 Evening, everybody. Murder is a road. Welcome. Thanks for coming. There is no shortage in our land today of people who have views and are eager to share them with you about subjects like opioids and addiction, subjects like vaping and organ transplantation, and so forth. There is a shortage of people who have spent their careers both in continuous medical practice, in this case, psychiatry, and in more or less continuous research, including of the most basic kind. Our guest tonight qualifies on all those scores and many others. She's been a scholar, an author, a Yale medical school, and much more recently at the American Enterprise Institute, and someone who has just finished a full year in the epicenter of the opioid epidemic, both practicing her medical craft and studying and trying to learn about this very important social phenomenon. So it's a great treat to bring it to Purdue. Someone I confess to have had a great admiration and a friendship with for a long time. Please welcome my friend, Dr. Sally Sattel. Well, Dr. Sattel, you're a person I know that not prone to do this, but I'm going to insist that you talk just for a little bit about your personal background, which is an interesting one, and also credentials and qualifies you to talk about the various subjects we're going to cover tonight. OK, when people ask me that, I think, well, what's the most meaningful beginning point? So I think I'll start with when I went, decided to go to. Kindergarten. No. To medical school, because I was never a pre-med. I went to college at Cornell in the 70s, and it was brutal. It never occurred to me, frankly, to go to medical school and had it. I probably would have been discouraged by the just rapacious competition between those guys. And it was unpleasant. Anyway, so I went to the University of Chicago to be an evolutionary biologist, because I had this great romantic idea about Darwinism. And I loved it there. But it became clear to me that's probably not what I wanted to do. And you had to be so dedicated, because if chances are, you would end up in a very small college town. And I've grown up in New York. I've always lived in big cities, except for last year. And I just knew that wasn't me. And I didn't love it enough. And to devote your life to PhD work, and then being an academic in that field, you just have to love it. So I love the University of Chicago. But as I said, I was starting to think maybe this isn't the right career path. And my department just happened to be in charge of teaching gross anatomy and histology and neuroanatomy to the medical students. So I had a lot of contact with them. And they weren't like the medical students at Cornell. They were almost all from the Midwest. Most of them were either English or history majors or philosophy majors. They put medicine in there. Frankly, I think they tended to see it as a calling, a lot of them more than as a profession, which is how most of a lot of the students at Cornell seem to see it. And they had a real background in the humanities. And they were inspiring. And I thought, well, maybe this is something I could do. And I remember running into one guy who had done his psych rotation. And he was telling me about a patient. And I realized that probably more than any other area within medicine, psychiatry has an amazing scope. I mean, it can go from neurons to Shakespeare. Because on the one hand, you're going from the brain, which is about mechanism, all the way to the mind, which is about meaning. And it just seems so interesting. So I did apply to medical school knowing I wanted to be a psychiatrist. Most people go to medical school. They're not quite sure what they want to be. But anyway, I knew that's what I wanted. So I went and I graduated and did my residency at Yale. And I stayed on the faculty. And I was at the VA. The VA is an interesting institution. And one thing that jumped out at me was how well-meaning, but dysfunctional, their disability system was. And so this was now the early 90s. And we had a lot of Vietnam era and Vietnam vets. And a lot of these guys, and they were mostly men then, were probably highly rehabilitatable. But the disability system had gotten a hold of them, told them that they had a condition, often post-traumatic stress disorder that was disabling for life. And that, frankly, everything that went wrong in their life from the time they came back was a product of their exposure to the war. And remember, only 15% had been in combat, which is not to say that there weren't jobs, like truck drivers, which were highly dangerous. But in terms of actual exposure to combat, it was a minority. And they were just fed this narrative. Pardon me? That's the popular word these days, narrative. Yes. That basically they were destroyed by their war experience. And sadly, some minorities people are, not minimizing the intense trauma of the whole thing, but the good news is most people can be rehabilitated and live productive lives, but not if you're caught at the most fragile point in your life when you've just come out of a situation, you haven't readjusted to civilian life. And it's like a moonshot. If you're off a little bit when you come back, if there's no intervention, you'll be out there drinking and beating your life and not working, and it's a horrible situation. And we didn't catch people soon enough. We told them pretty early on, well, this is what happens. And here's your check. And you're not going to get your check unless you manifest these symptoms. But we should have, plus we're not even requiring treatment. I think that's still true in the VA, because the Veterans Disability Agency is different from the Veterans Health Administration. And so anyway, that was something very wrong there. So that got me thinking about policy issues. And then we also, this is just kind of a parallel thing. We also, there was also a program at the time that, oh, and we also, OK, so I was running the drug treatment unit. Well, what happened when people got their checks? They spent it on drugs. And it was just completely undermining my work. And I realized that there is clinical work to be done, but it was in a larger framework of the way the policy structure and the incentive structure was there. And it was wrong. And so when this policy opportunity came up, this Robert Wood Johnson Health Policy Fellowship, which was really great, you go to DC for a year and work with a senator. Or, well, you work in the administration or in Congress. And I did that. Did you ever return to Yale after that? So that was where you brainstormed. I wanted to get out. Well, and they changed the fellowship program after me, but so many of us defected that they now changed it because the expectation was that you'd go back and teach health policy. And to me, it was just regressive to go back. Although it was, I mean, it was wonderful. Yale was