the other thing is that I've seen is that qualities of papers of much poorer quality than normally would be allowed to appear in high quality journals that the the standard goes down when it's about about a drug and some kind of a harm associated with a drug one more and then we'll have to break for lunch there's been a lot of discussion this morning by the panel about the genetics of addiction we now have the capability of doing very good genome-wide association studies uh with people who are clearly addicted I'd like to know how much of this has been done so far in different types of drug addiction and if not much has done been done so far why not and when are the researchers going to do it there I mean there's quite there's quite a lot of that going on um basically looking at uh different variations at certain gene points but it's it's so extraordinarily complex and uh you have to do it in in such great numbers that uh one of the biggest problems is that a lot of these studies are done with very small numbers like the neuroimaging trials in particular because they're so expensive probably half or 75 percent of them can't be replicated we have this replication crisis right now in in in the sciences um and and so I I just don't believe any of these small studies anymore because most of them turn out to be to be wrong so the uh the the there was a naive optimism when the human genome was first uh um described uh and uh you know and all sorts of predictions were made about what was going to happen was a result of that but it's because it's it involves so many different genes in so many different areas each contributing a tiny bit of variability it's very very hard to locate it's not some huge effect uh size and that's one of the biggest challenges let me just respond to that briefly we are now moving into the age of personalized medicine and we do have the genetic information for this I think that the researchers should be able to get the appropriate information and addiction as well well not but they're actually in terms of personalized medicine it's very very limited application so far for exactly the same reason thank you can I say we do have to get going and I want to thank the panelists for their time uh mark quick yeah quick all this talk about genetics and environment we have to understand that causes in reality are not simple it's not one thing or another and genetic contributions they're impact changes with every year that a child grows speak up right yeah now every year that a child grows the genetic impact changes yeah changes and therefore uh a sensitive parent is going to figure out my kid is right now going to be you know really vulnerable to this more than that and by the way that's why I would say to that parent who I don't think we should have shouted down for my kid I would say no I don't want you to try heroin because you have a tendency towards you know whatever becoming depressed and this is not going to be good for you and I think that's part of being a sensitive parent thank you that would that was shouting down we're gonna we're gonna uh conclude the panel but I would like to give you a little bit of a homework assignment during lunch think about this and maybe talk amongst yourselves the Harrison act in 1914 was met yeah 1914 was mentioned that's where schedule one schedule two schedule three schedule four drugs came into effect is that not true with 19 what 70 1970 was a scheduling okay we have much more information now about what different drugs do is that scheduling we cannot do research is this true cannot do research and schedule one drugs well you can't but when I find that you can in very specific yeah I know we do a lot of research with marijuana heroin okay is it time to reconsider the scheduling laws so that we have this discussion over lunch please okay but yeah I hear what you're saying