 Hello, I'm Peter Szaroszy and you are watching Drug Reporter Cafe, our online video series on drug policies. I'm glad to introduce our guests today, both of them join us from the U.S., Roxanne Socier and Daniel Wolf, both from the Open Society Foundations. We invited them on the occasion of their joint paper that was published in the prestigious International Journal of Drug Policy with the title Biotechnologies and the Future of Opioid Addiction Treatments. As the title suggests, it explores new biotechnological innovations in the treatment of opioid addictions, such as long-acting pharmaceutical drugs applied in the form of implants and injections. Daniel, Roxanne, hello, welcome to the show. Thank you, Peter. Hi, Peter, thanks for having us. Can you first explain how do these biotechnological innovations, implants and injections work and how are they different from previous treatment methods, Roxanne? Yeah, sure. So as you say, we looked mainly at long-acting injectable and implantable treatments in our paper. This includes buprenorphine formulations that last anywhere from a week up to six months. In the U.S., we have probufine, which is four rods about the size of a matchstick each that are inserted into the upper arm for about a six-month period. It was approved several years back, but it's actually had limited uptake, probably because it requires a special training and kind of a minor surgery for insertion. We also have sublocade, which is buprenorphine injected subcutaneously into the abdomen, which provides treatment for about a month. In places like Europe and Australia, you have buvidal, which is weekly or monthly buprenorphine. So there are several long-acting buprenorphine options, depending on where you are and more coming to market. We also have vivitrol here, which is an extended-release naltrexone. It's different from methadone and buprenorphine, which are opioid agonists, and as you know, work by binding to the opioid receptors in the brain and activating them. Naltrexone is different. It's an antagonist. It binds to the opioid receptors, but blocks them so that opioids can't reach them. With long-acting naltrexone, it lasts for about 28 days. So with all these treatments, rather than being daily treatments, you receive an injection or an implant, and then the treatment is released into your body little by little over a set period of time. And they're touted for their convenience, but as we'll talk about throughout this conversation, they're desirable to some because the person taking them can't skip doses or divert their medication. Thank you. We are speaking a lot about addictions, and there are many competing definitions and models of addictions. Some people even reject that to use the term addiction as such, because they say it's ideologically loaded. So, Daniel, where do you stand in this debate? And how would you conceptualize addiction? Yeah, I agree that addiction is a very unstable and ill-defined term. And despite assertions, for example, that addiction is, quote, a disease or a brain disease, the reality is that it relies on the narration of the person in question to help, quote, diagnose it. I think for the purposes of this discussion, I would define it as dependence on a substance, which society is not willing to provide people through medical prescription or socially approved means, and whose use brings negative social consequence. And those consequences are obviously determined by social context, like since societies have different laws regarding and tolerance for different substances, different prescribing practices, et cetera. Ironically, the treatments we talk about, which are for opioids and labeled as addiction treatment, or treatment for, quote, substance use disorder, another very vague and problematic term in the U.S., might be better termed anti-use treatments, since the medicines that are implanted or injected block all other opioids prescribed or not. But we used the term addiction treatment in our paper, in part because it was on a volume about addiction treatments more generally, and in part because we felt it was important to look at the issues raised by these medicines and the way that they are commonly marketed and deployed, not because we have such confidence in the term addiction. Okay, so in your paper, you wrote that the future of addiction treatment is biotechnological. So what we see also developments in other fields, such as cognitive behavior, therapies, and other non-technological methods of addiction treatment. So why do you think that the biotechnological solutions will prevail? I totally recognize the value and importance of behavioral strategies and social support, and I personally feel like mutual aid from people who use drugs to each other has been among the most critical elements of, quote, recovery. That said, and this is particularly true in the U.S., but increasingly in the field of addiction treatment, which the U.S. funds 85% of in the world, a combination of corporate interests on the one hand, the bias toward new and patentable money-making interventions, a generalized mistrust of the long-term nature of behavioral change, and tensions between what I would call the system interest in sort of controlling or containing people who use drugs, and the space and the tension between that and leaving the