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Rethinking Recovery: Compassionate Harm Reduction with Dr. Taylor Nichols · In Moderation

• 0:18
  Speaker 1: Hey everybody, welcome to episode.
• 0:20
  Speaker 1: Ok, I think, yes, no, I know the sixty nine minus one.
• 0:23
  Speaker 1: Yes, yes, you got it.
• 0:25
  Speaker 1: Oh, yes, all right Episode that's what yeah?
• 0:28
  Speaker 2: Sorry, Taylor.
• 0:29
  Speaker 1: We're doing sixty, nine minus and then plus.
• 0:31
  Speaker 1: Like you know how it's.
• 0:32
  Speaker 1: Like we set BC, like you know, to that BC, like that's basically ours is sixty.
• 0:41
  Speaker 1: Like you know, like people sit around in armchairs and sip their whiskey and laugh at, not like that.
• 0:46
  Speaker 1: You know basic humor.
• 0:47
  Speaker 1: You know what I'm saying.
• 0:48
  Speaker 1: Yeah, of course, good, okay, well, I mean we just, I guess we'll just jump right into it.
• 0:55
  Speaker 1: Taylor, why don't you tell us a little bit about yourself?
• 0:56
  Speaker 1: Because I feel like in the last few weeks, rob, we've kind of like shot the shit for 20 minutes and then we're like oh, we should probably introduce the guest, or something like that.
• 1:03
  Speaker 1: We spent a lot of time, probably more time than we should.
• 1:07
  Speaker 1: So how about we cut that back dramatically and just let you introduce yourself here?
• 1:13
  Speaker 3: I'm Taylor Nichols.
• 1:14
  Speaker 3: I'm an emergency medicine and addiction medicine physician.
• 1:17
  Speaker 3: I live in Sacramento, california.
• 1:19
  Speaker 3: I work in a low barrier harm reduction based clinic in Sacramento and I also work sort of across the continuum of care for people who use drugs, including for patients who are hospitalized on inpatient consult service and in residential treatment as well.
• 1:36
  Speaker 1: Okay, Now I'm very curious, because you say harm reduction Okay.
• 1:41
  Speaker 1: So to me that means there should be less harm, and that's about as far as I get Hitting somebody slightly less with the baseball bat.
• 1:50
  Speaker 1: So like yeah, like there's harm, and then you take less of that and that's harm reduction.
• 1:55
  Speaker 1: That's pretty much all I know.
• 1:56
  Speaker 1: Can you tell me like what actually that might?
• 1:59
  Speaker 3: be.
• 1:59
  Speaker 3: That's a great question.
• 2:00
  Speaker 3: So harm reduction, the premise, the sort of basis, the original definition of harm reduction.
• 2:09
  Speaker 3: It is born of people who use drugs, created by people who use drugs, for people who use drugs.
• 2:15
  Speaker 3: And the idea is simply any positive step towards whatever that goal may be.
• 2:21
  Speaker 3: So I like to use the term recovery from the context of like, the verb to recover.
• 2:29
  Speaker 3: People who are in active use may have negative consequences of their addiction or their substance use disorder and from their use they've lost things, for example, and so to recover those things is their recovery process.
• 2:47
  Speaker 3: I don't think of recovery as abstinence only.
• 2:50
  Speaker 3: Recovery can be whatever people want it to be, and so any positive step towards that goal to reduce the harm that their use is causing to themselves or their community is harm reduction.
• 3:04
  Speaker 3: So it doesn't have to be abstinence, it can be simply drinking less.
• 3:11
  Speaker 3: You can be taking one beer away a day that somebody's drinking.
• 3:15
  Speaker 3: That is harm reduction and it is supporting them in those goals, in being able to accomplish those positive steps that are helpful to them and decreasing the harm to them and to their community.
• 3:29
  Speaker 3: So, it's really yeah, it's any positive change.
• 3:32
  Speaker 2: I imagine that you know going cold turkey could be actually more harmful for some people.
• 3:38
  Speaker 3: Yeah, absolutely, and some people don't want that as their goal, and my goal in working with them as a patient in clinic is just to define what their goals are and then help them accomplish them.
• 3:53
  Speaker 3: And if it is to remain abstinent from a particular drug forever, fine, I will support them in that.
• 4:00
  Speaker 3: I'll help them find the recovery spaces that are abstinence only focused and help them achieve those goals.
• 4:06
  Speaker 3: But say they come to me and they have a few different substances that they're using.
