8 Disgusting Foods ‘Fear Factor’ Contestants Actually Ate 🤢 | MTV Ranked

8 Disgusting Foods ‘Fear Factor’ Contestants Actually Ate 🤢 | MTV Ranked


– [Madison] I literally can’t do it. – You can do it. There you go, there you go, there you go, there you go, there you go. Keep goin’, keep goin’. – Yeah, good job.
(claps) – There we go. – Good job.
– You good? (retching) – [Madison] I don’t wanna go home. – [Man] Keep goin’, keep goin’,
keep goin’, keep it goin’. – You got it girl, drink it. – [Man] You did good. (retching) (gags) – My biggest fears are definitely eating anything that’s alive. Having it squirm inside my
mouth, that sounds really gross. – Put the Vinegaroon in your mouth. – [Beena] Oh my God, ew. – [Ludacris] This is fear
factor, this is what we do. Come on Andrea, you got this. (squelches) There you go. – [Andrea] It was absolutely horrible. It was moving around, it just
tasted disgusting, I mean, that’s gonna be in my
nightmares for a while. (laughs)
That was gross. – You guys ready? (grunts) Three, two, one, go. Uh oh, he’s goin’ for the habanero. (group chattering) – Get it all in there,
all in there for me. – Straight for the ghost pepper. – [Brenden] The spices, they kick in on the first one, but
then the ghost pepper, it tastes like Jean-Claude Van Damme punched me in my throat. – [Quenlin] You good,
it’s cool, it’s cool. I like it baby.
– That’s about halfway full. – [Quenlin] Hey, come on. – Another ghost pepper. Oh, how hot is it? (group chattering) Disgusting. Ghost pepper. – [Brenden] The ghost
pepper, like, kicked in, tasted like 7,000 spices
over the border in my mouth. – Pick it up, faster, faster. (spits) Okay, hit the line. Quenlin start drinkin’. Oh, he picked all really,
really hot peppers, – C’mon baby.
– So, this is gon’ hurt. – Do you feel the throw-up coming up? – [Quenlin] As soon as
it got in my throat, I felt that something just grab me, I can’t let him down, but my body isn’t gonna agree with what’s goin’ on. – [Ludacris] All right switch, switch. – C’mon baby.
– That’s a hot sauce mustache right there, I see it. (intense music) (spits) – Ew, don’t throw up, don’t throw up, ooh. Brenden and Quenlin– – They talk a lot of (bleeps). – They do. – And I just, I just wanna shut ’em up. – Hey come on, hard to watch. – [Brenden] Hurry up. – [Quenlin] You’re moving slower because you got this fire in your mouth and I have to stay focused
and listen to my brother. – C’mon, this may be it. Still need more. – [Brenden] Hurry up, hurry
up, hurry up, hurry up. – [Quenlin] Havin’ to go back for an extra shot, I
really was about to die. – Quenlin picked the less hot pepper. That means his mouth
must still be burning. Go. (slurping) (group chattering) He’s drinkin’ it, he’s goin’ for it. (crowd shouts) (shouts) – [Brenden] I can feel
me about to throw up back into my cup, but actually held my throw up in
and I drank through it. – Let’s see the mouth. Time. Natto, fermented soybeans. (shouts)
– That came back out. (gags) – That is only the first one. In order to move on, they
have to eat three items faster than Tam and Johnathan did. – [Woman] The thought process was swallow everything whole, don’t bite it, don’t let it linger in your teeth. – Eat slow so it’ll stick to your tongue and make you throw up. – But, once it come back up and you swallow ’em again
it was nice and lubricated. You got it babe, go, eat it. I’m waiting for you. – [Man] He can’t keep it down though. Let it come up, let it come up. (shouts) – Go, go. They hopin’ for the cupcake. – No, no. – [Ludacris] 100 year old egg. (crowd jeers) (squelching) – Swallow, come on swallow. – [Man] Can’t down it like that. – [Woman] Oh you ate the whole thing. – [Ludacris] Tam is ready,
she wants them to throw up. – They gotta come out, let it come out, let it come out, let it come out. – Every time that we felt
like they were gonna beat us, we would trash-talk. It was all mental. – Your body wants to get rid of that. – [Ludacris] Five minutes. – [Man] When I’m eating,
I started sweatin’, I was puttin’ in the work. – You got it. – [Man] Using’ every muscle in my body, just keep the food down,
keep the food down. – Throw up! – You’re good (gags), you’re good. – [Ludacris] You got it, go. – Habanero, please, habanero. – Habanero please.
(laughs). She’s beggin’ for the habanero. – Where is this headin’? – Cheese. (crowd jeers) But not any cheese, that is
the stinkiest cheese on Earth. – Oh my God.
– That smell, that smell. – [Man] I was gaggin’ all over the place but I was just like, just get it done, get it done, get it done, get it done. – Are you swallowing? (gags) – Six minutes. – [Man] Suck all them fingers. Savor it, savor it. (crowd shouts) – C’mon, keep it down,
keep it down (mumbles). Time! Now, are you guys ready? – [Team Members] So ready. – All right, three, two, one, go. – [Man] Someone’s impressive. (crowd oohs) – There you go, bam. All right. – [Woman] The only thing on my mind was getting it done as fast as possible. Not even thinking about
what was in my mouth. – She does not look happy right now with that snake in her mouth. (bleeps) Wrong, they got the code wrong. – Money bags let’s get it. All you can do is be happy
for somebody’s demise. At the end of the day,
you tryna win the $50,000. – [Ludacris] Second attempt
to get the first code right. They got it right. (intense music) Two minutes. – [Woman] Oh that’s an active one. – Good God, he looked like he liked that. – [Ludacris] All right,
going to second code. – Don’t say anything, don’t say anything, I need to concentrate. – Come on now, talk it
out, you guys can do it. Nobody learns phone numbers anymore, so of course this is difficult. They got it, they got the second one. Three minutes. Uh, oh. – [Man] Right when I grabbed
the scorpion it hooked on to my mouth, and I was trying to like shove it in,
so the scorpion bit me. – [Ludacris] Two scorpions,
one code left, $1,000. This is it, this is it, they got it right. (spits) (rats chittering) – Oh my God. When I was laying in that tub with hundreds of rats
crawling all over me, I felt every single
foot of all those rats, all over my body. – Oh my God, it’s in my
ear, I can feel the feet. – Ready, three, two, one, go. – [Man] Let’s go Aisha, you got this. – Oh man.
– Gotta get the cheese. – Oh my god. Fighting a rat for cheese– They’re kissing me. They bite, and they suck and bite. – [Man] Oh my God. – [Ludacris] There you go, you got one. – Don’t be scared, you got it. – [Ludacris] There you go, there’s two. – It smells like (bleeps) in here. (laughs) – When I saw Aisha in the tub
of rats I actually was scared. We both have a fear of rats, but like, we’re never not gonna not try something. – [Man] Oh my God. – [Ludacris] There you go, that’s three. – Get me outta here, please. – [Ludacris] There you go. – Oh my God. – [Aisha] Oh my God, it took it. It’s hard enough trying to find the cheese, and then little ass (bleeps) just comes and takes it away. – [Ludacris] There you go, one more, go steal yo cheese back. Time. (whoops) Hurry up Tracy, come on, dump those leeches on Erin. (screams) There you go mom, there you go. – When they attached, it was a lil’ bite, but, it was mostly the sliminess and the cold water affecting my mentality. Torture. – [Ludacris] I know it’s hard, Erin, I know you (mumbles), but
50,000 is on the line. (crowd shouts) All right, let’s see how many stick. – [LeAngelo] Tracy and Erin,
they consistently surprised us. – They overcoming some things that I wouldn’t think they
would, so, I’m nervous. – Stay on balance. I knew they was gonna get in the cleavage. – [Erin] My boobs are pretty big, so, I thought that would
be an advantage for us. – Hey, limbo. (dramatic string music) There’s one that is
making a home right now. – [Erin] Ow, ow, ow. – Ooh. That’s it, all right, chugalug, chugalug, don’t swallow one of those
things, please don’t do that. (crowd jeers) Man, looks like Erin’s
been to a party before. – Go, go, go. – Time. Grab those cans and open ’em. – [Joe] It’s gonna be a challenge for us, but nothing’s gonna stop us. – [Ludacris] All right
Joe, you have liver pate. Smells good?
(Joe groans) Beef liquid extract. – That don’t smell too good. – Espresso. All right Kyle, you have Chipotle peppers, old sardines, nutrient-dense fish, sardines are great for
you, and Alfredo sauce. (gagging) All right, put those in the blender. (crowd shouts in disgust) – All that juice, you
know what I’m saying? Oh, yeah.
(crowd laughs) (liquid pours) Kaylee’s favorite bro, Alfredo and hot sauce you know what I’m saying? – That’s thick. – One, two, go. One, two, three, stop. – Oh my, what. – Holy (bleeps). – [Ludacris] All right, how you feeling? – I’m feeling worried. – How are you worried, you burnt your tongue this morning? – It’s chunky. – Kyle are you ready?
– Yes, sir. – Three, two, one, go. – FTP let’s go, pound it, pound it, pound it, let’s go Figgy, come on, don’t even think about it, it’s protein let’s go.
– Taste that liver. – Let’s go, it’s protein, swallow. – [Kyle] Mine had chunks of sardines and it was thick and nasty. – Let’s go, swallow
that (bleeps), let’s go. – Taste those chunks, that is fish guts. Are you chewin’? – Oh (bleeps) yeah, it’s chunky. Chewing was the hardest part, but I didn’t really taste it, so I think that stopped my gag reflexes. (gagging)
– No, come on. (crowd jeers) Almost done bro, let’s go,
last set, best set right here, let’s go, let’s go baby. – [Ludacris] You did it, he got it. All right Joe it’s on you.
– Let’s go baby. Chug, chug, chug, chug,
– Time is ticking. – Chug, let’s go. (cheers) – Man, did that taste good, Joe? – Tastes like ass. (laughs) – Go for the chunky John. – [Ludacris] Wait a
second, do I hear Kevin rooting on John right now? – John’s been doing good. (laughs) – C’mon, please, I’ll help
you out later after this. I’ll get all of theirs. (crowd shouts) – [Woman] This is why I love you. – I don’t even know what mayo-kraut is, but Madison, this one’s for you. – Mayo-kraut, mayonnaise and sauerkraut. That’s the chunkiest one of them all. – Oh man, that looks terrible. – The way they were
taking the cups before, they didn’t seem like they
got ’em down that easily. – [Cynthia] Oh, yeah, this
should be interesting. – [Man] There you go, there you go. – [Madison] There’s gotta
be something else in that because as soon as it hits the back of your throat, you’re done for. (gagging) I literally can’t do it. – [Ludacris] Madison, it’s
like Christmas eggnog. – [Madison] That’s the worst thing I have ever tasted in my life. – I wish I could relate, but I (laughs). In fact, I’ma go get some champagne while y’all are taking so long. (laughs) – Oh my God. – This my kind of party. – I don’t even know how
to explain that flavor. – I believe in you, all of the people here actually believe in you. – [Man] There you go, take a breather, take a breather, hey you’re
good, you’re good, you’re good. – She can’t swallow it. – [Man] Swallow it,
swallow it, swallow it. (gagging) – [Madison] I literally can’t do it. – You can do it. There you go, there you go, there you go, there you go, there you
go, keep going, keep going. – Yeah, good job. – There we go.
– Good job. – You good?
(gagging) – [Madison] I don’t wanna go home. – [Man] Keep going, keep going,
keep going, keep it going. – You got it girl, drink it. (retching) (intense music) – There it is. (grunts) – There’s no way. – [John] Party over. – That is the worst thing
I’ve ever had in my life.

Naming the flu: H-something, N-something | Infectious diseases | Health & Medicine | Khan Academy

Naming the flu: H-something, N-something | Infectious diseases | Health & Medicine | Khan Academy


So we often talk about
influenza in terms of letters. I’m sure you’ve heard of
H1N1, or something like that. And what I wanted to do is
explain where that naming system comes from,
what it means, and how it relates to the
three types of influenza that exist–A, B, and C. Now let’s say I went
around the world collecting all the different
influenzas I could find. I might find some
type C influenzas. I might find some type
B influenzas, as well. And I would find probably
lots and lots of type A’s, because there is so
much diversity among the A’s. Lots of different types. Now, when you have
a few viruses, it’s fine to say, well, it’s
a type B, or it’s a type C. But when you have this many
viruses like I’m drawing for type A, it becomes a little
overwhelming to simply say, well, it’s a type A. Because
you’re probably thinking, well, there are so many different
types, tell me more. I want to know more about it. And so in order to
find out more about it, or tell someone more about it,
what people have come up with is a new naming system. Or kind of a different
naming system, other than just the letter. So what they do is
they say, OK, let’s go back to what the
virus looks like. We know that the virus has kind
of an outside, an envelope, right? That’s what I’m drawing here. And on the inside, the
influenza virus has RNA. And if it’s a type A
virus or a type B virus, that means it has
eight chunks of RNA. The type C actually
has only seven. So this one that I drew here,
this must be a type A or B. And I’m going to go ahead
and tell you it’s a type A. And we know that
on the outside type A’s have some proteins, right? They have some
proteins I’m drawing as kind of a little
hand, because this is to remind me that it’s an
H protein, or hemagglutinin protein. And they also have
a type N protein. And so type H and type N.
Remember, H is hemagglutinin, helps the virus get into cells,
or hold onto sialic acid. And type N is neuraminidase,
and it kind of nicks the sialic acid, and helps
the virus get out of a cell. Now, scientists have been
looking at these proteins for awhile, and they’ve actually
counted all the different types of H proteins they could find. They found that there are about
17 types, meaning they all do the same thing, they
all have the same job, but they’re slightly different. Their proteins and
their structure might be slightly different. And if you count up all
the different N proteins, there are actually only 10. So 10 different
types of N proteins, and 17 types of H proteins. Now, if every virus has
to have some H and some N, how many different
combinations would you get? Well, you simply
multiply them, right? You simply multiply
17 times 10, and that means there are 170 combinations
you can actually come up with in terms of different types
of H’s and N’s coming together. So if that’s the total
number, then we can use that to actually name the different
types of influenza A’s. You can actually
say, well, maybe this guy has the third type
of H and the second type of N. And if that was the case,
we’d call it an H3N2. And maybe this guy has
the first type of H, and the first type of N,
and that would be H1N1. And maybe this guy is H5N1. Or maybe this is H7N2. I think you get the idea. Basically, you just kind of name
then based on the H and the N that they have on the outside. Now here’s something
to think about. What happens if you actually
look at this little virus, and you find that this
virus has the first H and the first N. Does that mean
that these two are identical? Are they the same? Well, the answer is no. They’re not
necessarily the same. I guess they could
be the same, right, but they may not be the same. And you’re thinking, well why? They have the exact same H and
N. How could they be different? Well, remember that there’s
a lot of RNA in here. There are eight segments of RNA. Eight RNA segments. And H and N are
just two proteins. There are other
proteins that this virus has inside of it that
might distinguish these two from each other. And so if this is
the newer one, you might say, well, this
is the novel H1N1 to distinguish between
the two different viruses. So whenever you see
words like novel H1N1, now you understand why they’re
coming up with that name. They’re just trying to help
you distinguish new from old. So actually what I did is I
went ahead and made a grid. I made a grid of the H
types, and the N types, all 17 H’s and all 10 N’s. And what I wanted
to do is show you that you can actually
make this really simple. You could say, well,
obviously if you have this first H
and this first N, then in this grid I
would type in H1N1. This is where H1N1 would go. And at the other end of the
grid, let’s say down here, you could actually say,
well, this guy down here at the H17N10. And I could do this for all 170. I could go ahead and name
all 170 using this grid. So out of these
170 combinations, the one that humans
care most about are the ones that most
commonly affect us. And it turns out
that H3N2 and H1N1 are two that are dominant
in human societies, human populations. Now this wasn’t always the
case, but at the moment in 2013, that is the case. Actually back, let’s say about
four or five decades ago, a more common one was H2N2. In fact, H2N2 caused
lots and lots of disease. Many people got sick
from H2N2, and it was a cause of a pandemic. But since then, H2N2 has kind
of been replaced by these that we see now. So I’m going to
erase H2N2 entirely. Because nowadays, we see
more of the H1N1 and H3N2. Now, why do you suppose
that would be the case? Why would some be more
dominant, or more common, in human populations
over others? I mean, there are
so many combinations you could think of, right? Why did these two
do such a good job? Well, the answer is that from
a virus’s perspective, if it’s trying and get to as
many people as possible, it’s got to do a really
good job of transmitting from one sick person to another,
so that it can spread really, really quickly through
a whole population. And both of these
viruses do that. They actually spread from person
to person really effectively. So if you have the flu, and
we know that it’s a type A– I should have
written that earlier, because this naming
system, we said, is only for type A’s– if you
know you have a type A flu, the chances are pretty high that
you have either one of these– either H1N1 or H3N2. Now, with all these
other possibilities, where do we see all these
other H and N viruses? Well, it turns out that,
unfortunately for the birds, a lot of these
viruses affect them. So birds are actually where you
find a lot of these viruses. Now, here’s my bird. And it turns out that almost
every virus that we’ve found can be found in a bird. And these are pigeons,
ducks, you get the idea. There’s only one
virus, actually– or one type of HN
combination, I should say– that you don’t
really see in birds. And that’s this
one, this H17N10. Interestingly, this
one is seen in bats. So all of the other
combinations are seen in birds. And in fact, not just birds. Some of these you’ll see in–
let me write out here– horses. Some of them you’ll see in pigs,
you’ll see in dogs, and birds as well. So a lot of different animals
can get these other HN type viruses. But again, just to
stress the point, the ones that we see in humans
are usually H1N1, or H3N2. Now, let’s say that
you do work with birds, that’s part of your job. And one day you actually see
that there’s a sick bird, and unfortunately for you,
you pick up the flu from it. And this could be
one of the other H combinations, HN combinations. So maybe pick up H5N1 from
this poor, sick, little bird. Or maybe you pick up H7N2. This has all been
actually shown, that these viruses can spread
from birds over to humans. And so maybe you
pick up H7N3, H9N2. There are a few of them, right? If you pick up one
of these viruses, then you would get
sick, obviously, because you got the flu. So it does cause
symptoms in humans. But the key idea is that,
at the end of the day, it doesn’t circulate. These viruses don’t
seem to circulate as well between humans. And as a result,
the dominant viruses still remain these
ones that actually do a better job of going from
person to person– these two human viruses, or these
two dominant human viruses. I’ll write “dominant.” Because again, you can get sick
with some of the other ones, but these are the ones
that we most often see in human populations. So the last thing
I want to mention is the naming structure. It gets a little bit
fuzzy and confusing, because sometimes we actually
name things like “avian.” Sometimes you might
see “avian,” which is another word for “bird.” Or you might see “swine,” which
is another word for “pig.” So if you hear the terms
“swine flu” or “avian flu,” what do they mean? Well because RNA pieces
get shuffled back and forth between birds, and
humans, and pigs, from time to time, what
they do is they basically try to identify,
where did the genes come from for this
particular virus? Did it come primarily from
a bird, or from a pig? And based on what
they find, they think, OK, we’ll let’s
call it “avian flu,” or let’s call it “swine flu.” But honestly, I think those
terms are very confusing for a lot of people. And it’s probably easier to
just think about them in terms of H’s and N’s.

Is Climate Change Aiding Spread Of Infectious Diseases?

Is Climate Change Aiding Spread Of Infectious Diseases?


>>>>PEGGY: THE PROLIFERATION OF DISEASE CARRYING
INSECTS. AS MY GUEST STANLEY MALOY, DEAN OF SDSU’S
COLLEGE OF SCIENCES EXPLAINS OUR WARMING WORLD HAS BOTH SCIENTIFIC AND ETHICAL IMPLICATIONS.
STANLEY, THANKS SO MUCH FOR JOINING US. LET’S START WITH THE SCIENCE.
A REPORT BY WORLD BANK RECENTLY FOUND THAT THE EARTH WILL BE ABOUT FOUR DEGREES HOTTER
BY THE END OF THE CENTURY. WALK THROUGH HOW THESE SINGLE DIGIT TEMPERATURE
CHANGES ARE LINKED OR COULD CHANGE INFECTIOUS DISEASE TRANSMISSION.
>>>>STANLEY MALOY: FOUR DEGREES IS BY THE END OF THE CENTURY F.YOU LOOK AT WHAT’S HAPPENED
SO FAR, JUST IN THE LAST FEW DECADES, IT’S ONE DEGREE.
SO NOW YOU ASK THE QUESTION, ONE DEGREE, HOW IMPORTANT CAN THAT BE? WELL, THE ANSWER IS
IT CAN BE VERY IMPORTANT. LET ME GIVE YOU AN EXAMPLE.
THERE’S THIS BACK TEAR BACTERIA M THAT CAUSES A PRETTY SERIOUS INTESTINAL ILLNESS, AND YOU
GET IT FROM EATING SHELL FISH. WE SEE IT IN NEW ORLEANS, OTHER PLACES, WARM
PLACES, WHERE YOU HAVE SHELL FISH. NEVER, EVER, EVER SAW THIS IN ALASKA.
IF YOU LOOK ATÊ>>>>PEGGY: IT WAS TOO COLD.
>>>>STANLEY MALOY: IT WAS TOO COLD. THE WATER TEMPERATURE WAS 13.8 DEGREES, 14.8
DEGREES AND THIS ORGANISM ALL OF A SUDDEN CAN BEGIN GROWING HIGH ENOUGH LEVELS WHEN
YOU HIT 15 DEGREES. SO WHEN YOU LOOKED AT THE WATER TEMPERATURE
IN ALASKA, AND AS IT INCREASES, WHEN IT WENT FROM AROUND 14 DEGREES TO JUST OVER 15 DEGREES,
ALL OF A SUDDEN AN OUT BREAK, AND SINCE THEN IN THE WARMER WATERS, IN IT’S A MAJOR PROBLEM
IN ALASKA.>>>>PEGGY: THERE’S ALSO EVIDENCE ABOUT THE
TEMPERATURE RISING AND MOSQUITOES MIGRATING NORTHWARD.
>>>>STANLEY MALOY: THAT’S RIGHT. BOTH THE DEVELOPMENT OF MOSQUITOES AND PATHO
JNS THAT LIVE PATHO JENS THAT LIVE INSIDE OF THEM ARE BOTH DEPENDENT STRICTLY ON TEMPERATURE.
WHEN YOU MOVE FROM THE TROPICS UP NORTH, TYPICALLY THE TEMPERATURE’S COOLER.
AS THE TEMPERATURE IN THE NORTH WARMS, ESPECIALLY IN THE WINTER, IT ALLOWS THESE MOSQUITOES
AND THEIR VECTORS TO BEGIN MOVING NORTHWARD, AND WE’RE BEGINNING TO SEE A LOT MORE DISEASES
LIKE MALARIA MOVING TO HIGHER ELEVATION IN THE MOUNT BS AND TO HIGHER LATITUDES.
>>>>PEGGY: YOUR PARTICIPATING IN THE CENTER OF ETHICS FORUM HONORING THE 50TH ANNIVERSARY
OF SILENT SPRING AND THIS FOREFRONT OF THE ENVIRONMENTAL MOVEMENTÊ THE MODERN ENVIRONMENTAL
MOVEMENT HERE IN THE UNITED STATES Y.WANT TO SHOW SOME VIDEO OF WHAT THAT LOOKED LIKE
BECAUSE BACK IN THE DAY, YOU KNOW, IT WAS TALKING ABOUT THIS BOOK IT WAS RATHER INSTRUMENTAL
ON THE BAN OF INSECT SD OR PESTACIDE DDT BECAUSE OF ITS AFFECTS ON BIRDS.
WHAT’S INTERESTING ABOUT THIS IS IT HAD A DOWN SIDE.
THE BOOK HELPED TO CREATE THE BAN, THEN THERE WAS A BACK LASH.
>>>>STANLEY MALOY: THE BAN TACK TOOK AFFECT BECAUSE THERE WERE BIRDS DYING, ANIMALS DYING,
ASSOCIATED WITH THE USE OF THIS INSECTSIDE. THE PROBLEM IS THAT SOME OF THOSE INSECTS
THAT WERE DYING WERE IN FACT HARMFUL PATHOGENS. MALARIA IS A GREAT EXAMPLE OF THIS.
THERE ARE MORE PEOPLE WHO DIE DUE TO INFECTIONS WITH THOSE DISEASES.
>>>>PEGGY: COULD THERE BE A SIMILAR BACK LASH F WE TRY TO PREEMPT THIS EVOLUTIONARY
RESPONSE OF INSECTS TO THIS GLOBAL WARMING OR THESE PATHOGENS, COULD THERE BE SOME UNEXPECTED
BACK LASH LIKE RESISTENCE? FIRKS WHENEVER YOU MESS WITH NATURE.
>>>>STANLEY MALOY: WHENEVER YOU MESS WITH NATURE YOU DON’T KNOW WHAT THE EXPACT IMPACT
WILL ONE OF THE THINGS WE HAVE NOW THAT WE DIDN’T HAVE WHEN RACHEL CARSON WROTE SILENT
SPRING IS WE HAVE A LOT BETTEDDER WAYS OF MANIPULATING ORGANISMS.
FOR EXAMPLE, A VERY BIG TRIAL IN THE WORLD NOW LAZ TO DO WITH THE MOSQUITO THAT TRANSMIT
SAID DINKA VIRUSSISM PEOPLE ARE RELEASING THESE MOSQUITOES THAT CANNOT DIVIDE.
THEY CAN’T POPULATE.>>>>PEGGY: I DO WANT TO GET TO THIS, CLIMATE
CHANGE, IT’S PART OF THE CENTER FOR ETHICS, HOW IS THIS A MORAL OR ETHICAL ISSUE?
>>>>STANLEY MALOY: WE’RE CAUSING A LOT OF DAMAGE TO OUR ENVIRONMENT RIGHT NOW, A FEW
COUNTRIES, LOT OF OTHER PARTS OF THE WORLD ARE SUFFERING THE DAMAGE THAT WE’RE CAUSING
AND FUTURE GENERATIONS SUFFER THAT DAMAGE TOO.
>>>>PEGGY: THEY HAVE NO SAY IN ITAL THANK YOU SE MUCH FOR YOUR INSIGHT.

