 Welcome to the addiction recovery channel. I'm Ed Baker and I'm your host. I'm very pleased today I couldn't be more pleased than to have as our guest Dr. Nora Valkov. Thank you doctor for being on the show Yes, Dr. Valkov is the director of what will soon be it's not official yet but it will soon be the National Institute on Drugs and Addiction at the National Institutes of Health. NIDA is the world's largest funder of research on health aspects of drug use and addiction. Dr. Valkov's work has been instrumental in demonstrating that drug addiction is a brain disorder. This is a very big deal. Thank you doctor for that. She received the international prize from the French Institute of Health and Medical Research for her pioneering work in brain imaging and addiction science. Dr. Valkov's professional distinction is unparalleled. She is a national university of Mexico City recipient of the Robin's Award for best medical student of her generation. She was chosen as Time magazine's one of Time magazine's top 100 people who shape our world and Innovator of the Year by U.S. News and World Report. She's one of 34 leaders who are changing health care by Fortune magazine. So I'm just I couldn't wait to read that because I'm just so impressed with your career. I want to thank you deeply. I've been following you for a long time. I read your blogs. I read your blogs. I tune into videos whenever I can get my hands on them and I'm honored that you're on the show. Well I'm very happy to be here and it's a pleasure for me to be part of it. So thanks for doing it. Yes. I want to Dr. Valkov. I wanted to begin with something of a personal nature. You know it's obvious to me and anybody who's been you know watching you and following your career that you're deeply motivated from from a very genuine inner place that that you're you're energetic. You seem tireless and you seem continuously focused. So I'd like you to share with me and with my audience what is it that that called you to this. What is it. What is it that drives you so. Well I think that and I think that we've spoken about it in the past and we always try to get simple answers and to complex issues and what drove me to the field and my passion is we all have in terms of personal experiences. Also there is a scientific one and then as a position to my experience as as doctor and seeing how we basically completely neglected individuals with substance use disorder and to me being taught medicine in a way that made absolutely no sense and then when I went into psychiatry this I was exposed to the same situation where we were not taught how to even screen for substance use disorder at least so how to treat the substance use disorder in the patients that were being admitted to the in patients psychiatric unit. Most of whom had substance use disorder problems. So this was to me antithetical to anything that that actually speaks about quality medicine from the scientific perspective. I've always been fascinated by the human brain and what is it that makes up uniquely humans and what is it that makes you uniquely as individuals. Each one of us and there is a process that I value enormously which is the capacity that we have for self-determination and the notion that we can make a decision of what we want to do with our lives and carry through and yet addiction destroys that capacity in ways that are really very difficult to understand from the perspective or from the perspective if you have never been addicted just from observation they are extremely impossible and so scientifically this is something that is amenable for inquiry and study and so I was fascinated by the notion of with the advent of imaging technologies to be able to investigate the function of the human brain when someone becomes addicted and to compare that of the function of someone that does not have the problem and to try to set the systems that get engaged that get disrupted by exposure to drugs and link them to the actual behaviors that emerge when you become addicted and then there's that personal element that in my family on my mother's side there is history of alcoholism. My grandfather actually only belongs to me until my mother was was dying from cancer and she told me the story because otherwise it was a secret that my father care father my grandfather had actually had a severe problem of alcoholism and had gone to treatment and relapse and in the last relapse unable to contain that self-hatred by his inability to contain his alcohol drinking he killed himself and this was something that was revealed to me as a secret in a way that was very very devastating but the other one my uncle my favorite uncle apart from everything else he was an extraordinary man but he also suffered from alcoholism and that led him to be rejected by the family in in ways that that I felt were basically reflected that stigma that we have for addiction and that notion that we believe that the person is responsible for their acts the penalizing attitude the assignment of attribution to the disease process to the person so there was the personnel that I had lived through and that basically did not make any any emotional sense to me and too was was associated with a very strong price in my family of suffering and of secrecy the second from the perspective of science the opportunity that we have to uncover what are the systems that actually enable us to have self-determination and the third one which was the one as a physician to to sort of figure out what is it what information do we require in order to change a culture in the helper system that has neglected and stigmatized substance use disorder and this was particularly important because by not dealing with it as a health condition in the helper system we open the door to perpetuate the criminalization of people that take drugs which is extraordinary deleterious and promotes the stigma so those are the personnel the scientific and the physician my professional one as a physician reasons why I am so passionate about this issue yes a perfect storm has unleashed you know an incredible career and we're all indebted to you first of all I'm sorry to hear of course about your grandfather and your uncle but thank you for being frank