• 4:12
  Speaker 3: Say they want to completely stop using opioids but they also drink and they don't want to completely give that up.
• 4:19
  Speaker 3: Yet I'll approach that person and say, hey, we have a medication like buprenorphine that we can use to help you manage both the withdrawals and then the cravings.
• 4:28
  Speaker 3: That can help you remain abstinent from opioids.
• 4:31
  Speaker 3: However, we don't have to say just stop drinking or manage to wean you down off of that.
• 4:38
  Speaker 3: We can say, all right, how much are you drinking now?
• 4:40
  Speaker 3: Oh, 12 beers a day, on top of using fentanyl.
• 4:43
  Speaker 3: Say We'll get you off the fentanyl, then we'll work on the alcohol.
• 4:47
  Speaker 3: And when we work on the alcohol we'll say, instead of drinking a 12-pack, try bringing that down a little bit, see if you can get yourself down.
• 4:55
  Speaker 3: What's your goal?
• 4:55
  Speaker 3: Oh, you want to get to a six-pack a day.
• 4:57
  Speaker 3: All right, let's split the difference and work on that.
• 4:59
  Speaker 3: For now you got there, okay.
• 5:01
  Speaker 3: Then let's keep going down to a six pack.
• 5:03
  Speaker 3: And then, when you get to a six pack, what are?
• 5:05
  Speaker 3: How do you feel?
• 5:06
  Speaker 3: What are the harms that you're feeling to yourself?
• 5:09
  Speaker 3: Or are you still feel that there are harms to your community surrounding your use?
• 5:13
  Speaker 3: And if you're not, to where your recovery goal is and you say no, I still think I should cut back more than we'll work on that.
• 5:21
  Speaker 3: But that's the idea is to sort of, you can create those positive changes through small steps and focusing on what is causing harm and how do we reduce that.
• 5:34
  Speaker 1: It seems like kind of better, but not necessarily perfect, right?
• 5:39
  Speaker 1: Like we're just trying to focus on better yeah, perfect is the enemy of good.
• 5:43
  Speaker 3: Right, we want good, and perfect is sort of like an artificial definition, because abstinence is not everybody's goal.
• 5:54
  Speaker 3: Perfect might not be abstinence to a person, to society.
• 5:58
  Speaker 3: Society might say abstinence is the only option, right, in which case you're following so a social definition of perfection.
• 6:05
  Speaker 1: But that may not apply to an individual and that's kind of like I like that, just because you know we do that just more on the basis of nutrition.
• 6:13
  Speaker 1: Like hey, someone's drinking I don't know like six sodas a day and say like, hey, maybe like five, four, like I feel like with drugs it's a little bit more.
• 6:21
  Speaker 1: Uh, you know it's a little different, maybe a little bit more extreme, maybe more, maybe more important, but, like you know, still we kind of try and do something similar.
• 6:29
  Speaker 3: We can look at somebody from a nutritional standpoint and say, hey, why don't we use a harm reduction based approach?
• 6:36
  Speaker 3: And that's okay.
• 6:37
  Speaker 3: But when you talk about harm reduction in the context of drugs, people are like, oh well, they just have to quit.
• 6:54
  Speaker 3: Like well, that that's not consistent with harm reduction.
• 6:57
  Speaker 3: That's not really how we do things.
• 7:02
  Speaker 1: I think the only like harm reduction, uh, like policy that I have seen and discussed and that I always thought was interesting, and maybe you can speak to it a little bit, is kind of um, I don't know what the hell the term is like the needles uh, basically like safe and just.
• 7:17
  Speaker 1: But they also hand out like needles, like, like you know syringe exchange, syringe yeah yeah, okay, yeah, let's go syringe, let's go with needles like, like you know, syringe exchange syringe, yeah, yeah okay, yeah, let's go syringe, let's go with that.
• 7:27
  Speaker 1: And so you know, because on the one side they'll say like, oh, you're giving people syringes, basically you're, you're allowed, you're saying, yes, it's okay to do drugs by giving them these, these needles.
• 7:35
  Speaker 1: Is what the the opposing side, I guess would say to that those policies.
• 7:40
  Speaker 3: And I would respond to that by you're taking a community of people who are using drugs, you aren't going to immediately change that and you are reducing the risk of harm, of bloodborne diseases within that community, and so this is actually speaks to the origins of harm reduction.