space for people to narrate or guide their own recovery, make technical solutions really, really appealing. It's also the case that they can be very effective, and I don't want to minimize that. Biotechnologies, though, are attractive in part in addiction, precisely because they work around the behavioral or around the mind of the person with all of its complexities, and as Roxanne said, in the case of these medications, you can't stop them even if they want to. Yeah, when I read your article, I had the feeling that for some treatment providers, it is more important to make patients easily controllable and manageable and not so much make them as happier human beings. But at the same time, we also see many examples that some patients themselves welcome these innovations and volunteer to try them. I have this question to both of you. Are biotechnological solutions inherently worse than psychosocial methods, or is it only that they are used as a tool of social control and discipline that makes them a very strong? Roxanne, do you want to go first? Either way, I mean, yeah, thanks for bringing that up, Peter. I think when you're talking about things like vaccines or brain surgery that are irreversible, it brings up kind of thornier ethical issues. But as far as the long acting treatments that we talk about in our piece, you know, I welcome the ability for people who use drugs and who want treatment to have more choice about the types of treatment and the delivery systems and the length of treatment and all of that. It's really the context in which these medications are delivered that can make them problematic. Tim Rose and Carrie Lancaster have this concept that they've talked about of evidence making interventions, kind of in contrast to evidence-based interventions. And the idea is that public health interventions can look very different in different contexts. There's no one real fixed version of an intervention. They're all shaped by human and non-human factors, which could include things like doctors, lawmakers, administrators, clinical guidelines, surveillance measures. So you think about some of the places where they have more draconian drug policy context, and you can imagine how a technology that could offer one more choice to drug users in one place could constrain choice or autonomy in another if it kind of crowds out other options. And there's often a disconnect between the way that people like researchers envision these medications and their real-world use. I remember reading an article on qualitative research that was done about how drug users would feel about long-acting treatment. And it contained a checklist at the end with the suggestion of questions that providers could ask patients to help them decide on treatment, things like, how does the patient want the medication to make them feel? Do they like feeling a steady state or do they prefer some ups and downs? Or what are the patient's goals in treatment? And if this was always truly a conversation, then I think I'd feel much rosier about the long-acting treatments. But, Peter, I think you hit the nail in the head with your question about whether the goal is to make people happier human beings or to make them more manageable. There's been some research, which I think is really interesting, but little discussed, looking at naltrexone and social bonding. The research is looking at the effects of naltrexone and what they call healthy volunteers. So not people who use it for a drug treatment, but just kind of run-of-the-mill volunteers for this study. And they found that naltrexone reduces feelings of connection to other people close to you and also heightened responses to social stress. Now, as we know, social supports are really important to recovery. I think it's Johan Hari who says the opposite of addiction is connection. So you can imagine that something that gets in the way of that feeling of connection can inhibit recovery, never mind happiness. But hey, I guess the person isn't getting pleasure from drugs, at least. Maybe to add that the context into which and the evidence-making intervention in the U.S. context that these medicines are operating in is one where criminal justice and control of people who are criminal offenders is very present and interwoven with any response to addiction, so-called health response to addiction. And one of the things that we have seen, even while recognizing that these medicines have actually been really helpful to people, and I have personally spoken to many people who have gotten a lot of benefit from all of these long-acting formulations. So this is not to say that they are bad or that they are reducing of valuable support necessarily, but it is to recognize that criminal justice systems have been a primary target by the manufacturers and marketers of these medications. And that criminal justice systems, of course, are not contexts that are particularly conducive to free and informed choice, to patient autonomy, to changes in response, to patient feedback about difficulties with the treatment or the dosage. And it's telling that these companies have gone directly to, for example, sheriff's offices, prison wardens, drug court judges to try to promote their product and have come under some scrutiny for these marketing practices. Roxanne can actually say more because