a great place. But I wanted to move on. Down in New Haven after they've seen DC. Well, Potomac fever can be chronic. So we know it's not how you spent your summer vacation. How'd you spend your last year? Tell us a little about the project you immersed yourself in, where you were, and what you saw and did. Well, I may have mentioned I've been working in methadone clinics for a long time. So and then, of course, the opioid. I'm doing this crisis simply because the words become a cliche, not that it's not a crisis. And so I felt I knew urban opioid crises. We're not even a crisis that's endemic at that point, but not Appalachian. And in our methadone clinic, almost all the patients started using drugs in the Carter administration. I mean, the average age is 57. And almost entirely African-American pills had nothing to do with anything. I mean, it was a completely different narrative. And so I wanted to see, well, also all you heard was, we don't have enough help. We don't have enough help. And so I had that waiver to do buprenorphine. And I thought, well, I can help. And I needed a vacation. I needed a sabbatical from my sabbatical, which is what being at AEI feels like. And so someone suggested I call J.D. Vance, who wrote Hillbilly Elegy, and just ask him if he could find me some place in Ohio. And he found me this little town called Ironton, Ohio. And there's a door prize for anyone who's heard of it. Anyway, it's in the southeastern corner. So Huntington, West Virginia, and Ironton. Ironton's the smallest of them. It's 10,000. And I think Huntington is 50,000, and Ashland's about 20,000. And Huntington's the one that's been on the map a lot. They're really a wonderful mayor. And they have made some progress there. But so that's where I went for a year, did some clinical work, interviewed a lot of people, just trying to get a sense of the progression of the problem, how a town responds to it. I'd never lived in a small town before. And so I'd never seen the connective tissue of a small place. In DC, when you pass a store that's empty, you don't think twice. Well, there'll be something else in there. You don't think that a whole family is now decimated, and the people they employed, and the ripples that go outward. And a town that has not that uncommon, sadly, I'm sure, but only 20% of people who pay taxes. And cutting services, and maybe you won't have a fire department, that kind of thing. And don't go to Walmarts, but go to this local play. I never heard of me to buy local. I would have my local. I'd buy what I want. No, could help more people this way. And so I'm sure that's not as eye opening for a lot of folks who are from smaller places. But that was different. And of course, everyone is intensely religious. And I'm an atheist Jew. From New York. That's redundant, isn't it? But I was so, my best friends were, one was a priest, and two others was a couple who were intensely Baptist. But I'm told that's redundant as well. And these were people who, I mean, I've been to church more in one year than my life. And they really were very devout people who were truly trying to emulate. I mean, I remember we were in a driving to a restaurant. I was with the wife, and the husband was catching up. And he came, and he looked kind of shaken and turned out he was in a fender bender in the parking lot. And anyway, apparently there was some damage to the car. But he was OK. But anyway, and then of course they say grace before. And he, so the first thing out of his mouth is praying for the woman who hit him. I hope he's not too upset. I hope it doesn't cost them too much money. And I'm thinking, where I come from, my cousin Allen, who's a union lawyer, would have been all with a neck brace. And maybe I can get some money out of him. If that's what, I'll take some of this. I mean, I know they were still hoping they could make some inroads in terms of my belief system. And I'm pretty immune. But it was so moving that they truly cared about people so much. The famous historian Paul Kennedy and a couple of colleagues at Yale had an interesting course. I wrote a column about it when I heard about it, where instead of a conventional senior or a capstone project, the student is, or a final exam, the student is allowed to, over the summer, give them a stipend to go visit some place they'd never visited, one of his students visited a place in Texas and had exactly that experience. No encounter before with the value that faith can bring in the lives of people who are in difficult situations. Yeah, well, in fact, these particular people weren't. They were the helpers, so to speak. But yeah, that was very inspiring. And their attitude was great, too. I want to ask you about addiction. I'm going to do what our great alum, Brian Lam, does to people all the time. Done to me a few times. I'm going to read you something you wrote. And then you tell us. I'll just bow it. Well, in a book you wrote, but just before this field trip, extended field trip, you took exception with the idea that addiction is, you said, it's not a chronic condition for many of the people that are using these substances. You said, it's impossible to understand addiction if one glosses over the reality that addicts do possess the capacity for choice and an understanding of consequences. The clinical reality is the most effective interventions aimed not at the brain, but at the person. Would you talk about that? Yeah, so I've always been critical of, gosh, back in 95 or something. The National Institute on Drug Abuse decided, it's funny, anytime you decide a clinical matter is something versus something else, you don't have to wonder how socially constructed it is. That addiction was a brain disease. And I always thought, god, that is so weird. And the risk of such a reductionistic definition is that you won't see the whole person, certainly not arguing that the brain is involved for heaven's sakes. I wouldn't challenge anyone who gave an hour-long lecture about how all the neurotransmitters in the circuitry are still mapping that out. But of course they're involved. Why would people take drugs if they didn't operate on the reward centers and all this kind of thing? But it's just too narrow. It's like flattening people into a dopamine pancake. And it doesn't acknowledge the fact that people use drugs for reasons. And that is critically important to helping people. I mean, there is a why here. And why it doesn't make sense with most other? Why did you get breast cancer? What kind of question is that? I don't know, bad gene? Maybe I was exposed to something, environment, bad luck, mutation. I don't know. Why does your thyroid? I don't know. Why do you use drugs? Oh, that's a question that makes sense. And so there's that. And you mentioned choice. Now, I don't mean choice as in, oh, just snap out of it. Although people do. And we, as clinicians, just