U.S. Surgeon General Leads Panel Discussion on Combating the Opioid Epidemic

U.S. Surgeon General Leads Panel Discussion on Combating the Opioid Epidemic


Good afternoon, everyone. I’m Jeff Flier, Dean of
Harvard Medical School. And it’s really a great pleasure
to welcome you all today to the grand
rounds, as we gather to address the
current opioid crisis and together work
toward solutions. It’s certainly one of the
most important and troubling public health challenges facing
our communities and our nation today. Right now, four
people die each day of opioid overdoses in
Massachusetts alone. And since 2004, more than
6,000 have died in this state. Governor Baker’s administration
has recognized and quickly risen to the challenge,
establishing the state’s Opioid Addiction Working Group,
which has taken a leading role in addressing this crisis. One of our HMS assistant
professors in psychiatry, Todd Briswald at
Cambridge Health Alliance, has been working with
that state group, which includes professors and
faculty from four Massachusetts medical schools. I’d also like to
recognize at this time the work of the Massachusetts
state legislature, especially the leadership of
State Senator John Keenan, who is with us today,
and any other elected officials who might be here. Thank you. We’re all working to further
develop our curriculum competencies so
that we can improve how we teach future physicians
better pain medicine prescription practices
and give them a more accurate understanding
of the signs of addiction. And we’re also working to
de-stigmatize substance abuse disorders. Along with that,
planning is ongoing as to how we’ll integrate
the new curriculum across all of our teaching
hospitals and throughout the multiple clinical
areas outside psychiatry. But, as most of you
are probably aware, solving this complex
health problem is very difficult, because
prevention and treatment of opioid use disorder
is intertwined with the many challenges
involved in humanely supporting people who are struggling
with chronic pain, addiction, and other behavioral
health problems. In addition, many face
structural barriers to good health, including
poverty, homelessness, and other social challenges. But if there is one
thing that we’ve learned through
basic science, it’s that solving the hardest,
most complex problems requires collaboration
and partnership across diverse labs, academic
disciplines, and institutions. At HMS, we are
working to marshal the considerable
resources of our school, our affiliated hospitals, and
our clinics, several of which are leaders in the
treatment of addictions and behavioral health, along
with our external education programs and our Center
for Primary Care, all together to effectively
confront and rapidly reverse this devastating epidemic. So all of this brings us back
to the work of our meeting today and the introduction
of our guest panelists. First, I’m delighted to
welcome Dr. Monica Burrell, Commissioner of
the Massachusetts Department of Public Health. Dr. Burrell’s department is
responsible for spearheading our state’s response
to the opioid crisis. Welcome back to Harvard,
Commissioner Burrell. [APPLAUSE] Next on our panel is Dr. Sarah
Wakeman, an Assistant Professor of Medicine here at HMS,
and Medical Director of the Mass General Hospital
Substance Use Disorders Program. MGH developed this
program as a new approach to opioid epidemic,
and it has made it one of the highest
clinical priorities of a hospital-wide
strategic plan. Welcome, Dr. Wakeman. [APPLAUSE] And our third guest
panelist is Michael Duggan, who can speak very personally
about the opioid crisis. An Arlington native,
Michael is the founder of Wicked Sober, an
organization that helps individuals and
families struggling with addiction by connecting
them with treatment resources. Welcome, Michael. [APPLAUSE] And finally, our very
special guest today– let us all welcome US Surgeon
General Vice Admiral Vivek Murthy. [APPLAUSE] Thank you very much. Thank you so much for
that warm welcome. It is so nice to
see so many friends in the audience–
Bill [INAUDIBLE], you in particular–
and so many others. Dean Flier, thank you
for that kind welcome and for welcoming
me back to Harvard. It is really nice to be here. I have actually spent a
lot of time in this room in particular. And I remember so vividly,
as if it was yesterday, just how many
amazing experiences I’ve had in this
system, training at Brigham Women’s
Hospital as a resident, working there as an attending,
having the incredible privilege of teaching students during
my time in residency. And all of that has just
been an incredible privilege. And I’m reminded of that
when I come back here today. So I just want to
thank you for that. I also want to tell
you that– you probably know a lot about what
the Surgeon General does. But I find often when I
travel that people have heard about the Surgeon General. They know the Surgeon
General exists, but they have no idea
what I actually do. And I often find
that people have these strange misconceptions. They recognize me from
a box of cigarettes or from a bottle of alcohol. [LAUGHTER] And they think that’s
my main job, is stamping boxes and the bottles. [LAUGHTER] And it happens at
least once a week or so when we travel
that I get mistaken for an American Airlines
pilot because of the uniform that I wear. [LAUGHTER] But I’m assuming all
of you know better. I do not work for an airline. But instead, my job as
Surgeon General is twofold. It’s to ensure that
people across our country have the best possible
information that’s scientifically
grounded that they can use to improve their health. But it’s also to oversee the
United States Public Health Service Commission
Corps, which is a group of 6,700 officers
all around the country, and in fact, around the
world in 800 locations, who have dedicated their
lives to improving public health in America. These are doctors and dentists,
nurses and physical therapists, pharmacists, environmental
health experts, veterinarians, and even public
health engineers. And I bet you didn’t know
that there were public health engineers, but
there actually are. And they respond during
times of emergency, like in hurricanes or
tornadoes, that compromise the health of our country. They also help ensure
that on a day-to-day basis that our federal agencies
are doing everything they can to improve the
public health of the nation. And that is actually the
reason why I wear this uniform, is this is the uniform of
the US Public Health Service Commission Corps. I’m glad that we’re
all here today to talk about opioids, because
a few days ago I was in Phoenix. And in Phoenix, I met
an incredible young man who works at a center called
Community Bridges, which is a substance use and
addiction treatment center. And he told me this story of
how, when he was a young man, he felt like he
didn’t quite fit in, always felt something
was strange about him. And the first time he really
felt normal or comfortable was when he took
prescription opioids. And he remembers
that moment vividly, because it was the moment
where he got hooked. And as he tells it, he
began taking more and more of those prescription
painkillers in the months and
years that followed. He even told me at one point
that a couple years after he finished high school, he
was actually diagnosed with testicular cancer. And he went through a
pretty major surgery. He was treated, and he was told
that he would hopefully be OK. But three years
later, he was found to have enlarged lymph
nodes in his abdomen, and was told that there was a
recurrence of the testicular cancer. Now, for nearly anyone in this
room, if we were in a position where we were told we
had a recurrent cancer, our reaction would probably
be one of sadness and dismay. But that wasn’t
the case with him. He was actually overjoyed. And he was overjoyed
because he figured he’d need to have
a major surgery and would likely get
more prescriptions for opioid medications. He told me that story
to illustrate just how powerfully addiction
can take hold of your brain and impact the decisions
that you make and corrupt your judgment. And that’s what he experienced. That’s what so many people
living with addiction experience each and every day. So this is really
quite profound. And when we look
at the numbers, we find that there are
nearly two million people in our country who are addicted
to prescription opioids. And we see that there are
also millions more who are impacted by family members,
friends, teachers, and people in communities, including
doctors and nurses who are caring for these folks. A question is how
did we get here? Well, about 20 years ago, as
many of you may well remember, clinicians were urged to
treat pain more aggressively. But they were urged
to do so often without being given the
training and the tools that they needed to
understand how to treat pain safely and effectively. This also coincided with heavy
marketing of opioid medications to doctors. And many of us were even
taught that opioids were not addictive, as long as
they were given to someone who had legitimate pain. I was having dinner with a
friend who’s a cardiologist down in Florida the other day. And I mentioned this
to him over dinner. He put down his fork,
and he looked up at me, and he said, wait, you
mean that’s not true? And he was trained
at some of the best programs in our country. So there’s a lot that
contributed to this problem. But what it’s led to is
unfortunately a quadrupling in overdose deaths since 1999. The quantity of
opioids prescribed has also quadrupled since
1999, tracking very closely with the rise of the epidemic. So what does this mean? Well, it means something
in very real human terms, because besides the
numbers that tell the epidemiology of the illness
and how much it’s costing us in terms of dollars, there’s
a very real human cost, a cost that I see very
often when I travel around the country and talk
to families, a cost that many of you see in your
day to day clinical practice, recognizing that so
many of our patients, whether they come in with
a primary complaint that’s linked to addiction or
not, often have addiction in the background, something
that we have to be aware of and we have to manage
if we want to improve their overall health. So what do we have to
do to get past this? Well, I think there
are a few key things. And the good news is
that a lot of this is actually being done
in Massachusetts, which is exciting and encouraging,
and a reason why I think this state is a
bright spot in the country. But we have to ensure that we
are sharpening our prescribing practices as clinicians so
that we can prescribe opioids when necessary but avoid
them when they’re not. We also need to ensure that
we are expanding access to treatment, that we
are getting naloxone in the hands of people who are
at risk for overdose, as well as first responders and, in
some cases, family members. We have to educate the public. Many people in the
public don’t also recognize that
opioids are addictive. As one patient’s family
told me, a patient who sadly had a child who overdosed and
died from opioids– her mother said to me, I got a
prescription from the doctor, so I assumed it was safe. Why would our
doctor ever give us something that could
kill our daughter? That’s what she said. And unfortunately, there
are so many parents that have gone through a
very similar experience. So we all know, as clinicians,
that every medicine has benefits and potential risks. But when it comes
to opioids, it’s clear that we have to do more
to help the public understand what some of those risks are. And finally, what
we also need to do, which is perhaps more
difficult than anything else, is we have to change how our
country thinks about addiction. We can’t pass a law
that will do that. We can’t build a single program
that will change attitudes around the country. But right now, there are
too many people in America who think of addiction
as a character flaw, as a moral failing. And as a result,
it makes it harder for people who are living with
addiction to come forth and ask for help. It makes it harder for
people to accept treatment centers in their neighborhoods. There are so many
people who would have no problem with a cancer
treatment center being set up in their neighborhood or a
heart disease treatment center. But when you talk about
having a methadone clinic in their neighborhood, that’s
a whole different issue. And many of them are
concerned about that. And why is that? It’s in part because of how
we think about addiction. So that’s something
that we have to change. And our office made a decision
very early on in my term that I would make this
a priority during 2016 and the years that followed. The reason is partly because
of my own clinical experience, seeing so many patients
struggling with addiction. Part of it also had to
do with nurses at Brigham and Women’s Hospital,
who, on my last day– actually at the Brigham,
when I was leaving– pulled me aside and said,
Vivek, if you could do just one thing during your time at
Surgeon General, please do something about the
drug crisis in America, because it’s tearing
our communities apart. But I also decided to make
this a priority because of the families that I met all
around our country, families who said to me time
and time again, please do something to help us. Our communities are struggling. So that’s why I have
made this a priority. That’s also why
President Obama has made this a priority, because
he too has heard from families. He too has seen the pain
and the cost of addiction all across America. So in addition to visiting
communities like Boston, where we can talk about the
challenges that we are facing, but also the solutions
that we’re implementing, I will be, next month,
issuing a letter to the 1.2 million prescribers of opioid
medications in all 50 states, a letter that will urge our
colleagues to join a movement we are building to turn the
tide on the opioid epidemic. We will also urge
practitioners to follow a key set of best practices
which will help them treat pain safely and effectively. And since, as clinicians,
we all love pocket cards, we’ll also be including a
pocket card in that letter so that you can keep
that in your white coat or, increasingly, in your
black fleece as many of us seem to wear. And that’s something
that you can refer to that will
help guide you when you’re making decisions
about opioid medications. And later this year, I will
be issuing the first ever Surgeon General’s
report on substance use addiction and health. Surgeon General reports
have been an important part of how we have addressed public
health crises in this country. In 1964, my predecessor,
Luther Terry– who, by the way, lived in Brookline also. But Luther Terry issued
the country’s first report on tobacco, which began
50 years of activity in reducing smoking rates that
helped us go from a smoking prevalence of 42% in
1964 to under 17% today– still too high, but
progress has been made. And the goal of
our report will be to bring together the
best available science on prevention,
treatment, and recovery so that clinicians
know what to do, so that policymakers
know what to support, and so that families
know how to approach their children or
their loved ones when they’re dealing
with addiction. That’s a purpose of our report. It’s also to help us change
how our country thinks about addiction. In closing, I just want to
share one last thought, which is a question about
whose responsibility this is to solve. We have so many crises
in America right now. And often, when we
think about them, we can ask ourselves, well,
one, whose fault was it, and two, who should
clean up the mess? But what I want to tell
you with this problem, with the opioid crisis,
is that this is not any one group’s responsibility. This is all of our
collective responsibility. This is a problem that can’t
be solved unless policymakers and clinicians work together
with families and faith leaders to change not only how
we think about addiction, but how we prevent and treat it. And we have an especially
important role, though, as clinicians to play here. And you might think,
well, that’s of course, because we can prescribe. And if we can change
prescription practices, then we can impact
this epidemic. And you would be
absolutely right. But I think there’s
something even bigger, which makes it important that
we in particular step up. And that’s that
over the centuries, society has accorded us a
special place, a special degree of respect that comes from
an appreciation for why we enter this profession
in the first place. Many of us came to
the healing arts because we wanted to
relieve suffering, because we wanted to
improve people’s lives. And with that has come
a moral responsibility to not only care for
individual patients, but to step up and
help address some of our country’s most
intractable public health problems when they arise. I learned early on when I was
young, as an elementary school kid sitting in my
parent’s office, where they saw patients
day in and day out, that they was something
more than the science that was contributing to that special
look of respect and honor that my parents’ patients
accorded to them. My parents– their
patients looked at them for hope and for help
during times of hardship. Their community looked
at them for hope and help during times of crisis. And the opioids crisis is
one of those moments where the country is looking to
our profession for hope and for help. And my desire, my
hope is that we will step up, that we will
fulfill that responsibility. So part of the reason
we’re here today, and why I’m so thrilled that we
have a wonderful panel with us, is that we want to talk
through some of what’s actually happening with this crisis and
how we’re addressing it here in Massachusetts. We want to talk a little bit
about how individual clinicians can change their practice
and can play a bigger role, in fact, in helping to not only
prevent addiction, but treat it as well, particularly
with buprenorphine. And we want to hear a bit
about the experiences of people who have lived through
addiction and who have come out on the other
side and helped show us that recovery is
not only possible, but that the story of
getting to recovery can be a source of empowerment
for many, many others. So with that, I want to turn our
discussion over to the panel. I’m going to begin by
addressing a couple questions. And you can all
still hear me, right? Yes. Mic is officially working. I start by addressing
a couple questions. And then we’re going to
open it up to the audience so that all [INAUDIBLE] have
some time to [INAUDIBLE]. Wow. [INAUDIBLE] All right. Let’s hope it stays. So I want to start
our first question with Dr. Burrell, our
Commissioner of Health here in Massachusetts. First of all, Dr.
Burrell, thank you so much for being with us today. And you have played
multiple roles when it comes to medicine
and public health during your career. You’ve been a clinician. You’ve treated patients with
substance use disorders. And now you’re also
looking after the health of the entire state. So I’d like you to share a
little bit with us about what approach Massachusetts is taking
to address the opioid epidemic, and in particular, how
is the state interfacing with clinicians? Sure. Well, first, everybody,
thank you all for being here. It’s nice to see so
many familiar faces. And I want to, on behalf of the
Baker Administration, welcome the Surgeon General here. It’s quite an honor for us to
have our National Public Health leader coming to Massachusetts
to learn about what we’re doing to battle this opiate crisis. As many of you know, this is
the number one public health issue of our administration,
and we are working very hard to bring down the death levels. The numbers are astounding. There were over 1,500
predicted deaths last year from opiate overdose. And that’s over
double just 2012. When we think about those
numbers and the individuals behind them, we
have come together, Governor Baker put us together
as an opiate working group cross-sectorally, and we came
up with 65 recommendations and a 19-step action
plan that looked across the area of prevention,
intervention, treatment, and recovery–
many of the points that Dr. Murthy raised to
make sure that we address this issue across a sector. In prevention, we’re talking
about prevention, crime rate prevention, so that individuals,
parents, students, coaches, community members understand
the risks of opiate misuse. And then we’re talking
about prescribers. As many of you
know, Massachusetts is, again, first in the nation
to have all four medical school deans– thank you, Dr.
Flier for your leadership on this– all four medical
school and dental school deans have adopted a core competency,
10-core competencies, that we will teach every medical
and dental student before they graduate so that
we’re all starting with the same basic individuals
enter their clinical practice. In interventions, we are looking
at getting naloxone or Narcan throughout our communities. We’re increasing the
number of treatment beds. And we’re working
towards improving the options for
recovery, including recovery homes and
sober home living, as many individuals
find themselves tackling unemployment and homelessness
as well as they struggle to get better. I will say, the most
important thing to me is our State Without
Stigma campaign. And when Dr. Murthy
and I earlier today were speaking with
some patients, when we asked them, what
would it take for you, what advice do you
have for individuals– and he spoke about
his own struggles with getting the courage to
tell people in his community or his medical provider
or his own doctor that he had issues with
substance use disorder because he was embarrassed And for us, we have to get
over this issue of the stigma. This is affecting all of us. We have to look at
substance use disorder for the medical
disease that it is. And until we get
there– and that’s both from us and our internal
biases as prescribers as well as community members–
until we get there, we won’t be able to
make sure that all of these services that we have
are accessible to everyone. It’s a big barrier,
the stigma issue. Well, thank you. Thank you so much. And I certainly appreciate
your efforts and the governor’s efforts in this state. So please, convey our gratitude
to him for what he is doing. I want to turn to Dr.
Wakeman for a moment to give us a bit of a
clinical perspective here. You also have
trained in medicine. You’ve seen the many
facets of addiction. You’ve now come to a place
where you’re treating people who are living with addiction. And I want you to help
us address something very practical
here, because I find that when I speak to
clinicians, and when I think about my own time
practicing here at the Brigham, the prospect of
treating patients with substance use
disorders seems like a monumental challenge. It seems like the amount
of work and training that would be required to
be able to do something like prescribe buprenorphine
would be incredible. And this is even when you’re
sitting at academic center, where you have some
additional sources of support. So what I’d love
for you to demystify for us is what is
treating substance use disorders actually like? If we want substance
use disorder treatment to be part and parcel
of training for everyone in medicine, do you think it’s
practical for someone who’s practicing primary care medicine
right now to take on substance use disorder treatment? So I would love for you to
comment a little bit on this. Thank you. And thank you so much for
being here and for having me. It’s an incredible honor
to be on this panel. So I think that’s
a great question. I actually was a
primary care resident. I trained in the
primary care program at Mass General Hospital. And I’m a primary
care physician and I’m board certified in
addiction medicine. So I do both. And I would say that
treating addiction is both the single
most rewarding thing I do in medicine and
one of the easier things that we do in medicine. As internists and
as specialists, we take care of very complex
chronic medical disease that has components of behavioral
parts of people’s lives, genetic risk, and sort
of fundamental biology. And addiction is exactly that. So I actually think
diabetes is sort of the perfect metaphor for
both how we deliver care and what the disease is. So addiction is as genetically
inherited as diabetes. It’s about 50%,
based on your genes. And like diabetes, there
are some components of lifestyle or exposure. And then there’s
a lot of biology. So patients who have
addiction, their brain is fundamentally changed. And the story that you described
is a perfect description of what happens–
that, by definition, people who are in the throes of
addiction behave irrationally. And I think that’s
one thing that’s so hard for family members and
for the public to understand, this idea of sort of why
can’t they just stop? And literally, the
part of our brain that helps us make decisions
about choice and to weigh risk and benefit and think
about consequences gets damaged in addiction. And the good news is
that recovery happens. Actually, most people with
addiction will get better. It’s a totally
treatable illness. But it takes time, like
other chronic diseases. And if patients die
before they get there, obviously, we’ve
lost the battle. And so I think the approach
is very much what we do in primary care every day. It’s meeting the
patient where they are. It’s patient centered. It’s a shared decision
making process around what type of treatment
works for that patient. And it’s a combination
of medication and behavioral interventions
or lifestyle interventions. And so I think it
maps out perfectly into what we’re doing. But the big thing is stigma. And that’s what Commissioner
Burrell mentioned. And with medication
treatments in particular, I was actually on a
panel earlier this week with a gentleman
who’s in long term remission on buprenorphine. He’s been in remission
for eight years. And he said that it was harder
for him to tell his family that he was on buprenorphine
than it was for him to come out as a gay man, that he
felt such intense stigma around the use of medications. And I have many patients who are
doing fabulously in recovery. They’re working wonderful jobs. And they don’t tell
anyone that they’re on this lifesaving
medication because they perceive this message that
somehow that treatment is not valid. And so I think fighting stigma,
not just with the disease, but actually with the
types of treatment that we offer people is crucial. Well, that’s very,
very powerful. And I would also just
want to flag for folks when you actually look
at how much time it takes to get trained at administering
buprenorphine for the waiver, it’s actually about eight hours. That’s the length
of the training. So it’s achievable. It’s actually easy to do. And it’s incredibly gratifying. This is the piece, I think, that
many clinicians who have not actually engaged in treatment
don’t necessarily understand, is that we are living in a
time where physicians are burning out at very high rates. And part of the reason
that we’re burning out is we often don’t feel we
have the tools and the time to treat the challenges
that our patients have. And that lack of
self-efficacy, when it happens year after year
after year, can burn people out. And if training and treatment
actually gives you the ability to have impact– and
I believe that impact is one of the most powerful
antidotes to burnout. When you feel like
you can actually have a positive impact
on a patient’s life, that gives you energy. It gets you excited. It renews your sense
of mission and purpose. And so I would certainly
love to see more clinicians, especially primary care
clinicians getting trained in buprenorphine treatment. That’s part of what we’re
trying to encourage training institutions to do as well. So thank you for sharing that. Yeah, thank you. I want to turn to Michael. Michael, you have an
extraordinary story– a story not just of how you
worked through addiction and came out on the
other side, but a story of how you turned
pain into a passion for helping other people. And I think it’s
really extraordinary. And I would love
for you to– we’ve had the chance to
hear your story when we were down in Atlanta
at the Rx Summit but I would certainly
love for you to share some of your experiences
and the journey that you went through with
the folks who are here today. Awesome. Well, thank you for
the introduction. It’s an honor to be on the
panel with doctors as well. I’m also an M.D. My
initials– Mike Duggan. [LAUGHTER] i just want to put that
out there– probably longer than a lot of
people in this room. So I’m very excited to be here,
great discussion so far, happy to participate in it as well. My story certainly isn’t
unique, especially for a lot of the stories we hear today. I grew up in a typical
Irish Catholic family. There was a lot of alcoholism,
a lot of addiction. I grew up playing
sports for a long time. That was my outlet. That’s where I found myself. And I just want to
make something clear. What I share is my experience
and my experience only. And there’s a lot
of path to recovery. I’m a person in
long term recovery. And what that means to me is
I haven’t had a drink or drugs since April 14th, 2009. So I’m very grateful
to recently celebrate seven years in recovery. [APPLAUSE] Thank you. It’s weird looking
up at everybody. I feel like everybody’s
looking down on me right now. Shame on all of you. But in terms of the
process I went through, I just want to make
something clear– that the experimentation
of alcohol and marijuana certainly played
a big part of that and how old I was
when I experimented with both of those drugs, and
the increased likelihood of me developing a substance
use disorder, especially with the introduction
of prescription pain medication when I broke my
wrists from a hockey injury senior year playing hockey. And at that time, I
remember the experience. The first solution to the
pain was prescription opioids. And there was no lesser
alternative given. There was no family
history that was drawn. There was no questions
asked or other alternatives that were discussed. It was also during the time
that OxyContin had first started coming around
in the early 2000s. And I think, at that time,
based on mismarketing practices, it was prescribed
for moderate pain. And when I had
that introduction, it certainly paved the way in
a lot of ways for my decision making afterwards, without
even realizing the control it had over my thinking. And shortly after that
first interaction, I had surgery on my wrists
to repair nerve damage. And the solution to the
pain after the surgery was more prescription
pain medication. And then after that, I also
had my wisdom teeth pulled. And the prescription
for the pain was prescription
pain medication. At that age, it was easier
for people my age that I knew and I grew up with to
access pain medication, either legally or
illegally, than it was to get somebody
to buy them alcohol as an underage individual. And the process for
me had many detours, let’s say, many different
paths that I had taken. I personally have
been on Suboxone. I’ve personally been
on the Vivitrol. I’ve personally
been on methadone. So I certainly tried
different attempts at getting myself
clean and sober. One thing I will mention
is my first experience in a detox program– I
remember them asking me the question, what are your
plans when you get out of here? My planning got me in there. So I just want to
make that clear. The last thing I think
that anybody really should have been asking
me at the time were what my plans were, because
a lot of the information that I was getting
was coming from people that I was using drugs
with versus people who were health care professionals
that were properly educating me on options and resources
that were available to me. And I would tell them
or direct them as far as what direction I was
going to choose to go down. And you know that, obviously
created a lot of pain in a lot of situations that
I wish I never went into. But at the end of the
day, there was a light at the end of the tunnel. Fortunately, I’m here to share
a story of recovery, of hope, having the opportunity to
receive proper long term treatment. And I think the biggest
problem, and the reason why I founded Wicker
Sober was if you look at addiction as a
disease of unmanageability and if you look at addiction
as a disease of isolation, those two things– if