she's identified quite a few worrying examples across the country. Yeah, well, I mean, in terms of scrutiny for their marketing practices, actually, our incoming vice president, Kamala Harris, as a senator, expressed concern about the marketing practices of Alkermes, the company that makes Vivitrol, and the large amount of money that they spend lobbying federal officials. But when Daniel talks about the appeal to the criminal justice system, we were looking at to see what the reaction from drug court judges, prosecutors, others would be, and found this really telling quote on Facebook from a prosecutor in Indiana that I'll just read to you. He says, he's talking about his Vivitrol program. Participants will be required to take a monthly shot of Vivitrol, which is a drug that prevents opiates from reaching receptors in the brain, and prevents the person from enjoying the effects of the drugs. Vivitrol patients will be placed on home detention to keep a close watch on them, and will waive their Fourth Amendment rights against warrantless searches. So this is the kind of context in which this medication is often being offered in. And even when it's not as vivid and punitive as that, we have seen the rise, for example, of Vivitrol courts, multiple states that have incorporated Vivitrol into their criminal justice sentencing, oftentimes with the exclusion of other treatments that might work as well or better. And in fact, there has been no evidence that Vivitrol is better than any of the older, longer, better studied treatments, for example, methadone and buprenorphine, the short acting formulation. But when you survey, as one researcher did here, criminal justice officials, people report that they prefer Vivitrol, the blockade, because evidence has shown that it's more effective in preventing relapse. Of course, really what is happening is that this medicine snaps more neatly into the preconceived bias about what we should be doing with people who use drugs, which is removing from them whether they like it or not the option to use in the name of public health and safety. Well, it is really telling that taking away the joy is identified as a treatment benefit for people. So both of you talked about informed consent, and that's one of the central issue here, and that some people give their consent before using these implants, but later they can't change it. So what do you think? Can we really speak about informed consent in this context? Is it really informed consent or how to resolve this ethical issue? I think there is such a thing as informed consent, even with a long acting formulation. I also think that the medical providers who are delivering these treatments have an obligation to listen to and consider the feedback of the patients in their narration of their experience. So Vivitrol, for example, is marketed as something that will reduce cravings. It is not universally reported that that is the case, and in fact, many people experiencing craving or very much feeling anxious to return to drug use immediately after cessation of the long-term effect return to opioid use, where, in fact, as anyone returning after a period of abstinence, they run a very high risk of overdose. People who are using the long acting buprenorphine formulation, some of them report that the dose that they're given isn't sufficient and they need to supplement with oral medication, et cetera. I think one of the dangers of these treatments is that the technology begins to drive the clinical protocols and that doctors don't necessarily feel the need to listen to patients any longer but just say, look, I've delivered you the appropriate dose and that's the end of that. That is also true with older biotechnologies like regular old medicine when it comes to addiction. And so one of the things that these medicines elevate is the need for a new treatment ethics. Maybe we can talk about that a little bit later. But in many ways, the issues raised by these are technical or versions of very long-standing issues in addiction treatment more generally, particularly when it involves a prescribing doctor who controls your ability to continue on a medication or abstain from so-called extra medical or illegal use. Again, you mentioned how these methods are used in the context of the criminal justice system and in your paper you are writing about car serial prescriptions. Is this a new term you invented? What does it mean? Yeah, I guess it may be a new term we invented, I'm not sure. You may have heard of for example of car serial feminism where the solution for some of the problems that women face, for example, with domestic violence, etc., is to incarcerate offenders. In this case, car serial prescription for us refers to the practice of when you can't lock up the person locking up the receptors in their brain. And I will say that even though Roxanne mentioned at the outset that buprenorphine was an agonist, it's also an antagonist. So sublacade is called sublacade for a reason, because it blocks the effects of other opioids. And one of the things that makes these medicines so attractive to people is this blockade effect. I believe that in the name of so-called health response, it has become very common for us to say we need a health and not a criminal justice response to drugs, but much less common to look at the