don't see them. Because obviously they haven't come to us. But the idea that through drug courts, which are diversionary mechanisms, because I don't see why people would be incarcerated for even committing minor crimes. But it diverts people into treatment programs. And there's kind of a sanctions and reward system there that you do well. You get supervision. You get more freedom. If you're having problems, well, they do supervise you more carefully. Some of it, I mean, the spirit is not supposed to be punitive. It's supposed to be therapeutic. But there is a care and stick dimension to it. And the retention rates are better. No surprise. They have leverage over you. But people often do better than they do in regular adjudication kinds of mechanisms. And there's a massive history on what's called literature. I mean, on contingency management, which is rewarding people for cleaning your own screens and things like that. Your clinical practice would have been the most successful consequences or choices you have confronted people with. I'm sorry. I can coach you. Well, if you're trying to help somebody, and you pointed out that there are rewards or there are consequences, which ones? You chronicle some in your books. Oh, which ones are? Well, some of them are actually very, I mean, they're simply things, like little vouchers that you can give people to go to Walmart or a movie theater or stuff. But that adds up. And it's not easy for a standard, for a non-research setting to do that. Now, in methadone clinics, we kind of have a built-in leverage, because we can give people more or less bottles to take home. And that's they don't have to come in as often. But the idea that people, if we call it a brain disease, then it puts it on a par with Parkinson's or Alzheimer's. And as an analogy I like to use is if you confronted a person with Alzheimer's admittedly while he or she could still understand your proposition and said, I'm going to give you a million dollars if your memory doesn't deteriorate any further or shoot your dog if it does. That's a meaningless proposition, because even though there are brain changes and addiction, they're not the same kind of brain changes in a condition like Alzheimer's, which makes the person impervious to these kinds of contingencies. And we can take advantage of that. And I mentioned people using drugs for reasons and how important that is. And if I can go back a little bit, though. I feel I give a little bit short shrift to Ohio, is one thing that really solidified for me is this idea that we don't pay enough attention to the distinction between what I would call individual versus communal addiction. I mean, the kind of people that you would treat in kind of an upscale psychiatric practice or God forbid, a family member who kind of had everything, well, the parents were fine parents, went to a good college, had everything given to him or her. But for whatever reason became involved in drugs, you often find when you scratch the surface, even if things always looked great, even if the person was the president of the class and the captain of the football team and the prom queen, for whatever reason, with all the advantages, he or she just always felt either terrible about herself, either incredibly socially uncomfortable, just dealing with some sort of inner turmoil. And drugs in the short term can be very helpful. And alcohol can be very helpful with that kind of thing. But that's an individual problem. That's kind of a psychological basis. And that's, again, in a way, when you're a psychiatrist, clearly you're dealing with the individual always. But that's kind of a different picture than when you have whole communities that are using drugs. Because when you have the case, the classic case of the individual who appears to have everything using drugs, then it's the drug, I always think of drug, I don't even call it a disease. To me, it's a symptom of something that's derailed, dislocated within the person. But when you have a whole community, then that's a reflection of a sick community. And solutions are somewhat different. And often out of our control, because I'm not going to be able to bring jobs in as a psychiatrist, but sometimes they're structural. Your books and articles are really readable, but they're very data rich. And one area that you documented opened my eyes a lot, had to do with the percent of today's opioid users who have been longtime users of other things. In other words, you've taken, I think, some exception to this idea. This was all sort of inflicted on a lot of people by nefarious marketers and drug companies and so forth that it just came out of nowhere as some sort of conspiracy. Right. Well, the data show very clearly that most people who abused prescription pills were never prescribed those pills in the first place and give people citations for that. And that within the pool of people who are prescribed and develop problems, these are folks who either had a drug or alcohol problem before or are struggling with some sort of, not even necessarily a psychiatric problem, although a depression and anxiety, but some sort of profound immoralization or some sort of existential problem. I mean, one example I gave earlier is, I mean, so the stories you read in the media, they're not always this cut and dried. Everything was great until my doctor prescribed, well, when you dig past it, things weren't so great. Now, an example where things pretty were pretty great, but completely went off the rails, is something like this where you have, it's frequently a young person, but who is, let's say, going off to college. So I actually met this guy who had a scholarship to Ohio State for football, and he was great. He knew it was a long shot that he probably ended up being an accountant, but maybe he actually could be in the NFL. And he was really psyched. And in his senior year, he got in a car accident. And it really messed up his throwing arm, and basically it ruined his dream. And so he was prescribed opioids for the pain of his accident, but then he became addicted to them. And he became addicted to them because his life was ruined. It really wasn't. I mean, of course he ended up going, could go on and lead a very productive life, but his vision for himself at the time, and it's obviously devastating to a young person when your whole identity is formed around a certain kind of future and takes a long time to recalibrate. And but that's why he became addicted. I mean, there's a deeper story. It's not what I call the tubercular model of addiction. You're around drugs and you catch it. It's never that easy. And that's, again, sometimes how it's portrayed. And all this has incredible clinical implications. We will reserve the last several minutes for questions from students or others. And they may want to come back to addiction, probably will. But you've