The Opioid Epidemic: What Everyone Needs to Know

The opioid epidemic refers to the enormous surge in opioid addiction and overdose over the last several decades in the United States. Much of the epidemic has its origins in medical practice. Devastating consequences of the opioid epidemic include increases in opioid misuse and related overdoses, as well as the rising incidence of newborns experiencing withdrawal syndrome due to opioid use and misuse during pregnancy. Opioid overdoses accounted for more than 42,000 deaths in 2016, more than any previous year on record. An estimated 40% of opioid overdose deaths involved a prescription opioid.

Episode VI will explore the less than obvious connections between mental illness and substance abuse. We would like to assert that one, often overlooked foundational connection is, the unhealthy need that leads to the opioid use, which completely destabilizes a Healthy Mental decision-making process. Are we still in an epidemic in 2022? What are harm reduction policies and what have been their outcomes? Which populations are currently most affected? What can individuals, neighborhoods, communities, cities actively do to assist in solving this epidemic? What are good Samaritan laws? Are their signs that the tide is changing? What are the Trust factors in need of transforming that will lead to satisfactory resolutions?

Show Topics and Highlights

There is a lag between technology and knowledge and the criminal justice system

A physician's background beliefs may influence their decision making

My own efforts have been in getting new technologies into African American and Latino communities.

There's what we call an opiate, and then there's what we call an opioid.

Everyone has a genetic element that dictates what their response is to medications

Are doctors ever held responsible, legally?

What training are doctors getting on proper use of opioids?

We've had great difficulty in changing the dosage requirements, which is set by law in some places, and we find that when people get inadequate medication they may end up using drugs to get by

A lot of a prescriptive practices involve the patient being given responsibility of taking the medication correctly.

There is a huge importance in getting a support system around the patient

There's more training and information needed on the best ways to work with people and making sure you're doing right for that person

This is where health equity comes into play. Because it's not just about making things equitable. It's about what investments would have to go on to raise the value of care.

The number of African American physicians is actually about the same numbers as it was the 1960s. Same as for the Latino community.

Profound Conversations Executive Producers are the Muslim Life Planning Institute, a national community building organization whose mission is to establish pathways to lifelong learning and healthy communities at the local, national and global level.   MLPN.life

The Profound Conversations podcast is produced by Erika Christie www.ErikaChristie.com

Full Transcript

Joia Jefferson Nuri

Hi, I'm Joia Jefferson Nuri, and thank you for joining us for Profound Conversations. This is a series of talks with professionals in the medical community about a lot of different topics. Our topic today is the opioid epidemic and what everyone needs to know. For years now, headlines on television, radio and newspaper have talked about the opioid epidemic. We're hearing stories of people dying, people becoming addicted people going to jail for stealing it. People switching from the opioids to heroin. But what actually is it that doesn't affect your life? You may be a little bit in the dark, to talk about it with your family. I think we all should. Let me tell you who's joining us today. Dr. William Lawson. He is emeritus at Howard University, Howard University College of Medicine. And we thank you for joining us. And for all of our guests. If you want more information, visit our website about their backgrounds. Also joining us today is Denis Antoine. He is a board certified psychiatrist and addiction medicine specialist. He lives in Baltimore also. Thank you so much, not also you live in Baltimore. Thank you so much for being here with me today. Dr. Antoine, I first want you to define what an opioid is.

Denis Antoine

Joia first. Thank you for having me today. I'm really excited to be part of this conversation. And it's a good question. And there are a lot of ways of looking at it. And sometimes we parse words, to describe it. There's what we call an opiate. And then there's what we call an opioid. And opiate, just to start out there is what would be naturally occurring. And we think back to probably the history in the United States thinking of the poppies flower that was brought in during some of the wars and the extract from that pop of flowers to naturally turn substance which is an opiate. And it hits one of the receptors in the brain, in particular, that leads to a pleasurable response and the more of it that you get, the more pleasurable response that you will be able to receive. And there are naturally occurring opiates in our body as well. Now endorphins and things like that we get a high from different activities, but it doesn't rival the high that you would get from that naturally occurring extract from the flower. Then you take a different step towards what we call an opioid, which is sometimes encompassing the natural park but also is this synthetically or almost factory made drug that also hits those receptors, but is much more potent at times. That's when you get into things like the fentanyl so the things that are more prevalent nowadays that are synthetically made, sometimes for medical purposes, and then they've been diverted into what we now see is reused that can be very harmful. So all those the opiates and the opioids are intended to hit that receptor.

Joia Jefferson Nuri

Opiates are they as addictive as the opioids?