with us about your your personal life I really appreciate that you know so the three on three levels you became deeply motivated to pursue an understanding of addiction and treatment for addiction I know I guess it was 2010 I think it was the American Society of Addiction Medicine released its definition of addiction that was heavily weighted there was some genetics involved but heavily weighted toward brain circuitry now were you care I'd like to just like have an addiction 101 I'd like you to maybe go through that initial definition dopamine the dopamine system inability to inhibit impulses that but then in 2019 there was this whole level added which was really very gratifying for me to hear the level of life experience how life experience can affect ones being prone toward addiction and one's ability to recover from addiction and then more recently your recent blog on pre-addiction I think is fascinating could you could you summarize that if you could yeah so let you first one need to keep the one on one on addiction and addiction is the situation that emerges when the person has such an intense right for taking drugs that they actually neglect other activities that are necessary for their well-being and that their urge is so so strong that it's actually leads to this compulsive pattern of drug self-administration with an inability to stop despite very adverse consequences so if you understand it from the perspective of neurobiology why is it that a person finds themselves in such a situation what the research has shown us is that the repeated administration of drugs in people that have vulnerability and the vulnerability can come actually from have had a very adverse childhood experience and in fact we know that a very childhood experience are one of the the factors that has the highest contribution to overall addiction clearly there are a genetic components and like him for example in my case in my family there are factors that makes us vulnerable and I suspect like God that research is showing that some of those genetic factors that make us vulnerable are basically allowed is reflect the way that we may respond to adverse environmental conditions so I am not an alcoholic I don't suffer from any addiction but also I've been very privileged in my upbringing had I been brought born in a condition of childhood adverse experiences I may have been at high risk of becoming addicted from those two factors so what is it that these predisposition factors are brought by adverse childhood experiences or by genetic itself how do they impact these behaviors well we know to start with that the reward system which is the one that motivates our action is disrupted by repeated administration of drugs we also know that if you are exposed to stressors that also disrupts your reward circuitry and this is fundamentally modulated by dopamine so dopamine which is activated by drugs with repeated administration leads to what we can simplistically call tolerance so you stop reacting to other regards that are less powerful but dopamine also modulates our frontal cortex and the frontal cortex is what we need in order to make a decision of what is the best behavior for me to do in any given circumstances and I can choose this is the best option for me right now and you come up with a plan to do it if the prefrontal cortex is not working properly number one you are not going to be in a good position to make the optimal decision of what should be the next choice in your behaviors and even if you make the right choice if the prefrontal cortex is not functioned properly you will not be able to carry it through and as a result of that what you have is a very malignant combination and intense right to take the drug because the reward system has been harmed by the use of repeated drug and that inability to self-regulate or to actually have optimal choices in behavior because your prefrontal cortex is also disrupted as a function of the effects of drugs in the dopamine system so you have very strong urges to take that drug and a very significant impairment with your capacity to make decisions and carry them through so this is at the essence of the symptomatology that we see in a person that when they become addicted when these systems get disrupted then you are that explains why even though the person consciously don't want to take that drug anymore they just cannot stop it so these are at the basic basic essence and the other aspect that I do want to add in terms of understanding addiction because it certainly helps us it was important in ultimately what happened to my grandfather that he ended up killing himself is the notion that as the disease process becomes more and more and more severe you start to isolate yourself and you actually you lose the capacity of well-being you will start to become depressed and very anxious and and you start to seek the drug and not not even to have a good sensation but just to feel normal so that enhance sensitivity to stress and the vulnerability for negative emotions then confounds the picture further making it harder and harder from people suffering from addictions or from why we now call substance use disorders to be able to seek help and to sustain the treatment and and so the path of these resistances in a way continue to take drugs so that is in in in a sort of one-on-one in terms of addiction then you asked me the last question which was why how do the concept of pre-addiction and why we are urging these new new proposal which is a proposal that actually Dr. Tom McClellan, Dr. George Cook and myself put for in a commentary there was a release I think it was released yesterday of today but the idea basically was born out of a sort of the notion of again copying what other interventions in medicine have done that have been successful specifically the idea of pre-addiction came from the idea of pre-diabetes that was first instituted in 2000 when the endocrinologist realized that people there were certain biomarkers that while the person was not diabetes if there was not an intervention there was a very high probability that that person would end with diabetes but on the other hand if they intervene in these very early stages they could obviate all of