ways in which health responses mimic the impulses of the car serial state, that is to control and contain people who use drugs, much like you would try to control and contain drugs and drug trafficking itself. And it is very clear whether it's the Indiana, the representative that Roxanne quoted, sheriff's offices who are using Vivitrol courts, or just the general marketing of these medicines as something that removes patient choice, that one of the things that makes them so attractive is that people basically can't choose any longer. And that is a carceral intent and something that fits very neatly with things like drug courts, which are a so-called third way or kinder gentler solution to the drug war in the U.S., but in fact reproduce many of the same dynamics that animate straight up law enforcement and arrest. Roxanne, can you talk a bit about how scientific evidence is used by these companies and the proponents of these methods to show that these drugs are superior to other treatment methods? Yeah, well, so I should be clear that there is no actual evidence that Vivitrol is superior to methadone or buprenorphine, which are of course the gold standards and have a much longer track record of use, as Daniel mentioned. Vivitrol was approved for the U.S. market in 2010 based on a single clinical trial of questionable ethics in Russia. Daniel's written about this in the Lancet before. It was a placebo controlled trial, so it wasn't compared to the standard of care methadone or buprenorphine. Of course, methadone or buprenorphine are not available in Russia, which prompts the question of why the drug makers chose to conduct the study there in the first place. And really, you know, concerningly, the study didn't evaluate overdose risk, which is an obvious concern with a treatment that eliminates your tolerance to opioids. So here's what the research does say. More than half of those who get a Vivitrol injection don't return for a second injection. A large study found that Vivitrol has no more impact than overdose at three and 12 months after initiation, then no treatment at all. And we did some research looking at adverse event reports, so reports of serious side effects that are reported to the U.S. Food and Drug Administration, and found concerning reports of overdose deaths. And it appears that the two months following the initial, sorry, the last injection are a danger period for overdose. And then Daniel also talked about the kind of evidence that's created by researchers when they say that this is the kind of treatment that should be used because it's the one that drug court administrator or criminal justice administrators think is the best treatment. This kind of idea that because people, because prison administrators don't find methadone and buprenorphine acceptable, we should just acquiesce and instead spend money to develop new treatments. There's an anthropologist who talks about the idea of the configured user. So when someone is developing a new technology, who are they imagining that future user to be? And I wonder whether pharma companies and those who fund drug development are always thinking about people who use drugs as the envisioned end user. Or if they're sometimes thinking about prison administrators or drug court judges and what will appeal to them, and then how does that influence the technology that's developed? We should also say that one of the things that prompted the investigation by Kamala Harris of the maker of Vivitrol was the fact that marketing representatives were traveling around basically saying Vivitrol is not an opioid and therefore playing again on the bias against opioids that are is carried in these systems. Despite the fact, again, that there's no evidence that the fact that it's not an opioid makes it a better treatment. But I think that one of the questions raised by these, and you know, it's ironic because one of the the subway and billboard, bus billboard and highway billboard ads in the US just showed big pictures that said, what is Vivitrol? And it's an interesting question. Is Vivitrol in fact a treatment designed for the patient? Is Vivitrol a convenient medicine for some of the biases that are carried by society about opioids and how to stop them? Is Vivitrol an addiction treatment or an overdose reduction treatment? All of these things are very much in play at the moment. As you may know, and as viewers may know, the US, and this has only gotten worse in COVID, is in the middle of a very severe overdose crisis with tens of thousands of people dying and we're on track this year to have more people dying than ever before. Addiction and overdose are not the same thing, but one of the things that the Vivitrol marketers have done is basically position this medicine as a potential response to the overdose crisis, even at a time when, as Roxanne mentioned, it may be that those who are ending the treatment, which is in fact, in real life settings, often the majority of people may not realize that they're at increased risk for overdose when they stop. And this is another thing that the company has come under scrutiny for, which is, have they in their marketing materials underplayed the risk of overdose in patients who stop the treatment? Has the company tried to market this drug in other countries, apart from Russia and US? Yeah, I