• 7:58
  Speaker 3: So it's very intrinsically linked to HIV and AIDS and the rise of HIV and AIDS as an epidemic or pandemic sort of globally, where people recognize that people who use drugs, people who injected drugs, were going to be at very high risk of HIV as a bloodborne disease, of HIV as a blood-borne disease.
• 8:28
  Speaker 3: And so practicing syringe and needle exchange and I use that term in the context of, like giving people needles I will just want to be careful about that, because syringe exchange some people say that has to be a one-to-one direct exchange and that can be harmful because not everybody is coming in with a needle to give like somebody who.
• 8:46
  Speaker 3: It's okay to just give people clean syringes and clean needles, regardless of if they have a prior used syringe or needle.
• 8:55
  Speaker 3: That may not be the way.
• 8:58
  Speaker 3: They may not have them, the ones that they had used, um and and it's okay just to support safe use and so that they are also not giving their needles to other people Say they want more than they have on hand for themselves.
• 9:14
  Speaker 3: They want to be able to give them to other people because they're using with somebody else, rather than giving them one so that they can then share it with somebody else.
• 9:22
  Speaker 3: That would defeat the point, and what we've seen with those is that it did directly impact and reduce the spread of bloodborne diseases like HIV and hepatitis C.
• 9:32
  Speaker 3: So when and we also know that when we take those things away, you know, when people who are antithetic, whose beliefs are sort of antithetical to that, come into power and they take away funding for those programs, we see an increase in the transmission of blood-borne diseases.
• 9:53
  Speaker 3: Right, and so the idea that you can just somehow make people who use drugs stop using them right is like it is fantasy.
• 10:04
  Speaker 3: Um, that's not how humans work.
• 10:06
  Speaker 1: Basically, what seemed to be like the war on drugs was right.
• 10:08
  Speaker 1: So, like war on drugs, are you all for it or just mostly for it, like which?
• 10:14
  Speaker 3: well, and I, like to say drugs will always win the war on drugs.
• 10:16
  Speaker 3: Every time they you make more prohibition-based policies, you're going to lose, but drugs will always win, because that's part of human nature.
• 10:25
  Speaker 3: People will seek to alter their consciousness, regardless of whatever policies we create, and so we should create policies that wrap around that reality and allow people to try to reduce the harm to themselves and society in the course of using drugs, and that's okay.
• 10:43
  Speaker 3: Like we can't just simply say nobody should ever use drugs ever and just like cover our eyes and our ears and pretend like it never happens, which is what we try to do more often than not, unfortunately.
• 10:58
  Speaker 1: Yeah, and then you end up with a lot of people in prison for drugs.
• 11:02
  Speaker 2: I feel like this syringe exchange probably acts as a foot in the door as well, since people aren't likely to go get help because they want to quit drugs, but they might go get help to get these clean syringes and then they get introduced to things.
• 11:38
  Speaker 3: Absolutely.
• 11:39
  Speaker 3: If people want to pursue any form of recovery, right?
• 11:40
  Speaker 3: If they want to, hey, yeah, come into this harm reduction center, this harm reduction based clinic, this overdose prevention site, and where you can get clean needles, you can get clean syringes you can use.
• 11:53
  Speaker 3: I mean ideally right If we created, if we allowed overdose prevention sites which are places where people can go, use their drugs in whatever form they use, safely and without the chance of law enforcement presence, without the chance, you know, in a non stigmatizing way, where people can come in, they can use drugs and then they can leave.
• 12:15
  Speaker 3: But that's also a place to access them.
• 12:18
  Speaker 3: That's a place to reach them for health care.
• 12:19
  Speaker 3: It's a place to reach them for health care, it's a place to check in on them, but it's also a place where they have a quote, unquote responsible person in charge who is at that time, not under the influence of anything and can administer Narcan, for example, to reverse an overdose.
• 12:38
  Speaker 3: Millions of uses of drugs in overdose prevention sites, zero overdose deaths.
• 12:44
  Speaker 3: If we really wanted to reach people where they are and provide them healthcare and provide them resources and access to be able to seek recovery in whatever version they want.
• 12:58
  Speaker 3: Overdose prevention sites are a perfect example of that.
• 13:01
  Speaker 3: Needle exchanges, harm reduction programs are examples of having that access in a place that is trusted by the community, of people who use drugs where't want to go to the hospital because they know that they'll be stigmatized.
• 13:25
  Speaker 3: And, as an ER doc, when I see that and I see how people are fearful of seeking care and they feel mistreated, they're not going to come in, they're not going to get care when they need it and it's going to lead people to die from simply not accessing care, right, and so in that way, we say that stigma kills.