Denis Antoine

It depends, there's a large range there. And some of those opiates, for instance, diacetylmorphine If you were to say it that way, you would think oh, that's just a regular old no medication as prescribed. That is the name for heroin. And that is also a cousin if you will of morphine itself, which we all know is prescribed by doctors. So they can be just as addictive but it's also how they're prescribed, how they're monitored, and ultimately, how that person uses them and the consequences that might come across because of the use and interaction with other people in the sphere. So it all depends on how the rest of the context is in that picture.

Joia Jefferson Nuri

Okay. Dr. Lawson, would you like to add something to that definition?

William Lawson

Yeah, actually these drugs been around a long time. They of course occur in nature but also during World War Two, the Nazis needed something for pain so they synthesize several agents, including ones such as methadone. And recently, it technology has advanced to the point that one of the agents, fentanyl was became extremely popular because 100 times more potent than morphine and as a result On. Individuals who divert these drugs illegally and get a lot more bang for the buck for these agents, and might add the endogenous opioids are not as potent because release in terms of neurotransmitter endings. But if you look at someone like Diane Orpheus, and some of the others, is far more potent than morphine itself is simply that it's that cost effective and meaningful to good synthesize those endogenous opioids. But they play a very important part in terms of functioning in terms of providing release with painful situations, in terms of brain summer euphoria. Some individuals, it's only that we're not using these agents is nature intended to when we've made them available for for health professionals, and for everyone else. So all it's kind of obvious is is not something unnatural, came out, was part of an natural response that we've evolved in terms of being able to deal with pain and pleasure.

Joia Jefferson Nuri

The first time I ever heard the term fentanyl was at the death of Michael Jackson. Was that a new drug at 2008?

Denis Antoine

It wasn't brand new at that point. I think there were other medications in the mix there on which is another thing that's coming up more recently that people aren't often just using one thing. And I believe there are other medications like Crowfall, and then that were in the anesthesia realm. I think what we're finding is that the medical utilization of those things and where people are using them in the surgery procedures are after they get discharged, eventually, as Dr. Lawson saying they might end up in ways that we didn't intend. And that's where you get towards using them as Michael Jackson was using a little bit more. And so it wasn't brand new in 2008, but certainly got more spotlight at that time.

Joia Jefferson Nuri

Dr. Lawson, you mentioned that this goes back to World War Two, when the Nazis figured out how to use it. You said as a natural Poppy that we I first heard of during the Vietnam War, you know, as a that's something they brought euphoria to to soldiers, they got back to this country with it. But over the last five or six years, there was a period there where every evening, the nightly news would open with a story about opioids. And there were Washington Post, front page stories about opioids. There's lawsuits, billions of dollars being flown around here, HHS, CDC are involved. What happened over the last five to seven years, Dr. Antoine, to make this headline news?

Denis Antoine

I think there's been a few things that plan it's a storm, if you will, that's come together. Part of it before that time period was that there was more prescribing in the medical setting of opioids for pain, and the different factors that went into that, partly that certain providers were told this is what we should make sure it's treated properly. And some of those advice that was given back then may not have been the right thing, but it was given so you saw prescribing of opioids going up. At the same time. You know, as we got closer to this five year period you talked about there wasn't necessarily the best teaching of how to manage people once that opioid course was done. So you know, an antibiotic when you take it, it's, you know, seven to 10 days, you've done good before opioids, that advice wasn't always given Oh, it wasn't always trained properly providers. So sometimes there was a tough landing at after the end of that course. And people had to find different ways to cope with the withdrawal from those opioids, and that would lead to misuse with other things. So that storm coming together and increasing opioid use led to it really going very wide across the country. And about five or so years ago, there were a series of strategies put in place by HHS, Health and Human Services to look at different ways of treating opioid use disorder. And that started with making sure there was more funding, making sure there was a better look at the data, making sure that there was increased access to treatment to ensure that people could have some type of relief from opioid use disorder since it was spreading for the multiple factors and probably more that I didn't mention there. So I think that's why the focus became that much brighter, at least from the provider standpoint. And in the resource standpoint, in the past five years or so.

William Lawson

It has some racial politics involved as well. It was actually a major problem in terms of the 60s and 70s turns the opioid epidemic among African Americans, particularly in terms of New York, Harlem, and others. The idea was it was widely used by jazz musicians and others. And as long as it was, in those limited population, there wasn't a national outcry about this, it was enough of a problem that some people like Bennett Prem who created the first office of drug abuse, and went out to try to develop some effective treatments. But it still was not recognized as a national problem. Then recently, when these aces became more available, and use not just in the African American community, but among the white community, the data came out, showing that the overdose rate was actually created to tribute to a load life expectancy, white whales, that then became recognized as a major health issue. And it was a contribution of a health app, two factors coming together. One was that these mattering, and at the end, once we were told to do what we could to make sure that patients weren't exposed to too much pain. That pain became the fifth vital sign of patients who had pain problems, we should try to release reduced pain as best we could. But in fact, the trade off was that many people began to use Office to deal with this, much of the public gonna recognize that we don't have to experience chronic pain, we have these drugs that are relatively safe, we use to deal with pain and also give a little buzz afterwards. And we have the situation now, in which many people are using it in a way in all the population of people having aches and pains, but when dealing with them by hand with what was fun at the time to be a relatively safe remedy to reduce pain, with minimal side effects.