mean, in Russia, they have actually different formulation, which is abdominal implants. And those are under investigation and seeking approval also in the US. But yes, and I have, I have, for example, sat next to officials from the government of Vietnam, who have had conversations with Vivitrol manufacturers and who are quite interested, despite the fact, ironically, that Vivitrol is also many, many more times expensive than, for example, methadone. So methadone in many countries can be as low as $7 per patient per month. Vivitrol is often more than $1,000 per patient. So it seems that those governments that that see drug addiction as a biochemical phenomenon and as a brain disease, they are more open to these kind of solutions, right? I don't know if I could think of any government that isn't partial to the tendency to want to control drug addiction by basically controlling opioid intake. I think Europe, for example, has had a more friendly relationship to some of the short acting formulations. But as Roxanne mentioned, these long acting formulations, both Vivitrol and the buprenorphine formulations are coming soon to a pharmacy also near you and Hungary or in, you know, in Australia, they're growing in popularity. I don't think that I think that the tendency to want to solve the problem by locking up someone's brain is often nearly universal response by policymakers who feel challenged by the much longer harder work of actually articulating responses that serve the needs of people. Okay, let's speak a bit about another drug, Suboclade. Roxanne, can you can you can you tell us what are the experiences with that drug? Sure. So a little while after Sublocate hit the market, we wanted to find out what people's experiences were. And we went online to look and found kind of a treasure trove of video blogs with patients detailing their experiences, both the good and the bad. Some of the good things that people talked about were the idea that you can wake up and feel fine and not need to worry about dosing or waiting for a medication to kick in. People like the lack of physical side effects like dry mouth, they liked some people like the lack of kind of ups and downs that they would feel with a daily medication. And people like not having to worry about having your medication with you or forgetting to bring it with you. Also, they don't they like not having to deal with the system that stigmatizes you. So you don't need to risk the nasty reaction at the pharmacy when you go to pick up your buprenorphine or to bring all your wrappers to your doctor to prove that you took your medication and didn't divert it. Now some of these are benefits of the medication itself. And some are things that could be addressed if we reduced the stigma of people on buprenorphine. And then there were also some bad, bad stories people, some people found it ineffective. Like they still had cravings or were experiencing withdrawals and had to supplement with oral buprenorphine on top of it, which kind of undermines those benefits mentioned. And sometimes doctors wouldn't believe that they needed to supplement. They thought they were just drug seeking. So they were left in a really bad position. Juan also had an infection at the injection site. One experienced undissolved medications or like this lump in the abdomen that just wouldn't dissolve. Some patients said they didn't feel in control. They couldn't predict when their medication would release. And others said that they didn't like the roller coaster of the long acting medication. So really a range of experiences depending on the person. And it's hard to tell from online video blogs how common any of these are, but these are issues of concern. So it seems that community organizing and advocacy among patients is really important here, right? To reveal what's happened. Yeah, to get those messages out more publicly, I think. So people can feel a community of shared experience. So there has been an obsession among some scientists to find the genetic root cause of addiction and to find the addiction gene and then switch it off, as well as finding a vaccine that prevents people to get high forever. What do we know about these solutions, Daniel? Look, I think we know a number of things, including that we don't know enough for them to work. The idea of, for example, being able to blockade something in the brain to end addiction is not new. And in fact, the search for a so-called addiction vaccine is not new either despite the fact that the National Institute of Drug Abuse, the US institution that funds most of the world's drug research, frequently gives grants, so-called new research or grants, to advance this hypothesis. What we've found with other brain technologies, for example, the kind of stereotactic surgery that is used in China or Russia to so-called destroy the parts of the brain that are associated with addiction, is that a big question is, will you also turn off other sources of pleasure, connectedness, etc., in your attempting to blockade the addiction effect? It's also the case that the idea of genetic, a solely genetic or solely brain receptor response to social conditions and sort of social, psychosocial behavioral issues is often too simple. I'm reminded of the many efforts to identify the gene associated with homosexuality. And in