covered a lot of other ground, and I want to expose the audience a little bit of it if we can. So in a fascinating book that's been out two or three years, I love the title, and you say you don't, brainwashed. You challenged a lot of what you see is overclaiming or overhyping around brain scanning and so forth, what we can learn from what part of the brain light up at the given different stimuli and so forth. So there are some fascinating chapters. I'd like to ask you just say a word about each of three of them. First was neural marketing. First tell the audience what it is and why you think maybe it's been oversold so far. Basically a scam. But the book is not about neural. I mean, I worship neuroscientists. I mean, they are the smartest, they're brilliant, and their work is fantastic. And the technology is out of space marvels. I mean, it's incredible. So none of this is a critique of their work or of serious scientists. The critique was to the extent to which these, or the fruits of these technologies is brought into the public square. And it doesn't hold up yet in making a lot of these claims. So for example, and I have to be honest, this lighting up. I started writing this in 2008 and with my colleague, Scott Lillian-Fell, who's a brilliant psychologist at Emory. And that was when I remember the science section of the times and everywhere we'd say, this is your brain on this and this is the love section and this is the hate section. I mean, it's utterly ridiculous. And to be honest, that's largely stopped. I'd like to take credit for it. And now, you don't even really hear about that much. The people who said that they could sell your products for you if you would just let them measure. That's ridiculous. And they still have the, I mean, it's amazing how well these books do as business books. But I mean, I think a lot of these people in marketing are always looking for some sort of quick formula. But yeah, the predictive value of this is very low. What about the value or efficacy of brain scanning for light detection? That's probably the one area where there is some, I don't want to say real promise, but put it this way, in laboratory settings, and they're highly controlled and often pretty, I mean, these are lies that are in the context of, for example, did the subject put an object in this closet or that closet? And they can actually tell, I think, better than average. Better than a polygraph, maybe. Oh, well, those are known to be unreliable because they measure galvanic skin response and other measures of arousal, which can be just as high if you're innocent. I don't want to be accused of this. Probably worse. And if you're a very practice liar, you'll probably sleep by. So I mean, it's interesting that they might be able to tell with greater than choice accuracy which closet you did put the watch in, but how relevant that becomes. So it's interesting on a small scale level. And then you have to think, well, what is a level of accuracy that's acceptable anyway in a legal setting? I mean, I don't have the answer. It should be 99%. Should be 90%. We're so bad at it anyway. And as you know, we're not good at it. Humans are notoriously bad at detecting lies. So that's why there was even an interest in trying to mechanize this in some way. So I mean, right now it's in a heuristic phase, but it might develop. Who knows? The part that I always found more intriguing, well, there is a chapter on addiction, of course. It's trying to go beyond the brain. I mean, it's just one explanatory level. There's a psychological explanatory level of addiction and a behavioral and a cultural and a sociological. And they're not mutually exclusive. And some may be more relevant to some people. And others are more relevant to the same person at other times in their life. But to just privilege the neurobiological, why would you do that? You miss so much information. And then there's a chapter on free will, which I figured out. I haven't. But this idea that, in a way, that transcends brains, because that's a philosophical problem. That's really the issue there. You documented how it's creeping in, not creeping in. It's barged into courtrooms and into the law as a exculpatory under the guise of neuroscience. That's deeper than the free will. I love the title of that chapter. My amygdala made me do it. Oh, right. Yeah, that's a little different from the one chapter on free will in a more philosophical sense, which, again, I can't add to. I can only tell you that brain science can't resolve that, because that's a philosophical question, whether we have free will, because you decide, effectively, what counts as free will? I mean, I guess I'm a deterrent. Well, technically, I guess I would be a compatibilist. But there is a big level of determinism. But as long as people can plan, can change their mind based on new information, then they've got enough free will. Bringing scans into courtrooms is to show that this person's brain is damaged in a way where they can't even plan, or their capacity to control their impulses is so impaired that they can't. So it's out of the realm of philosophy and more in the realm of neurology. And that's true. Some people can't. Some people do have such severe brain damage. They can't. But there's usually an accident associated with it. And they're a little more straightforward. It's when you get into situations where people commit horrible crimes for whatever reason. And this is just an effort to mitigate the punishment, to make it seem as if they couldn't do otherwise. But the brain scan cannot show us that. They can't. I'll say yet, because who knows what we'll discover. But they cannot distinguish impulses that are irresistible from those that were not resisted. You said that before we leave this, I just want to venture an observation. You said that perhaps unlike its use in the courts, where as far as I know, it's continuing to be employed. Yeah, it's not working that well, luckily. That's sort of the question I was headed for, because in the neural marketing sense, there's a market test. At some point, if people discover that it's not helping me sell the product, it's a scam or something close, they quit buying it. There's a control mechanism that may not be there in the purely legal setting. I think judges are becoming more skeptical. Luckily, there's a lot of judicial education. And luckily, a lot of it's taught by my friend Stephen Morris at the University of Pennsylvania, who is a law professor. And this is one of his people who specialize in neural law are often on the more skeptical side of things. So that's one nice sort of check on all this. And I think juries tend to, unless it's a corporation, they want to hold people accountable. So it hasn't seemed to have run away and poisoned the system. But you know that? As I said, we wrote that in, well, we started writing