Joia Jefferson Nuri

Yeah, in previous Profound Conversations episodes, we have discussed, at length, the trust factor between the medical community and the population, especially among the African American population. And this is a situation where, in your previous shows, we were talking about trust around the transplant process, do you trust the doctors do African Americans fear that there'll be let to die so that somebody else could get their organs. And the doctors we interview recognize that that's a real problem. That trust factor in history has proven not just for African Americans, but in particular, African Americans where there's no trust, or very little trust or doctors? From everything I know about this opioid epidemic and everything you're saying here. This is a problem brought on to the community by their doctors. And everyone's trusted when they got this prescription, that this is going to be okay. How do you address that? Either one of you.

Denis Antoine

I think, first you have to acknowledge the history that is there. You can't just say it wasn't anyone's fault. And now let's just move on. I think you have to recognize that past and recognize that there is probably intergenerational trauma, not just trauma within one individual but intergenerational trauma, as Dr. Lawson said, starting from the 60s and 70s, up until now, that we have to recognize and as to black psychiatrists, we know that the psychiatry field has a an added layer of lack of trust due to different types of diagnoses before in the 60s and 70s that I think have earned some distrust on the part of the African American community and persons of color. So first starting there and recognizing we understand why there can be this trust, but then starting with reliable persons, people who have an intimate knowledge and background and connection with these communities, to establish a safe trajectory forward on how we can relieve this pain from the community as well because I don't think the community wants to have this pain, but it has to Start with people that are trusted and are willing to stay around for a long period of time, not just for a couple of years for a brand, but sticking it out for something that's going to be sustainable and helping the community long term. So that those would be my initial thoughts.

Joia Jefferson Nuri

Okay. Dr. Lawson, I have a follow up question. But I would like you to respond to that.

William Lawson

Yeah, I think that just bring in another point. And that is that there was a study showing that many white physicians simply didn't trust African Americans with pain medication. And in fact, it showed that African Americans are less and less likely, the pain medications, and then other groups, this attitude, woman that the physician is looking out for the best interest of African Americans. So it became an issue of how to address this point. And it's an important point of recognizing that sometimes, to address problems, we had to pay a price in terms of looking at the benefit risk ratio. The other point that's extremely important is that many African American physicians, all physicians, were given misinformation about the relative safety of these agents, and the marketing. And physicians are no different than anyone else. The information they got wasn't something you got from medical school, especially when you got a new product on the market. You get it from this companies that are selling the products. And they're correcting once this if you take the drugs is the spread, and don't go beyond those. And many of these things are relatively safe. But in many folks in the community recognize that the jewels in the in the community, there are off label, there are other streets, everyone's safe. But they thought that when they were prescribed by the physician, that there was supposed to be another layer of safety in that thing. And these are supposed to be drugs that are approved by FDA to be safe and effective. What they found was otherwise, that people were dying. And this along with the information about says progress at Tuskegee is that in which African Americans were treated, when the heads simplest and so forth, and to a narrative in the community, that metaphor for Nevada may not have your best interests at heart, we need to clearly there's a need to make sure that our providers, even if they are working, not in the academic setting, but in the community setting, if the latest updated information, and that information has been appropriately addressed in terms of the usual regulatory organizations.

Joia Jefferson Nuri

Dr. Antoine you said earlier about this five year HHS program that was going out to the community and treating the addiction, what is going on to treat the doctors who either gotten this information from the pharmaceutical companies, as Dr. Lawson has said, or withholding from a community because they there's some racial bias there about how black people handle pain medications, like we're naturally addicted, that did different people. I don't know if that's true. But what is happening? What training are you getting from this money from this? What are doctors being told? Now I have a friend who had hip surgery and got no opiates, you know, she opioids she was sent home with Tylenol, because it sort of sounds like the medical profession is going the opposite direction when she had pain later than Tylenol can manage. What are doctors, what training are doctors getting?