you look at success that 12-step programs
have, for example, part of the 12-step
program is admitting that your life is unmanageable. And I think society as a whole
had unrealistic expectations, expecting me to manage my
own care and get myself well. And I think we were falling
short on the lack of support services in between
the coordination amongst treatment,
which was important. So we started a hotline in
order to work with individuals in the system, in the process of
navigating them and connecting them to resources. I remember being in a
program and being discharged with a phone number list,
saying, here you go, these are some options for you. And a lot of times, I never
made those phone calls. Or when I did, I
would quickly find out that there was limited
bed availability, which would cause me now to either
give up in the process and use because I wanted
to avoid withdrawal, or wait or delay it until,
unfortunately, maybe something happened, a consequence
happened that maybe stopped me in my tracks. And another reason why
we started Wicked Sober was for the families. My mother is a very
intelligent woman. She’s a nurse at Mass
General Hospital. But when it came
to addiction, she was getting a lot of
the advice from me. There’s a lot of stigma. There’s a lot of
guilt. And there’s a lot of shame
within the family. And places she
would call, nobody would give her any
information, saying they need to speak
to me directly, which was unrealistic
at the time. So we do a lot of
work with families, put together treatment plans,
coach them on education, coach them on support
groups that they can attend, like Learn to Cope, which you
recently addressed as well, and were to obtain
nasal naloxone, Narcan, and provide
intervention services and help them talk to
their loved ones as well. Well, thank you, Mike, for not
just your story, but for all you’re doing to help
other people as well. Thank you. Appreciate that. You mentioned naloxone and
the nasal Narcan as well. And as it turns out, I
have some demos right here for those of you who
may not have seen this. Now, the reason I bring this is
because I think many of us who see patients have had the
experience of having seen a patient in a clinic
or in the hospital and asking the patient, so
what medications are you on, and they can’t tell
you the medicines, but they pull out
a handful of pills that are blue and red
and pink and white. And they say, well, you
probably know what these are. These are my medications. And of course, in the back of
your head, you’re thinking, I have no idea what
these are because I don’t know what they look like. Well, it turns out that part
of what we’re trying to do is ensure that more people
have access to naloxone. So I wanted to make sure
people knew what these actually look like. So what I have here are an
injectable dispenser for Narcan and also a nasal
dispenser for Narcan. And this is relatively
new, the nasal formulation. But these are
relatively easy to use. And it turns out that it
actually gives you instructions that you can hear. And how many of you have
actually seen this before and used it? So just a few people. So what I’m going to do is I’m
actually going to take it out, and the I’m going to
hold it up to the mic so you’ll hear what
it actually says. [BEEPING] This trainer contains
no needle or drug. Precautionary. [BEEPING] So then what I’m going to do
is I’m going to take this off. –to inject, place black
end against outer thigh, then press firmly and hold
in place for five seconds. Do you mind if I demo on you? There’s no need, but– To inject, place end– Ow. –three, two, one. [BEEPING] Injection complete. And that’s literally it. This trainer may be reused
for training purposes. Let’s make sure this
quiets down a little bit. Hold on. –and white outer case. This is always the hardest
part of the demo, is getting it to quiet down again. There we go. This is the nasal application. And, here this is
actually fairly simple. What you do is you hold
it with two fingers, put your thumb behind, which
is where the release is. And then you insert this
into one nostril, either one, doesn’t matter. And then you just
simply push on the back. And that dispenses
the medication. You just need to give one dose. This is a one dose cartridge. And then you wait
two to three minutes to see if there’s a response. And if there isn’t, then
you can give another dose, both of the intranasal
one, and also you can give a second dose of
the injectable as well. So it’s that simple. Now, different states have
different rules around Narcan. Some states, it’s actually
quite hard to find. Others have made it much
more easily applicable. In Baltimore, for example, they
have a standing prescription where anyone can walk in
and actually get naloxone, whether you’re using
opioids or not, because we know that many
times, family members play an important role
in administering this to their loved ones. So this is what Narcan is about. But I also just want to touch
on one thing that Mike said, which is about the
treatment, the phone numbers that you said you were
given several times when you were in the hospital. I’m willing to bet that
every clinician in the room has had the experience
of sending a patient out with a phone number
to call for help and knowing somewhere
in the back your head that it was very unlikely
that they would actually be able to use that. And that feels
really, really bad, because you feel
like, gosh, I really know there’s more
this person needs, and I can’t actually provide it. So I’m making both of us feel
better by just giving the phone number. And what that points
to is the fact that if we really want to
provide the help that people need, if we really
want to tackle the problem of
addiction, we have to ensure that the full
set of wrap around services are available. And whenever we talk
about more services, it sounds like more money. And says, well, where are we
going to the money for it? Well, what I would say
is that we can’t actually afford not to do that, because
we are paying far more in terms of emergency room visits, in
terms of lost productivity, in terms of human suffering than
we could be if we only invested more in the treatment side. And that’s one of the reasons
why President Obama actually made it a point in his budget
request for the next year to request about $1.1
billion in new funds to fight the opioid epidemic. And a significant
portion of that is going to expanding treatment. If it’s actually
funded by Congress, about up to $20
million of those funds would actually come to
Massachusetts, as well. But this is why those
funds are so important. It’s because it’s about
providing the kind of follow up services, wrap around services,
that folks like Michael and so many others need when
they’re dealing with addiction. I want to now just
turn to our audience. We have time for
a few questions. So I wanted to see if anyone
would like to ask anything. Sure. Right over here. Hi. Good afternoon. Thank you so much for
coming to speak at Harvard. My name’s Danielle Beck, and I’m
a fourth year medical student here. And I recently completed the
eight hour Suboxone training here as part of a pilot study. And I’m also a member
of the Student Coalition on Addiction in Massachusetts. And we completed
a statewide survey that showed a serious
gap between wanting to be trained in order to treat
patients with substance use disorders and actually having
the skills to treat patients with substance use disorders. Given this gap in
training, would you support Suboxone
training being integrated into the medical student
curricula across all states nationwide? I would. I think it’s important
for all clinicians to know how to treat
substance use disorders. If you think about
it, whether you’re a cardiologist or
a dermatologist or an ophthalmologist,
you’re given basic training in how to adjust blood
pressure medications. And you’re giving that training
because, even if you don’t use it every day, it’s a basic
skill set that we have to have, especially given the
prevalence of hypertension. Substance use
disorders are becoming increasingly prevalent. And what is clear also is that
people living with substance use disorders don’t
always have easy access to the medical system. What that means is that
we should be moving toward, essentially, a
no wrong door policy, whereby any interaction
with the health care system enables someone
living with addiction to be able to encounter
someone who can provide them with treatment. And so that’s why,
yes, I would be supportive of
expanding our treatment and making this and
thinking about substance use treatment as part of
the basic tool kit that every clinician
should have. Thank you. Thank you all so much
for the wonderful work that you have been doing
and for addressing us today. This has been a
great discussion. My name’s Scott [INAUDIBLE],
and I work as an adolescent medicine physician and addiction
medicine physician here at Boston Children’s. And Mike, your story
really resonated with me, because I see a lot of patients
in exactly the position that you found yourself in. I can think of a
16-year-old patient who I started on buprenorphine
a couple of weeks ago. I remember sitting there,
starting him on the medication because he’d been struggling
with methadone and other pills that he had been
buying off the street. And as I was doing
the induction, he was sitting there
reading a Harry Potter book. And I remember thinking,
this is such a juxtaposition of something that we think of
as a typically adult disorder combined with somebody
reading a book that’s made for children in my exam room. And so my question
for the whole panel is what thoughts do you
have and what efforts are we making at the local,
state, and national level to address prevention and
treatment for young people, since we know that
the life course trajectory of these
things starts quite early? Did you want to [INAUDIBLE]? Were you directing the
question to Michael? Yeah. Well, I think a lot
of us could certainly touch base in different
aspects to that question. One thing I just want
to mention in terms of medication-assisted
treatment is medication isn’t the treatment. It’s just a treatment
aspect to that as well. It’s very important. When I went to an
out patient program, I would go to a Suboxone doctor. And then I would go
to a Vivitrol doctor or I’d go to somebody who
prescribed me methadone. I think we have to provide
all options to find out what’s going to be best
for the individual, not necessarily what’s
going to be best for the provider, prescriber. And in terms of
where stigma can be a huge problem is if
you’re referring out to an abstinence-based program
as part of your treatment when you’re on medication
like buprenorphine, that may not be something that
an individual feels necessarily comfortable in versus being
in a group with other people that are on the
similar type medication that they are as well
receiving treatment. And I think that happens a lot. In terms of work,
as of right now, there’s a ton of advocacy work
and grassroot organizations that are going into a
lot of the high schools, a lot of the middle schools,
and having the conversation. So that’s obviously
very important. There’s still that concern
that a lot of parents have that they don’t want
to have the conversation with their children. They think it’s too early to
have that conversation as well. So we still have to
overcome those obstacles when we go into the schools,
when we speak to the students. A big problem for me, in terms
of the possible directions that I take, that
I had taken, was addiction is a chronic illness. And it needs to be
treated as such. And there was limited
case management services that were done. I know you had mentioned how
much we’re costing by not doing anything differently. And a lot of times,
it’s detox only, which detox is a quick
fix solution that we’re providing the
highest level of care and providing the most
expensive services, and we’re discharging an
individual with no follow up care. So we’re really missing the wrap
around services and the case management services to work with
people on a long term basis, providing them a
continuum of care. And I think that’s where
we still fall very short. But we’re making extreme strides
in the right direction, which is good. Let’s see if we can fit in
maybe a couple last questions. Go ahead. Thank you so much. It’s truly a
privilege to be here, a part of your leadership
around these issues, Surgeon General
Murthy and our panel. My name is Patrick [INAUDIBLE]. I’m a primary care doctor at
Lynn Community Health Center. I’ve also trained at the Mass
General Hospital and practice at Mass General. And I wanted to make a point
about and ask a question about the integration
of services. So we all know that pain
is multi-disciplinary. And there are many ways to
treat it other than opiates. And I can think about the
difference in my practice at Chelsea Health Center and
Lynn Community Health Center, where we have the
privilege of being set up with a really rich set of
neighborhood health services, so that when I meet a patient
with addiction or with, perhaps, an appropriate
opiate– benzodiazepine use, for example– I can tap
colleagues for warm handoffs to assess whether
they’re catastrophizing around the pain, whether there
are behavioral components around that, whether we’re
appropriately addressing various traumas in a
trauma-informed way– I feel able to provide the care
I need for my patients without having to own that
all in a 15 minute visit. We also have team structures
so that patients are reviewed on a monthly basis
who are high risk and who have the support
of a team’s recommendations as I go back to a
patient to explain why we may need to move them off
those [INAUDIBLE] prescribing or reduce their level of dose. And so how do we think about
the structured integration that support the ability
of us to provide the care at the point of care? So Pat, I will address
that in a little bit. Nice to see you. So I think part of
the reason of coming to you here as this group
is the answers are here. So we know that team-based
care is good for diabetes. We know that engaging
multiple disciplines across different sectors,
even outside of medicine, is the way to take
care of people with cardiac best
or cancer survivors. The same holds true for
substance use disorder. You know models
of care, as I do, where the behavioral health
is integrated directly into the primary care. And those are the best models
and the most successful. So for you all, as leaders
in the field of medicine, I would ask you to
think about ways to get these models and
these best practices and enhance them
throughout the system, because I think this is a real
opportunity for us to finally get issues of behavioral
health illness incorporated as they should be in primary
care in a holistic way. Go ahead. Thank you. Scott Sigman, I’m a practicing
orthopedic surgeon here in Massachusetts, also a member
of Governor Baker’s new Chronic Pain Management Commission. So elective surgery,
in Mike’s story, is a very common one, has
become an inadvertent gateway to the substance use problem. And as many as one
out of 15 people that are exposed to opioids in
the setting of elective surgery will go on to substance use. So we’re doing a
really great job here trying to re-educate
our physicians. We now want to also try to
educate our patients to have them empowered to recognize that
there are opioid alternatives that are out there. For example, I use
liposomal bupivicaine with excellent success and
really dramatically reducing the need for
post-operative narcotics. One of the problems
that we’re seeing here in Massachusetts, as well
as across the country, is that the cost of the
use of the medication is considered too much. We have silo pharmacy budgets. We have hospital
administrators who are saying, it’s too much money
on the front side. And I guess the question
I have is for a strategy as to try and balance the amount
of money used for prevention to, say, down the road,
can we save lives, and can we also reduce the
overall cost to society? So are there
strategies that we can talk about where we can balance
that out with prevention? I certainly appreciate
that comment. And I think what you
shared is actually a concern I hear all
around the country, which is that the
alternative sometimes costs more than the opioids,
whether that’s IV Tylenol or whether it’s going
to PT three times a week and having to dish out a
co-pay each time you go, which is more time
and more money. So there’s certainly
an issue here. And I think part of
what we are working on, and I think what we need
to collectively work on, is in having more conversations
with payers about how we shift and change what we
pay for, recognizing that investing more in
lowering the cost of some of these alternatives upfront
can save us a lot more cost down the line. But I think this also points
to the importance, again, of integration, because the
more we have integration with different elements of our
health care delivery system, I think the easier it is for
us to understand the costs and benefits of different
decisions we make. Many of us have operated in a
fairly siloed universe when it comes to practicing medicine. And we can see, even
on a small scale, that when you have
consult services that don’t talk to each other,
that can cause tremendous pain for everyone. That can cause increases
in length of stay. That can cause increases
in complications. So I think the integrated
systems, some of which we saw earlier today at Boston
Health Care for the Homeless and also at the Boston
Medical Center these are great examples, I think, of
how we need to bring services together. But they have to
also be combined with conversations with payers. And that’s part of what
we’re trying to drive now. I think that there’s a
recognition that there are many folks who probably
contributed to this problem over time, but now it’s our time
to all come together and chip in and make sure that we
are a part of supporting the solution. I know that our time
has nearly run out. So let me just take
one more question then I’ll take a comment at the end. Go ahead, sir. Thank you for coming. I really want to,
first, start off by saying that I
love your hashtags. So I’ve used #stepitup. And now, #turnthetide is great,
because I’m from New Bedford, and so we’re, in
New Bedford, one of the small cities
in Massachusetts that’s struggling with
the opioid crisis. I’m Dr. Mike Rocha. I’m a cardiologist. I’m actually not from Harvard. I’m a UMass Medical Center grad. And I actually trained at Tufts. But we really are
struggling in our community. And one of the things that
we’ve tried to look at is how do physicians in
a community setting– because we’re here in
an academic setting– and how do we come together in
communities where we need to be on the ground to get that done? And I’m going to
share with you what we’re doing in New Bedford. What we’ve done over
the last several months is we’ve put a
coalition of doctors together from all
subspecialties– cardiology, anesthesiology, emergency
room physicians– and we’ve decided to embrace
the Turn the Tide in what we were trying to do. And exactly the
things that you’re talking about at the
community level– we’re talking about advocacy. So what has to change
in our community, how we can connect with people
outside of our community, public health education, which
we’ve already showed the movie “If Only” and had James Wahlberg
come down to our community to get that conversation
going with the kids, and also to improve physician
pain medication practices. And last night, we
actually had 85 doctors at a restaurant in
New Bedford that had a continuing medical
education meeting last night with
Dr. David Kassovitz from Boston Children’s Hospital. And we met with our mayor. So what we recognize is that
we have tremendous power when we work together. And I think that’s
one of the things, as physicians, that
sometimes we forget, is that we work in our own
offices, our own emergency rooms, our own operating rooms,
and that when we really come back to what we’re supposed to
be doing is to help and serve our patients, if we
just show up and care with hope and compassion, we
can make a big difference. And what I’m going
to ask is this how do we leverage our
practitioners in the community to come together in a way that
we aren’t reaching right now? Now, we can talk about it
at the public health level. But how do we interact
with public health and the clinicians better? That is a really good question. I have a lot of
thoughts on that. But let me do one thing,
if you don’t mind. I’m going to hold your
question for a moment. I want to get a comment
here, and then I’m going to come back and
answer your question, OK? And we’ll wrap up the session. I wanted just give
a moment to Shoma and to Blaine, who are
two of our partners who are here, because I
want them to share something that they’re helping
work with us on. Shoma is from the Institute
for Healthcare Improvement, and also Blaine is from PHFE. And both of them have been
incredibly important partners for us in building this
Turn the Tide campaign. And in addition to sending
the letter and the pocket card out that I mentioned,
we are also creating a website where
we can have clinicians go to understand what
other clinicians are doing, to hear some of their stories
about how they changed their practice,
where they can also hear the stories of patients
who encountered clinicians who helped them, where they
can print out materials that they can share with
patients, a simple way to educate people who are
coming through their door. So I want to give Shoma
and Blaine a chance to share a little
bit about that. Thank you so much. It’s such a privilege to be
partnering with you in this. And in many ways,
Mike, your question is at the heart of
what we’re doing, which is to say, how can we
really think about the fact that this needs, as the
Surgeon General said, a community-wide approach? And if it takes a
community-wide approach, we need ways to bring
community together across health care,
public health, patients, community members. And so at 100
Million Lives, what we’ve been doing
is building some of the tools, the
resources to make that possible for people,
and also for people as, for instance, the
State Without Stigma– what a fantastic thing to do, or
what Wicked Sober is doing– how can we make these bright
spots visible to everybody across the country so
that New Bedford might be inspired by what
Wicked Sober is doing and what Boston is doing? And Boston might be inspired
by what New Bedford is doing, and what a community in Alabama
might find that they develop can actually help to accelerate
our collective work together. 100 Million Healthier
Lives is all about creating unprecedented
collaborations that recognize that people with
lived experience, community members, and community leaders
across sectors, all the way to the federal
level, all need to be part of creating the
solutions together. And it’s just an absolute
honor to be helping to partner in this way to
address what, as a primary care physician, I have
found in my patients to be one of the most
challenging issues of our time. And I just thank the
Surgeon General’s office for taking this on and for
doing it so intentionally, and in a way that is so
humane in the way in which it calls people to action. Thank you so much. Good afternoon, everybody. It’s a great honor to
be here this afternoon to address this
devastating health crisis that you’ve heard this afternoon
affects all of our communities, from South Boston to
Cambridge to Paisley Park. And I really want to
applaud the Surgeon General for taking a bold and
innovative approach in moving us from awareness to action. I’d also like to acknowledge
three of our PHFE board members who are here with us today. As an infectious disease
physician by training, I come from a world of
HIV, where no one really believed, in 1991, that
25 years later– that is to say, in 2016– the
end of the AIDS epidemic in cities like Boston
and New York would be a realistic discussion
that we might be having. However, those discussions
are taking place today, because as you’ve heard,
when we come together in collaborative
and meaningful ways, we can tackle even the most
intractable public health challenges. And that is our call
today to action, as you’ve heard from
the Surgeon General and this wonderful panel. As a national
nonprofit agency that provides program and support
services to optimize population health, PHFE, or Public
Health Foundation Enterprises, was thrilled when the
Surgeon General reached out and approached us to
take the lead with IHI in building a different
and dynamic partnership and an innovative
digital platform to reach prescribers
in addressing the opioid crisis in America. This collaboration
and our support in bringing together
the talent and resources to build this new
platform, creating a digital home for this work
is a natural fit for us. PHFE’s service model
is built on advancing evidence-based programming
through partnerships with academic researchers,
innovative public-private consortia, and
government agencies so that we can bring lasting
structural change that improves the health of communities. And we do this in
a variety of ways. We bring evidence-based
pilots to scale, partnering on
innovative social media and marketing, as
we have done here, building creative
fellowship opportunities, providing fiscal
sponsorship or grant development and
administrative support for large research and
population health initiatives. PHFE currently partners
with researchers at UCSF and the San Francisco
Department of Health to better understand key
aspects of this crisis, including evaluating trends
in local opioid overdose death rates and analyzing
this impact of change in prescriber practices and
illicit opioid initiation and overdose. Additionally, PHFE supports
the LA Community Health Project, which provides
overdose prevention and naloxone training throughout
Southern California, links those affected by drug
use to primary health care, offers hepatitis C testing,
and provides other kinds of outreach and support. Most recently, we have
partnered with IHI’s 100 Million Healthy
Lives to exchange promising evidence-based
strategies and outcomes from our work with
other organizations that are seeking to make meaningful
and impactful change around the world. These partnerships and
others are more completely described on our
website, phfe.org. And I invite you to
visit our website and follow us on our
social media channels. Finally, it’s
clear to me– and I hope it will be to you today–
that in reaching out to two large nonprofit organizations
whose missions center on collaboration with
partners across all sectors, that the Surgeon General is
sending an unequivocal message that business as usual
for us as physicians will not be enough to
reverse the worsening opioid crisis in America. We now need to
partner in new ways, as you’ve heard today, across
silos of institutions, research areas, research sectors,
harnessing cutting edge technologies and communication
platforms, educating ourselves and others in
evidence-based strategies that can be brought to scale
so that we can apply our best skills and talents toward
turning the tide on this most unfortunate epidemic, as we have
done with other public health epidemics in our recent past. So in collaboration with the
Office of the Surgeon General, PHFE stands ready to embark on
this journey with all of you. And we thank the Surgeon
General and this wonderful panel for your help today. Thank you. [APPLAUSE] I want to thank everyone
for coming today and for participating
in this conversation. I want to thank in particular
our wonderful panelists, Dr. Burrell, Dr. Wakeman,
and Michael Duggan for sharing some of their
experiences and perspectives with us. And I just also want to say
this in closing, and partly in response to your
question, Dr. Rocha. It was a perfect question
to actually end on, because you brought
up the issue of power. And one thing that I’ve often
thought of over the years is that clinicians are looked
at by people on the outside as people who have tremendous
power and influence. But many clinicians
themselves feel disempowered. They feel like they
are being asked to do more and more
with less and less. They feel that they
are seeing problems that are bigger than the
skill set that they have to apply to those problems. And as time goes on,
people feel like they’re operating in large institutions
that often don’t care that much about them, that they
can’t actually influence. And there’s a strange
dichotomy between the power that people think we have and
the we sometimes feel we have. But the truth, I think, is
that we do have more power than we believe. I had a member of
Congress tell me once that he got constituent
calls all the time, that he would say,
if, in one day, one call came in
from a doctor, that was listed as a notable event. He said, if 10 calls came from
doctors on a given day, that was a full blown crisis. And it just went to show
how infrequently members of Congress actually
hear from clinicians. But I will tell you
from my experiences, even long before I was Surgeon
General, that I have seen time and time again when clinicians
take an issue up of importance, whether it’s substance use
disorders, whether it’s mental health, whether it’s
violence, that communities listen, that they care and
they need and appreciate that leadership, because
our voices are more powerful than we often realize. And we have the ability
to affect more change than we sometimes recognize. So I want us to
think about that, because to overcome
this epidemic, we’re actually going to have
to do that kind of organizing. We’re going to have to come
together in communities and not only help each other
change our clinical practice, but we’ll have to demand what
it is that we and our patients need. If that’s better
reimbursements for alternatives to opioid medications,
then that may be it. If it’s more
integrated service so that we don’t have to send a
patient out with just a phone number and just
hope for the best, then that integration is
what we have to fight for. If it’s more funding
for treatment programs so that people can actually get
medication-assisted treatment, then that is what we
have to fight for. But I want you to know now,
being on a different side of the fence and sitting
inside government, that I can tell you firsthand
that when clinicians speak up, people do listen, even if
it doesn’t feel like it. And especially on
a local level, you do have the ability to
change how we operate and how we do business. But it takes us stepping out
of our comfort zone, often. It takes us stepping
out of the role that we were trained to play. And I would love, in the
future, to see medical students and residents trained not
only in how to provide care to patients, but
in how to advocate for them, especially when they
can’t speak up for themselves. That’s a skill that’s
essential to all of us. When we look back
in 20 years, I want us to be able to
look at this moment and say that this was an
inflection point in time. This is a time where
the country woke up to the magnitude of
the opioid crisis, where we realized just how
many lives were being destroyed by it, but also a
moment where we decided to do something about it. And I want this to be a
moment where we, as clinicians in particular, can look back and
say that this is the time where we stepped up to take that
role upon us that society so often wants us to step
into, a role as a leader, a role as an advocate, a role
where we can help change what’s happening in our communities
and ultimately create a foundation for better health. So I want to thank all
of you for your interest in being part of
that movement that we are building to turn the
tide on the opioid epidemic. I want to thank you also
for the work that all of you do each and every day to
better health, whether it’s for individual patients
or whether it’s for the entire state
of Massachusetts. And certainly, we are looking
forward to having all of you join the movement. You should get the
letter in July. And even if you don’t
get it in the mail, we’ll make sure
that it’s sent out through as many
organizations as possible so that you can sign up, so
that you can take that pledge, and so that you
can join physicians from all 50 states who want
to be a part of the solution. Thanks so much. Thank you, Dean Flier. It was great to be
with all of you today. I appreciate it. [APPLAUSE]