the pathology linked with diabetes and that's why we basically and and the beauty of it also was that it was recognized as a condition pre-diabetes with the advantage then you can put resources in order to cover for that intervention that's necessary to improve the behaviors that will lead you to interrupt the course from pre-diabetes into diabetes so so our thinking was akin to that can we identify a condition where the use of drugs is actually harmful but it does not fit the criteria of a substance use disorder in such a way that we can intervene and obviate that transition into a more moderate or more severe substance use disorder with all of its associated devastating consequences and and and to the extent that we can consolidate number one we can have healthcare providers screening and then doing the interventions that are appropriate and they should be reversed for you and to the extent that we can start to in a discourse that we feel open to speak about pre-addiction this also should help antagonize that stigma that still permeates for addictions in general i i read about i read your your blog on the subject and i read also the the paper that you wrote the blog on i was fascinated by it what fascinates me is the continuing evolution of this definition of of addiction in 2019 when the american society of addiction medicine revised its addiction there were some commentaries that i i happened to read because i was trying to follow it closely and in those commentaries they began alluding to what you're talking about but in a different way they were suggesting that the term addiction be solely relegated to late moderate and severe substance use disorder and it's been my experience in the field and and tell me if it's been your experience too that the word addiction began being sort of a like a broad definition of everything from very mild substance use disorder to the most severe substance use disorder and in that way it lost its specific specificity i've come into contact with many people who because of that they see people in early stages of the disease who enter into spontaneous remission where they make a choice i had a consequence so i'm not going to take drugs anymore and they do it sometimes those people are defined as people with addiction so it causes the public to kind of think all people with addiction should be able to just decide not to do it and it feeds into stigma have you have you seen that have you had that experience absolutely all the time and i think it is also clinically very deleterious because the concept is is when you are we are putting most of our resources towards the severe substance use disorder but if you look at it in terms of consequences now we're seeing for example that a very significant portion of people that are suffering from overdoses or from the negative consequences of drug taking people that could fit the criteria of a mild substance use disorder are not that their their symptoms don't justify the administration for example of medications and so nor the administration of an admission into an inpatient setting so they get neglected and there is very little research work that has been done specifically to the mass of substance use disorder which is the majority is that the largest number of cases and it's also that the early stages of the disease process in which any intervention can interrupt it and can save the person's life but again we're not putting the resources on it we're putting the resources in the more severe and and so to me one of the things that was most valuable that i value the most about the dsn5 diagnosis for substance use disorder is that they became very explicit about severity mild moderate or severe and and by doing that they are opening up the door for us to try to figure out um what are the appropriate interventions dependent and that's the severity of the disease condition and so currently for example at nida we're funding research to try to understand what is it that the best intervention should be for someone that we would call pre-addicted to opioids or could also fit that criteria which would fit the criteria of a mild opioid use disorder where it is not justified to give them methadone where it's not justified to give them buprenorphine so what alternatives are there available that lead to the best outcome so this is an area that needs research and it also by creating the evidence one can develop guidelines and then one can get reimbursement for those services so this is this is why i actually uh resonated very much with that concept as a means to bring attention to a stage in the early stages of the disease process of addiction and that whereas we call addiction the severe soft lung use disorder we want to bring attention to that mild soft lung use disorder which in that definition really is not addiction itself is the early stages is the pre-addiction basis yeah thank you thank you for that work and i think that's going to be important moving forward into the future of health care for people who use drugs in america and i thank you for that you know that so what about the present though dr valkov when we when we look at the present it's overwhelming i think you use the word tsunami and um i think you've uh used the uh triple wave theory then you have dan chikaroni who uh researcher out in california who's added the fourth wave of the quadruple wave meaning methamphetamine and other stimulants well we're we're up against something today in america that you know and i know and my viewers know is just unprecedented what about that what about the present um i think it was near 108 000 people in 2021 correct was 108 000 people yet the equivalent of 35 world trade centers in in one year i think it's a person taken from us every 4.8 minutes what what about that what are people on your level thinking about that what is your hope for these people who who are taken from us at such an accelerating rate what what what's your what's your opinion on that well i mean obviously i think that we um these these terrible numbers these tragic numbers um are clearly in a way brought up the urgency of the issue across multiple agencies and and across people that come from very very different backgrounds because