Denis Antoine

So I think there's a system in place that not only are doctors getting training for certain things that we call risk evaluation and mitigation strategies, which is a real big way of saying we want to make sure you're giving it to giving in the right way and not giving it in a harmful way. That's part of that strategy that's been put out there. We're also saying that more people are getting access. So for instance, over the past five years, there have been acts that have expanded how many folks I can treat at the same time with medications like buprenorphine Things that require special licensing. So before it was I could only hold on to maybe 30 to 50 Folks, and they raise that level so that people that are willing to give that good care, they would have access to do more. I think beyond that there's a focus within that five point plan on looking at data. So certain elements are coming out to point out Well, Dr. Lawson said that, we just need to know that black people aren't getting the medication. And then part of the data that's also coming out, that's getting hopefully more publicity publicizing is that even though there's been a steady rate of opioid overdoses overall, in some places declining for black men, it's actually gone up 38% over a period of time in the past five years. So part of it is the data. And then other parts of it is make sure they're monitoring of the system to ensure that doctors have to check certain things and making sure that it's done properly. So it's a multi, you know, multi pronged approach. But I think all to make sure people are doing it and not just being trained, because teaching isn't always learning you got you got to make sure folks are shown the right way and doing it the right way.

Joia Jefferson Nuri

Are doctors ever held responsible, legally?

Denis Antoine

Absolutely. You know, when doctors have different programs, such as opioid treatment programs, which I'm director of one or have different or just facilities such as buprenorphine programs, the DEA still does checks. And they definitely ask at these visits, are there any people you're concerned about with their prescribing practices? And you've seen places like pill mills that have been closed down in multiple states, where there are financial and incarceration consequences with that? So there is responsible there? Are we exactly where we need to be? No. Dr. Lawson, though, said as well, this system needs to be looked at to make sure that companies aren't putting out misinformation. And I'm also for certain things such as insurance companies, making sure that there aren't barriers put in the way of people getting the right treatment. Just because a doctor prescribes the right thing, doesn't mean an insurance company's gonna fill it.

Joia Jefferson Nuri

Dr. Lawson.

William Lawson

Yeah, and also on this extensive programs that's been promoted in terms of education for organizations that support physicians such as Merton associated Academy for addiction psychiatry, as well as improving organization for primary care, surgery, and others, it is given large sums of money to go into the community to educate folks. Moreover, it's also sent to the dean for one medical school that's incorporated this in terms of their, their training programs, as well. But the again, part of the problem is that many, especially African American Latino alone, physicians are much more likely to work in communities in which their limited resources and high vibe. And so they mean that often had the opportunity to get the cat can have educational knowledge, the degree to which it can be practically useful. We have requirements in terms of continuing education, but it assumes that the person will have the time and the effort to be able to devote education time, as well as the very real patient needs that they have to deal with as well. And one of the ongoing patient needs has been folks seeking relief from pain. And we had some newer technologies that can help deal with addiction, such as drugs, such as people normal, and others. But what we find again, and Mt. f7, looking at getting new technology in to the African American community, and Latino community and the physicians, and we found that drugs such as people are less likely to be used by African American and Latino physicians. They certainly aren't made as aware of it. And also their regulations in terms of whether or not insurers will pay for the use. And so as a result, folks can get addicted. But the usual way of dealing with it is either by the correctional system, or by some sort of therapeutic recovery method. And in the unfortunately the correctional system approach has been one As we emphasize in this country, my doctors being Prescott secured for use of these agents inappropriately. Absolutely. But as also we've seen a case in which physicians who have used appropriate treatments to try to reduce addictions by themselves being prosecuted as well.

Joia Jefferson Nuri

And why? Why is that? Why would a doctor who's doing it appropriately be prosecuted?

William Lawson

Because of lack of knowledge by legal providers or by the criminal justice system. For instance, we've had great difficulty in changing the dosage requirements, which is set by law in some places for getting buprenorphine. And so what we find is that people get inadequate people often, and as a result, they end up using drugs or using drugs, again, the physician who provides the larger dose of people often could be, in fact, had been prosecuted. So, so there's some unfortunately, there's a lag between technology knowledge and the criminal justice system.

Joia Jefferson Nuri

Okay. Okay. And during the reading, to get ready for this show, I realized, I guess is to twofold question about the function of the brain, and addiction. And the medical profession and the advice people are getting from some of the articles I read, doctors who prescribe opioids tell their patients stay ahead of the pain. So you're going to take the opioid on a schedule, long before you're in crippling pain, because the body doesn't heal from this article, body doesn't heal, and it's in pain. So you're telling people to stay ahead of the pain. So you're going to take this opiate, three, four times a day, ahead of the auto schedule, you know, eight, noon, whatever the schedule is, and then you're give you give people a prescription, or doctors do give prescription and may have 90 pills in this bottle. So you're telling them to take it four times a day, you're gonna give them 90 pills. Now, can the brain was down having that much opiate opioids come into their body for maybe a month? What are we setting it up for addiction? Dr. Antoine?