• 13:45
  Speaker 3: Because of the stigma that is within healthcare, among even my colleagues, right.
• 13:49
  Speaker 3: Something that I fight amongst my colleagues is that seeing them stigmatize patients who use drugs.
• 13:57
  Speaker 3: I have had people who have come in and they say you know, I know I'm a junkie, I know I, you probably just think I'm here to get drugs, but I really need help.
• 14:09
  Speaker 3: And I will pause and I'll say you know a little bit of like gentle redirection here, but like I don't think of anyone as a junkie and for fact I prefer to not use that term at all, um, and I prefer you didn't call yourself that.
• 14:24
  Speaker 3: You can identify yourself however you want, but I've had people like break down and cry to me over the fact that simply is like wait, you don't like, you don't care about that, you don't want to treat me as less than, and it's like yeah, I'm, you're here to for me to provide you care.
• 14:42
  Speaker 3: You don't have to humble yourself before me.
• 14:44
  Speaker 3: The opposite should be true, like you're here seeking care.
• 14:48
  Speaker 1: I'm sure that's not always their experience with other doctors.
• 14:50
  Speaker 3: Most of the time I'm sure it's not, and that's the stigma from doctors, from nurses, from other affiliated health professionals, right, and so fighting that within society, within health care, is critically important to making sure that, rob, just like you said, that people will access the care, because if you can give them a trusted place to go, they'll go there.
• 15:14
  Speaker 3: And then you can reach them and you can have those conversations like hey, how do you feel about your use?
• 15:19
  Speaker 3: Is it causing you harm?
• 15:20
  Speaker 3: Is it causing your family harm?
• 15:23
  Speaker 3: How are your relationships like?
• 15:24
  Speaker 3: We can make that better.
• 15:26
  Speaker 3: We can try to find an approach that will decrease that harm.
• 15:30
  Speaker 3: Um, and I guarantee you people will appreciate that approach more than just shunning them or stigmatizing them or telling them that they should just what, stop using drugs, like that's not gonna work so what are the?
• 15:45
  Speaker 1: I'm kind of curious like what?
• 15:46
  Speaker 1: The challenges are because you were talking about the, these places people can go and and feel safe, like.
• 15:52
  Speaker 1: What are the challenges to creating more of those places?
• 15:54
  Speaker 1: Is it the stigma?
• 15:55
  Speaker 1: Is it policy?
• 15:56
  Speaker 1: Is it the war on drugs?
• 15:57
  Speaker 1: Is it a little bit of everything like what's you know?
• 16:00
  Speaker 1: What are the challenges there?
• 16:02
  Speaker 3: We have nailed it, though All of those things like those places are stigmatized.
• 16:06
  Speaker 3: It is so.
• 16:08
  Speaker 3: I've had discussions with people, with policymakers, about overdose prevention sites and that's just a political landmine that a lot of people don't want to jump on.
• 16:18
  Speaker 3: Um it actually so I'm in California, I work with the California legislature in advocacy efforts and because it's I can walk to the Capitol from my house.
• 16:31
  Speaker 3: The California Assembly and Senate passed a bill to allow to legalize the creation of overdose prevention sites.
• 16:41
  Speaker 3: Both bodies passed that Right.
• 16:43
  Speaker 3: So bicameral state legislature had to get to the governor's desk.
• 16:48
  Speaker 3: The governor, gavin Newsom, decided that that was not politically viable solution, was too much of a political landmine, and vetoed it.
• 16:57
  Speaker 3: So that is not legal in California.
• 17:00
  Speaker 3: It would be great if that passed.
• 17:03
  Speaker 3: If they open one, I would volunteer to be a medical director at one because I just because I think it's that critically important.
• 17:11
  Speaker 3: So that's one step like from the top.
• 17:14
  Speaker 3: It's not even legal Right.
• 17:15
  Speaker 3: Despite the fact that bars are safe, consumption sites are for alcohol.
• 17:22
  Speaker 3: Consumption sites are for alcohol.
• 17:28
  Speaker 1: Um, we have collectively decided as a society that alcohol as a drug is different than other drugs and that's always been very interesting to me that we just kind of like I mean, we did try and and ban it for a little while, like a hundred years ago, and it went real kind of poorly.
• 18:09
  Speaker 1: And then we're like okay, no, it's fine.
• 18:10
  Speaker 1: And so, like I've always found that very interesting, like, yeah, all right, well, we just let it go, this is, it is what it is.