‘Tinderbox’: How Colonialism Shaped the HIV/AIDS Epidemic

‘Tinderbox’: How Colonialism Shaped the HIV/AIDS Epidemic


bjbjLULU JEFFREY BROWN: And finally tonight,
a new book explores the history and spread of AIDS in Africa. Ray Suarez has our conversation.
RAY SUAREZ: Since AIDS was first identified in the West 30 years ago, its toll across
the world has been vicious. It’s killed 25 people since 1981. An estimated 34 million
are living with the virus today. Just how the disease began and spread perplexed scientists
for years. A new book tracks the emergence of the HIV virus out of a remote part of Cameroon
to what is now Kinshasa in the former Belgian Congo. “Tinderbox: How the West Sparked the
AIDS Epidemic and How the World Can Finally Overcome It” connects the economies and atrocities
of colonialism to that initial outbreak and to current medical approaches to the treatment
and prevention of HIV in Africa. Craig Timberg and Daniel Halperin, welcome. DANIEL HALPERIN,
author: Thank you. CRAIG TIMBERG, author: Thank you for having us. RAY SUAREZ: The book
is about a great many things, but one of the conclusions that’s gotten a lot of attention
is the responsibility of colonialism for helping AIDS break out of the deepest rain forests
into the rest of the world. How does that happen? CRAIG TIMBERG: Well, the virus that
became HIV was infecting a community of chimpanzees for hundreds of years, probably thousands
of years. And scientists now theorize that it actually made its way into the human population
several times over centuries. As humans caught infected chimps, butchered them, the blood
probably passed through a cut. What’s crucial about the moment that leads to the actual
AIDS epidemic is that at that exact moment, there are new intrusions of steam ships and
porter paths as humans move into these remote places where the chimpanzees lived. And it’s
at that moment when HIV becomes a human epidemic, starts moving down the rivers and into the
birthplace of the epidemic, if you will, in Central Africa. DANIEL HALPERIN: And even
to this day, there are small strains of HIV virus that exist. For example, in Cameroon,
there are more strains of the virus than anywhere else in the world. And some of these strains
probably originated during the last century, in other words, are more recent than the strain
that has caused over 99 percent of the deaths by AIDS in the world. So we hypothesized that
if it hadn’t been for the role of colonialism, that what we now know today as the type of
HIV virus that has become this hugely global problem might likely have become like these
other strains we have seen in Cameroon. It may have gone out and infected a few hundred
or a few thousand people. But we may never even have known about it because it’s a fairly
remote part of the world. CRAIG TIMBERG: And this is a place that was one of the most sparsely
populated parts of a very sparsely populated continent. And so were it not for the intrusions
of colonialism, it’s unlikely that the epidemic we know today would have come out in the way
that we have seen it, and in particular that they have been able to track porter paths,
where Africans are force marched to the jungle. They’re carrying guns and ivory tusks and
rubber. They have been able to track that to exactly the place where these chimpanzees
lived. And there would have no reason for those people to go there before. They went
there because they were forced to go there. And they come down these porter paths, they
go to these trading stations, they get on steam ships. And that becomes the actual spark
for this epidemic. DANIEL HALPERIN: We can now see in retrospect that this was going
on. And that perhaps gives us a little bit insight hopefully into how to approach the
problem today, that, as Westerners, we are not merely bystanders who care about what
happened in Africa, but in a sense we have a little bit perhaps of responsibility to
help remedy a situation that we may have partly helped to have initiated. RAY SUAREZ: What
happened in later decades, in the ’60s, ’70s, and ’80s, to allow HIV to become so deeply
rooted in Africa and also break out to the rest of the world? CRAIG TIMBERG: The two
very important things happened in the middle part of the 20th century. One is that HIV
makes its way on the railroads, on the highways into the parts of Africa where male circumcision,
which is an ancient tradition in much of the continent, is not in fact a tradition. So
when you cross over the mountains, and you’re suddenly in East Africa, you’re in the areas
where men aren’t circumcised. And, suddenly, instead of having infection rates of 1 percent,
2 percent, you get infection rates of 5 percent, 10 percent, 15 percent. You see the kind of
the disaster that we’re more familiar with, where entire villages, you know, lose a huge
percentage of their adults. And that kind of problem also moves into Southern Africa,
where also you have lower rates of male circumcision. And the other crucial thing that happens is
HIV makes its way to the Americas. It makes its way from Kinshasa in the 1960s to Haiti.
And that’s where eventually it works its way into the Americas, it works its way into the
gay American population, and it spreads much more widely eventually. RAY SUAREZ: But the
shadow of colonialism is never really gone from Africa, is it? When it comes to the way
we look at AIDS, look at AIDS sufferers, talk about and to the people who are HIV-positive,
how do you explain that part of it in your book? DANIEL HALPERIN: We believe, of course,
that the Europeans and North Americans and other foreigners who are in Africa now and
other places trying to help people with epidemic are in one sense completely different from
the colonials who were there a hundred years ago. They’re not there to rape and to plunder,
so to speak. They’re there with good intentions. They want to help deal with this and other
diseases. But there’s unfortunately a little bit of a kind of paternalism or a hubris maybe
that continues, a sense of, we’re the experts, we know what to do. RAY SUAREZ: There’s been
a lot of coverage in the book of the sort of condescending, paternalistic, tsk-tsk way
of looking at African societies where people were changing their behavior and not getting
much credit for it. CRAIG TIMBERG: When you look at what happened in societies when they
faced this problem, several of them sort of did the math. Right? They were faced with
an incurable disease. It was spread by sex. It was fatal. And in several societies, the
leaders of the societies, politicians singers, religious singers, led campaigns in which
they said, if we’re going to survive, we need to make changes in our own sexual behaviors
as a society. And that ends up being enormously consequential when you’re dealing with a sexually
transmitted epidemic. RAY SUAREZ: You don’t have a lot of love for the efforts to use
high-tech responses, particularly in the African epidemic, whether it’s antiretrovirals or
universal urging to use condoms. Sort of technical fixes don’t really get a lot of praise in
this book. And I think you conclude that they’re not going to work in the African context.
Why? CRAIG TIMBERG: These drugs are miraculous, right? This medicine brings people back from
the edge of death. And anyone who’s watched that happen understands the power of that.
And we want as many people to be treated as possible. And what — the issue we raise is,
it’s not enough to treat people who already have this virus. To really win the fight against
the epidemic, you need to prevent the next million, the next 10 million infections from
happening. And, now, drugs may play a role in that, but we think that the most powerful
role in the end will be played by the kind of things we’re talking about here, changes
in sexual behavior, increasing the prevalence of male circumcision. And that’s what history
shows. RAY SUAREZ: The book is “Tinderbox: How the West Sparked the AIDS Epidemic and
How the World Can Finally Overcome It.” That’s a pretty big ambition in that title. (LAUGHTER)
RAY SUAREZ: Craig Timberg and Daniel Halperin, thank you both. DANIEL HALPERIN: Thank you,
Ray. CRAIG TIMBERG: Thank you, Ray. DANIEL HALPERIN: This was wonderful. urn:schemas-microsoft-com:office:smarttags
place urn:schemas-microsoft-com:office:smarttags country-region urn:schemas-microsoft-com:office:smarttags
City JEFFREY BROWN: And finally tonight, a new book explores the history and spread of
AIDS in Africa Normal Microsoft Office Word JEFFREY BROWN: And finally tonight, a new
book explores the history and spread of AIDS in Africa Title Microsoft Office Word Document
MSWordDoc Word.Document.8

Meet a Bug Whisperer and His Traveling Insect Zoo | Atlas Obscura

Meet a Bug Whisperer and His Traveling Insect Zoo | Atlas Obscura


Like, from the moment I had consciousness they were always appealing to me. The way they look, the way they eat, the way they move. The way that their exoskeletons shine in the light. When you sort of dispel the hatred we have towards insects, you actually have a better shot at dispelling xenophobia towards different people. I have hundreds of different animals, mostly insects. I do live animal shows, where I like to showcase different animals that are very different from us. Hi, everyone. Thanks for coming. My name is Aaron Rodriques and these are all my pets. A lot of what we think are very dangerous animals are actually very, very peaceful. There are actually a very limited number of insects that can do you harm. The treatment that people give insects is sort of what prompts me into studying and liking them more. Because I do feel that way in a way. – He’s seeing you right now.
– Yeah, wow. He’s very shy. I didn’t have many friends growing up as a child. I felt like I was different from a lot of children. I couldn’t really understand them, and they couldn’t really understand me. [Whistling] I’ve only had one friend visit my room ever. Over here, I have my African twig mantis. Baby rose-haired tarantula. These are quail eggs. Green caterpillars that you can normally find in New York. They’re a pest. Black solider fly larvae. And in addition to live animals, I also have a few dead ones. It’s very crowded, as you can tell, but it’s also, I think, very cozy and comfortable. I keep this place at a very steady temperature, around eighty degrees or so. I think I had a show-and-tell at some point when I was eight years old, where I had beetle larvae and I wanted to show them off, and everyone was just really uninterested. So I thought, “Alright, no one likes insects. I guess. I’m just the only person who does.” As a child growing up I became sort of obsessed with them. My parents nurtured that passion. I first started going to the library when I was very young. For me it was just amazing because they had an entire section devoted to insects. There was just, like, so much violence and stealing in my school. There were a lot of people I just didn’t want to be friends with. Weekend after weekend, I would just stay in my room and just do something aside from socializing with people. In a lot of cases, insects were a crutch. It wasn’t until maybe last year that I started doing shows and really telling people how much I like it. It started with a Facebook comment. The name of the band was called Moth Eggs. I commented on the page, I said, “I breed moths, so I feel like should go to this show.” And then some woman saw my comment and liked it. It was all her idea. It feels like I sort of have an identity now that I’m open about what I like. It’s sort of like a coming of age story. I never really felt like I had something. I started this show and I realized that this is my thing. You can’t really love something if you’re afraid of it. You can’t really love something if you don’t really understand it. The fear and the hatred of insects is just the fear of the unknown. I definitely don’t regret being more open about who I am as a person. It’s just something that I’m really glad I did.

Termite Breakfast!

Termite Breakfast!


– Right now it is
breakfast time. Oh, no, there’s nothing
to eat in my ear. And what we’re gonna
do this morning is go out and search for Mr.
Bean’s favorite breakfast. Can you guys guess what
this tamandua eats? If not, stick around, because we’re about to show ya. Mr. Bean, you ready to
go find our breakfast? I think he’s ready. Come on, let’s go. (upbeat jungle music) They say that breakfast is the most important
meal of the day, and for the the animals at
Kids Saving the Rainforest, that is the absolute truth. This wildlife sanctuary
is a temporary home to many animal species, from sloths and monkeys to parrots and fawns. And on this sunny morning, I will be taking one of
the resident tamanduas out on a stroll to see if we can find
something delicious to eat. This is a real easy
morning for him. Normally, he would be crawling
around out here on the ground and searching in the trees. But this morning he
has a bit of a chariot, a Coyote chariot. Let me put you up
on top of my hat. There you go, that’s a good
spot for you to hang out. All right, now. Let’s head down the trail and see if we can
find some breakfast. Let’s see, do you eat leaves? Pick one of these. This looks delicious, actually. Look at the color of that. How about that? Does that look like something
you might wanna eat? No? No leaves, that’s right. Tamanduas do not eat leaves. That looks delicious. You wanna try that? Oh, sniffin’ it. Sniffin’ it, nope,
that’s my nose. Oh, no, you know what? You know what, can I eat it? I’ll eat it. – [Man] Yeah, you show
him how it’s done. – Can you hear that? His tummy is rumbling. I think we better get him towards exactly what it is
that he does love to eat, which are termites and ants. And you know what I
see right over here, on the corner of this tree,
out of the corner of my eye? A termite mound. Come on, let’s check this out. Look at this. Mr. Bean, what is that? Looks like a giant
mound of chocolate. You think there’s
anything in there that you might wanna eat? We put him up in the
tree, and sure enough, now he is searching for
the termites on his own, which is exactly what we
want to see with this animal that’s being rehabilitated. – [Man] Whoa, look
at that tongue. – Whoa, my gosh,
that tongue is long! Now, don’t you go too high. Careful up there. I might have to climb
up the tree with him. Let’s go back this way. Come here. Oh, look at that prehensile
tail in action right there. You see that? He can curl his tail
around a tree branch and stay completely in one
spot and hold up his body. All right, let’s go this way. There you go, go down that
way towards the termite mound. These mammals are
actually pretty picky when it comes to the type of
insects they will consume. I guess we picked the
wrong termite nest, because Mr. Bean had no interest in having these tiny
bugs for breakfast. So it was on to the next spot. Okay, so we cut a piece
of this dead tree off that actually has a different
kind of termite in it, and Mr. Bean is having a feast! Look at that! There you go. Oh, okay. Are there any ants in there? And watch how he uses
those massive front claws to break apart these
pieces of wood. Now, the wood is decomposing, but he will peel off the
bark and dig in there, exposing the termites, and then use that long,
sticky tongue to lap them up. Now, once they break
open a termite nest, then the termites
spill out everywhere, and they can use
that tongue to go lap, lap, lap, lap,
lap, lap, lap, lap, and lap them all up. – [Man] Wait, what
was that sound again? – Lap, lap, lap,
lap, lap, lap, lap. I can’t do that. Look how long my tongue is. Pretty long. I can actually touch
my nose with my tongue. Check this out. You see that? Most people can’t do that. – [Man] Whoa, you
can actually do that. – I can, I can pick my
nose with my tongue. Really, watch. Watch. – [Man] What? – I have a very long tongue. Not quite as long as the
tongue of a tamandua, though. This creature, when fully grown, the tongue can be as
long as 16 inches. That is over a foot. Can you imagine having
a foot-long tongue? That would be pretty wild. Where are you going? I thought we were going
to eat these termites. Come here, little buddy. Come here. Now, he does have termites
crawling all over his fur, and look at this. Check out the coat
of this creature. Go ahead, reach
your hand out there, and tell me what
Mr. Bean feels like. – [Man] Whoa. – Really coarse, right? – [Man] Really
course, like Brillo. – He is, he’s like a Brillo pad. Now, this really
dense fur protects him against termites and ants,
both the bite and the sting. The ants can crawl all over him, and he will not be injured. I wonder if he could go
up against a bullet ant? You know, I went up
against a bullet ant. That’d be a pretty
big meal for you. – [Man] Oh, wow. – Oh, there’s the tongue,
look at the tongue! Oh, he stuck his
tongue all the way out! That was crazy! I saw that! Can you do that again? Stick your tongue out again. – [Man] That looked like
more than six inches. – Yeah, that was, that was a lot longer than
I thought it was gonna be. That was probably
about seven inches. – [Man] How big will
Mr. Bean grow to? – [Coyote] Oh, they can be
about 35 pounds in weight. – [Man] Whoa, really? – And, yeah, you know, a lot
of the length in the body is the tail. This tail will end up being about 2 1/2 to three
feet in length, and then, of course,
this big, massive body, and they turn very
goldish in coloration. You can see that he’s
actually starting to get some dark fur here, and that is called being vested. That’s what they say. It’s like a vest that is growing
on the back of the animal. So all this white
fur will turn gold, and this fur that’s dark
right now will become black. Is that it? Are you all done? – [Man] Breakfast is over. – I think Mr. Bean has had
his fill of termites and ants. But how much fun was this? Spending our morning having
breakfast with a baby tamandua. I’m Coyote Peterson. Be brave.
(inspirational music) Stay wild. We’ll see you on
the next adventure. Wait a minute.
(music stops abruptly) What’s that? You think I should
try some termites? I don’t know, guys. Should I try the termites? – [Man] I don’t know. I heard they’re
pretty good, actually. – I am pretty hungry. Okay, I’ll try it. Mr. Bean, you’ve convinced me. Let’s go see if I can
eat some termites. (suspenseful music) See, you go first. There we go. Oh, yeah, all right. I see, I saw. All right, Mr. Bean,
I’m going for it. Are you ready? – [Man] You’re
really gonna do this? – Mr. Bean, you’re
not even watching. Okay, here I go, ready? One, two, uh. (Coyote grunts) – [Man] Keep going. You need to get a mouthful. (Coyote grunts) – Ugh! – [Man] Oh, let me see,
let me see, let me see. Oh, you really did it! – Mr. Bean! – [Man] Hold on, hold still. They’re all over your beard. – Mr. Bean, I did it! I did it! – [Man] What’s it taste like? – Ugh. Like crunchy, mmm. Rotten walnuts. Oh. – [Man] Oh, my gosh,
he actually did it. Oh!
(laughter) – Oh, I think I need
to wash my mouth out. This is gross. If you thought Mr. Bean
was an adorable anteater, make sure to go back and
watch my morning of exercise with Baroo, the smallest
tamandua we have ever seen. Like all baby animals, Baroo here is extremely curious. And don’t forget, subscribe, so you can join me and the crew on this season of
Breaking Trail.