Denis Antoine

Well I think what the field is really shifted toward and shifting towards in terms of the training that we've had, at least for the past five years is more of a symptom triggered approach. Because if we were taking the approach that you said, where it's just a steady dose all the time, it's, it's very similar to eating a salty food every day, you're just gonna get used to it. And after a while, you're gonna need a little bit more salt, because he stopped tasting the salt that you tasted before. But that's not how the field is going about pain treatment, this time or even withdrawal treatment. And we're shifting more towards having a baseline, if you will, just so we get most of it. But as the pain spikes up above a certain level, then you add a little bit of salt. As the pain gets down, you need less and less of it. Or eventually you get down to that baseline, and then you can taper off very gradually to get to nothing. But you're right, if 90 days of the steady dose, and the brain would be like, Alright, I need to shift now. And your receptors would change. Do we know the exact time point? That varies person to person. But that would be a tough approach if it became that way.

Joia Jefferson Nuri

Yeah.

William Lawson

And I want to emphasize that a lot of a prescriptive practices involved the patient given responsibility of taking the medication. And so we assume that we have a responsible, well informed patient. Unfortunately, what many of us have found is that patients on here about 30 to 50% of the information that's provided almost never read the package inserts, and essentially tried to take the medication is they feel they needed for their own personal needs. That's an ongoing issue. If you in country way, it's a free country. And wish you don't try to micromanage it and end up doing the opposite.

Joia Jefferson Nuri

Yeah, I am wondering, going back to Dr. Antoine to answer about, you know, hit that pain threshold and make it but everybody has a different pain threshold. I mean, stubbing my toe might be crippling for me, or doubling my toe I mean, not notice. So how Are doctors educated to educate their patients about what that threshold really ought to be to help to help avoid these addictions?

Denis Antoine

I think some of that starts with a conversation to really paint a good picture. Because, you know, just walking in the door, you won't know the answer of Alright, five milligrams of oxycodone is going to cut your pain down. This, I wish we had that test. I wish we had that imaging, or however we do, but we don't. So the other part of that is everyone has a genetic part of them that dictates the response to those medications. And we don't know that coming in the door as well. So it needs to be a close communication upfront, usually with types of events that will lead to needing those medications, you should be in a hospital for a few days or a couple of to start that conversation and then have case management or way of checking in to adjust pretty closely probably from week to week, in case someone overshoot or undershoot, I would say coming in the door that there isn't a set way of doing it that we're trying, it should be that conversation 80% 85% of the diagnosis is the story.

William Lawson

Yeah, I want to just add to that also, just want to emphasize that I do research in pharmacogenetics. And what we found is that there are real ethnic differences in terms of how rapidly medications are metabolized. African Americans and Latinos for many drugs, what we call slow metabolizers. That is that the drugs themselves or stay in the body longer, and they have offense? Unfortunately.

Joia Jefferson Nuri

Doctor, why is that? Why would an African American genetic, Latino genetic be different than a white person genetic as far as how long the drug takes to metabolize?

William Lawson

Yeah, I want to emphasize that this is not individual this is these are what we find friends of looking at population studies. So not all African Americans slow or fast metabolize. But fortunately, more. And it's become part of it has to do with differences in one, there is a dude in terms of the going cost a little metallic passage that different people survived because they had different ways of metabolizing certain substances in order to survive survive, every little passage was 50%, for many folks, also exposed to certain kinds of foodstuffs early in life. So there's a there's a variety of factors that come in, both at the receptor level, as well as at the level how these agents have rope broken down, that can result in differences in terms of handling of these agents. And again, I want to emphasize that Shogun said that the that there's some natural ways in which our bodies, which we've evolved to deal with different services, but opiates coming in as medications isn't part of natural development of the boundaries of the human race. This is a recent development. And we we are balanced if symptomatic, both and for that we can determine easily what is the best one for dealing with pain and which isn't.

Joia Jefferson Nuri

Yeah, Antoine, do you have a response to that or add to that?

Denis Antoine

No, I think the the body has different ways of adapting. And I think the Middle Passage piece just paints, how genetics are part of it. But it's also what happens around us, then that's something that there's a lot more research to be done to figure out, you know, how we can make sure that we pay attention to know how substance is effective so that when we're walking into the door with a doctor, we can say, well, this is what normally happens with me, do you think I should adjust one way or another? Oh, that was helpful to shape the conversations that you have with the doctor. And so that it truly is a bi directional two way conversation, not just a doctor telling you how to do something.