• 18:13
  Speaker 1: And then we're like okay, no, it's fine.
• 18:13
  Speaker 1: And so, like I've always found that very interesting, like, yeah, all right, well, we just let it go, it's it's, it is what it is and then we don't want people drinking in public.
• 18:21
  Speaker 3: So what do we do?
• 18:22
  Speaker 3: We allow them to drink in bars, and so if we don't want people using drugs in public, which is, like right now, the big hot topic, what do we do about the people using drugs in public?
• 18:31
  Speaker 3: Okay, we'll do what we did with alcohol and allow them to have a space to not use drugs in public.
• 18:37
  Speaker 3: Like there are easy answers to this that history has already provided us.
• 18:41
  Speaker 3: We just need to understand that history, and so that is one factor would be on a on a policy level.
• 18:49
  Speaker 3: Say that policy passes, where are you going to open it?
• 18:52
  Speaker 3: Well, stigma is going to prevent you from being able to open it, being able to operate.
• 18:56
  Speaker 3: There are, they already exist in Vancouver, excuse me, in New York, and Rhode Island is opening one, or just open one?
• 19:05
  Speaker 3: It is possible, but you have to get people on board with the idea that there's going to be an overdose prevention site in their neighborhood, right, and so stigma is going to be the problem.
• 19:14
  Speaker 3: That you's going to be an overdose prevention site in their neighborhood, right, and so stigma is going to be the problem that you'd face there.
• 19:18
  Speaker 1: On a on a local political level I bet you get people like protesting and like with the, with the little signs and everything outside.
• 19:27
  Speaker 1: One of those like they're doing drugs here.
• 19:29
  Speaker 3: We're allowing this we're allowing people to use safely and responsibly, in a way where they don't die or they could just use, as opposed to just shooting up in their backyard.
• 19:40
  Speaker 3: Right, or in isolation, or you know in.
• 19:44
  Speaker 3: You know some of it's public some of it's not public.
• 19:47
  Speaker 3: Some of these people are housed and don't have to use in public.
• 19:50
  Speaker 3: But they would rather not use in isolation.
• 19:52
  Speaker 3: They would rather not use alone.
• 19:53
  Speaker 3: They'd rather go to a setting where they can have a responsible person in charge who, just in case, can check on them, right?
• 20:01
  Speaker 3: These are all reasons that would be helpful to take people both out of isolation and out of the public and bring it into a safe space.
• 20:11
  Speaker 1: I think that one of the biggest challenges that that that this is just gonna face, is not to be callous, but I think we kind of have to just like talk about it.
• 20:18
  Speaker 1: People like, oh they're, they're druggy, I don't care about them.
• 20:21
  Speaker 1: It's the same thing with, like prisoners, like, uh, you know, whenever there's a bill that like tries to, you know, reduce cruel and unusual punishment in prisons, I've always seen like, oh, fuck it, no, they're prisoners, they put themselves there.
• 20:33
  Speaker 1: Who gives a shit about them?
• 20:34
  Speaker 1: And now you've got people using drugs, which to them, now you're as a criminal act.
• 20:39
  Speaker 1: So you know, they're also sort of a criminal and using drugs.
• 20:42
  Speaker 1: It's kind of this, this, this, this combination for people are like I just really don't care about this person, whatever.
• 20:49
  Speaker 1: So, like I feel like getting past, getting people to understand that like, hey, this is, you know, a human being.
• 20:54
  Speaker 1: It could be anyone, it could be someone you talk to.
• 20:56
  Speaker 1: They're struggling.
• 20:57
  Speaker 1: This is, this is a real, this is addiction.
• 20:59
  Speaker 1: We need to, we need to treat it, you know, medically.
• 21:03
  Speaker 3: That's going to be tough on a systems level.
• 21:05
  Speaker 3: Stigma works to other people and once you can other somebody, it's easier to then say oh well, you can.
• 21:11
  Speaker 3: Yeah, oh cal.
• 21:12
  Speaker 3: Oh, california had a proposition just this year to eliminate slavery from our state constitution, to like because if you are, if you are imprisoned, you can be forced to work without pay, right, but literally that was like under slavery.
• 21:30
  Speaker 3: That was sort of.
• 21:31
  Speaker 3: The idea is like oh, we're not gonna allow chattel slavery, we're going to allow people who are prisoners to work for free.
• 21:37
  Speaker 3: That was like the end around for slavery.
• 21:42
  Speaker 1: Yeah, and then we just arrested a bunch of people for whatever reason and now we have a bunch of slaves, basically.