The End of Antibiotics and the Future of Fighting Infections

The End of Antibiotics and the Future of Fighting Infections


Thank you all for coming. Tonight we’re going to talk about a very serious
subject. Um, the situation that we face with antibiotic
resistant bacteria. Antibiotics were once the silver bullet that
seemed to be able to cure just about everything. Now we look at 23,000 antibiotic resistant
bacterial infections every year. So let me introduce you to our panelists. Our first participant is the Director of the
Wisconsin Institute for Discovery at the University of Wisconsin-Madison. She was a science advisor to President Barack
Obama. Please welcome Jo Handelsman. Our next participant is a professor at Rockefeller
University where he is head of the Laboratory of Bacterial Pathogenesis and Immunology. Please welcome Vincent Fischetti. Our next participant is an associate professor
of Immunobiology and Microbial Pathogenesis at The Salk Institute. Please welcome Janelle Ayres. Our next participant is the Evnin Associate
Professor at Rockefeller University. Please welcome Sean Brady. and finally the Singer Professor of Medicine
in Microbiology, and the Director of the Human Microbiome Program at NYU School of Medicine. Please welcome Martin Blaser. Uh so, I thought that maybe a way to start
would be to show a video. This was an experiment that was done at Harvard
where basically scientists created at sort of gigantic petri dish, sort of kind of the
size of an air hockey table basically, and they seeded it with bacteria on either side
and then basically laced it with antibiotics. Starting at the edge with pretty mild levels
and then as you go further in, it gets more and more deadly until the central band has
a thousand times the lethal dose for Ecoli. It’s really kind of mind blowing. We’re going to see the bacteria, so just sort
of hanging out there and now they’re multiplying. This is sort of time lapse, so when they hit
that point, what they’re encountering that as antibiotics and then how are they getting
past it? I mean you can see them. It takes a little bit of time and what they’re
waiting for is growth of one or a very small number of cells in the population that are
already resistant. And so although there were many, many billions
of cells crossing the plate, probably one in a million would have resistance to the
antibiotic, so once those started dividing and- So they’re dividing and one in a million just
happens to gain this power to get past it? Well, they always had the power. It was preexisting in the population, but
then when the whole population is, the rest of the population is stopped by the antibiotic
because they’re inhibited by it. Then those few that are resistant start proliferating
and then they take over and that’s exactly what it looks like in similar terms when it’s
in the body, you know, you take an antibiotic and most of the bacteria will die, but there
will be preexisting mutants in the population that are resistant. That’s great. Well not great, but it’s amazing. It is definitely not great. Yeah, no it didn’t. I know, I know. Don’t get me wrong. We think of antibiotics as, as the sort of
heroic triumph of science. I mean, how did, how did we get to enjoy the
benefits of antibiotics? I mean, how did that begin? Well, it started with a chance discovery from
a by Sir Alexander Fleming. In the UK, who found a fungus on his plate
that was clearly inhibiting growth of staphylococcus on, on the Petri dish, and he recognized what
it was that this was a compound that was diffusing into the Auger and determined that it was
what we now know of as penicillin, but it was many years before it can be used in any
kind of broad scale way because he discovered that in 1929 and by the start of World War
II, we still, we’re not using antibiotics and they weren’t in general use. Why not? I mean you, you discover a drug, you know,
put it into practice. I mean, what was the holdup? They couldn’t make enough of it. That fungus produced some but not enough to
go into large scale production. And so during the war a scientist named Ken
Raper was worked for the USDA in Peoria and he decided as a war effort to put out the
call for penicillin producing strains of penicillium mold. So he told everybody in Peoria to collect
as many fruits and vegetables with that green blue fuzzy thing that you see on your bread
and fruit to bring those to his lab. And people did and he had this large collection
and it turned out it was his own technician who has gone down in history, as Moldy Mary
now. Her name was actually Mary Hunt and she brought
in the winning cantaloupe and it had a strain of penicillium mold that produces more penicillin
than any other natural strain to this day. And so they started, they moved it right into
commercial production and started pumping out large amounts of penicillin and they have
enough to be able to ship it the penicillin to the troops in Europe. And so World War Two was the first war in
which more people died directly of bullets and bombs than the infections that accompanied
them. Wow. So, and then once, once the war is over, then
antibiotic start to become more of just a general medicine for the public in general,
right? Yeah. And at the same time there was interest in
soil bacteria that produced antibiotics. And, and then after the war there was just
this explosion of knowledge of people, culturing organisms from the soil, screening them for
antibiotics and then moving into production. And so we had dozens of antibiotics coming
onto the market in the next decades. Sean, I mean, how would you sort of describe
like the sort of, the overall benefit of these discoveries of penicillin and some of these
other early antibiotics? I mean, what I mean overall, like in terms
of lives saved or someone, what are we looking at in terms of the scale of this? I think one of the figures that penicillin
alone has saved 100 million lives. And that’s penicillin alone. Yeah. So if you think about that single picture
that Joe talked to you, you see it in almost any microbiology textbook. That image has probably saved more lives than
anything in the history of science. So you want one kind of thing in your office,
you should hang that picture as a scientist because it’s made a larger impact on human
health than anything but, but that, that whole discovery, even today we’re still using those
antibiotics. So. So that’s the initial discovery, then you
think about almost everything that came out of what we call the golden age of antibiotics,
the forties, fifties, and sixties. So people were finding things not just on
cantaloupe but in other- They are culturing soil bacteria largely and
finding antibiotics. Almost every class of antibiotics that we
use today was discovered in that that time period. We have relied on antibiotic defense really
of those molecules and continually using versions of those molecules up until today. And that’s why we’re in the position we are
today. We, we’ve largely ceased discovering antibiotics
after the golden age, the late sixties, early seventies. Because we thought we were done. We thought we had solutions to these problems. That’s how good those initial discoveries
were. How, how much of an impact they made on human
health. What’s your sense of like when it started
to become clear that things weren’t going so well? Like when? When do you think that the sort of scientific
medical community said, I think we have a problem? Well that happened pretty quickly. I mean we were seeing resistant organisms
to penicillin early on. It was, it started Like a matter of a few years after? Probably a year or two After the introduction of penicillin. Exactly we already started to see early stages
of resistance, but you know, was it an organism here, an organism there, but, but it was occurring
at that time and it’s been occurring at an accelerated rate since then. Right. So Marty, what do you think is, what would
you say would be like one of the main factors that explain sort of how we got to this point
in terms of resistance? Like what are we doing that is causing all
of these bacteria now to be just so dangerous? So, uh, the short answer is that Darwin was
right and that is that there is survival of the fittest. It’s selection. We are using antibiotics in such magnitude
because of the miraculous nature of antibiotics, both the public and the profession says, well,
why don’t we just treat this person with antibiotics even if their symptoms are minimal. So there’s enormous pressure, selective pressure
of antibiotic use and it’s just, it’s just a mathematical certainty that there’ll be
resistance, but it’s not linear. It’s, it’s geometric because of the properties
of bacteria growing. Yes, but you have to remember that bacteria
come, most of them come from the soil and antibiotics are in the soil, so they’ve learned
for millions of years how to deal with antibiotics. So the systems are there for as long as you. If you expose them to antibiotics, those systems
become heightened, then become resistant. So they, they’ve seen these drugs or similar
drugs or antibiotics type molecules for hundreds and hundreds of thousands, millions of years. Marty, you, you’ve also been talking a lot
and writing a lot about the fact that our antibiotics are not precision weapons that
you know, you use them against Ecoli, MRSA, and so on, but that’s not the only thing that’s
going to affect. Yeah, so so antibiotics came of age when we
were, when we were really trying to eliminate these bad pathogens, but no one really considered
what was the effect of the antibiotics or the normal bacteria living in the body, the
normal bacteria that we call the microbiome, but now it’s clear that that when you take
an antibiotic for a skin infection or lung or urinary tract infection, that antibiotic
is getting everywhere in the body and it is selecting for resistant organisms in that
body. That’s suppressing some organisms and other
organisms are coming up and maybe some organisms are becoming extinct as well. So these are organisms that we might actually
depend on. It might be actually beneficial for us. And so in fact we know that one of the main
defenses against infection are our residual. Our normal organisms there, there, there,
the coast guard, they are protecting against invaders. They don’t want to share their turf and 50
years ago it was shown that if you pretreat mice or other laboratory animals with antibiotics
and then give them a pathogen like Salmonella, the, the level of Salmonella that it takes
to kill the mouse goes down by four logs, you know, by 10,000 falls. So Sean, I mean someone might say like, well
we have all these gigantic pharmaceutical companies. There’s lots of money that they can throw
at the problem. You know, there was penicillin and then there
were other things I can think of mycin and you know, you know, science marches on. So we’ve got like more in the pipeline, right? That’s the unfortunate thing. We have almost nothing in the pipeline. Almost nothing. You can, you can ascribe that to a number
of different reasons. We don’t get in a crisis because of one thing,
but we get in it because many things came together that we probably didn’t foresee. One of them being that our first round of
antibiotics worked so well right? That golden age of antibiotics when we were
describing them, people thought we were done and so so over the next ensuing 30 years antibody
discovery programs, both in academic and industrial settings largely shut down and so there are
almost no pharmaceutical industries that are putting at least the effort they used to put
in to finding antibiotics. The second thing is then if we’d been using
antibiotics, the same ones for 30 years, that means they don’t cost us anything anymore. They’re all generics. You can get an antibiotic for somewhere between
free and twenty cents a day in many parts of the world, so now you have an infrastructure
that doesn’t exist and you have a financial structure that doesn’t support the development
of antibiotics. So we are at a certain point trying to figure
out how to restart that pharmaceutical industry and how to make it worthwhile to restart it. Have to be some major things changed. It’s in direct competition with chronic disease
which is much more lucrative for the companies because it drug you take for the rest of your
life is obviously going to make them more money than a drug you take for five days and
then stop, and so even even now with the crisis that we all know we’re in, very few companies
want to move back into that area. And what they’re doing is taking a drug that
worked, became, an organism, becomes resistant, and they just make a modification on that
drug. It’s cheaper for them to do that than to start
from the beginning and now the virus can become resistant much more rapidly. So they work for maybe a year or two and then
they can’t use them anymore. Marty. And then there’s yet another problem and that
is that bacteria don’t respect borders and so what that means is that if, if a resistant
organism arises in another country like India or China, it doesn’t take too long for it
to come over here and because antibiotics are so inexpensive and because people think
that they’re so miraculous. In many of these countries, people are able
to get antibiotics over the counter, no prescription necessary. Parents are giving their kids 10 courses of
antibiotics a year in, in some recent studies funded by the Gates Foundation, tremendous
antibiotic pressure, very low cost, but somebody’s making money on those antibiotics. Resistant organisms are arising and then there
are the crossing all over the world, So this, so this sort of cheap marketplace
of antibiotics over the counter and so on is even helping to drive on- The whole antibiotic market is broken. Antibiotics are in one sense too cheap and
and, and are therefore overused and abused. And on the other hand there’s no incentive
to create new antibiotics that we want to keep and put in reserve for important infections,
which won’t affect tens of millions of people so that there isn’t that market. So the market, the economic model for antibiotics
is just broken. Just, just to put a number on that, right? Yeah. So the most recent, they’re going to differ
a little bit, but let’s say the six months, recent antibiotics that came to market made
about $10,000,000 each last year. 10, 10 million each. Right? Okay, that seems like a lot of money, but
just let’s say you’ve done all the clinical trials you need and now you need to synthesize
a production scale an antibiotic. It’s $150,000,000 investment, right? And the reason these things make a little
money is, is you don’t want to use them. You don’t want to use in this frontline defense,
right? You want to put them in reserve until you
absolutely need them. And so where’s the incentive? If, if forget the hundreds of millions you
put into development, just to make the thing costs you 10 times which you can sell it for,
sell it for a year. We really have to rethink how we, how we market
these things, how we as a community decide we’re going to put antibiotics in reserve
and put an upfront and of realization that these things are there. We need to pay for them as a community because
we’re going to need them some day. Alright, so let’s, let’s brighten things up
a bit by like actually, you know, you folks are actually working on things. So maybe we’ll start. We’ll start with antibiotics themselves, with
new antibiotics. So with Jo and Sean’s work. So, so, so you’ve been going back to the soil,
the soil that brought us all these original drugs. You think you think there are more there for
us to find? I do. I’m so, for a long time I went to other methods
for antibiotic discovery and you’ll hear about some of those that Sean’s developed soon,
but the reason I did that was that there were some references from the nineties that said
that the soil was mined. It was fully tapped and I’ve gone back to
the data and I can’t find the data and so now I question whether that’s really true
because in the ensuing decades my lab just spontaneously discovered antibiotics, novel
antibiotics from soil that hadn’t been discovered and we weren’t even looking in some cases. And so I. It just occurred to me one day, wait a minute,
it’s not mined if we’re finding them and so that’s the approach we’re taking is going
back and asking what is the frequency of new compounds? There was one paper that said the rediscovery
rate would be 99 percent, so if you found 100 compounds, 99 of them would be already
known. Well that’s actually not so bad if it’s true
because we can look at a lot more than 100 compounds with today’s methods, but. But I’m not even sure that that’s true because
it wasn’t really based on at least published data. Maybe somebody in a pharmaceutical company
has the data, but we haven’t seen it. So are there particular places that you like
to go look for new antibiotics? In a particular soil that is you like or is
it just in your backyard? Well, we’re looking at across the world, so
we have a worldwide network of undergraduate students. Undergraduates who are a fantastic and very
creative workforce. So we developed a course that is known as
the Small World Initiative and it’s taught in 15 countries and all over the United States
and about 10,000 students a year take the course and they dig up soil from whatever
environment is interesting to them and they come up with more interesting reasons than
I ever would for why an environment is interesting. And and so they have this great variety of
soils. They’re isolating very interesting antibiotic
producing organisms and now we have to go into the next stage which is figuring out
what antibiotics are produced. So we think that if we have 10,000 students,
each one gets at least 10 antibiotic producing organisms per year. That’s a lot of candidates. And so if we can crank through enough of them,
even if that one percent rediscovery or 99 percent rediscovery rate is correct, we still
have a lot of new compounds to look at. So Sean, what kind of approach are you taking
to searching for these, these new antibiotics? So about 20 years ago now, I guess, Jo and
a few other people were thinking along these ideas, thinking about is there a reservoir
in soil still of, of natural products and, and the thing that that percolated to the
top of the thinking of these people was that there’s data from even longer ago, maybe 120
years ago that it appears we don’t culture most of the bacteria out of the environment,
that actually the bugs we’ve been playing with represent a small fraction of the bacteria
in the environment. So let me ask you, so if you like take a sample
of a little sample of soil, first of all, like how many microbes are in there and how
much DNA are you talking about that you’re looking at from all of them? So it depends on whose numbers, let’s say
is there’s thousands, maybe 10,000 different microbes of which we culture about one percent. Just one percent,. Just one percent. And again, people have done better nowadays,
but they don’t solve the other problem, which is even if we can culture bacteria, we don’t
turn on their genes. Right? So even if you can bring bacteria in the lab,
they don’t know how to turn on the genes, they’re gonna make antibiotics for us. And so, so what we want to do is just look
at their DNA and you can get huge amounts of DNA at least in the context of molecular
biology out of a single gram of soil. And so it’s the coming together of this idea
that we can culture bacteria. We can sequence their genomes and we can. We can mess with genes, right genes in ways
that we can turn them on that really allows you to untapped this reservoir that’s been
tapped or untapped. So. So Vincent, I wanted to, to kind of shift
gears here and look at a way of dealing with bacteria that’s totally doesn’t involve antibiotics
at all. Um, there’s, and this is, this is kind of
a long running idea of basically sending the enemies of bacteria against them. I mean, can you explain the idea of this kind
of approach? What was sometimes called Phage therapy? Well phage therapy actually started before
antibiotic therapy. So, um, it was discovered by D’Herelle about
100 years ago. He discovered a, he had a vessel in the, it
was cloudy with bacteria and suddenly it disappeared, just disappeared in his eyes. And he said some things in there that killed
the bacteria, figured out that it was, it was a virus, a virus that only infected bacteria,
bacteria phage, it’s called. And that started a revolution at the time
to use phage to control infection. It was well before antibiotics. So these, so these viruses, they’re back,
they’re known as bacteria phage. So what are we looking at? So the blue thing is bacteria. The blue thing is the bacteria and the ring
around that is the cell wall of bacteria. When it attaches, it injects its DNA into
the cell and once that DNA gets into the cell, it takes over the self for the production,
a new virus particles and once those virus particles are produced, the phage have a problem. They have to get out of that organism and
they solve the problem by producing an enzyme called the lysine that drills a hole in the
cell wall. And since the pressure inside the bacteria
is greater than the external environment, the organism explodes and releases the bacteria
phage that had been produced in the environment. And that’s phage therapy using those phage
to kill the organism directly. What we’ve done is now taking that enzyme,
the specific enzyme that drills a hole in the cell wall, we can produce it recombinantly,
and when you add that enzyme externally, it does precisely what it did from the inside,
drills a hole in the wall membrane externalizes and kills the organism, so we’ve developed
the enzyme that the phage now uses to release its progeny phage. You could use phage themselves and that’s
called phage therapy as a means to control bacteria, but you can use the enzyme to to
accomplish the same thing. And there are particular species of phages
that can go after particular species of bacteria? The very specific, that’s the problem with
phage therapy is that they’re highly specific for the organism that you’re going after. So in order to kill, for instance of Staph
Aureus, you’ll need to produce a cocktail of maybe five or six or 10 or 15 phage to
get around the chance of organisms becoming resistant because the bacteria become resistant
very rapidly to phage. So they getting resistant to the phages as
well. Antibiotics, they’re just evolving, But that’s. That’s the normal system. The phage are trying to get into the organism,
the bacteria trying to keep them out. So that balance has been going on for a billion
years. Nobody wants to win that war, phage that want
to win because if they win, all is gone. If the bacteria when. Well they can’t get enough DNA into them to
to, to, to modulate their, their, their DNA themselves. Right. Because bacteria are taking in. They are taking in DNA and so they need that. That acquisition of phage DNA that doesn’t
kill them, that allows them to pick up genes if they, allows them to survive much more
rapidly. So then there’s this molecule that phage make,
this enzyme called lysine, and so you want to just try just using lysine rather than
the whole virus. We’ve been using lysine for almost 20 years
now. We have lysine and the beauty of lysine is
that they are very specific for the organism. We don’t see resistance, we’d never seen resistance. We’ve been doing this for 20 years that they
cannot become resistant to lysines because they’d have to remodel their cell walls, so
it would take them a very long time to become resistance. Probably hundreds of years before they become
resistant to actual lysines. So those are anthrax organisms and we’ve added
lysine to them and you could see what happens to them. This is real time. They just explode and disappear. So you can take 10 billion organisms in a
test tube and add up five few micrograms of lysine, within a couple of minutes, they’re
gone, so it works quite well. We have enzymes and they’re quite specific,
so you don’t run into the problem, the antibiotic problem where you kill everything. Your normal floor and the and the organism
you’re trying to kill that. Quite the, the, the, the staff enzyme will
kill staff. Anthrax enzyme kills anthrax. So you, you’re, you’re targeted killing. You’re not affecting your normal flora. So why isn’t everybody using lysine? I mean, what’s the, what are the challenges
that you still face? Well, we’re in clinical trials right now phase
two. Phase one showed that it was quite safe. We’re in phase two in the hospital. So about 117 patients which would sure be
done by the end of this year, treating MRSA infections, endocarditis, MRSA, septicemia
and Endocarditis. Heart infections? Heart valve infections and septicemia, bacteremia
and we’ll know by the end of the year. So Janelle, I mean you had touched on this
earlier about, you know, maybe paying more attention to our own sort of host health in
terms of dealing with these infections and you know, you’re, you’ve been doing a lot
of research into, into tolerance. Maybe you could sort of describe sort of the
overall idea that you’re pursuing and then how do you know how that might translate into
an actual treatment for a patient? Yeah. So I think that the, uh, what is evident to
me with our perspective, uh, in developing antibiotics and antibiotic history and the
approaches that have been described by my fellow panelists is that they’re all based
on the question of how do we kill microbes and developing ways to kill microbes. And we are approaching this from a different
perspective. We actually want to understand what it takes
to enable a patient to return back to a healthy state and to survive infectious diseases. And um, there’s, we, I talked about sepsis
and how in sepsis and this is the case with other infectious diseases as well, there’re
significant physiological damage that occurs and that leads to physiological dysfunction. And in order for a patient to return to a
healthy state and to survive an infection, they have to be able to. You have to be able to alleviate that damage
that’s occurred, um, and, and restore the patient back to normal physiological function. And our assumption is that if we just kill
the pathogen, we should be able to do that, but that’s not necessarily the case. You can have patients where antibiotics are
effective in them, but the physiological damage that they’ve endured kills the patient anyways. And so there’s, we are taking a variety of
approaches to understand, um, if our body encodes ways to protect us from infectious
diseases by promoting health and alleviating physiological damage. And about 10 years ago now, we discovered
that in addition to our immune system, which protects us from infections by killing pathogens,
we’ve discovered that we encode a distinct defense strategy that we call the cooperative
defense system. And this is a defense system that, um, is
essential for us to survive infections. And it protects us by executing what we call
tolerance mechanisms or disease tolerance mechanisms. And these are mechanisms that our bodies encode
that alleviate physiological damage during microbial interactions. And so these are mechanisms that promote our
health without killing the pathogen, so you can induce these, um, tolerance responses
in, um, a host and they will be perfectly healthy and survive the infection despite
having the pathogen present in their body. Um, and we like this approach because this
provides a new avenue for treating infectious diseases that will enable us to promote survival
of the patient, but they also, um, in theory should be what we call anti-evolution proof,
meaning that pathogens should not evolve resistance to such strategies because we’re targeting
the, the patient and the physiology that’s affected by the, um, the infectious disease
without having a negative impact on microbial fitness. It almost sounds like the microbiome is so,
so complex with hundreds or thousands of species that, how would you ever disentangle it well
enough to be able to make it into medicine? You have to have a hypothesis. You have to conduct clinical trials. Clinical trials have advanced cancer therapy. They’ve converted HIV infection from a lethal
disease to a completely treatable disease with longterm step-by-step clinical trials. That that’s what the field needs. Of course, that’s what we need in to to restore,
to have working antibiotics, to develop new antibiotics as well. Yep. Sean. We do similar things with the human microbiome
to do the soil because we look at the molecules that these bugs make and we’ve in fact found
antibiotics that are effective against MRSA. So these are. These are antibiotics made in our bacteria
living inside of us. Coded by the bacteria living inside of us. And we’re sort of antibiotics factories. Yeah, we, yeah. We may not need to undergraduates anymore. We may just have to mine our own microbiome. Or the undergraduates’. To add to the complexity, we also have bacterial
phage in our gut and they are modulating. So we have phages that are attacking our bacteria
inside of us all the time. We eat, drink phage all the time. Ten trillion phage pass through our gut into
our tissues everyday, everyday. So they’re everywhere. There’s 10th of the 31 phage on earth, so
they’re everywhere. We eat, drink phage all the time, so they’re
in our gut, they’re modulating the organism up and down, so you have a bloom of phage
and they are killing these particular organism. You have a reduction in up in that organism. We don’t know what physiological effects it
has on our bodies, but it has to have an effect and, and understanding the modulation of phage
and our gut flora is a, is another area that people are starting to look at. And then Janelle, like your own body is then
responding to all these different things going on inside of you. I mean. Absolutely, it’s a bi-directional relationship. So, um, we’re, we’re recognizing the microorganisms
that are in our intestine, but also some microbes induce host responses or immune responses
to that are not effective against themselves, but will be effective against other microbes
within the community. So, um, through this, bi-directional communication,
it goes back to ecology 101. They’re, they’re using the host to also shape
that ecosystem. So I’m gonna open it up to questions in a
little bit. But before I do that, I just wanted to get
a sense from all of you about sort of the human side of all of this. I mean, we, we talked about how the industry
incentives are all quite perverse and you know, it takes time and effort to find these
antibiotics or to develop these other alternatives. So are there, do you see changes in a good
direction in terms of, of, you know, creating a sort of these scientific or social customs
or, or, or procedures to help get us towards this better situation where you might use
the, these things? Or are we just going to, you know, like not
be able to define these replacements because there isn’t enough support for it. And Marty, what do you think? The bottom line is that we need to be better
stewards of antibiotics. We could create 10 new antibiotics or 10 new
lysines, but unless we use them better, uh, the, uh, the resistance will get to us. The bacteria are, are selected for resistance. So we’re, we have to reduce the variation
in antibiotic use. They’re using antibiotics a lot less in Sweden
than they are here. People are just as healthy as we are here. There’s a lot of regional variation in antibiotic
use. There’s variation from doctor to doctor, the
the practice, the public have to be better stewards. Understand that antibiotic use has cost. We’re using it as if it had no cost. So you think that we could even now, I mean
not even talking about these amazing possibilities that we’ve just discussed, you think that
we could reduce the amount of antibiotics that patients are taking and still be protecting. That will help us decrease the pressure. You know, one of the questions is why did
C diff move out of the hospital into the community? Why did MRSA move from the hospital into the
general community? But we might be able to get it back in. Right. So Janelle you were just nodding before. I mean, do you think. I think there’s some great data from antibiotic
clinical trials from 1920s and 1930s where with certain trials, the, the group that received
the placebo, 80 percent of them did just fine. We can clear infections on our own. We can survive infections on our own, um,
and I think a lot of times by the time a patient shows up to the clinic to get the antibiotics,
they, there are studies to suggest that they’ve already cleared the infection and now they’re
just getting antibiotics because they have some residual symptoms from the infection. So I completely agree with Marty that if we
can just temper our use of current, um, antibiotics that will help significantly. And what about you Sean? You were just talking about like, um, how
much money an antibiotic might make and how much money is required to do it. So like how do you, how do you even, how do
you get those thing numbers to balance out? I think the good thing is we’ve seen this
tremendous effort in the past decade to try and solve the discovery problem. We still need more money there, but we clearly
see there’s global impetus to say we need more antibiotics. Maybe there’re, I think there’re 50 recognized
major efforts in the past decade to, to support antibiotic discovery internationally. So I see that going in the right direction. I really do. I don’t know that it’s going to happen fast
enough, we’ll ever get enough money, but that’s in the right direction, but it’s the post
antibiotic issue. Not only our use, but how do we market it? How do we, how do we let those things survive? I still think we have a lot of hard thinking
to think about how we’re, how we’re going to do that and I don’t think we have, we have
a solution. We have great examples we can go to. There are lots of things that countries do
to put things in reserve. You can say our army is in reserve until we
need it. Right? We pay a lot of money for that. Why not think of same models for antibiotics
that we have them developed. They’re in reserve. We pay for them prior to their use, but before
we need them. I mean there’s a lot of thought that has to
go into that, but to me that’s where the gap is at the moment, but we need more money for,
for, for development of antibiotics. We see money flooding in. We still need more, but there’s really still
this question of how do we use them afterwards and how do we finance that worries me. What might help is the fact that we’ve been
using for years and decades or a broad spectrum antibiotics and they’re killing everything
and the reasons for that is when you’re sick, you go to the hospital and the clinician needs
to know what he’s going to treat you with. If he doesn’t know the bug that’s causing
the infection he has to give you something that’s broad spectrum. If we had diagnostics at the bedside, so if
someone comes into the hospital and we know exactly what organism’s causing the infection
you can treat with an antibiotic that is specific for that organism. Would have very little effect on your normal
flora, but we’re not at that point. We’re close. Our hospitals now can identify the organism
fairly quickly. Fairly quickly meaning what kind of time scale? Hours, so we’re at hours from days to hours. And if that. If you can do that, then you have antibiotics
that are more channeled to the organism that you’re killing, which would cause less side
effects. And I think that that might be a way to survive
this type of issue that we’re having right now. And then what about sort of uh, these, um,
less, we’ll call them less conventional things like phage therapy or using lysines or so. And do you like in terms of getting a regulatory
approval for these things, do you do, do you think that that is able to move forward quickly
enough or. Or are we, do we need a better way to sort
of like take in new ideas and try to get them approved to be used? Well, the lysine therapy has been quite successful
in moving through the system. Phage therapy has an issue, because phage
therapy is, is a concoction of many phage to control a particular infection. And since you could make a cocktail, I can
make a different cocktail that causes the same infection. There is no IP so there’s no incentive. The develop phage therapy if it does work
to some degree, but there’s no incentive there. But if you have a defined molecule then that,
I think that the pathway to get it out out the door is quite good. Alright. So Jo, I’m just curious, are you, when you
look ahead 50 years, do you see the sort of the dark picture they recast earlier or do
you, are you optimistic? I mean what’s. I’m always the optimist, but I also have to
be tempered by the fact that we developed a plan for antibiotic development and stewardship
when I was in the White House and there were some really simple things in there that could
have been done like stewardship of antibiotics in hospitals. So CDC has an eight point plan of what hospitals
are supposed to do. We found that only 50 percent of hospitals
in the United States followed that very, very simple plan, like having a strategy for an
antibiotic use in the hospital, training personnel in antibiotics. It. It was really kind of depressing and appalling
and we identified all the things mentioned here and then many others that we need to
steward the antibiotics, use them less, have better diagnostics so that we know when to
use them and we don’t even use the tools today that we have like diagnostics. I’ve, I’ve done this survey completely unscientific. I shouldn’t even talk about it, but it’s my
little way of keeping tabs on the docks. I asked in my lab, when people go for a sore
throat, go to the doctor, what do they do? And 10 years ago there was never a test. They just gave them the antibiotics in every
case. And then slowly we started seeing the strep
test, strep throat test being used. But even today, fewer than half are getting
a test before they get antibiotics. That just seems irresponsible to me. Any guesses why? I mean Marty, what do you? I mean you’re the doctor? I mean why, what? I mean what, it doesn’t make sense. It’s the problem of transparency, the medical
profession and the public overestimate the benefit of antibiotic and they underestimate
the cost, the effects of antibiotics. And so, uh, we, we have, we have to fix that
and I, I really agree about narrow spectrum antibiotics, you know, and, and as I said,
antibiotics are falsely inexpensive, why, why give someone a $500 or $5,000 antibiotic
when you can treat them with a $5 antibiotic. So the market’s broken, but we need to use
tax money just like we need to use tax money to buy interstate highways, uh, that, that’s
a public. Antibiotics are public good. We have to invest in, in, in antibiotics that
will protect our future, uh, as, as a public good. Okay, um, we have microphones. A question right in the back there. Thank you first off for the presentation,
that was really useful. Um, I just have two quick questions. So first I’m being. So how advanced and what are the, what is
the percentage accuracy on these diagnostic tools? Can they either be improved or is it just
because these current antibiotics are cheaper, they’re just not getting that much visibility. And my second question is, are there currently
government programs that are in place or in the pipeline? And the reason I ask this is because there’re
orphan diseases out there that don’t have a large market either, but yet there are a
lot of government programs that incentivize the innovations for this space. So I’m wondering if that’s something that’s
happening in the pipeline right now that will encourage innovation in the space. Great. So let’s, uh, let’s, uh, let’s take these
one at a time. So Vince maybe you could start us off in terms
of the diagnostics. Is it just a case that we already have really
good diagnosis but then they’re just not being used enough? Or are there a possibility to develop new
kinds of technology to really get these things identified fast? Well, right now they’re doing it by DNA analysis. So how does that work? You just get a number of organisms, a few
organisms from swab and they can take it and put it, extract the DNA, put it through a
machine and identify certain genes certain pathogens have. And they can do that within hours. Sometimes they’d have to grow the organism
very for only a few generations to get more organisms so they can extract more DNA. But it’s quite quite accurate. It just takes a little more time. It’s not at the bedside. It’s a few hours, but it’s better than what
we used to have which was overnight. We’d have to culture it, let the grow, organisms
grow overnight and then even another test usually two days before you get the identification. When you say at the bedside, are you saying,
I mean like a doctor comes, a nurse comes and takes your temperature at the bedside,
takes your blood pressure at the bedside or you’re saying- Well like a rapid strep test is in a sense
at the bedside. You can swab the throat and put it into a
solution that digests the organism and they have an antibody that identifies a molecule
on that organism. You can do that within 20 minutes. You get the results of that experiment. That’s at the bedside. We’re not there yet, but we’re close. And are hospitals like. It sounds from your, from your survey, I would
guess that maybe hospitals are a little slow to really snap up the best of these diagnostics. They are used. Some are and some aren’t. Just like the simple practices to reduce antibiotic
resistance, which don’t cost any money and in most cases some adopt them and some don’t. And Marty, I mean most antibiotics used in the United
States and most countries are used in outpatients. They’re not used, so the focus, 90 percent
of the antibiotics are used in outpatient, and most of the antibiotics are used for upper
respiratory infections, which we know that a big fraction are viral and are not bacterial
at all, so viral infections don’t respond to antibiotics. So we need a rapid diagnostic that will tell
whether that outpatient walking in has a viral infection or bacterial infection. In the doctor’s office as well. If we had that tool, we could eliminate a
lot of unnecessary antibiotic testing. One of the problems is that the antibiotic
costs $5. The test might cost $500. So our health system isn’t, It’s not working. Okay. So after we get fix antibiotic problem, we’ll
fix the healthcare system, right? Or first, what if, at the same time. Anyway, the second question was about what? What are, what are there? Are there any special government programs
that are actually like trying to, to push research about resistance forward with what’s
happening? So as, as you mentioned, I’m on this commission
that Jo was involved in setting up called PACCARB, which is President Obama set it up
by executive order and, and our mandate is to combat antibiotic resistant bacteria and
we have five different areas, surveillance, stewardship, new diagnostics, therapeutics
and international efforts working with other countries. So as, as part of these and, and the executive
order, uh, money’s have gone into something called BARDA, which is to develop new antibiotics,
to put money in, to make it more economically viable, to develop antibodies, to look at
antibiotics like orphan diseases as well. They’re, they’re special stipulations that
make it more attractive for companies to make products for orphan diseases. Great. Any more questions? Is prevention still a big thing in terms of
the washing of the hands thing, is that still the best thing we can do? I have one little version of that. I try not to touch anything when I go to the
men’s room. Does that work? So soap and water works. There’s no question, but on the other hand,
there are all these antibacterial products, uh, that are killing the good bacteria. Good bacteria help protect us against the
bad bacteria against the invader. So are they doing more good or good? Doing more harm. And I don’t know either. These things have hardly been tested and the
people who make them aren’t particularly interested in testing. So we should, we should just talk a little
bit about. I mean, we’ve lot, I’ve been talking a lot
about the gut, but the skin is covered in bacteria, right? And it’s a completely different flora than
we have in our gut or our mouth or our ears. In fact, the two hands differ a left and right. So. And are they, are they, are they doing, are
they doing good things for me right now? Yeah. They’re protecting your skin just like they
protect any surface they’re on, they’re good guys. You have to get used to this respect for the
microbes thing. Okay, okay, now I can handle this. And so, so if you use these sort of hand sanitizers
with the antibacterials- There are times to use them in the hospital,
it’s very important to use them because you have a lot of bad bacteria transmitting in
hospitals. So washing the hands and a variety of different
ways is important. And during flu season it’s very important
because flu is transferred by people’s hands. But if you take all of that collectively,
maybe that’s three percent of the time. The other 97 percent of the time, the benefit
is just leaving our microbes alone. I think the biggest thing any of us can do
is treat our flu symptoms very respectfully. Stay home, not, so you don’t transmit it,
wash your hands with soap. Purell won’t help with flu, but uh, that much
but certain, oh, well yeah, get get you saying get the shot. Get a vaccine. That’s right, and because I think more antibiotics
are given for flu like symptoms that turn out to be viral, but we don’t have the test
to prove that than probably any other disease, so I think if we kept the flu under control
and that can be controlled just by behaviors and washing hands and breathing in people’s
faces. When? Usually November or December till our early
March events. Vince? You have to realize that 90 percent of infections
come in through the mucous membranes. They’re not coming in on your hands. They are coming in through mucus membranes. Your eyes, your your genital track. So when you touch something that’s contaminated,
you’re not getting infected through your skin. It’s when you touch your nose, or you touch
your mouth that the organism then gets it. That’s how it gets in. You have to have a wound. Your skin is a barrier. The only other way is a wound. You’re bringing the organism from where the
other, whatever you picked up and you touch your nose and how many times you touch your
nose and your mouth. About 12 times an hour for the average person. Wow. In the back there. I think multiple of you stadia, but you were
basically because you were using bacteria. No, because you were developing and what do
you got? Penicillin and all which came from soil bacteria
and therefore the soil bacteria had natural built in resistance to the compound you were
using. A question, is it possible to synthetically
generate proteins or protein analogs which would bind to sites or would interfere in
other ways with mechanisms for which things have not developed resistance to because they
weren’t. They aren’t actually naturally occurring equivalent
to penicillin. Yeah. That’s actually an interesting point is that
I think they’ve done studies right where like they would look at old soil and actually actually
find that there were some resistance, resistant microbes like before the invention of antibiotics. That’s right. They’re all over it. My, my group has studied a site in Alaska
that’s essentially as pristine as you can find a site on earth and it has very little
exposure to antibiotics and we find a large array of antibiotic resistance genes. We also have found that when, purely synthetic
antibiotics had been introduced on the market, resistance has even faster in some cases than
to the naturally occurring ones. Penicillin’s been on the market for what,
60 or more 70 years and it’s still useful. Some of the this synthetic antibiotics can’t
even be used anymore because there’s so much resistance, so we’re dealing with evolution. I think that’s the answer to the question
of why there’s no universal cure or prevention because we’re dealing with evolving organisms. So I guess the lesson is that bacteria are
pretty awesome. They really are. All right. Well let’s give a hand for our panelists. Thank you for coming.