fact, there are so many variants of sexuality and of addiction and so many different social contexts that this returns us to where we started at the beginning. Addiction-defined how, with such an imprecise definition, the idea of a precise solution is quite questionable. All of that said, you know, CRISPR gene editing is probably to talk about biotechnologies whose impacts have not been fully explored. I would not be surprised if we saw some efforts at genetic intervention to reduce risk of addiction at least, sometime in our lifetimes. But I don't think until we look more critically at the definitions, I think I would be very suspicious of irretrievable or irrevocable solutions. And, you know, while we're talking about long acting injections and implants, the truth is that the longest acting of them is six months, where something like genetic modification is permanent. And I do think that there is a greater ethical scrutiny and in fact, a series of ethical concerns that is raised there. Even for life-threatening diseases, gene editing has been quite a controversial subject. I also think that the quest for a blockade, a permanent blockade, preventative permanent blockade, is something that will continue to receive funding regardless of how many times the experiments turn out to fail or underperform, because again, it snaps so neatly into what the drug-free fantasy that animates much of the medical response is. In your paper, you compare long-acting opioid drug treatments to contraceptives. Roxane, can you explain us what makes them similar? Yeah, there are a lot of interesting parallels to the experience of what is called long-acting reversible contraceptives. These are medications like noreplant, which is rods, again, surgically inserted into the upper arm, much like probiophene, but in this case active for five years, and deproprovera, which is a hormonal injection, lasting, I think, three months. These were also prompted at the time, or promoted with a kind of dual emphasis on patient convenience and patient responsibility, and motivated by this idea of concerns about quote-unquote user failure, much like Vivitrol. They were advanced by state institutions, in this case, often public clinics and public schools, but also noreplant was used in the criminal justice system. In some places, pregnant women who use drugs were given the choice to use noreplant or do jail time. There was one doctor quoted in a newspaper at the time who said something like noreplant is tempting to judges, because it's so long-lasting, it doesn't require any cooperation after it's implanted and can be monitored by a parole officer, just by looking at a woman's arm. They were heavily marketed to those who some would view at the time as untrustworthy or less capable of managing themselves, in this case, mainly poor black and Latino women and girls. In our case, of course, there's parallels to these medications being marketed to people who use drugs, particularly those under the surveillance of the criminal justice system. There was one journalist at the time who, I think it was in the New York Times, said that noreplant seems to offer the liberating possibility of family planning, but in America, it's most popularly touted by those who want to get a lock on the womb. And Daniel talked earlier about the idea of wanting to get a lock on the brain, so kind of a similarity there. But the comparison is especially apt to me, because neither of these technological fixes actually gets at the root cause of either problematic drug use or unplanned pregnancy, which could include things like poverty, criminalization, gendered power dynamics, kind of holds up the promise of a new solution without actually addressing any of those underlying problems. And an interesting point from the story of the long-acting reversible contraceptives is that women in places like Bangladesh and Brazil and India, they rose up and they organized field studies to document the real impacts of the medication. They pushed back against the long-acting medications being included in programs and in donor agreements, and they made demands around ethics. They wanted a choice of methods. They wanted truly informed consent about the risks of insertion and of removal. They wanted free and easy access to removal. And in the case of noreplant, they actually ended up helping to force withdrawal of the product from the market. And I just want to say that I think underlying both, and Roxanne mentioned this, but just really to highlight it, both contraceptive, quote, technologies and the state's use of them, and drug treatment technologies and the state's use of them, very much animated and strengthened by racist assumptions about who can control themselves and who not, who the state must control. You know, it is no accident in the U.S. that these long-acting contraceptives were disproportionately deployed in women of color even while the state said it was for them. And similarly, that the criminal justice system, most of those locked up for drug offenses are also black and brown people. So one of the things that the women's movement was successful in doing is making alliances between black and brown people, for example, in the U.S. and so-called, not their term, third world women in other places. We haven't seen the same kind of success along those