Joia Jefferson Nuri

Right. I wonder, I wonder. I'm wondering based on something that Dr. Lawson said about there are studies that look at the difference in how our body metabolizes drugs, based on our genetics. I'm wondering, has those studies infiltrated into the medical profession as normal history, but my suspicion is, at first it was race based and nobody cared. They just treated you, you know, make a decision about you based on their own prejudice, you know, and their own arrogance. and maybe once the world started to get a little bit more sensitive, they felt that they were racist if they started telling somebody, well, I can't give you the same thing and give Johnny Pooky. Because you do it differently. Even though that might be the truth, it all we have we, we don't do it because we're oversensitive or we don't do that sort of analysis, because the vast majority of the medical profession doesn't care about the race difference.

Denis Antoine

But I would go to the insurance companies for a second because the question in that genetic analysis, who pays for it, and who authorized the payment for it? I think more recently, there has been the ability to perform those analyses. But I would say it's not widely publicized how to get them for patients. And I would also say that oftentimes you would not be approved right away, they'd be a lot of out of pocket costs more than so there is a barrier there that doesn't fall within the doctor's hand, we know it can be done. But we also know that the hundreds or even 1000s of dollars that go along with that for my patients, 95% of my patients on that Medicaid, it might not be doable, not doable. So so that's the other piece of it that the medical profession knows it exists. I'm actually co investigator on a couple of studies right now doing those studies. But how to get it paid on a day to day that's that next step, almost that stage five implementation that we say how do we make it available to everyone? Turns companies can play a roll down.

Joia Jefferson Nuri

Okay, Dr. Lawson.

William Lawson

Yeah, and it's true for pharmacogenetic companies that's going on all from tests, for average practitioners just not cost effective. In terms of everyday decision making, and also, a lot of what we talked about, again, is terrible genetics, but also to Antoine noted, his belief systems. And the fact was that many occasions have treated African American patients simply believe that African Americans were in permanent most pain, sadly, did not offer the kind of support that they needed. And also working on an idea, even science on the textbooks I looked at in medical school, saying that African Americans were more likely to be substance abusers, when in fact, that is not true. So these kinds of belief systems still permeate culture above and beyond and the extent to which to physician me care, and is a background belief that may influence decision making. And one point that Antoine noted, is the importance of getting the appropriate support system is just just the patient. And they provided. But good programs made sure that we have patient advocates, that we have nursing support, that we have recovery support. So that impulse do get in the problems, I have questions, it can have a dress, unfortunately, this kind of integrated care simply is not available for much of the country.

Joia Jefferson Nuri

This brings me to the $5 billion settlement from Johnson and Johnson. And as I read, where where that money goes, it seems to me is just cycling back around the same players who's doing the drug rehabilitation centers, who's doing whatever it doesn't seem to me like a lot of that money is going to reach the hands of practitioners that deal directly with the African American community. It was pretty generic. And then I want to add to that, bake back to what you were saying that to Antoine about bringing in the insurance companies, should it not be the pharmaceuticals company responsibility to do this level of research, to make sure that their medications are doing the right thing? Of course, insurance companies are going to try and save money. That's that's their mode of operation? And are they and are they particularly responsible for what a pharmaceutical company is selling to a doctor, and what research a pharmaceutical company does? So in that $5 billion, I didn't see Now granted, I don't see the entire lawsuit. But from what I read in the media, none of that is going to Doctor education, or to any of the studies that would specialize the psychiatry that would be needed for this. So I'd like to get your response to my statement, and in general to the $5 billion that Johnson and Johnson allegedly is going to put into the pool.

Denis Antoine

It was a great question. Great, great couple of questions there. I think we have a deeper discussion on our hands at the state level. And I was recently part of that discussion for folks within the Maryland, of who are thinking about what's going to happen with this money and their bills and policies that are being introduced at the state level to decide how some of this is going to be divided up. And, and it's gonna be interesting. We said some of the same things like we don't see how the money is going to get to this research or how to do that. And I think it's on the stage to do things like what Maryland is doing, which is building up racial disparities, the opioid task force to make sure that their policies in place to add the ethic ethical principles that you're talking about for this $5 million, because people have their professional responsibilities and individual morals. But ethically, there needs to be an equal distribution of this to make sure that we're looking at these health equity issues. And there's going to be more of a debate for that. And I do hope those funds get there. It's just not quite clear in my mind that, as you said that it's mapped out that way.

Joia Jefferson Nuri

Yeah, Dr. Lawson, a response to my statement and $5 billion?