The Chronic Pain Epidemic: What’s to Be Done?

The Chronic Pain Epidemic: What’s to Be Done?


[MUSIC PLAYING] DAVID FREEMAN: Hello, everybody. My name is David Freeman. I’m the managing editor of
the impact and innovation section of The Huffington Post. I’m also the moderator
for today’s panel, which is about what can be
done about the chronic pain epidemic. This event is presented jointly
with The Huffington Post. And this program is part of
the Dr. Lawrence H. And Roberta Cohn Forums. Dr. Cohn passed away in January. But we’re pleased to have in
the audience Roberta Cohn, and their daughter,
Leslie today with us. The event is also presented and
associated with Harvard Health Publications. The Forum, The Huffington Post,
Harvard Health Publications are streaming this event
live on their websites. It’s also streaming on Facebook. So people can feel
free to join in. And joining us today we have
four panelists– three here and one remotely. To my immediate right
is Cindy Steinberg, who is the National Director
of Policy and Advocacy US Pain Foundation, a member of the
Interagency Pain Research Coordinating Committee of
NIH, and policy council chair of the Massachusetts
Pain Initiative. So welcome. Dr. Vaughan Rees to her right
is an addiction specialist and lecturer on Social
and Behavioral Sciences at the Harvard T.H. Chan
School of Public Health. Dr. Anne Louise Oaklander,
who is Associate Professor of Neurology and
Director of the nerve unit at Massachusetts General
Hospital, Harvard Medical School. And joining remotely
from a secure location is Linda Porter,
Director of the Office of Pain Policy of the
National Institutes of Health, and co-chair of the
National Pain Strategy. I should also mention
today that we originally were to be joined by
Josephine Briggs, director of NIH Center for Complementary
and Integrative Health. But she couldn’t be here. So thanks to her as well. So the program will include
a brief Q&A at the end. And you can e-mail questions to
the forum at HSPH.Harvard.edu. You can also participate in
a live chat that’s happening on the forum site right now. And so let’s get started. Chronic pain affects
millions of people. I guess it’s actually
tens of millions. But I think we’ll
find out about that. So let’s take a look at a clip
from the University of New England of someone who
lives with chronic pain. ERNIE MERRITT:
Through the years, my job has always been
working with my hands. I went to high school
and then the army, and then became a plumber. And at work I was working in
a confined space too long. And I went to stand up and I
couldn’t stand up straight, and ended up going
to the doctor after. And they found out it
was a herniated disk. So from there I had the
one back surgery where they took part of the disc out. And I was good for a year. I went back to work. And sitting on my
toolbox, I went to get up, and my leg gave out. Went back to the doctor. And they said a disc
fragment broke off. You need another surgery. They said we have
to do a fusion. And they put the
rods and screws in. They took some more x-rays,
like six months, eight months, then a year. Said the fusion didn’t take. Your screws are moving
in your vertebrates. It was 2001 was
the last surgery. I woke up with a
brace around my waist. I said, what’s that for? And they said, well,
that’s temporary. We want to make sure that it’s
going to have time to fuse. I still wear the
brace to this day. I never get back to work after
that, because I didn’t recover. So I wear a $2,000 brace
to be able to stand or sit. For the aches and pains I can
only take Tylenol or Advil, because I can’t take medications
because I have another disease. It’s narcolepsy. But I need something,
because it’s almost like an arthritis building. It’s hard to explain
it to some people that don’t have chronic pain. DAVID FREEMAN: So Cindy, you
work on federal and state pain policy. And you’re also someone who
lives with chronic pain. Tell us about the
scope of the problem, and also your own experience. CINDY STEINBERG: Sure. I learned about
chronic pain because of an accident that happened
to me more than 15 years ago. Yet I still live every
day of my life with pain. I had a career in business
that I really loved. And one day I was
opening up a file drawer. And unbeknownst
to me, moving men had stacked cubicle walls
against the back of a file drawer. And I opened it. And the cabinet
and all the walls fell on me, pinning me
underneath the cabinet and the walls and crushing me,
and causing extensive damage to my spine and back. And I spent five years
searching for help, trying many different
therapies in what was difficult and confusing and
sometimes demeaning experience. I finally found a terrific
doctor who helped me. But he insisted that
I give up my career. So he was right. And I walked away
from a career I loved. I hung a sign at a local library
that I was starting a support group for people with pain. And people just
started showing up. So people with carpal tunnel
and migraine and disk disease and rheumatoid arthritis
and cancer and neuropathy and with conditions
I’d never heard of like vulvodynia and CRPS
and Ehlers-Danlos and Marfans and pudendal neuralgia. And more and more people
just kept coming each month. It was all ages– teens to their
90s, men and women, all socioeconomic backgrounds. And it’s been 16 years. And I’m still
running that group. At this point, more
than 350 people have just come to this small
local group in the Boston area. And a remarkably
common experience for everyone that
comes to the group is that they’ve had
to see at least four or five practitioners
before they can find help, if they ever do. It’s frustrating. It’s exhausting. And it’s costly. Pain devastates the very
fabric of people’s lives. Marriages sometimes fall apart. Friendships are lost. Many are unable to
work and earn a living. They can’t care for their
children and their families. Their self-esteem suffers. They’re unable to enjoy things
that give them pleasure. And they become
housebound, isolated, and sometimes depressed. And then, of course, there
is the relentless physical experience, which may be
burning, stabbing, gnawing, knifing, and other
unpleasant sensations. I equate it to feeling like
you’re a prisoner trapped in your body. But it’s worse than that. You are a prisoner who
is being tortured 24/7. And there’s no means of escape. And yet when people seek help
from health care providers, they’re often met
with skepticism and doubt and mistrust and an
appalling lack of compassion. David talked about the numbers. The scope of chronic pain
in America is enormous. Pain is the number
one reason why Americans visit their doctor. It’s the leading
cause of disability. The Institute of
Medicine has documented that 100 million people
live with chronic pain. And approximately 10% of
those have pain so severe they’re disabled by it. Yet, chronic pain is
largely misunderstood by policymakers, the media,
and the public at large. And there are many challenges
in treating chronic pain. But a critical one
now is the tendency to conflate the opioid epidemic
with the pain epidemic. People with substance abuse
disorder and those living with chronic pain are largely
two separate groups of people with very little overlap. Opioid pain medications are
one of many possible treatments for pain. They don’t help everyone. And for the people they do
help, they don’t completely take the pain away. But for many pain
sufferers who take them responsibly and
legitimately, they are a lifeline that
allows them to function and have some quality of life. DAVID FREEMAN: So
that’s interesting. You talk about this kind of
conflation of the opioid issue and chronic pain. Vaughn, you’re an
addiction specialist. So what’s your take on that? How do you balance
this idea of wanting to make sure people get
the help that they need without stigmatizing
them, and also protect them against
needless risk of addiction? VAUGHAN REES: Well,
David, it’s certainly become a big problem in the
United States in recent years. And we’ve seen an
enormous increase in uptake of the use
of opioid analgesics in the general population. Clearly– and Cindy makes
a very good point that– these are medications
which serve enormous good for people who have
problems of chronic pain. Unfortunately,
what we’ve seen is that the use of
opioid analgesics is not necessarily confined to
the population of patients that have chronic pain problems. And we’re seeing an increase
in use of opioid medications among substance using community. We’ve seen over the past
decade and a half something like a fourfold
increase, not just in sales of opioid medications,
but in the rate of use of those medications,
and indeed, overdose deaths attributable to
opioid analgesic medications. So as we’ve seen a
proliferation of use of opioid analgesics
potentially to benefit patients with chronic pain
problems, we’ve seen similarly problems
in substance use problem among the substance
use community. So finding that
balance of providing appropriate medications
for chronic pain patients while minimizing or
preventing consequences, those consequences
of substance use is critical from a public
health point of view. DAVID FREEMAN: And so
Anne Louise, you’re a neurologist studying pain. So you have your own
unique perspective. And you treat pain patients. So what is your perspective
on chronic pain? ANNE LOUISE OAKLANDER: Well,
I think they brought me into back clean up. And so I’m a physician,
actually, a peripheral nerve specialist. And my interest in
pain really came out of knowing that quite a bit
of unexplained chronic pain is due to abnormalities
affecting the nerves that carry pain sensation, which
is the so-called small fibers, the thinly myelinated
and unmyelinated axons. So I have a very
different background than most pain specialists
who are anesthesiologists. And indeed, they’ve
brought their tools that they learned for managing
acute and operative pain into chronic pain with
the best of intentions. But unfortunately,
the studies really hadn’t been done to look at
the efficacy and the safety of a lot of these treatments. For instance, such as nerve
blocks, for the long haul. And so I think we’ve learned
maybe a bit later than we would have hoped that we have to start
thinking about new approaches. Some of the work from my lab
is helping to address that. One of the studies– or I should say that
much of the work we do relies a lot on bringing
objective measures into the pain field, of
which the most useful are tiny little skin biopsies
taken under anesthesia from the lower leg. And they come into my lab. I direct this facility
here at Mass General. And we can actually
get objective evidence to know when a
patient might have neuropathic pain as a cause of
their particular pain problem. This has turned out
to be very important. For instance, it
helped us to identify a new type of small fiber
neuropathy that actually affects kids and young people,
arguably the worst people to be stuck with this
chronic pain problem. And also in a
prospective study we were able to use these
methods to show that about 40% of people with the
label of fibromyalgia have objective evidence
that in fact they have this kind of
peripheral nerve injury. What’s the point? We’re not just trying
to call it another name. But the point is
is that if you get diagnosed with a peripheral
nerve neuropathy, there’s a path forward. And there is objective
treatments that in some cases can really help people to
get beyond the problems which you two were speaking about. DAVID FREEMAN: So it’s
a way to new treatments, and also to de-stigmatize
this in a way to get this objective
measure of pain. ANNE LOUISE
OAKLANDER: Absolutely. And I echo your comments
that in the past, many of these patients with
what I call “mystery pain,” meaning there is no clear– you
had a very clear cause of it. But many of the patients develop
chronic pain problems out of nowhere. And the part of their
body that is painful doesn’t have an apparent injury. So as Cindy said,
this used to be attributed to psychopathology. And I’m not a psychiatrist. So I can’t address that. But I do know that a lot
of these people in fact have neurologic potentially
treatable causes of their chronic pain. DAVID FREEMAN: OK. Well, Anne Louise, you
mentioned batting cleanup. Actually, that
falls to Linda, who was kind enough to join us
from a vacation in her– I think it’s in Wyoming. So thank you very much. So you’re the co-chair of the
National Pain Strategy, which was released last March by
the US Department of Health and Human Services. And this is the first
plan from the government to reduce the
chronic pain burden. So why did the government
need to get involved to create a plan like this? And what is the result
of that plan’s release? LINDA PORTER: So you
know, the government recognized along with external
stakeholders across the country that we really need a
change in the way we perceive pain, the
way we manage pain, and the way we help
to prevent pain. As Cindy pointed out, there
are hundreds of millions of people who live with pain. On a daily basis there
are tens of millions who have severe pain
that’s not treated well enough for them
to prevent disability to keep from their lives. Some can’t go to work. And can’t go to school. Some drop out of their
social activities. Despite the fact that we
spend hundreds of billions of dollars every year
on better paid care, we are not preventing these
people from suffering. So we have a health care
system that’s not addressing some of the main problems. But it goes beyond that. We also have on the
other side of this sort of a culture of
prescribing opioids as sort of a practice
that has become more prevalent over the years,
rather than providing patients with alternatives
to opioids to reduce that reliance on opioids. So this prescribing
practice I think has made a big contribution
to the opioid epidemic. On the other hand,
we need to balance that if we are to
help people move away from this sole reliance
on opioids with better alternatives to pain care. So some of the major problems
I think that we recognize that we need to deal with
is that most pain care now is delivered in the
primary care setting. And the physicians who are
providing care at that level, they don’t have the
appropriate training in order to manage complex pain
conditions to really identify the individual nature of pain
and the individual responses of people to their treatments. They don’t have
the time to spend with people who have complex
pain, persistent pain. And they don’t have the
resources to offer up other therapies, whether it be
physical therapy or mindfulness or cognitive behavioral therapy. They’re not available to them. And so at that level
we’re dealing not only with a lack of ability to
treat patients appropriately, but we’re also dealing with the
stigma that people with pain live with. So what we needed and
what was recognized– not just by the federal
government, again, this is a national, not
a federal pain strategy– is that we need to move
away from an approach to pain on a unimodal everybody
has the same treatment, everybody has the same problem
to a multidisciplinary approach that’s patient-centered
based on the needs of the individual person,
and that can provide them with a set of alternatives
that best approach their personal strategies. In order to do
this, we really need to approach it from a number
of different directions. We need to provide access to
care for the many, many people who don’t have appropriate care,
whether it’s because they live in rural settings, whether their
insurance companies don’t cover the appropriate care, or
enough of the appropriate care that they get. They may be restricted
on many levels for so many physical therapy
treatments, things that we know are helpful like
yoga and mindfulness are very rarely paid for by most
people’s health care providers. So we need to take
this to a level where this multi-disciplinary
approach is provided in a biopsychosocial
model of pain. So pain is not just
a physical problem. It needs a
psychological approach. It’s really sort of
a multimodal, again, patient-centered and
integrated approach. We also need a
better research base so that the programs
and the offerings that we do have for
people with pain are appropriate to their needs. We understand the risks. We understand the benefits. And we understand the costs. And we can weigh all
those things out together. So the National
Pain Strategy takes all those different
aspects and approaches them with the lead of the federal
government over a number of different variables. And I hope we’ll go into
that a little bit more. But the last thing I want
to mention at this point is that we do, as
Anna Louise mentioned, have evidence to improve
some of the approaches that we use for pain care. We aren’t necessarily getting
that evidence base out to the clinic. And so this is another place
that the National Strategy hopes to make improvements
in health care. If Josie Briggs had been
able to attend today, I think she would
have made a point to let you know that the center
that she directs at the NIH has focused a lot of attention
and a lot of its resources on looking at the benefits
and risks of therapies that are considered perhaps
nontraditional, or that are part of a
multi-disciplinary approach. So we know, for instance,
through clinical studies that massage can be
helpful, that acupuncture can be helpful, that
yoga can be helpful, and that mindfulness
can be helpful in a lot of these situations. But access to those programs
and payment for those programs is something that we’re really
missing from the big picture. But the evidence
base is expanding. And I think that’s an important
piece of the move forward. DAVID FREEMAN: Well,
it sounds complicated, especially as you’re
saying, getting it out to the primary care physicians
to put this plan into action. So we’ll get to that
in a few minutes. But let’s turn to a clip now. The rest of this session
will be more about ways to address the epidemic. So here’s a clip from KBIE,
a documentary called Oh, My Aching Back, which
is provided courtesy of The Huffington Post. So it talks about exercise as
a way to treat chronic pain. SPEAKER 1: 3, 2, 1, Hit it. Go. Don’t let your knee deviate. Yes. Yeah. Go, go, go! You got it. Hurry. Come on. Get the bar set up
for your own body. SPEAKER 2: The human body
is an extraordinary machine. It’s engineered
to bend and move. But when things go wrong,
there can be mystery pain. SPEAKER 1: Kelly gets a
little special attention because she’s coming back from
an injury, a little flare-up. KELLY: I just have
that phantom back pain that didn’t come from injury,
didn’t come from an accident. SPEAKER 2: At Fulsome
Physical Therapy, these folks are making
an investment together, using sweat equity to
conquer that chronic ache. SPEAKER 3: Couldn’t
sleep at night. I mean, wicked pain. SPEAKER 2: And recover
from major injuries. SPEAKER 4: Two spinal fractures,
four pelvic fractures, and a hand fracture. SPEAKER 2: So what
would possess people with debilitating pain to put
themselves through all this, risking more soreness
in the process? KELLY: I don’t have
that pain anymore. It’s zero. SPEAKER 3: It’s immediate. And I get strong right away. DAVID FREEMAN: So let’s
go back to Linda a bit. You know, she was talking
about this pain strategy. Again, it sounds complicated. And I’m wondering in my
experience going to the doctor, I don’t have chronic pain. But there’s a really push
to get people in and out pretty quickly, which I guess
whatever happens to Obamacare is still going to be an issue. So what exactly needs to
change from that level? How is the strategy
involved in National Pain , how is the implementation
going to work? LINDA PORTER: So the
implementation structure is in place now, and
is moving forward. It’s being coordinated through
the Office of the Assistant Secretary. And it will actually
involve themes that were set up in the report– the National Pain
Strategy report– that cover a number
of different areas. So we’re looking at
population research so we can better understand
the prevalence and the issues surrounding pain,
as well as being able to monitor over time how
different interventions are a benefit to pain. We’re also looking at
provider education, which I think is foundational
to improving how we care for patients. So there will be resources
made at different levels and multi-disciplines for people
who [INAUDIBLE] care with pain. We’re also looking at– and
I think this is a really important piece– is the payment and the service
delivery for pain care. And I think this gets
a little bit more to your targeted question that
we are running pilot studies through the Centers for
Medicare and Medicaid to see how public and private
care is actually now covered, pain treatments, and
to make adjustments in how those are paid for
through those insurers and for reimbursement
for the doctors according to the best practices. So how does a multidisciplinary
approach to pain, how do we pay for that? What’s the cost
benefit to the insurer? And most important, what’s
the outcome to the patient? So those questions are
being addressed with along with better
prevention strategies. So using prevention
strategies in the workplace. These are prevention strategies
that are self-management based, which includes things
like healthier lifestyles, exercise, of course,
should be included in that. And also on public
awareness– and I think this is also a key
piece to the strategy of how people who do not
suffer with chronic pain perceive those who do. The stigma attached
with it, and especially for those who are in
need of taking opioids through their pain there’s
an additional level of stigma there. But also helping
people with pain communicate with their
physician so they can ask what their options
are, where they can get access to those options,
and how, again, this patient-centered
team-based approach can improve their
situation and their lives. DAVID FREEMAN: Can you talk a
bit about disparities in pain? Chronic pain? LINDA PORTER: Sure. So disparities is kind
of a global term that includes differential
responses to pain and pain treatments based on
genetics, racial differences, cultural differences. But I think the biggest
focus of the National Pain Strategies for disparities is
how do we best help people who are in vulnerable populations? Whether it be young children who
can’t communicate their pain, whether it be older people
who have different responses to drugs. How do we best manage them. How do we reach out to them
perhaps through a community setting. But also people in racial
groups or ethnic groups, low socieconomic groups,
or live in rural areas who are having difficulty
getting even a primary care physician, and especially
getting a sort of a specialized program set up for them
because they don’t have access, or they can’t afford access. So disparities is
a broad term when it’s addressed to pain
because it’s partly the individual disparities. But it’s partly the care
piece of it as well. And this is a huge issue
that the Pain Strategy hopes to begin to address. DAVID FREEMAN: So it sounds
like a pretty complicated plan. And I want to ask
you about funding. It’s a big plan. Who is going to pay for it? And what about research
upstream from the implementation of the plan? What’s the funding
picture look like? CINDY STEINBERG: So
it’s a great plan. It was put together
by 80 experts from the medical community,
the patient community, the scientific community. And I applaud Linda for
co-leading that effort. But right now the truth is
it’s an unfunded mandate. So basically there is no budget
allocated at HHS right now to fund the National
Pain Strategy. The kinds of things
Linda was talking about was sort of small
demonstrations here and there. But they’re not
going to fund it. And we heard from the ION
that $600 billion annually is spent on pain now
because of lost productivity and direct health care costs. I gave the example of the
people in my pain group. Everyone’s had seen four
or five practitioners before they find help. So there’s a lot of
wasted money we’re spending right now that
if people recognized, they would see that
the cost of doing this would be saving money. And right now it’s not funded. DAVID FREEMAN: What
about research? You can talk a little about
the funding for research, basic research in pain. CINDY STEINBERG: Yes. Actually, there is another
federal strategy underway right now that Linda
didn’t yet mention, which is called the
Federal Pain Research Strategy that’s a companion
piece to the National Pain Strategy. Linda is also working on that. And the intent of
that is to look at what is needed in
basic biomedical research. We do not yet understand the
basic biological mechanism of pain in the human body. And because of that, we see that
treatments we have right now are inadequate. So the kind of groundbreaking
work that Anne Louise is doing is not that well funded. Right now the NIH has a
$30 billion a year budget. But less than 2% of it goes to
basic biomedical pain research. And we really need
to change that. So the Federal Pain Research
Strategy right now being worked on is an effort to point
us in the right direction. That’s going to need
to be funded as well. DAVID FREEMAN: So what about–
let’s return to this issue of kind of– you’ve talked about conflation
between this chronic pain problem and the
opioid abuse problem. So Vaughan, can you tell
us a bit about that? I mean, how do you
avoid conflating these things to
protect patients, from stigma, but also from
the risk for addiction? VAUGHAN REES: Well, that
is the big challenge I think that we’re
seeking to try to resolve. Clearly what we need
to do is to work to ensure that pain medication
meets the needs of chronic pain patients while reducing
access to opioid analgesics among those who are
engaging in the use for recreational purposes,
or for purposes of abuse. We’ve seen a number
of plans put in place that have helped to reduce
that, providing better information to patients,
ensuring that patients don’t make those medications available
to other family members or friends. Proper disposal of medications
has been an important strategy. We’ve seen the introduction of
prescription drug monitoring programs in virtually every
state in the United States, which again, have
helped to reduce use of opioid medications
in inappropriate ways. We’re also seeing
better strategies to reduce diversion
of opioid medications, both from the place of
manufacture and distribution, which make their way into
criminal black markets, as well as sales of
illicit opioid medications on the streets. So law enforcement