it cannot be ignored and it cannot even ignore even with also the the very high numbers of deaths that we have seen with covet and tragedy um both of those issues are very present and right now they account for an equivalent number of deaths so but they are very different in multiple circumstances and yet they should share the element that that individuals that are most vulnerable are the ones that are highest risk of its most adverse consequences which of course is dead the the the issue what it tells us is that it's not going to go away just by itself that it requires attention and that it requires the interaction and the cooperativity of the agencies that is not going to be one single approach and solution that's going to solve the problem for the ability and the capacity that we have to tailor the best interventions to provide the greatest support to people that need it and the communities so we have to stop being so inflexible in many ways that in many ways that's the way that we have dealt with addiction in general either it's total and absolute abstinence or nothing or you basically end up in jail or incarcerated those practices have not solved the problem and in fact the problem has gotten worse we also need to embrace the fact that what is going on in our country reflects certain social circumstances that are making people vulnerable to taking drugs and as we were discussing about what are the issues that lead you to vulnerability and just we discussed genetics or you scared me very clearly it is very likely that the reasons how genetics are basically expressing that vulnerability relates to the environments in which you find yourselves and I didn't say it just physically I do believe that if I had been born in with multiple childhood adverse experiences with my genetic background I could have ended up with an alcohol use disorder and by the way quite severe so understanding the social components that are engaged in the trajectory of addiction and the responsibility that we have as a society to face them so that we can provide alternatives and buffer them in ways that are not making so many people vulnerable to drugs and substance use disorders that would be what I would say that the COVID pandemic along with the over those crises is forcing us to look into in order to solve it I strongly believe absolutely that it is solvable that there are actions that if we implement that we put the resources and we sustain we definitely can control and overcome the overdose crisis but we need to put the resources and we need to continue to work together I mean here is not that me yeah I'm the science agency therefore I'm going to tell you what to do I build the science such that it can hopefully guide policies so that it can inspire others to take the treatments into the community and it's been very frustrating to build up evidence of prevention interventions of how to protect children and adolescents for taking drugs that are not being implemented so the evidence is out there but it's not being implemented so that's to say why how do we transform that willingness of putting the resources that are necessary to substantiate the structure to protect people from from drugs and and if they do have a problem with a substance use disorder to help them protect them from overdosing and dying and all of the negative consequences and to help them achieve recovery because recovery is clearly achievable and that's a message that I would like to say most people and this is something that people don't really know most people eventually achieve recovery the problem is that that can take many many years and in the process they can have very very negative consequences that can actually jeopardize their life and their health and their families that's why it becomes so important to do aggressive interventions it's just like when you have cancer right your your physician your health system does does not make a mouse around it just basically comes up with a plan and provides the resources that are necessary we should be able to do the same thing with substance use disorder I mean I I couldn't agree with you more you're probably familiar with Dr. Jew Young Park from Rhode Island Brown University she's written a paper on the social determinants of addiction more and more people are speaking about this and that's encouraging to me because I've been in the profession for a long time I'm in my own personal recovery since 1984 so I've been a student of this for practically half my life years ago no one was talking about the social determinants of addiction they were talking about weakness moral failing you know criminal personality that that was what that was what addiction was associated with so because of people like you and research like the research that you do and your teams do the consciousness is slowly raising but like you I'm frustrated too because we know so much but we don't act a lot on what we know for me in my community what's happening in Vermont today we're seeing a lot of people die from overdose we've had the highest rate in overdose increase for 2019 20 and 21 second to us is Kentucky and then West Virginia it's very very sad for my state we lost 215 neighbors in 2021 in my county we lost one vermonter a week 51 vermonters in 2021 so this is a state mind you where we have widespread use of naloxone very behind getting naloxone all over the place we have incredibly very low barrier access to buprenorphine medication for opioid use disorder we have fentanyl strips we have a safe syringe programs we have wound protection kits we have harm reduction up to a point but even with everything we are doing we have we have recovery centers in every county open seven days a week no charge where people can go and find their pathway to recovery we have very very active a a na all over the place but even with all this the rate of death is accelerating so when I look at that I I wonder well I want to move into harm reduction now because that seems to be the type of intervention that's designed now for the present to reach those people out there who are in the shadows suffering from maybe from lives of persecution early adverse experiences stigma how do we reach them dr. valkov when you