it in 2008. And I think a lot of the enthusiasm, it's how many, well, it's 11 years later. Yeah, that's one nice story, I think. Good. So let's change subjects rather abruptly here. You've had some interesting comments about the whole matter of vaping. And why don't you share a little bit of that with us? Well, the vaping situation was different a year ago than it is now. When I first started following vaping in 2014, my impression was that just in articles you read, just in a kind of atmospheric way, there was sort of, oh yeah, maybe that's great for smokers. And of course, it simply is a manifestation of this classic public health strategy, which is harm reduction, which is, in this case, either tobacco or nicotine harm reduction. But I should really be tobacco harm reduction in a sense, because nicotine itself is fairly innocuous in otherwise healthy people, which isn't to say it isn't addictive, but in terms of creating health problems. Not for everybody. Pregnant people shouldn't smoke or even, although they, OBGYNs will use patches all the time for women who won't stop. But from about 2014 onward, there was a growing, I don't know, it's not really an industry, but it was a growing sort of a constant drumbreed of detraction from vaping. And much of it, I'm sorry to say, I think was perpetuated by the Centers for Disease Control. It was only seen through the commissioner's eyes or the director's eyes as a big threat to kids. It was going to lead kids to, it was going to renormalize smoking and be a gateway to smoking. And I'm not saying that was not a legitimate concern to have. I mean, it's an empirical matter. Is that going to happen or isn't it going to happen? And it was clear it wasn't happening. Smoking in kids has been going down for decades and even became steeper once e-cigarettes became available. So you could much more persuasively make a case for e-cigarettes being a ramp off smoking for kids than introducing kids to smoking. Although let me please stipulate, teens who do not smoke should not vape. But that never became clear. And yet, again, just those warnings and that it caused popcorn lung, if you've heard of this, but which is a very dangerous pulmonary condition. There's not been one recorded case of that. We are nicotine causes cancer. I mean, all of these, the American Lung Association, I mean, people and institutions you would otherwise want to respect, we're just giving out false information. We don't know anything about them. That's ridiculous. Now, we don't have, obviously, decades of data because they haven't been around that long. And I'm not saying they're safe, but the point is they are much safer than smoking. They emit the aerosol and e-cigarettes, which has nicotine in it, propylene glycol, vegetable glycerin, flavoring, and I think I said nicotine. I don't know what years of inhaling propylene glycol will do. I mean, it's in asthma inhalers. But again, you're vaping constantly. You're not using your asthma inhaler constantly. And we don't know what long-term will do. But every reason to think it will be a lot less problematic than smoking for all those years. And I think I said this, but the number of toxins slash carcinogens emitted in e-cigarette vapors are many fewer than in cigarette smoke. And that's the whole key is to take the smoke and keep the nicotine. That's the harm reduction part. And many fewer of the, I mean, I said many fewer, and at much lower levels, but not at zero. And that's why we don't know what's going to happen. And if you don't smoke, you shouldn't start to vape. But none of that was ever at the forefront. And all you had to do is look at the UK and England where they are so progressive on this matter. They're equivalent of the CDC. The Public Health Service was always promoting vaping. The Royal College of Physicians estimated that it's 95% safer than smoking or 95% less dangerous, I guess I should say. Maybe it's 80, but they measured it based on those toxins I mentioned, 95% fewer. And their National Health Service, they sell vaping. They have vaping stores in their hospitals. I mean, they are just the mirror image of us. And maybe that's one upside to a socialized medical system is they want to save all this money so they're promoting it. No, there isn't enough. Anyway, but it's fascinating to see how we've responded so differently. Americans have a, we put much more emphasis on, much more anxiety, I should say, on youth than they do. Not that they want their kids in any danger at all, but their trade-offs are different. So in other words, how much emphasis do we put on perceived or speculative harms to kids versus known advantages to adults? And we just, we weigh that differently. Plus there is this long history of, I mean, e-cigarettes were given the worst name possible in retrospect. They were named to appeal to smokers. Oh, a different kind of cigarette. Great, and this one will be less dangerous for me. But a lot of the tobacco control people who've been fighting big tobacco and smoking, which is the right, smoking is the right enemy for all these years, all they heard was cigarette. And so that just immediate flashbacks to the 50s and 60s when the big tobacco companies were pushing reduced tar filters and reduced tar and nicotine cigarettes as safer, but they were never safer. So it looked like we're being sold another bill of goods. Plus there was a lot of confusion over the degree to which big tobacco was invested in this industry is a minor part of it. Up until last year when Altria invested in Juul out of 35%. And even that still makes independent vaping stores and vaping companies the majority, but it still was a pretty massive stake and no question. But again, because it seemed like a product, again, of big tobacco, of course it couldn't be trusted. And then when you hear nicotine, I mean the two words together, nicotine addiction, scare the hell out of people. But in this world of harm reduction, which is basically everything, just needle exchange, we don't have any problem giving methadone to heroin addicts, but why do we have trouble giving nicotine in an inhaled form to nicotine addicts? It's a real interesting double standard, but much of it's, I think, caught up with this confusion about how involved this traditional enemy has been and also misunderstandings about nicotine. Again, it's relatively benign in adults. And then this misinformation cascade just developed. And I don't blame the average person for the impact polls show taking over time that people are much more suspicious of e-cigarettes now, and more than half think they're as dangerous or more dangerous than smoking. And these vaping bands now, excuse me, the flavor bands, are just going to push, I mean, what do you think happens with prohibition? It's just going to push more people back to smoking or to bootleg flavored vapes. And we've seen what