strategies have also been somewhat helpful in terms
of reducing the prevalence of use in that respect. But overwhelmingly, the
reason for the substance or the opioid
analgesic epidemic– abuse epidemic–
is a consequence of the pharmaceutical industry
for promoting these products in inappropriate ways, both to
consumers and to prescribers. And as we start to develop
alternative strategies to opioid medications,
and we start to reduce inappropriate
promotional activities by the pharmaceutical
industry, we will see reduced demand
for opioid medications at a population level. Something like 99% of
hydrocodone medications prescribed globally
are prescribed in the United States. And that’s a
statistic which speaks to the power of the
pharmaceutical industry in promoting that product
at a national level. And I think we recognize
the need for alternatives for providing opioid
medications in a safer way. And I welcome the plans that the
panelists have described today. DAVID FREEMAN: I want to ask
Cindy about your perspective on it also. But that statistic
you mentioned. Was it 99% of the
prescriptions were written for the US patients? VAUGHAN REES: For hydrocodone. DAVID FREEMAN: For hydrocodone. VAUGHAN REES: And Vicodin. DAVID FREEMAN: And what is
so different about the US than, say, Europe, or
other parts of the world? VAUGHAN REES:
Well, I think we’ve got a very aggressive
pharmaceutical industry that has actively promoted
the product in the US. And it’s partly a consequence
of a number of factors, which include prescriber preferences,
patient preferences, and federal regulations. DAVID FREEMAN: Cindy, do you
have a different perspective on that? CINDY STEINBERG: Well, I do
have a different perspective on that. And that is, I said,
and Linda said, that 100 million Americans
are living with pain. That is a lot of people
living with pain. And I think at this
point right now because of all of the sort
of tamp down of prescribing, we’ve seen prescribing drop now. I think it’s 25%
prescribing is down. Yet, the opioid overdose
deaths are continuing. Why is that? Because I think we’ve moved
beyond prescription opioids, which are now harder to get. And we have abused
[INAUDIBLE] formulations. And people unfortunately with
a disease of substance abuse have moved to illegal substances
like illicit fentanyl that’s coming into this
country from overseas. And so for example,
Massachusetts Department of Public Health released
data just a few days ago. And they’ve been doing some
incredible groundbreaking work in data, showing that
only 8% of people who died of opioid abuse
between 2011 and 2014 had a legitimate script
for that medication. And so it’s not the
pain patient, per se, that’s abusing the medication. Unfortunately now there are
illegal substances coming in. And people with
substance abuse who can’t get the
medicine any longer have now switched to that. And it’s a huge problem. So we need to really
work on substance abuse at the same time that
we work on chronic pain. DAVID FREEMAN: So I want
to shift gears a bit. And I’m not sure we
talked the other day, and I’m not sure of
whose term this was. We talked in terms of
an activated patient. It it’s your term or your term. But Anne Louise, can you
talk about what advice given your perspective,
what advice you would have for patients
other than to make sure. And you talked about having
seen multiple practitioners. How can you be an
activated patient to get the care that you need? ANNE LOUISE OAKLANDER: You
know, I think it’s tough. When you have chronic
pain, you don’t feel well. A lot of people
develop depression, difficulty exercising, income
problems, as Cindy mentioned. But somehow it’s very
important to try and maintain some level of hope for the
future and to persist, I think, and to push the
health care system to try and allow you access
to those physicians who might be able to find
something new for you, to keep up with new discoveries
that are being published, and not to just accept
well, this is all we can do. You’re going to be like this
for the rest of your life. So again, work– a lot of
it sponsored by the NIH , like our own work, is making
new discoveries and offering new options to patients. I was working this morning on
our next NIH grant proposal. Did you hear that, Linda? LINDA PORTER: I did. ANNE LOUISE OAKLANDER:
Going in in February about preparing for clinical
trials of a whole new set of treatment options that
have nothing whatsoever to do with pain pills or opioids for
a specific subset of patients. DAVID FREEMAN: But it sounds
like a very inefficient process to keep at it, to keep
at it, to keep at it. Isn’t there a way
to short circuit that, to go straight to a
practitioner who can give you the help that you need? ANNE LOUISE OAKLANDER:
The problem, as we’ve said several
times, is education. One of the conditions
that my group works on– tarlov cysts– is a
completely unappreciated cause of back pain. Perhaps some of the
people in the video we saw earlier might have that. And it’s something that’s
actually visible on MRIs. But radiologists have been
taught that tarlov cysts never cause problems. And it’s actually treatable
with quite respectable results from procedures. The big problem is at
the level of education. Most physicians, let alone
other health care providers, have never heard about this. Fortunately, I’ll put some
of our papers on this topic, including the first one ever
we got in the New England Journal of Medicine. It’s the highest
profile journal. I’ll put it on the website
so you can learn more. DAVID FREEMAN: Thank you. So do you want to talk briefly? We’ve only got a few
minutes left before we start with our questions. But I wanted to get
your perspective, Cindy, of the activated patient,
given your own experience. CINDY STEINBERG: Absolutely. And I think Anne Louise
really made a good point about trying to continue to
find things that help you. And you know, unfortunately,
though, for most people living with pain, there is
no cure right now. And I think the
first thing comes with accepting that we
are not understanding it enough to find a cure. And therefore you have to take
an active role in managing the pain yourself. And I think the most effective
thing, as Linda mentioned, is to find a number of
different treatments that work for you, that
perhaps each one helps reduce the pain maybe 10% to 15%. And overall, you’re reducing
the pain 50% or 60%. And you can function. And so it’s individual. What works for one person
doesn’t work for anyone else, or for other people, often. So you have to find the right
combination of treatments that work for you. And that requires your
being actively aware and trying different things. DAVID FREEMAN: So talking
about trying different things. I wondered if
everyone on the panel could weigh in on this question
about these alternative or non-pharmaceutical
approaches. And Linda, maybe
you want to start. What’s your perspective on the
sorts of things that maybe need to be implemented more broadly? LINDA PORTER: You know,
we’re finding out now that so many of these
non-pharmaceutical approaches are effective, especially
when they’re bundled together and are directed to the
needs of the individual. I think Cindy made a good point. When we say chronic
pain, we’re looking at so many different
pain conditions, and so many different patients
that respond individually. But we do know for a number
of different conditions, that certain of the
non-pharmacological approaches are effective. It’s research-based. They’re probably effective for
other pain conditions as well. But the research
hasn’t been done. So you know, something as
simple and probably very cost-effective as massage
for low back and neck pain can be very helpful,
especially when it’s bundled into a
multi-disciplinary package. And I think that
integrated care is really an important component of the
non-pharmacological approach, because it’s typically not one
individual treatment that’s going to help a patient. But it’s a package of
patients that’s designed to help that individual. It’s not an easy way to
manage a chronic problem. And it’s not easy
for the patient. And it’s not easy
for the physician. But you know, the
patient awareness piece comes into this so that they
know what their options are. They know what might
be best for them. And they can work with
a well-educated provider to know which of those
treatments is best. And I know, it’s a complicated
picture, as you said. One step at a time. DAVID FREEMAN: And I wonder if
[INAUDIBLE] here on the panel. Anna Louise, do you want
to talk about the things that you think are most
perhaps under used, the sorts of treatments
from your perspective? Non pharmacological treatments. ANNE LOUISE OAKLANDER:
I agree completely that we’ve relied
too much on popping the pill, which kind of fits
well into our current health care model. And of course, those pills
do help a lot of people. But there are entirely
other strategies. Probably the single two
most important alternative strategies that I see– number one is stopping
smoking and improving cardiovascular risk factors. Because when you smoke, your
blood vessels clamp down. And it shuts off the
blood flow to an area that may be diseased
or not in good health. I’ve had chronic pain
patients whose pain has been dramatically
improved just by getting them to stop smoking. And weight loss,
of course, is very important for a number
of diseases, including arthritis and musculoskeletal. Weight loss in many
cases can reverse diabetes and
diabetic neuropathy, which is a major cause
of painful neuropathy here in the US. So when we hear
alternative treatments, we think about yoga and massage. But in addition to those
effective treatments, there are other things
that we can do, even in our own homes, that
can have a direct impact. DAVID FREEMAN: Well,
thank you very much. We were talking earlier too. And especially in light of the
election here in Massachusetts, I guess recreational marijuana
use has been approved, as well as in California. So it seems like we’re at the
beginning of this new shift in our drug policy. Vaughan, I wondered if you
could talk about marijuana specifically, but then also
anything else that you think that is underused from
your perspective that could help people with chronic
pain, other than drugs. VAUGHAN REES: Sure. Well, I don’t want to suggest
that marijuana is underused. But. Marijuana certainly does
have some analgesic benefits for many patients,
and is preferred over opioid medications because
of the different qualities that it has both in terms
of its analgesic qualities as well as its other
psychoactive effects. As we’ve seen new
marijuana laws introduced at a state-by-state basis,
including medical marijuana laws, decriminalization,
and indeed, legalization. We’ve seen an uptick
in marijuana use in virtually all of
those jurisdictions. What we find interesting
is that particularly in those states with
medical marijuana laws, we’ve seen a decline in the use
of opioid medications, which suggests– we’re not completely
sure we understand what’s going on there–
but it does suggest at least that patients who are
making use of opioid analgesics are making a switch to,
or preferring, marijuana. The long-term
consequences of that, we don’t completely understand. And of course, we do have
concerns about uptake in use of marijuana,
particularly among youth. So so there may be some
potential benefits. But, of course
risks of introducing decriminalization, and indeed
legalization, of marijuana. But it does provide one
potential alternative. And there are some
pharmaceutical products that have been
approved by the FDA for the purpose of analgesia
among other effects. But in addition to marijuana, of
course, as Linda has mentioned, there are some great
non-pharmaceutical strategies. And I would also include to
the list that she’s mentioned, cognitive behavioral
therapy, which helps patients to think
differently about the pain and to gain some
mastery of management over negative thinking or
catastrophic thinking that often causes pain
symptoms to become worse. And exercise therapy has
been particularly helpful for many individuals. And the use of
those strategies– those psychological
interventions– in combination with
pharmaceutical or pharmacological approaches
may be particularly beneficial and reduce reliance on
pharmacological methods of providing analgesia. So there are options. And the research base
is rapidly developing to help to literally loosen our
dependence on opioid analgesia. DAVID FREEMAN: So and what
about your experience? I know you shift your
posture some, right? That’s one way that you
deal with your pain. What things have you found to
be most helpful for your pain? CINDY STEINBERG: So what I do
is a combination of things. I use medication. And I limit the amount
of time I’m upright. Literally I’m up an hour. And I lie down for 25 minutes. And that helps me control the
level of pain I experience. I do an exercise program,
a water-based program, and a land-based
exercise program. And combining all
those things enables me to function while still
living with pain, but having it much reduced. DAVID FREEMAN: OK. I think now Lisa’s got
some questions for us. LISA MIROWITZ: I do. Thanks a lot, David. We do have a lot of
questions coming in. This is one from our live chat. What advice do your experts
have for those chronic pain patients whose doctors
will no longer provide opioid treatment? Many have been on
these treatments successfully for 10 to 15
years, and are just cut off with a final 30-day supply. If they cannot
find a new doctor, should they go to the ER? Methadone clinics? What should they do? These people are lost in pain,
and don’t know where to turn. DAVID FREEMAN: Thinking of
Anna Louise, and also you. Who wants to weigh
in on that question? ANNE LOUISE OAKLANDER:
Well, I can weigh in on it from the perspective
of provider. I think you can weigh in on
it from other perspectives as well. But as a physician, I hear this
story from some of my patients. And I think it’s tragic. And it’s just really
not called for. In many cases the patients
are very stable people who have been using their
medications stably, sometimes for decades. And what I have
advised patients to do is if they’re not able
to find another provider, that they contact their state
Board of Medical Registration and let them know that this has
been done so that the board can look into it and make
sure that it’s not part of a larger problem
with that particular medical practice. And the board may be
able to help direct them to more suitable providers. DAVID FREEMAN: Do
you want to weigh in? CINDY STEINBERG: Yeah. Sure. I mean, that is a huge
problem right now. And the advocacy groups are
hearing from many people now who are not only not able
to get the opioid medication that they need,
but doctors are not wanting to treat people
with chronic pain. We’ve even had a nurse on
the board of Mass PI text us a picture in a doctor’s
office in Springfield that said we no longer
treat chronic pain patients. Literally, people with
pain are being turned away. And doctors are so fearful. Why is that? Because lawmakers,
unfortunately policymakers, have had this knee-jerk
reaction and said, oh my God. All opioids are bad. Therefore, we have
to do everything we can to limit their use
down to almost nothing. And so now doctors are so
afraid to prescribe that they don’t want to prescribe. And they don’t want to
see chronic pain patients. It’s a huge problem. And I think the
pendulum has swung too far in the other
direction right now. ANNE LOUISE
OAKLANDER: And I think we also have to mention
that a lot of this is prompted not so much by
that individual patient, but by that provider’s fear
of being sued, whether– CINDY STEINBERG: Or
brought before the board. ANNE LOUISE OAKLANDER: Or
brought before the board. CINDY STEINBERG: I mean,
right now in Massachusetts, in the bill that we’ve
just recently had– and it will give you a sense
of why doctors feel this way– is that lawmakers now have
written into the law now that passed in March that every
doctor’s amount of prescribing is going to be monitored by the
Department of Public Health. And anyone who is above
the mean or median of their kind of
practice group is going to get a letter
from the medical board about their prescribing. And so as a doctor and
thinking, oh my God, I’m going to get a letter
from the medical board. I too as a doctor would be
afraid to prescribe anymore. And that is law now
in Massachusetts. LISA MIROWITZ: Thank
you for addressing this, because we have had a number of
questions about this as well. So thank you. Shall I take another one? This is from Facebook. Can the panel talk about
chronic pain induced by emotional trauma rather
than by physical trauma as the underlying trigger. We have had a couple of
questions about that. So I wanted to ask. ANNE LOUISE OAKLANDER: I would
say as a neuroscientist there is an emerging literature
about the effects of emotional
trauma, particularly in the young, in children, or
in many cases these are animal experiments in young animals. And there is evidence that
some of these early traumas can indeed cause
changes in the way the nervous system develops. I don’t think that this really
has practical applications yet in terms of treating the
person on the street. But nonetheless, scientists
are beginning to pay attention. And Linda, you might have a
comment about that as well. LINDA PORTER: Yeah. I think research
is really beginning to understand that there’s a
certain period in early life where emotional trauma
or physical trauma can make people more susceptible
to chronic pain conditions later in life. And so as we move forward
with the Federal Pain Research Strategy, which Cindy
mentioned, that’s an effort to put together
a long-term strategy of how we direct pain research to
sort of improve the agenda and improve the outcome of the
research dollars that we spend. And a lot of the
conversations there have focused on the need for
more research in that area, because there does appear to be
perhaps a certain age at which there is a susceptibility
that is stronger if there’s some kind of early
trauma to lead to chronic pain later in life. And so even beginning to
identify that window of time where early interventions
post that kind of trauma could help prevent
later chronic pain. Those are all big questions
that are looming out there now. And clearly, things
that are going to rise to the research
priorities that are recommended for the
federal government to focus their research dollars
on in the upcoming future. Important area. DAVID FREEMAN: Would the
intervention possibly be therapy at that point? What sorts of
interventions might there be if there’s an injury or
something at an early age? LINDA PORTER: Therapy would
certainly be one of them. Especially if these individuals
could be identified as in need. There could be if there is
an initial physical pain insult resulting
from the trauma, then there could be also
kinds of interventions like cognitive
behavioral therapy, or exercise, rehab therapies
that would associate more with the pain condition. But clearly, this
psychological therapy is likely to be an
important component to that. DAVID FREEMAN: Did
you want to add– VAUGHAN REES: I would just
add something to that. I think looking a
little more broadly among psychiatric
centers and trauma alone, other co-morbid
psychiatric problems can also enhance the
perception of pain, including anxiety problems,
problems with depression. And it is among patients
with those sorts of concerns that we see increased risk
for development or problems of substance use. And so that represents a
particularly high-risk group. And I’m not clear
on the data on this. But I would wonder also whether
those with a history of trauma might also be at
risk of problems of opioid-related substance use. And for which alternative
types of interventions are recommended. DAVID FREEMAN: Do you
have another question? LISA MIROWITZ: We’re
running out of time. We have a lot of questions. And you all can go on
our chat and see those. I just am wondering if anyone
from the studio has a question. AUDIENCE: Yes. I’m wondering if you
could speak a little bit to the intersection of mental
illness and chronic pain. And it was mentioned
that chronic pain can cause mental illness. How about the management
of the mental illness aspect of chronic pain and
the intersection between that and problems of addiction? VAUGHAN REES: That’s a
very important question. I think that there
is a relationship between psychiatric symptoms
and perception of pain. As I mentioned a moment ago,
that there is also clearly a link between the experience
of symptoms of anxiety and depressive
disorders and increased likelihood of substance use. So I think this represents an
important area particularly that suggests vulnerability
for problems of substance use, as well as for increased
chronic pain problems. And we need to engage in
efforts to understand that more effectively to manage
problems for those patients better clinically. DAVID FREEMAN: Cindy, did you– CINDY STEINBERG: Yeah. I do want to comment on that. I’m glad you brought that up. It’s a good point. And if you think
about what I describe when I talk about the
experience of living with pain, if you can picture yourself
living with this kind of pain 24/7 and what it
does to your life, I’ve had people in my pain group
whose spouses have left them. They can’t take care
of their children. They can’t make social plans. And so your world gets
smaller and smaller. And oftentimes people
become incredibly isolated. And the combination of that
often can lead to depression. And so I encourage people
that are experiencing pain to get counseling, because it
affects so many other aspects of your life. I mean, I’ll never forget
this really amazing story that Phil Pizzo, who is the
former dean of Stanford Medical School, the chair of
the IOM committee, he himself, after the report
was released about pain experienced pain himself. A doctor. And he ultimately
had such severe pain. He described the
fact that he was Dean of Stanford
Medical School and he wasn’t leaving his house. And he became so depressed,
clinically depressed, until he managed to
push for a diagnosis like Anne Louise
had talked about, and ultimately got
help for his pain. But I mean, imagine something
like that and chronic pain doing that to them. So I think it’s a really
important point that people should seek counseling. ANNE LOUISE OAKLANDER:
And also I think– go ahead, Linda. LINDA PORTER: Very
briefly here too. We also know that some of
the brain circuitry that’s involved in pain and
depression and anxiety and the reward circuitry
that’s related to depression are overlapping in a
number of different areas. And we’re beginning
to understand that. And I think that’ll help as
far as treatment approaches. Anne Louise? ANNE LOUISE OAKLANDER:
Well, I was just going to say at a
practical level, if I see that I have a patient
with substantial chronic pain, I always try to ask them. I say, how are you
coping with this? If I were you, I
would be depressed. How are you doing? And I emphasize
that it’s not that I think their depression is the
cause of their chronic pain. But I say, look, we may not have
great treatments for your pain. But there’s quite reasonable
treatments for depression out there. So why don’t we at least treat
that part of your difficulty that we have effective
treatments for. And I would encourage
patients as well not to conceal this
from their physicians, but to bring it up very openly. There is treatment. DAVID FREEMAN: So we’re
running out of time. But really quickly,
I think we have time. I wonder if each of you could
offer a policy takeaway. And my understanding is
that these will be collected and distributed to policy– some influencers specifically. So do you want to start, Cindy. What do you think? What’s the policy
takeaway for you, quickly. CINDY STEINBERG: As a person
who lives in the policy world, I can think of a lot of them. But my number one
thing, I guess, would say to dramatically
increase the pain research budget, because we need to
find more effective treatment options. And I think Anne Louise would
probably agree with that. Just one thing I’d
say more quickly also is that in terms of
lawmakers, particularly at the state level, I’d
like them to understand that people with pain
need to be at the table when you’re making
decisions, and that to try to find balanced
approaches that don’t harm one group while helping another. VAUGHAN REES: I
would suggest that we need to reduce the prevalence
of opioid analgesic medications across communities
in the United States, and replace them
with better options. Of course, these
medications need to continue to be made
available for patients with chronic pain problems. But we need to do a better job
of prescribing them, monitoring their prescription,
screening patients that have a potential for
abusing such medications or being involved in the
diversion of those medications to the streets of the
communities from where they come from. So we need to
strike that balance. But overwhelmingly, we
need to reduce our reliance on opioid medications, reduce
the prevalence of their use across communities, and seek
better, safer alternatives. DAVID FREEMAN: Anne Louise. ANNE LOUISE OAKLANDER:
And I’m going to say something odd for a
clinician and a researcher. But I think we need to do better
with getting the message out to other health care
providers and to the public about the discoveries
in many cases that have already been made. An opportunity like this to
speak to a large audience is terrific. Far more people will watch
this than read my papers in some persnickety
medical journal. So let’s find ways to
disseminate the research that the NIH is funding, and get
it out to help patients faster, quicker, better. DAVID FREEMAN: And
Linda, how about you? LINDA PORTER: All of
the above, obviously. What I would add to that is
I think what we need to do is really start to move
towards a payment system that covers multi-disciplinary care
for people with chronic pain, and that the public payers
can take the lead with that. And as we understand
better how that benefits both the payer, and especially
the outcomes for the patients to start to move
in that direction. DAVID FREEMAN: OK. Well, I think that
about ends it, Linda. Thank you very much. Anne Louise, thank you. Vaughn, Cindy,
thank you very much. And I’ll encourage
the people who are watching online that
the conversation continues on the forum website. ForumHSPH.org. So thank you all very much. Thank all for the panelists. Thank you very much. Bye bye. [APPLAUSE]