think of them those are the ones in my view those are the ones that are dying a poisoned unregulated drug supply that's that's what they have access to what what are we what are your thoughts on that because I know you think about it all the time you have to what are your thoughts on that yes I think about it all the time and I think that in many ways ultimately we have certain beliefs and thoughts that are basically fed by the circumstances that we live and one of the aspects that I think that you were alluding that accounts for why we're seeing such a high rise in mortality including in vermont has to do with the fact that the access to drug contaminators with fentanyl has just accelerated and while we had seen a very significant rise of fentanyl since 2016 it was predominantly used to contaminate heroin and yet now we see that most of the drugs in the elicit market are contaminated with fentanyl and these poses particularly high risk higher risk because people that are taking opioids like heroin have tolerance to the opioids so even if they take a very potent drug like fentanyl it definitely be absolutely can harm them or if you have no tolerance you are certain that it's going to harm you like you're very extraordinary high risk much higher risk of overdosing that if you have some level of tolerance so we are seeing that the very dangerous drugs that currently are out there in the elicit drug market is making people vulnerable to overdose deaths that in the past is not that they are taking more drugs is that they are getting exposed to more lethal drugs and that is contributing to increases in deaths all over the country and and the very tragically too we saw for the first time starting in 2019 a doubling in the number of adolescents dying from fentanyl and and the use of of heroin the use of methamphetamine cocaine among other lessons is extremely slow low is the lowest that it is that it's ever been but they do take prescription drugs and and whereas in the past prescription drugs do have harmful effects but many of them do not produce overdoses but now if they do get their hands on an elicit prescription drug that contains fentanyl they are a population at risk for overdosing and this is what we hypothesize is causing the bear more than doubling in the number of teenagers that are dying from overdoses over a two-year period so fentanyl is changing the game changer at many many levels and we need to as a society and I think this is where your questions were coming how do we take that into consideration when determining our action plans to protect individuals I mean obviously ideally of course we want them to reach recovery but if they are not ready what is it that we can do to protect them so that they do not die in the process and they never ever get the chance to recover because they die so how can we protect them and that is we're upon the and the administration has embraced these as as an important target harm reduction interventions that can help people where they are in their trajectories whether we like it or not not not every everyone is ready for treatment and there are many factors that determine your level of readiness at any one given point but we need to act and think with humility and understand that the circumstances of people are very diverse and that there are going to be individuals that no much no matter how much effort we we place upon are not ready for treatment so how do we protect that you know and that reduction comes to play you know so I I think in one of your recent papers you talk a little bit about that you talk about fentanyl test strips you talk about certainly safe syringe programs there's no doubt about the efficacy of safe syringe programs preventing all kinds of health consequences you know I wanted specifically you mentioned overdose prevention sites and I I know it's a controversial subject I know this the data isn't clear on it but you know you know of alcove and and and and you you must know a lot about it you must have an opinion on it now you know that in Rhode Island legislation has been passed there are two sites scheduled to to open you know that in New York I had Kalin C she's the senior program director at on point in New York I had her on the show recently they have a site in Washington Heights they have a site in East Harlem and they have two mobile vans that go into the Bronx where I was born there so there's this stuff happening in America and the data the only data we have in America is from on point and it's looking good they've reversed many overdoses they've had thousands of uses they've decreased the the public use of public injection the public disposal of syringes so I don't think you have research on that yet if you do share it with me but but just knowing what you know initially about what's happening in New York what do you think about that is there a place for overdose prevention sites in in America let's if we could just forget about it's kind of impossible but forget about the Department of Justice for a minute okay just make make believe that there were no legal blocks to overdose prevention sites do you see a role for them in America well and you're asking me and and my perspective I mean because we are a science agency I guide my answers in terms of data because my own what my own beliefs on these things is not what is relevant what is becomes relevant is where is the data and you are speaking absolutely Vancouver and we've been funding research to determine the benefits of the in society in Vancouver and it clearly has shown that it is not they've never had a single overdose test and they don't model into estimate that they basically save approximately 50 lives every single year not only that they are actually because it's a comprehensive program they are able to engage people in treatment so and they also have shown that they are not only effective in preventing HIV but this effect is so large that actually has reduced the incidence of new cases of HIV in the whole community of Vancouver so the data from Vancouver shows very positive beneficial effects there is data that has also emerged from Australia also showing that it has saved an equivalent they have seen more cases it started to operate