• 21:46
  Speaker 3: And so California was trying to.
• 21:48
  Speaker 3: People in California were trying to eliminate that from within our state constitution.
• 21:53
  Speaker 3: That got voted down.
• 21:55
  Speaker 3: To eliminate that from within our state constitution.
• 21:58
  Speaker 3: That got voted down.
• 21:58
  Speaker 3: People are okay once someone is othered enough with saying you can, you can treat them poorly.
• 22:03
  Speaker 3: It's not me, I'm not a criminal, I'm not going to jail, I'm not going to have to face this and, yes, you can treat them that other person badly, and so stigma is really an effective tool for doing that.
• 22:16
  Speaker 3: Same thing is true with people who use drugs.
• 22:18
  Speaker 3: Right, just like you said, liam, like that's, that's spot on is is people are already saying well, that's a criminal act, you shouldn't be allowed to do that, which, like that, already becomes a problem because that's based on the war on drugs.
• 22:32
  Speaker 3: And then also, we don't like people who use drugs and therefore you're a criminal and you're a person who use drugs.
• 22:38
  Speaker 3: We can treat you poorly and we don't really care if you live Like the idea that an overdose prevention site with zero deaths is not a good idea is telling me that you don't care, then that people who use drugs stay alive.
• 22:52
  Speaker 3: Right, like if somebody, if somebody, if I, if I pitch that to a person and I give them data and they're like yeah, but we had.
• 23:00
  Speaker 3: You know.
• 23:00
  Speaker 3: It's like, how many fentanyl related deaths did you have in San Francisco just this past month?
• 23:06
  Speaker 3: Over 40.
• 23:06
  Speaker 3: That's less than it was a few months ago, where it was like in the seventies to eighties.
• 23:10
  Speaker 3: It's coming down.
• 23:12
  Speaker 3: That's still more of a large number than it should be and it could be zero.
• 23:19
  Speaker 3: And so if I propose a solution that offers zero deaths and you're like no, we don't want to do that.
• 23:25
  Speaker 3: What that says is your values don't align with saving the lives of people who use drugs right.
• 23:31
  Speaker 1: I remember one politician I don't remember which state it was, but basically their policy was like, hey, we should allow people to get two doses of narcan and then after that you don't give them another one.
• 23:42
  Speaker 1: Or maybe it was three and you don't get four.
• 23:44
  Speaker 1: I don't remember the exact number, like I just remember, and I was like this is just a really kind of wild idea where you have like paramedics show up and they kind of pull out a list and they look and they're like oh, I'm sorry, terry, you know you've received two of them.
• 23:58
  Speaker 1: We're just gonna have to sit here and watch you die because we can't give you a third one.
• 24:02
  Speaker 1: And people like there was people that were like, yes, totally like three strikes and you're out or whatever, just like, and I'm like that's is that the solution?
• 24:11
  Speaker 3: it's like, and it seems like to a lot of people the solution is just let them, let them die, like, if we're being honest here, like it is, it's, and I don't feel like that's gonna do what they think it's gonna do well, there are so many layers to that and and, and it's true if you look at so many other facets of the conversations we have around healthcare right, the ideas about repealing the affordable care act, the idea that, well, we don't just let people die, there's the emergency department, like that's not primary care and like people should know that.
• 24:46
  Speaker 3: And also, not everybody makes it to the emergency department for the like massive heart attack that they have.
• 24:53
  Speaker 1: They seem to care about price and money and costs like that's way more cost the costly than you know what you the other.
• 24:59
  Speaker 1: The alternatives right.
• 25:01
  Speaker 3: And so those conversations are old, tired conversations that are had over and over and over again in different ways about different topics, based around the idea that we can other people oh, you can't afford health care, oh you, it's.
• 25:15
  Speaker 3: It's all around in people's minds who and what is deserving enough, and the problem comes when people can say that other person is not deserving enough, regardless of their humanity.
• 25:30
  Speaker 3: I think you know, and it's always about, oh, punishing the other people.
• 25:35
  Speaker 3: So like, oh, undocumented immigrants, they shouldn't get health care.
• 25:39
  Speaker 3: They're like why they're like?
• 25:41
  Speaker 3: You know people will say, well, they don't deserve it, they haven't paid enough taxes to earn it.
• 25:46
  Speaker 3: I am as an ER doc.
• 25:48
  Speaker 3: When I work in the emergency department, I have a mandate to provide care to anyone, regardless of their ability to pay.