black market products do, because those are the folks who are dying from this lung problem, and these folks who are getting sick. And I think the first cases appeared maybe the late spring. And now it's up to about 1,600 people who've developed these pulmonary illnesses and maybe under 40 have died. But that's being blamed on vaping. Well, vaping is just a delivery system. You can vape commercial regulated quality nicotine, or you can vape black market contaminated THC. And that's what's accounted for the vast majority of these deaths. I mean, I'll just say one more thing, but think about it. Vaping products, which are all regulated by the FDA, they're not approved yet, but they're all regulated. All their flavors and all their devices have to be registered with the FDA, which they are. I mean, yeah, registered. They've been around for 10 years. All of a sudden, people are getting sick. I mean, that has the hallmarks of acute contamination. And it's been such a dangerous thing to have conflated vaping of, again, legitimate commercial e-cigarettes with black market THC. So it's not a story about vaping. It's not a story about e-cigarettes. It's a story about black markets. And it's gotten very confused. People have started smoking again. And people who like to use THC, they're misled into thinking, well, this isn't a problem of what I'm doing. So people who like both nicotine and THC are disadvantaged by this miscommunication. We're going to go to audience questions. I hope students will beat their elders to the microphone, but first come, first serve. I'm going to do that in just a minute, but you go ahead and claim a spot. But just in case that wasn't contrarian enough for anybody. Oh, we can talk about organ sales. That's next. Let's just do a little bit. And Sally, you should tell them that this is not purely an academic matter with you. But what are your views, which are somewhat unorthodox on organ transplantation and sales? Well, I've come to this issue truly organically in having had a kidney, actually two kidney transplants. Don't know why I don't have diabetes or any convalescent vascular disease or the classic kinds of problems. So anyway, thank God I found donors twice. And I'm very good to my interns, because you never know. Maybe another time. One's a close friend and another tremendous author. Yeah, Virginia Pastrell, who hopefully one day you can hear from her. So I was lucky that I did find a donor and then another one. But so many people don't. And about 12 people tomorrow will be dead because nobody gave them a kidney or they couldn't outlast the waiting list, which has, ironically, now it has about a little under 100,000 people waiting for organs for kidneys, about 120,000 waiting for organs. But it was over 100,000 a few years ago. And if this doesn't sound perverse, the reason fewer people are waiting is because of all the overdoses. They were able to transplant a lot of the kidneys for people who died from opioid overdoses. But in any case, this is only going to get worse. That's the trend, more people needing organs all the time. And in 20 years, 30 years, if we're sitting here, we won't be talking about people donating organs because we'll be growing them in pigs or we'll have micro dialysis filters or printed organs. I mean, there's no question technology is going to change this. Your grandkids or great grandkids or whatever are going to think it's barbaric. You had to get a kidney from a person. That's not going to be the case in 50 years on positive. But it's the case now, and a lot of people are dying unnecessarily because of a shortage. So why not give people a massive tax credit, a tuition voucher, a contribution to their 401k, money they can give to a charity if they're willing to give a kidney to save someone's life? I'm not talking about a classic free market where there's bidding or there can be a class of, I suppose, corrupt practices. This is a third party, which would either be the feds or some sort of sanctioned entity, would just be there to recruit people if they're interested and they're healthy. And of course, they would go through all the testing. It would be no different than the current system. You could go to the UI hospital right now and say, I'd like to give a kidney to a stranger. And they put you through a lot of testing, medical, of course. And it's to protect you and the potential donor. And you'll meet with a psychologist or a social worker to make sure it's not a Jody Foster situation where you think if you give a kidney someone's going to fall in love with you or something like that Hinckley, John Hinckley thing. I mean, that your expectations are realistic. You understand the risks, this kind of thing. The only difference is you would get something in return for saving someone's life. And of course, altruistic donation, like I had, would continue to go on. I mean, many people, I mean, God forbid, you're relative as pancreatic cancer. Oh my god, what the world could you do? If your relative needs a kidney, if you're healthy enough, give it to him or her. So that's pretty much that idea. And you know what, it's not that radical. I'm not the first person to come up with it, God knows. In fact, it was first discussed in the 60s. The first kidney transplant was 1954, I think, or 53, 53, but to an identical twin because there was no immunologic matching then. Or the, I should say, the immunosuppressive regimes were not well-developed. And were pretty brutal still up until the 90s, even though 84 was a big jump with cyclosporine. But this has always been an issue. And Al Gore, who at the time was in the house in 1984, he spearheaded the National Organ Transplant Act, which really made a whole system out of the organ procurement and distribution system. But at the last minute, he put in section 301, which made it a felony, to receive or give anything of material value for an organ. And that was because he didn't want to see basically a free market. But he did say, if this doesn't work, we'll have to move to incentives. And no one ever tried to get him to reiterate that. I think he didn't want to revisit the issue. But the idea has been around for a long time that, well, why can't we incentivize people to donate? What are you afraid of? What are you afraid of? You're afraid of basically people doing something they're going to regret afterwards, impulsively acting, maybe a poor, desperate person, impulsively acting to do this, and then regret it afterwards. And we can protect all of that by not giving what desperate, impulsive people want, which is immediate cash. So you build in a waiting period of at least a year, and you don't give cash. I mean, my specific plan happens to be a fundable tax credit of $5,000 a year for 10 years. Somehow everyone seems to intuitively think $50,000 is the right value. You can give drugs. No, I guess that's a bad