William Lawson

Yeah, the good news is that which was before in terms of the tobacco settlement, and many of us learned, I was in Arkansas at that time. And almost all the money went to reduce state budget. So that so there's an awareness that the monies will be diverted for non specific uses. Much more. So it was before the tobacco settlement. Okay, unfortunately, Brian noted, the devils in the details, yeah. And whether or not it's going to be any kind of systematic way. Because you got to, you got to find monton. Chicken Coop now, a systematic way of making sure that that money is is going to be go to the purposes this is intended. On one hand, is it Well, the good news, we're not getting the federal government because they've wasted and so forth. But the bad news when they give it to local entities, is you have local interests becoming involved, right? And you also must look at a way of seeing how can you get out to community related groups, who often do not have the infrastructure to be able to even apply for these brands. And many community groups simply don't, and just being a minimum of folks trying to do good. But now you're talking about setting up a distribution centers, setting up ways writing, the managing data, setting up outcome measures, which many community organizations simply do not have the know how, or the expertise or the resources to do it. So there's a tremendous opportunity. But is is is a devil in the details and the extent to which community groups will have the political clout to be able to keep their money from the diverted for uses that weren't originally intended.

Joia Jefferson Nuri

Well, Dr. Lawson, you just confirmed all my fears. Thank you. Thank you for that. You just confirmed all my fears about $5 billion. I wanted something that Dr. Lauth, Dr. Antoine said, he said something about ethical practices. And I talked earlier about building trust. In our earlier programs, we talked about CO work. And that would be a relationship between the doctor, the medical doctor, the psychiatrist, the caregiver, whether that's a spouse or anyone else, and the patient? And is there room in this, that we can now have a conversation, you said that all the learning that will happen? You're in the hospital for a few days, if you're ever given this, if a doctor gave you this prescription, you were in a hospital for a few days, and there's a conversation, but is it a dialogue? Or is a finger point? This is what you must do? Is there an engagement? Is there a co working between the patient and the doctor or the nurse who's giving this education?

Denis Antoine

Should there be or is there I think is the question. Yeah. I think as there's more training and information on the best ways to work with people, principles and ethical principles that will come out will be autonomy, and also things about beneficence to making sure you're doing right for that person and thinking about doing it in a way where there's informed consent. And part of that means that you tell the person what's going on make sure they understand and work with them to do something that's feasible, don't just say, here's what you're going to do, no matter what you think and argue with them about it, get to think of different strategies depending on where they are. And that's where training about things like motivational enhancement, if there's some ambivalence about which way to go, or having a good understanding about a person's social context and their, you know, ability to take these medications regularly before you just give it a description, or coordinate psychiatrist, we take that context in more naturally, we probably have a little bit more time than other specialties. But as we get more training and information and and practices and hopefully in policy to make sure people are doing these things, I think we'll make the shift to what should be to what is I can't, but certainly say, especially with the the data that Dr. Lawson talked about where African Americans aren't getting these medications, I can't say that we're fully there right now.

Joia Jefferson Nuri

Okay. Dr. Lawson.

William Lawson

Yeah, I want to note the work that a colleague of mine, Lisa Cooper has done in which she went out and basically looked at the relationship between patients and their physicians, particularly African American patients, and basically found that in many instances, it they didn't communicate with patients, or when it did communicate with patients did it in a non in a dictatorial stance, she's promoted programs in primary care, to promote more interrelationship dialogue type of method, and fan has been very effective in terms of improving patients, adherents. And also outcomes. And psychiatry is begun to do that. But much of the field still is not there yet. A lot of us get this service to it, but it simply doesn't happen. And it gets overwhelmed by the other needs that exists in terms of the medical community. So that will be ideal to ensure that we monitor and keep track of, and make sure that we have a relationship between the provider and the patient, in which they are much more of an even setting, and also in which the expectation is that providers successfully educate the patient, and that the patient feel that they can get the information they need to address their needs. Again, that's that's the unfortunate still, the exception is an ideal that we're working towards. But practically. And also, unfortunately, there's not many incentives to do this.

Joia Jefferson Nuri

I'm wondering if, even though it's my question, and it's my hope that there'll be a co work, and like you all saying it's out of the norm. I'm wondering, well, I have as you were answering Dr. Lawson, I'm picturing the Medicaid, I used to be a reporter. And I would do a lot of City News here in DC, and for no producer, and you would go into the offices of the Medicaid doctors, the doctors who took it, and you'd walk there, and you'd, you'd go to the lobby, and you would see that the people there were old, very sick, or very young with very young children. And there'll be 20 people waiting in the waiting room, maybe that's an exaggeration, there'll be 15 people waiting in waiting room could be one doctor in this practice, and maybe two nurses. So how is that possible? For that one doctor, to take on 15 people and 15 individuals in the way that we're talking about now? How, what help does that doctor need?