I think it was in 2000 so it is at least four years earlier than the site in Vancouver and they also have not observed a single case of an overdose and I have called actually I called the Vancouver site it was like three and a half months ago to find out because the Vancouver has also a very serious problem with fentanyl where there things have changed with fentanyl where they may have seen overdoses associated with fentanyl they haven't seen a single one no one that goes to these sites has died they've seen overdoses absolutely they've seen many overdoses they've seen many overdoses but not a single case of death and so in that respect you start to say well from the structure that these sites are placed in big cities they seem to have very positive effects also these safe injection sites safe injections I take drug administering sites or overdose prevention centers are all over the world I mean I'm highlighting Vancouver and Australia because that's where we have the most data but there are at least 100 sites throughout the world that have been operating now for many years and what I think is telling is that we are seeing more and more being developed and I think that it's also telling that in Canada we started with the site in Vancouver my understanding is that they have now more than 30 sites operating not comprehensive like insisting by Vancouver but actually nonetheless providing places where people that can administer drugs safely the question is how much all of that is translatable to the United States so we have been funding the site in New York that opened up to try to evaluate the outcomes and from what we are hearing in New York they basically have been able to say several people that overdose which of course is what they are one of the reasons why one puts these systems in place these places in place so but we need to now that they are going to be several other centers that are likely to be opening in Rhode Island in Pennsylvania and San Francisco it would give us an opportunity to understand whether there are differences between these places depending on the city depending on their resources provided by by these safe injectors like all the safe injections like safe at the overdose prevention centers and the cost associated with them because if it's a very comprehensive center of course it's more costly but on the long term it may give you a greater investments because you're providing the treatment as opposed to some of these mobile safe and license for administering drugs that are less costly but cannot provide all of the services that could benefit patients suffering from substance use disorders so there is a movement and sometimes what happens is that the practices that were tend to be propagated and if indeed it is shown and it is economically sustainable because that has been one of the questions that are to me is important let me know of the sites that have been evaluated are in big cities where you have a relatively high throughput of individuals coming in and out if you build one of these places in a rural area you can start to see why it may not be optimal because you don't have enough utilization to justify the cost and and where you also have limited resources that can be invested on something else because that's again when you're making decisions on how to optimally provide the help that people need that is always whether we like it or not unfortunately the issue is we're all working we're all working within certain projects and we need to within those projects operate to try to get the maximum benefit well thank you and I understand that and I'm just thrilled that your agency is looking at it and researching it and I'm you know to hear you speak about it and speak of it in such positive terms is very encouraging to me I had some statistics from from New York from Kailin Sea this is at six months so November 30th to June they had the 1400 participants 1400 24 000 uses they reversed 350 350 overdoses and only had to have an ambulance involved five times and the complications weren't the overdose they were in addition to the overdose the the um the medical system the emergency room the emergency departments have been relieved of like an incredible amount of activity in each overdose in New York there's two detectives assigned to each case each one of these cases did not need any detectives so the cost savings in terms of medical um hospital stays uh ambulances and police work was was phenomenal so that's just in six months showing a great uh cost saving so so that's very encouraging but as you're saying that's that's in New York City can that be scaled to a a rural environment namely Burlington is what what I'm I'm concerned with my my hometown right here we have 43 000 people living in Burlington and we did a study of overdose fatalities in the Burlington area we have a heat map that shows they're very densely concentrated right around the Burlington area and where there's a lot of public transportation so we have a kind of a a location picked out where what would be optimal for an overdose prevention site we have the support of the mayor of the city council the state's attorney the attorney general um and and countless citizens now in in the NIH of report of 2021 they they recommend they recommend following the American Medical Association's recommendations and the American Medical Association recommended that there be pilot projects pilot overdose prevention sites set up where there was support from the community and a perceived need in the community and that they would be followed in research to see if they work so in my view we we we had almost one Vermont to die a week in a small area Burlington which isn't in county in my view if we can raise the the funds we should be allowed to implement an overdose prevention center an overdose prevention site it should be researched and we should see whether or not it works I don't think that anybody should really make an assumption that it can't be scaled to any environment and I I don't I don't I don't see how that could possibly be true yeah I know but you're speaking of what you call rural and there's rural and rural and I was thinking for example in terms of some of the areas in West