• 25:55
  Speaker 3: And again, liam, like you mentioned, that is the most expensive way to provide care.
• 26:00
  Speaker 1: No kidding.
• 26:01
  Speaker 3: So you can't say that we truly don't believe people deserve care, because we've decided as a society that everyone who comes through the door in the emergency department has to be provided care, like we passed the law.
• 26:19
  Speaker 3: That's what EMTALA says.
• 26:20
  Speaker 3: We'll see what the next four years brings, because like I don't know.
• 26:23
  Speaker 1: that seems like something that could that some people would be like, well, let's just get rid of that, then it's problem solved.
• 26:38
  Speaker 3: I mean, that is the you're right, though.
• 26:39
  Speaker 3: That is the legal safety net that mandates that emergency medicine physicians provide care to everyone who comes through the door.
• 26:42
  Speaker 3: If you got rid of that, that would be a problem.
• 26:44
  Speaker 1: That would be.
• 26:45
  Speaker 1: That would Are some hospitals.
• 26:46
  Speaker 1: Are they all required, or is it like some hospitals don't have to?
• 26:50
  Speaker 1: I don't know.
• 26:51
  Speaker 1: I was curious about that.
• 26:53
  Speaker 3: Yeah, if you have an emergency department, okay.
• 26:56
  Speaker 3: So if like say you aren't an emergency department, say you're in urgent care, you do not face EMTALA.
• 27:04
  Speaker 3: Um, so under EMTALA certain, yes, any emergency department.
• 27:11
  Speaker 3: Or or, frankly, because it's the emergency medicine treatment and uh, emergency medicine treatment and active labor act, so anyone in active labor, so you have.
• 27:21
  Speaker 3: If you have an obgyn department, if you have a labor and delivery unit in your hospital, they're also beholden to mtala for labor and delivery, even if they say like didn't have an emergency department, it's just a obstetric hospital.
• 27:35
  Speaker 3: Like they're beholden to mALA standards because of the active labor part of the emergency medicine and active labor and so, yeah, I mean it's the same idea with harm reduction principles.
• 27:47
  Speaker 3: Right, we can reach everyone.
• 27:50
  Speaker 3: We can save their lives.
• 27:52
  Speaker 3: We have the tools to do it we can save their lives.
• 28:00
  Speaker 1: We have the tools to do it.
• 28:01
  Speaker 1: We have to have both the political will and which yeah, that's a big hurdle, I guess.
• 28:04
  Speaker 3: It's just yeah it's a huge, huge hurdle.
• 28:06
  Speaker 3: I mean that's that's realistically the biggest hurdle.
• 28:08
  Speaker 3: And then and then the practical implementation of those tools is also difficult.
• 28:15
  Speaker 3: Right On a local level you have to like, find the place that allows you to do that and you have to reach the people you need to reach.
• 28:21
  Speaker 3: And so it's sort of twofold fat or two factors to achieve, to be able to accomplish those goals.
• 28:30
  Speaker 3: But we can get there.
• 28:30
  Speaker 3: We just need the, we need people to believe in it.
• 28:33
  Speaker 1: How do, how do we get there, Like what?
• 28:36
  Speaker 1: You've been doing this for a while.
• 28:37
  Speaker 1: Do you see anything that works better more often?
• 28:42
  Speaker 1: Just like kind of on the person level, like we're talking to people right now, like kind of wondering what, what can, what can we do?
• 28:48
  Speaker 1: Like you know, like a vote, sure, like I get that, but like what is there anything that that we can do individually?
• 28:56
  Speaker 3: like I get that, but like what?
• 28:57
  Speaker 3: Is there anything that that we can do individually?
• 28:58
  Speaker 3: It's a really good and tough question and frankly it requires a lot of people to do a lot of self-reflection.
• 29:02
  Speaker 3: Um, because we can accomplish these hard political things if there's the people power and the individual will to do them right.
• 29:13
  Speaker 3: People politicians are beholden to their constituents.
• 29:16
  Speaker 3: If enough constituents are clamoring for something, then that politician may change their mind.
• 29:22
  Speaker 3: But that requires a lot of people to do a lot of critical self-examination.
• 29:26
  Speaker 3: Right, I did not start in it at so, going to medical school, I was not a believer in in harm reduction, I just I.
• 29:34
  Speaker 3: To medical school, I was not a believer in in harm reduction, I just I, I.
• 29:38
  Speaker 3: I didn't start from that place.