Denis Antoine

I would say, you know, this is where health equity comes into play. Because it's not just about making things equitable. It's about what investments would have to go on to that to raise the value of that care. Part of it's going to be finding a way to help that doctor pay things more efficiently. Meaning how can you get that information before the patient gets into the room, we've been doing something now helping them mission. This is a homeless therapeutic community in Baltimore, where we actually have myself as one of the main doctors where we have about 200 men there in the building, and they have to come for treatment, but we try to get a snapshot of who they are with standardized outcome measures before setting the door. We make it easy for them to access that thing in other ways as cell phones become more accessible. It's not quite there yet, but there could be ways to say Then people, you know a questionnaire beforehand just to say, hey, take a couple of minutes. Let me know your pain, let me know how depressed you might be feeling right now. So you can have a running start. Wow. And that is part of what this $5 billion not the opioid restitution from but HSS is thinking about how to make things more precise that can give that doctor are starting, and also making sure the work that they do gets better reimbursed because every state thinks about the Medicaid reimbursement. But there's a push on that policy side to increase the reimbursement that doctor could have a more cost effective way of doing things, as Dr. Lawson pointing pointed out, that cost effectiveness matters that much more for that duck.

Joia Jefferson Nuri

Dr. Lawson?

William Lawson

And part of that will probably didn't mention, but is the manpower problem, the woman power problem. That is the number of African American physicians is actually about the same numbers as it was the 1960s. Same as for the Latino community.

Joia Jefferson Nuri

And that also, why is that? I mean, we're talking 40-50 years. Why is it that we don't have more black doctors?

William Lawson

It all, we go back to the educational system, in which, unfortunately, African American males are diverted elsewhere, we find this happens in the 10th grade, that African American males are less likely to get the basic science courses that they need to be able to go further. They are visible distractions in the community, in terms of the teachers themselves, then what kind of careers should think folks think about, and then, and also the huge entertainment system, if you want to be successful, going black going to entertainment, whereas it's a lot harder to become Michael Jackson, especially five foot six, that isn't a physician. And fortunately, their efforts in many communities to try to change that narrative. But as is overwhelmed by the huge message has come from the larger narrative of our society. And that is that this is that the best route for success, we'll need to get involved in terms of these areas that are not medically not related to medical care. And going into a healthcare field and medical field is hard. It is not easy. And if your first seven generations in your family, to have enough money to have education, it's very, very, very, very difficult.

Joia Jefferson Nuri

You don't have that support.

William Lawson

And the other thing needed, at the end of that is we have some technology that now thanks to the internet is many more opportunity to be able to spread on services with fewer people. I have over 1000 patients on a system on an internet network for secondary services. But I haven't because of the availability of the internet, many communities, African American communities, rural communities, low income communities, do not have access to the internet. It's not there. And as a result-

Joia Jefferson Nuri

That really got emphasized during COVID, where kids couldn't go to school because there was no Internet, where they were one virtual. Yeah, we found that we have five minutes left to go in this program. It's been very stimulating. I want to thank you both. I thank you again. But as far as this opioid epidemic is, just briefly, tell us what would be your dream for moving forward? They gave you $5 billion or better question. And on top of poverty and racism and crack addictions and high infant mortality rates, what is opioids done to us as a race of people in this country?

Denis Antoine

I would say I'm gonna try to answer both at the same time, the money and the effect on us as a community, I'd say we need to try to re heal the community because underneath that with our alongside that they've been reminders over these past two years of racial disparities in the incarceration system. In terms of the police brutality, they've been reminders that COVID itself has affected blacks, more so than other populations. And there's been another no separating the community because we've been doing in different ways, and the COVID virus itself has had some disparate effects on our community. So if there's an opportunity here is to put more of the supports in place so we can heal together, more community support safe places that night for children to grow up with, so they don't get into the cycle in the first place. support for families so there can be healing, the trauma that probably grows even from the abuse standpoint during this COVID times, and then also treatment for opioid use disorder. So it's a it's a large approach that's needed to heal the community because, for several reasons we've been reminded and and reinjured over the past couple of years.

Joia Jefferson Nuri

Okay, Dr. Lawson, you'll get the final word.

William Lawson

Yeah, just want to emphasize what Dr. Antoine said, the sad part is that much of what we've seen is not new. The good news is that we provided before by being creative, and looking at utilizing the resources within our community to address these concerns. The opiate crisis tied in with the disparities was seen in terms of COVID with the high homicide rate, the high suicide rate and, and a low mortality associated with chronic diseases addressing this issue in turn to generate those resources to reduce disparities, or I think, have a benefit across the board in terms of improving the outcomes for African Americans and for other groups as well.

Joia Jefferson Nuri

Dr. Antoine, Dr. Lawson, I thank you so very much for an hour of your time to share your wisdom around this crisis in our community. And I hope when it stops when the new stuffs covering it, we don't stop the work toward finding a cure and better treatment maybe then the opioid, the opioids and so thank you very much for everybody from on this team on or I can talk I can talk for everybody on the team of Profound Conversations. I'm Joia Jefferson Nuri and we thank you for joining us.