Virginia that you basically have nothing and you have people so far away from one another and there is no transportation is so that's what I was thinking I wasn't thinking of a place where on top of everything else you have a very very densely concentrated population where you are seeing the overdoses and that also you've identified a site that is reachable these are conditions that lead you to believe that you will sustain that use of that facility and and but but that's unfortunately not the circumstances in other places that have pieces in the Appalachia region for example where they actually have difficulty even getting access to teachers and to healthcare minimal healthcare so there is there are areas that are very remote where this is that again they don't therefore there the question is what is the most valuable intervention how do we provide the help to those individuals that are in these remote areas so we can protect them so but in the way that you describe your community it seems that it is reasonable to predict that the social facility could be justified and that it could provide the benefit that you're intending to provide and you you should research it thank you thank you we are and the other thing I think you mentioned you've mentioned resources a number of times and you know believe me I have no idea on your level what what it's like you know with the limited resources and the amount of work you have to do however it's kind of ironic Dr. Valkov that that that right now because of accelerated overdose deaths over the past 20 years we're seeing a lot of money coming into the state the opioid wholesale distributor a class action suit 58 million dollars is coming into Vermont over the next 18 years the Sackler family there'll probably be more money coming in through that stream the Biden administration just passed a one point what four 1.5 billion dollars like specifically earmarked for harm reduction so I mean all these allocations are a result of tragedy and that's what I think is ironic but the fact of the matter is that we have more resources now at our disposal than ever before my fear is that this money will not be spent on primarily on an immediate and efficacious approach to overdose death but it'll get filtered out to lots of other things because that's just the way it is when funds become available everybody wants some of them for good reasons but I see this right now this point in history as as kind of a perfect storm of opportunity we have a tsunami of death but we also have a rising tide of resources the the the if we can just focus those resources on the ones most at risk I think we can get through this point in history and then move on to some of the wonderful things that you've mentioned about prevention and early intervention and early addiction and you know intervening earlier in the process and saving lives earlier and saving money in the long term that's that's just the way I um I see it do you have any views on that yeah no one I wish I could tell you just you're absolutely right we let's focus on these very severe people that we have in order to prevent them from dying and the reason why I do not I'm basically think it's not so simple is that now as I was saying at the beginning we're seeing people dying from overdoses that are not coming with a severe opioid use disorder that may be occasional users of drugs and that includes the teenagers that we're observing that includes of the older people that seek out medications in the illicit market because their clinicians are not providing them to sleep better or to actually for pain and then they overdose so we are seeing the complexity over those crises forcing us to see that if we want to decrease and reduce the mortality we have to tackle both the severe but also the mild substance use disorder that is not so simple as it was at the beginning and that's why I again and I was saying we need to be thoughtful on strategizing how to maximize the resources that we have so that they have the greatest impact and while money is coming in what I can I always look at it in terms of that relative amount of money that is coming to address the overdose crisis versus the amount of money that is coming for the COVID crisis I mean there's absolutely no comparison and I do understand that there are differences in magnitude two to a certain extent but there's no proportion and in my view and I basically very supportive of putting the resources for the COVID and to me it has been wonderful to see that vaccines are available to anyone that testing kits are available to anyone that antiviral and that's the way that we should be dealing with an issue of substance use disorders treatment available to anyone that needs it and interventions that are tailored to the situation of the person and yes indeed for the COVID this is an important very important component let's prevent it so these aspects are to me a lesson on how to basically take a process that we have realized we need to put our heads together in order to give the resources that ensure optimal outcomes and and we have not brought it anything close to that with overdoses that we draw up and and because I think it is they are not considered at the same level of importance addiction as a disease is not considered the same level of importance as infectious diseases or Alzheimer's or cancer and yet it is it's devastating and unfortunately you know tragically this is true but but but we have to end now I have a few minutes thanks thanks to you people like you I think of John Kelly I admire John Kelly tremendously Vivek Murthy there are others who have really stood up against stigma over the decades and you're one of them and um you know I just thank you for your leadership I thank you for your your your piercing analytic skill if and your your the way you stick to it I thank you for this interview and educating me and my audience I thank you for your generosity you know to give us an hour of your time with the kind of schedule you have is just really something that we're all I'm sure deeply grateful for dr. valkov so thank you for your career thank you no thanks and I appreciate the opportunity to speak with you and your father thanks very much thank you