lines yet for people who use drugs. The international network of people who use drugs has issued a position paper on long-acting formulations for addiction treatment, but I don't think we've seen the same solidarity or what one anthropologist called women patient success in making them, quote, obligatory points of passage in the discussion about how treatments are deployed. Drug users have yet to achieve that status and that efficacy in cross-cultural and anti-racist organizing. My final question is to both of you. In your paper, you call for a new treatment ethics. Can you explain us how this new treatment ethics should look like and what are the take-home messages about this new treatment ethics for professionals or decision makers? Let's start with Roxane. Yeah. Okay. Well, there's various areas where we could talk about the kinds of ethics that are needed. One of them is a choice of treatments rather than just a single one. In Rhode Island, one of the states here in the United States, a small one, they're one of the places where in prisons there's an actual choice of all three FDA-approved forums of medication-assisted treatment. So people can choose methadone, buprenorphine, or naltrexone for a treatment when they need it. And when they're given the choice, people rarely choose naltrexone. So really offering the choice. Accessibility of all treatments, including financial accessibility, accurate information around the treatments, like the women's movement demands about information about safe removal and stopping the treatment safely. And then removal of barriers to daily medications too, like give people take-homes. Take away the need for a daily visit to the clinic. So that has to be part of it too. But more largely, I think we talk about in our paper moving from the idea of compliance or adherence to this concept of concordance. And so on the one hand we have compliance, which is kind of the concept, you know, measuring how closely someone follows a physician's recommendations. It's kind of one-sided, very paternalistic way of viewing things with the physician making decisions. So there's also the concept of adherence, which implies some more discussion between patient and physician to come to an understanding about the recommended treatments and measures then how someone adheres to that plan. And there's now a movement towards the idea of concordance, which is the idea that the aim of the relationship between a provider and a patient is to create a therapeutic alliance between equal partners. And that the physician needs to not only express their opinion, but needs to enable a patient to be able to voice theirs. So there's respect for the patient's agenda. And to me, this would include respect for endpoints or treatment goals that are other than complete abstinence from illicit drugs. You know, some people may well wish to get, you know, a kind of higher rush from their medication while others may want to feel even and steady all the time. It would trust patients to be believed as narrators of their own experience. So to me, the answer is an additional or more advanced techno fixes to monitor patients or ensure compliance with the doctor's plan. It's about creating spaces where patients know that they can be honest about their goals and experiences without punishment and without retribution. Yeah, more options are great if they actually result in more choice for the patient rather than more nuanced control for the system. Yeah, I once visited a heroin-assisted treatment clinic in Copenhagen, and I had never been to such a clinic before. And the doctor who was in charge said that she started each conversation with the patients there with the question, what is it that you want from treatment? Do you want to get very high? Do you want to just be stable? Do you want to inject this heroin using the vein scanner that we have in the clinic or do you want to go into the bathroom and inject it yourself? Do you want to take it as an oral solution? And one of the things that was so radical about that for me was not actually the prospect of administering heroin as a medical treatment. So of course, that's unusual. But just the attitude that treatment would begin with that open-ended inquiry with the patient's interests as the preeminent focal point as opposed to a preconceived notion of where you are trying to get in forcing people to abstain from drugs. And I think if that ethic can rise to the floor, then long-acting tools are a very valuable addition to the arsenal. And that we would move away from the idea that treatment success is defined by the system rather than the person who is ostensibly being helped. And that would be an incredibly important and valuable addition to the discussion. So Roxane, Daniel, thank you so much for educating us about this exciting and worrying news, new trends from treatment addictions. And thank you so much for being with us. Thank you very much for having us. Really appreciate this and also your work. Yeah, thank you. It's been a pleasure. And thank you for those who are watching us online on Facebook. Please follow us on Facebook and Twitter. And if you like the show, please give us a donation today. This show is produced by a non-profit organization financed by private donations. So we appreciate all donations. Thank you very much.