idea. And you know what? The thing is, I've looked at, there have been a number of polls and surveys done on this. And I mean, I don't know what people think. And when I do lecture on it, I would sort of do a before and after poll. What do people think about this idea before and after? And usually, most people are receptive to it unless they're bioethicists. And then afterwards, even more people are receptive to it. But in these polls, the average person is very receptive to it. They don't like the idea of a market market, or me giving you cash, because they're afraid of, well, then only people who could afford it would be able to engage in this kind of exchange. Now, you could argue that would still benefit others because it would get people off the list who had, everyone would move up. But there's something unsettling about rich people buying there, even though we do it every, we, I'm not one of them, do it all the time. But still, I'm sympathetic to that. And that's why a third party arrangement would obviate that issue of only, this way, everybody who's as poor or rich as anything could benefit this. So again, you don't give the cash, you don't give it right away. And then some people say, well, only poor minorities will be interested in this. That's an empirical matter. I am to think graduate students are the ones who are gonna do it. But, but... We may have a graduate student waiting with a question here, so let's take it if we can, right over here. Well, I can't have an answer to that particular objection, but I guess we can wait. Hi, I'm Megan, I'm a pharmacy student. And I just wanted to ask, so we talked in the Q&A session this afternoon and also a little bit about disability. And I was just wondering, I guess since we know that that system was a little broken, what kind of social services, as far as like addiction, recovery and treatment, like should we take model after like the way Sweden does it because they seem to do pretty well, but not everybody gets treated. But so I guess what in your eyes is a good way of going about that? Well, I mean, we know how to do pretty good drug treatment. It's just that the workforce is not robust enough to deliver it. And there are a lot of shoddy treatment programs. So that means two problems that the standards aren't high enough in some of these programs and there aren't enough people to deliver it. So I don't think it's so much that it's rocket science about how we should be treating folks. I think people should have a choice. Not everybody, if you're talking about opioids, which is the only thing where you actually have any meaningful drug treatment, drugs for pharmaceutical treatments for, but not everyone, some people can be in drug-free settings. I'd like to give people certainly a choice. Again, I think there are, SAMHSA has a great manual on how to deliver treatment. You gotta follow people for a long time. This is not something that you treat in 28 days and you're done with, but so that infrastructure is a big problem and that gets back to funding. And when folks live in communities that are really distressed and it's challenging because you can treat people, but if they go back to situations that they perceive as being that are very stressful or don't offer opportunity, it's a bit of a setback. So there's just a lot of rehabilitation involved and I don't think maybe we put enough emphasis on that end of things, but I think all the ideas are fine. I just, again, I don't just think the implementation is suffering, did you have something else in mind though? No, just that the way that it works in Sweden, obviously they have socialized healthcare, so you have to apply and then your local welfare board okays your treatment and then they pay for you to be sent. And I guess I was thinking more about payment and social services because we had talked again about disability, so money coming from those avenues I guess was more of what I was curious about. Well, I think Medicaid expansion is really, I mean, I know that probably upsets you, but it's really been helpful in this regard. So we're paying for it. So yeah, I don't know enough about what goes on in Sweden. I mean, everything in Sweden is hard to, a lot of it's hard to generalize. It's a more, it's such a more homogeneous population. I don't mean you shouldn't look across cultural things, but it's always a challenge on what you can extrapolate from and what you can't. But in any case, I think I'm gonna stick with what I said before, which is, we kind of know what to do and in places with Medicaid expansion, there seems to be coverage for it, but it's a lot of its quality control and more people to do it. Thank you. And there's a question behind. I'm just gonna come up here. Hi, my name is Fatima. I'm also a pharmacy student. I was curious, how do you feel that people that struggle with chronic pain are sort of affected by the recent changes in opioid prescribing habits? Yeah, I think that's one of the massive unintended consequences of cutting down on prescribing, which had to be done. I mean, doctors were way too profligate with the medications and I'm talking about for acute pain. For sure, some people need 30 pills, but I mean, excuse me, 30 days worth, but most people don't. Most people don't even, I mean, there's data on this. They don't even finish the prescription. And then unfortunately, we'll go in a medicine chest and then those get diverted. So there was definitely an important reason for doctors to become much more conscious of prescribing. Can I just interject the question? Some have said that the reimbursement system incentivized doctors to give 30 days because they weren't gonna get paid for if the patient came back. Oh no, I think the surgeons didn't want the people to come back. No, don't bother me here. No, I'm sorry. That's the point that some were making. Oh, I just think they honestly didn't want to be, if anything, they wouldn't pay for it. I don't know about that. I thought you were gonna say that Medicaid paid for, covered all these medications. People went to pill bills and stuff like that. So that's the other side of the expansion. But what's happened, though, to chronic patients is, I mean, let me back up. Even in the acute phase, I think, and there's a lot of variation by state, but some places require the patient to come back after several days. And when you're in a rural area to come back and you just have surgery, it's outrageous in position. So I don't necessarily mind the limits. I mean, I do mind it because I'm big on physician autonomy, but I understand why they built in these seven day limits but then make it easier to refill it. It shouldn't be a burden to have it refilled and for someone else to show up at the pharmacy, maybe with the person's ID, but I'm here for my spouse to pick this up or my friend. But it's the folks who are on the legacy