On getting stung by annoying insects such as Sargon of Akkad | Curio v1e6

On getting stung by annoying insects such as Sargon of Akkad | Curio v1e6


Just a quick warning: this video contains
lots of footage of a guy getting hurt by various animals. If that sounds distressing to you,
feel free to skip it. Reading Ayn Rand: Huh, I thought people with
disabilities did deserve rights, but it turns out they– Hello! This video is probably a mistake. Section 1: Introduction – A puppy that nobody
loves There’s this YouTuber called Coyote Peterson,
and I’d like to talk about him for a bit – so I will. I mean, it’s my video. So yeah [GROSS MOUTH SOUND] who is Coyote Peterson and
what does he do? Well, he’s a nature filmmaker who travels from
place to place making videos about creatures that he finds interesting, and occasionally,
as part of ongoing series, he gets stung, bitten, or pinched by bugs, fish, crustaceans
and other creatures people usually avoid for exactly that reason.
I’d like to state before I start that I really like Coyote. I think he’s great.
His enthusiasm is infectious and he really knows his stuff and it just comes across that
he really loves animals and bugs and nature. He has fun catchphrases and he doesn’t swear
or get mad even when he’s in pain. I first discovered Coyote with his video STUNG by a COW KILLER! literally an hour after reading news about Cow Killer Ants, because it was
suggested to me, because of the algorithm (praise the algorithm). The video begins with
him holding a Cow Killer or Velvet Ant, which is actually a flightless wasp apparently,
close to his arm using forceps and then getting stung. It immediately flashes back to show
the buildup to the sting. Enter Coyote’s first catchphrase: “I’m Coyote Peterson
and I’m about to enter the sting zone with the Velvet Ant”. What follows can only be
described as the purest form of entertainment. A grown man is shaking and writhing in pain
while saying things like “Oh my gosh guys this is super bad” and “Oh wow, Oh wow
okay” and otherwise trying to relate the experience live to the audience, and then
at the end he says this beautiful cheesy outtro line “Be Brave. Stay Wild. I’ll see you
on the next adventure.”
The next video suggested by the algorithm (praise the algorithm) was STUNG by a TARANTULA
HAWK which again, was a bug I had only just been reading about the day before. I had been
reading that a biologist had recommended that should you be stung by a Tarantula Hawk, the
best course of action would be to just “lie down and scream”, so uh, yeah. I do want
to see Coyote Peterson get stung by a Tarantula Hawk wasp. “I’m Coyote Peterson and I’m
about to enter the sting zone with the Tarantula Hawk”. Unsurprisingly enough what Coyote
does after getting stung, is lie down on the ground and scream. “Be Brave. Stay Wild.
And I’ll see you on the next adventure.” I knew I’d been given something magical
and I immediately watched just every Coyote Peterson video I could. I’ve seen Coyote
enter the sting zone, the bite zone, the pinch zone, the chomp zone and the spine zone. I
kept asking out loud “Who is this idiot? Why is he doing this?” I had so many questions.
Who was giving him the money for this? Why would he put himself through this? How had
I never seen this before? Why does he call himself Coyote? A coyote is just a puppy that
nobody loves. Actually, this is kind of apt, because Coyote
is really cute and charming, but if he weren’t kind of annoying too, it would probably be
really hard to watch him get stung and bitten and pinched by all these different creatures.
However, I think there’s something deeper going on here, so I’d like to examine what
exactly is the appeal of Coyote Peterson. You see, after watching what I’ll group
together to call his “pain zone” videos, I went on to watch him rockpooling and finding
a 2ft long enormous black sea slug. I watched him handling an octopus, and then feeding
a galapagos tortoise. Of course I like watching nature documentary content, and Coyote is
really charming and fun, and even though it was a joke I already feel bad for calling
him a puppy that nobody loves, because I love him and clearly so does everybody else. Section 2: Why we want to watch Coyote Peterson
suffer Schadenfreude is such a well-known phenomenon,
that I honestly probably could have satisfactorily written this section by just saying “schadenfreude”.
However, I want to look at this a bit more. Another popular video series I have been suggested
repeatedly is Price Points by Epicurious. In this series, an expert will try to guess
which is the expensive something and which is the cheap something. For example a coffee
expert will try two coffees and tell you which is the expensive coffee and which is the cheap
coffee. Along the way, the expert will explain the processes and inside knowledge of the
product as part of their deduction. Despite the educational content of these videos,
the real appeal is, again, schadenfreude, the pleasure in seeing someone else suffer.
Unlike Coyote, these experts are not suffering physically, but the appeal of the video from
the thumbnail is that they might suffer socially. They will make a claim based on their expertise
and despite their expertise they could be wrong, which would be embarrassing. Neuroscientists
have shown that social pain – such as having your feelings hurt, being embarrassed or being
proven wrong – is processed by the same parts of the brain as physical pain.
The difference between Price Points and Coyote’s “pain zone” videos is that Coyote is making
the videos himself and Epicurious is hosting the experts on. This means that while Coyote
is offering his own suffering as the allure of his content, Epicurious is treating the
experts in a somewhat hostile way, at least in the marketing of the video.
From the point of view of the “pain zone” videos, Coyote is a charming host who for
some reason has decided to get stung and bitten and pinched a lot. He has to be charming because
it’s his content and he wants to be liked. Because of this, you develop attachment to
him as a character over time, and you feel drawn to watch his videos about other things,
videos where he doesn’t get hurt. From the point of view of Price Points however,
the experts are there for two contradictory reasons – to inform and to suffer. The suffering
is the appeal of the video, but the education is the content of the video. I think for me
at least, this is why I like price points less – the experts aren’t set up to be liked,
so I don’t feel an ongoing attachment to the people giving me the information.
The thumbnails of the Price Points series are deliberately put together, in my very,
very professional opinion, to make the experts in the videos look like pretentious dickheads.
This builds them up as characters that we would like to see suffer, and then the premise
of the video introduces the possibility of seeing them suffer social pain.
They are experts, and you know that because the title says so, but if they guess that
edible lube A is more expensive than edible lube B and they’re wrong, they’re going
to suffer and you’re going to enjoy it, and their deep knowledge of what makes a high
quality consumable aphrodysiac lubricant isn’t going to mean shit!
This is where they are similar to Coyote, who has an enormous knowledge of animals,
marine life and insects. He’s an expert (and he dresses just like Crocodile Dundee
so you know that he’s an expert), but if he’s stung by a Tarantula Hawk, that knowledge
isn’t going to do much for him. He’s going to have to lie down on the ground and scream,
just like anybody else. Section 3: Creatures of habit Another reason Coyote Peterson’s videos
have been great to watch is their dependable content. Each video fits the same template
pretty perfectly, and I’ll lay it out for you here. Sorry Coyote, for selling your trade
secrets away. At the start of the video you will see a short
clip of the thing that you came to the video to see, followed by a drumming track played
over an animated title sequence. Next the video cuts back in time either to Coyote talking
to camera or narrating, explaining where he is and what he’s doing. He will give you
some facts about the animal that is the feature of the video and by about two thirds of the
way through you will be brought back to the point you saw at the start. If it is a “sting
zone” video he will mention the “bullet ant challenge” and if it is a “pain zone”
video generally, he will say “I’m Coyote Peterson, and I’m about to enter the [pain]
zone with the [name of animal]”. He’ll then give his reactions to whatever situation
he is in, and then wrap up by saying “Be brave. Stay wild. See you on the next adventure”.
Magic. Another series of videos I’ve really enjoyed
thanks to the algorithm (praise the algorithm) is the Sharpest kitchen knife in the World
series by a channel that I only just found out was called Kiwami Japan while looking
that up, and up until now I’ve just been calling “knife guy”.
In this series, the knife guy makes knives out of various different materials, including
but not limited to kitchen foil, cardboard, wood, rice and jelly – yes, jelly. Even though
the processes for making the knives vary a lot, in a way these videos are even more dependably
repetitive, because at their core only two things happen in every video: Knife guy makes
the knife, and then he cuts things with the knife.
These videos are so appealing, to me at least, because although I love to make stuff, and
watch videos sometimes to learn how to make stuff, I know I will never make any of these
knives. I am not watching these videos to learn, I am watching them to stave off boredom.
They are comforting, and safe, and I know exactly what I am about to see when I click
on Sharpest ice kitchen knife in the world. The appeal of repetitive content can also
be a trap for its creators – repetitive content is comforting and good to half watch, lazily,
in the background. This means that viewers don’t necessarily get invested in the content.
I certainly like knife guy and I’m impressed by him making the sharpest pasta kitchen knife
in the world, but if he got a new job and didn’t produce videos anymore I wouldn’t
be heartbroken. What makes Coyote’s “pain zone” videos
different, despite their formulaic setup, is that they are based around investment in
Coyote as a personality. The more of them you watch, the more you care about Coyote.
In a strangely meta moment, Coyote’s cameraman Mario revealed in one video that he had had
a T-Shirt made that said “Coyote R U OK” because that’s what he said, word for word,
in every single video, right after Coyote entered the sting zone. We are often creatures
of habit, but sometimes those habits can act as feedback loops that drive us in one direction
or another. This is the way that most YouTube personalities build their channels – they
create masses of formulaic content so viewers can get used to them and find them comforting
and safe. The genius of Coyote’s pain zone, is that
investment in his wellbeing, rather than simple tolerance of his existence, is the basic requirement
of watching. After all, schadenfreude may be a powerful draw, but if someone appears
to be really truly suffering, in a lasting sense, the pleasure that can be derived from
it dissipates quickly. In other words, we want to see Coyote suffer just a little bit,
and then we want to ask “Coyote, R U OK?” That said, I don’t think that genius is
entirely intentional, because if it were, it would be a very cynical reading of what
Coyote Peterson is trying to do. I just can’t interpret Coyote that cynically, because every
time I look at him I see a little kid wearing a wide-brimmed leather hat, sitting an inch
away from the TV, watching Steve Irwin or David Attenborough.
So to understand why these videos are made we’re going to have to get right inside
them. We’re going to have to enter the sting zone. Section 4: Entering the sting zone Why would we watch someone put themselves
through pain so excruciating the only advice for it is to “lie down and scream”? Why
would we want to watch that again and again? Is there a reason to watch that beyond sadistic
desire to watch someone suffer? I want to offer a more positive look at this series.
I want to see what we can get out of the Sting Zone which is a bit more positive.
When I see the thumbnail to a Coyote Peterson video – before I’ve seen him get stung – I
want to know what it’s like to get stung by that insect. It’s not like I want to
get stung, but I want to know what it’s like. I have a curiosity, like an itch. I
want to know how bad it would be. Hearing a description isn’t enough, reading about
the biology isn’t enough. For some reason though, seeing Coyote get stung, seeing him
tense up and sometimes yell and use his phenomenally mild swears… yeah that does it. After I
watch one of those videos I’m not curious anymore. There’s no part of me left that
might see a cowkiller ant in the wild and be legitimately stupid enough to think “they
say it’s really painful but how painful is really painful”?
This isn’t just my reading of these videos by the way. Coyote only has one sponsor on
his videos, and it’s a sting pain relief product targeted at Americans who might get
stung by your average yellow-jacket wasp. They didn’t commission the series, they
approached Peterson after he made himself pretty well-known, but it’s honestly pretty
reassuring. If Coyote Peterson says it helps a bit to use that product after he gets stung
by the tarantula hawk, then yeah, I’d probably get that product if I thought I was in danger
of yellow-jacket stings. I like it as well because the only thing I’ve
advertised in my videos so far is Fidgeters, the fidget toys I make myself at home, and
I only ever intend to advertise things that I’ve made. I find Coyote advertising sting
relief not too far from that. Even before he got the sponsor though, Coyote
Peterson included in these videos a level of educational content and advice that is
really valuable. He says in almost every video that these insects only attack if they’re
aggravated, and that if you see one in the wild, you should just “admire it from a
safe distance”. I think that’s another way those videos
are better than other kinds of obvious, repetitive media like them. Coyote is educating people.
He’s showing people why they don’t want to get stung by these insects, what they can
do if they are, and letting them know they probably won’t if they aren’t massive
jerks. Section 5: Carl Carl, if you’re watching this, thanks for
watching 4 sections of hardcore Coyote Peterson analysis. I know you don’t have the best
patience for YouTube videos, so it means a lot to me that you stuck it out to the end,
champ. On July 13th this year, Donald Trump, the
billionaire that lots of white people in America voted for in order to protect against corporate
interest in politics, visited the UK. His visit was protested by over 100,000 people
in London alone, and more across the country. Two of those protesters were us, myself and
Natalie. Now it’s time to introduce a new character
to the story. Also at the protest was Sargon of Akkad. Wow, that’s a pompous name…
Also at this protest was Carl Benjamin. Carl is a YouTube personality who used to
be quite relevant, starting with gamergate, and then with the wave of anti-feminism, but
basically stopped mattering after the main surge of gamergate was over and lots of gamers
went back to their regular lives. Back when he was famous, he took part in a discussion
with Richard Spencer, the Neo-Nazi, in which he made Spencer look really smart and well-informed
and basically gave the guy a share of his audience. He also took part in a debate with
an academic feminist, Kirsty Winters, in which he got completely hilariously demolished.
When Carl takes part in well-moderated debates he just embarrasses himself, because he can’t
use any of the tactics he’s learned to instinctively reach for.
More recently though, Carl joined UKIP along with some other right-wing YouTubers in an
attempt to radicalise their fanbases. The fact that he is an active member of UKIP,
more than anything else, is why I was quite annoyed to see him being interviewed by the
BB-fucking-C at the Trump protest. The BBC tries to do what it considers to be
balanced journalism. Their approach to this is to always show an alternative to whatever
they’re showing. If they have a left-winger, they need to have a right-winger on. If they
show you Coke, they also have to show you Pepsi. Now, UKIP and UKIP members officially
make a lot of noise telling people that they aren’t an inherently racist party, but,
the protest was an anti-racist protest, so I’ll let you make up your own mind about
what the BBC thought they were doing by interviewing Carl.
Let’s be clear. Carl isn’t a politician, he isn’t a political expert or a great thinker,
he’s an edgy shitposter. His current shtick is that he’s read Starship Troopers – the
book that got adapted into a movie which is basically a satire of it because it’s more
or less just fan-fic for Nazis – he’s read that book and he’s telling everyone that
he thinks their society is perfect. [ Dig up quote – He’s telling everyone that this
is a picture of a great society – SERVICE GUARANTEES CITIZENSHIP!] I honestly can’t
tell if he’s sincere or if this is a complex meme-strat in service of making everyone think
he’s just a fucking moron? I don’t know Carl, I can’t see how this benefits you
at all. Well that was his most recent moment in the
spotlight anyway, until right at the last minute while making this video he went on
a podcast and said that [LONG SIGH] age of consent should be on a case-by-case basis.
Anyway, when I saw Carl at the protest, I was pretty annoyed, but I mostly felt that
it’s best to just ignore him. After all, most of the stuff he does nowadays is just
trying to claw back the attention he used to have.
I thought it would be best to ignore him because I’ve seen him argue before. He argues in
tremendous bad faith – or as my french friend says, “bat face”. I’ve done a bit of
debating, and what bat-face arguers like Carl do is basically the polar opposite of real
debate. I’ve also, as I said, seen him debate and he just made a huge tit of himself. [explain
with graphic] As a point of interest, in case you don’t think he argues in bad faith,
you should check out his stream from right after the protest where he stood for hours
defending Trump because, in the stream he says to a live question that he only supports
Trump “to trigger the libs”. He’ll use a series of leading questions
“wouldn’t you agree that this” or “don’t you think that that” in order to lead people
to the conclusions he’s trying to make them draw. If you try to point out what he’s
leading you towards, he’ll deny it. He’s not in the business of discussing ideas, he’s
in the business of repeatedly stating a set of beliefs for the people watching on his
livestream. Why do I say all this, you ask? Well, because
I’ve watched a really good series by Innuendo Studios titled “The Alt-Right Playbook”.
The series goes over the strategies that the alt-right – oh, sorry, alt-centrist? Classical
liberal? I can’t remember which one Carl is identifying as nowadays – strategies people
like Carl use in order to stop people listening to people on the left and reaffirm their ideas
for their fans. You probably know where this is going at this
point, but I went to argue with Carl. Honestly, the biggest part of it was a dumb sort of
curiosity. I knew Carl was going to be better prepared with studies he’d misread and cherry-picked
statistics to quote to back himself up, I knew exactly what he’d do to win the argument
for his viewers, but a dumbass part of me thought “I know they say getting in a bad-faith
argument sucks a lot, but how much is a lot”. I really did know exactly what he’d do,
but that curiosity is a powerful itch. The bad-faith strategy that Carl uses most
is the Motte and Bailey, also called the bait and switch. In this strategy, your bad-faith
arguer will take a premise that everyone agrees on (that’s Carl’s leading questions) and
build on top of it a statement or claim or even just implication that is total nonsense,
despite being appearing superficially connected. If the person they are talking to rejects
their premise, they are totally flummoxed. For example, when I talked to him he asked
me “is there too much immigration in the UK?”. News around immigration, even the
most progressive news, at best plays the defensive on this issue, explaining why immigrants aren’t
as bad as you think, which is why my answer “immigration is a good thing” really caught
him off guard. When he couldn’t gain a foothold in order
to ask his series of leading questions, he changed topic in a way that’s almost comical.
He abruptly shouted “so, ISLAM.” When he started asking his leading questions about
islam, I could see he was trying to lead the conversation to the conclusion that muslims
shouldn’t be allowed into the UK. I pointed that out, he denied it.
At some point in there he made the astonishing claim that 200 million muslim are radical
terrorists hell-bent on destroying the west which… if there were 200 million people
all ready to fight and die for any ideology, that war would be over already. What a weird
fucking thing to say. At another point, he claimed that immigrants
depress wages, which as I’ve pointed out in a previous video, is one of the talking
points a couple of steps up the ladder of the white-genocide conspiracy theory. [expand
on this in vid] He generally got a lot louder and angrier
talking to me than he did talking to other people, and I think that’s probably because
I let him know that I knew what his game was. I called him by his name and I talked into
his GoPro, and I was pretty visibly disappointed when he asked his leading questions. I think
he knew I knew what he was doing, and he kind of hated it.
There’s a bit before I started properly talking to him, when he was still arguing
with someone who didn’t recognise him, where I let her know that he was a member of UKIP.
I knew so well what he’d do that when she turned around and asked him if it was true,
and he said “A proud member of UKIP” you can actually see my mouth moving in time with
his words. I mean you can kind of see it. It’s difficult because I’m 6’3” and
he’s a bit shorter so at that point my head was mostly out of frame.
I’m not trying to say that I won this argument by the way, I’m just trying to explain that
I had knowledge about this particular thing before I went in, and it didn’t do much
for me. After this shitty, embarrassing argument, I wanted to lie down on the floor and moan
loudly for a while until the toxins left my body.
I need to explain this better, and to do that I need to take a bit of a detour, and look
at the worst Coyote Peterson video ever made. Outside of his Pain Zone videos, Coyote made
a video called Beard of Bees GONE WRONG. In the video, Coyote has shaven off his usual
adventurer stubble and he’s going to put on a beard of bees. He’s expecting to get
stung a couple of times, but he’s not expecting what happens. For some reason the bees start
stinging him over and over and over and over. They’re stinging his lips and his eyelid
and his face is starting to swell. He has to shake them off and run, and as his face
distorts with stings he has to say, through swollen lips “Be bwafe. Ftay wiwd. I’ww
see you on the next adfenchu” This video sucks because Coyote isn’t expecting
to get stung. When I say it sucks I mean that it illicits a totally different response from
me as a viewer. It isn’t a morbid fascination, it isn’t scratching that curious itch. It
sucks and I hate it. If bees had tiny bee GoPros and a YouTube
channel, and they uploaded this video, they could probably title it “Leftist SOYBOY
Coyote Peterson stung by RATIONAL Bees” and all the fans of bees would fucking love
it. All the Coyote Peterson fans would hate it because it would be proving how useless
his bee-knowledge is when he isn’t expecting to get stung, and that same social pain I
talked about before, the pain of being proven wrong, would drive them away from it. It would
make them feel terrible, even though Coyote’s bee-knowledge wasn’t really proven wrong
here at all. If anything he shows he knows how the bee pheromones work, and he knows
how to shake them off, but nobody can say that he won that round. That video is clearly
Bees: 1, Coyote: 0. What I’m trying to say here, really, is
to learn from my experience. Don’t get stung. What I mean by that, is don’t go on a bad-faith
arguer’s platform and play their game. If you know some lazy shithead in real life and
you want to argue them go ahead. If you can bring them into a moderated debate with you,
go ahead. When Carl debated Kirsty Winters, he got burned to the ground and she salted
the earth so nothing would ever grow there again.
Trying to change people’s minds isn’t getting stung, but playing their game is,
and it sucks. If you see a Carl Benjamin in the wild, admire it from a safe distance.
It won’t sting you unless you aggravate it.
Be brave. Stay wild. I’ll see you on the next adventure! Outtro:
Apologies to Kristi Winters, whose name I got wrong repeatedly in this video, like an
idiot. I’d like to thank Hann the Mann who makes the music for Curio, as well as various
friends and family, and a couple of my left-tube colleagues who checked through and helped
to write this essay. Thanks most of all to you, the viewer, for watching this video all
the way to the end. Especially thank you for watching all the way to the end if you’re
a fan of Carl’s. Like, why are you here? This channel is where I argue that Bloodborne
is anti-capitalist propaganda. You think I’m joking but that’s an actual essay I’m
writing. Anyway, this video was a bit heavy for me
so I’m gonna do something non-political next time and talk about Fargo. If you really
really liked this video and want to support Curio there is a Patreon and a ko-fi, or for
regular updates you can follow me on twitter. I’ll link to Carl’s stream in the description
for full context, but I don’t really recommend you go watch any of his videos, they’re
a bit boring. You’d be better off checking out Coyote Peterson’s channel, which I’ll
also link to. Bye for now.