What IF we went beyond disease

By Adem Lewis / in , , , , , , , , , , , /

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

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