patients, these folks who are on these high dose opioids for a long time. To be fair, some percentage of them when they first developed these, and we're talking intractable, horrible, imagine the worst headache you ever had, multiply it by 100 and have it every day of your life pain, you know, maybe when they first developed these syndromes, they could have been managed differently, and today they probably would, but they weren't. And so they're on fentanyl patches and Oxycontin and Percocets or breakthrough pain and all this stuff. And you know, for a lot of them it worked, it's working and it makes the difference between anything from between being bedridden to getting out of bed and going to the bathroom and going into the kitchen, to being bedridden and being a doctor. I can't tell you how many doctors have been taken off their medication. And I work with this genius woman who's, she's like an underground railroad for pain paste. You can kind of find them some doctor who's more enlightened, but it's a horrible situation. Another colleague is keeping a registry of people who've killed themselves because doctors are, and the doctors are scared. The DEA seems capricious at times. Others obviously should have definitely rated pill mills, but other times it's not clear whose door they're gonna knock on and with so many doctors who are afraid, you get one brave guy in town who's gonna treat all the difficult people. So of course he's writing the high prescriptions and then he calls attention to himself. And it's a terrible problem. We were much too, I think, blunt with these interventions and... We have a terrible problem, which is we're running out of time, but there's one more... Uh-oh, more than one. You guys wanna flip for it? Try to be quick with the question and the answer. Sure. So you talked at the beginning about kind of communal addiction, like the addiction of an entire community. So I was wondering, could you identify maybe some of the causes that you see for that and any, I don't know, favorite policies that you have that address those causes? There's no short answer to that one, but basically, this is almost an obscene abbreviation, but this town I was in, it wasn't like Janesville, Ohio, or something where Wisconsin, right? Where the GM plant or others overnight drops off the face of the earth. I mean, this was, like many places, a more gradual evacuation of industry, starting in the late 60s, and then going on and on and on until... Xirenton was an iron town. And so, I think economic problems did kick this off, where unemployment and then men lose their... I mean, it's totally dislocating to not have a job on every, so many levels, and that led to family dysfunction and more drinking, and now you've got generations and generations. So whereas for that one, maybe for that first, when it first started happening, economic revitalization would have been completely enough. And now, bringing back jobs, and there are jobs in these places, but they're not well-paying jobs. And all the promising kids leave, and you're left with the addicted people and the old people, and you've kind of hollowed out your middle class, but now you've got, when it's multi-generational, then you've got problems of growing up in communities and families where men don't work, or women don't work, and that's pernicious in terms of everything. I mean, especially when they're adults or addicted, they're not paying attention to the kids, they're not setting examples for internalizing discipline and schedule and routine and accountability, and it all just is just an accumulation to the point where we've had patients who, the idea of, for some of them, I mean, some work really hard, but the idea of working in that kind of accountability is almost a foreign idea if you can get disability instead for anything. Let's do that, or an entitlement, and in some ways, being a clinician, I can talk much more easily about this than a policymaker, because I can tell you that working is the best therapy. It's not because it's better for society, it's the best therapy for you to be busy, to have a structured day, to have interaction with people, to have a sense of purpose. So it's easy for me to say it because it's clinically indicated. How about one more, while we're breaking the time, let's do it. When you talk about cost-effective, long-term care, can you speak to the importance of non-clinical recovery support services, and in particular, have you seen a growth around the country of recovery mutual aid societies that are more accepting of medication assisted treatment? Oh yeah, definitely. You know, there's a great guy, William White. Does that name ring a bell to you? Yes, ma'am. Oh, do you? A big thing. Okay, well, if you ever want to know anything about the history of recovery, the status of recovery, or movements, he's the one to go to. And anyway, so yes, there's much more acceptance. I mean, I think things like AA are great, for whom they work, obviously. People should try different AAs, they all have different personalities. And, I mean, again, the medication part, I mean, if you think of recovery on a continuum, I mean, the most downstream thing is reviving somebody, so that's with Narcan, and it gets less pharmacologic as you go down, or go out. And yes, there is the drug treatment to stabilize people, because that's what methadone and bubonorphine do, they stabilize people, they're rarely enough, and then you get into the psychological and behavioral therapies of relapse prevention, and then vocational rehab and all this, and then, depending on what the person's needs are, how do you cope in this world? Some people are responding to deprivation, and some people are responding more to deficits in themselves, they don't know how to manage. And being in a community of people who are recovered, hopefully they have various stages, so they can see people who've been successful, and that's very inspiring, and learn from their strategies, that's huge, and that's the majority of the trajectory, it's that end of it. Well, it's been a great evening, Sally, Dr. Sattel, I know that the crowd appreciates it, and in particular, I know we have, for instance, a dean sitting down here at the front who now relieves, she doesn't have to close the psychology department, there really is, there's a whole lot of value there still, and nobody's brain scan's going to take that away. And there's so much else we could have covered, I do recommend her books to you, there's a whole realm of quackery that we didn't get into, that you've taken a look at and illuminated, but Dr. Sattel said to me that she, having spent a long time in academe, but also more recently in Research Institute, that the one advantage she finds is she feels somewhat more free to speak her mind, and she sure did, didn't she? Thank you very much, Dr. Sattel, for being with us.