• 29:39
  Speaker 3: I grew up, um, as a person with a father who has alcohol use disorder.
• 29:43
  Speaker 3: Um, I grew up understanding the AA abstinence only sort of mantra, and they're sort of the pseudoscience that guides that threefold model of disease, all of those things.
• 29:58
  Speaker 3: And so I in my mind was like, oh well, abstinence is the only answer and harm reduction isn't helping anyone and you're not really saving lives.
• 30:07
  Speaker 3: And then I finished medical school, I went into, started my emergency medicine residency at UCSF and San Francisco General, where plenty of people were using drugs and seeking care at the only county hospital in San Francisco, which is San Francisco General, and I had to face it head on and say, oh okay, I get it more now.
• 30:30
  Speaker 3: Now I recognize that I am part of a system that is causing harm to people because they're using drugs, and I was recognizing that people were coming in fearful of being stigmatized, of being looked down upon, of being treated poorly, and that they were more often than not.
• 30:48
  Speaker 3: And when you are faced with that reality, when you accept that you are part of a system that is causing harm, the only logical answer to that is to seek to reduce that harm.
• 31:01
  Speaker 3: And so I had to fundamentally confront what I believed, and seeing and trying to understand how and why people were using drugs and what that really looked like in a practical way, like on the street, helped me to understand that I needed to change my perspective, not them.
• 31:23
  Speaker 3: And so that's how I got to this place and then I practiced emergency medicine.
• 31:29
  Speaker 3: I finished residency, I practiced emergency medicine full-time for years and then saw more and more of of the same, saw this as a systemic problem in multiple places where we were taking the wrong approach to this and at that point I was like there's got to be a better way to do this upstream from the problem.
• 31:54
  Speaker 3: Like the emergency department, I wasn't solving people's substance use from there, right.
• 31:59
  Speaker 3: So then it was like this is a larger scale problem that I need to now go upstream and do that work um, outside of the hospital and try to encourage people to one change their own perspective within healthcare which I do when I'm, you know, working and when I speak to other hospital systems and that sort of thing.
• 32:21
  Speaker 3: And then the other part is like getting people into treatment and trying to change their own perspective, because there's so much self-stigma and there's so much shame within recovery communities, and trying to get people to critically examine from even within recovery spaces, within addiction medicine, within you know, people who are in AA and not say, not demonize AA, but to say, hey, we can reflect a little bit more on, like where we're at and how we can help people who are using drugs, alcohol or other drugs.
• 32:57
  Speaker 3: I like to just say drugs, because alcohol is a drug, but people are using all of them, right, and so if, if I can change my perspective, if other people can change their perspectives, we could get to a place where we can advocate more broadly, form that like coalition of people who want to see this change, then you will make that happen.
• 33:19
  Speaker 3: You can get to the point where, like we got to the point where the bill passed both the state legislature or passed through both houses of the state legislature, the assembly and Senate enough people voted for it.
• 33:32
  Speaker 3: Right, we have, there's some political will there.
• 33:34
  Speaker 3: But then you need a coalition of people who will go to governor newsom and say you better not veto this this time, like if he believes that it is more politically viable for him to to sign that bill than to veto it, he will sign it.
• 33:49
  Speaker 3: He knows from, like, doing the political calculus, that that's not going to play throughout the entire state.
• 33:55
  Speaker 3: Right, and so if you get enough people to to advocate then.
• 34:01
  Speaker 1: So then, so we have a solution.
• 34:02
  Speaker 1: Then what you're saying is we just need more people to spend years of their time addressing the problem directly and seeing the flaws in the system that we currently have in order to understand how other maybe things that they didn't believe before might actually be the answer or maybe we just need to have more people emergency residency yeah, yeah yeah, totally it's a, it's a very, very easy solution.
• 34:28
  Speaker 3: No, I mean on a, on a on a practical level though, if we can get people to just understand right, if it's there's inertia in change, if you, if I can change and I can change other people's minds, right, the, the downstream effect, right, say liam say I change your mind and rob, I change your mind.
• 34:49
  Speaker 3: There's two.
• 34:49
  Speaker 3: And then if you both change two people's minds by actually an MLM.
• 34:53
  Speaker 1: We need an MLM.
• 34:54
  Speaker 1: We need a pyramid scheme.
• 34:57
  Speaker 1: We got to get a pyramid scheme of change, people's minds.
• 35:01
  Speaker 1: Maybe we shouldn't market it as that, but like that's good behind the scenes, that's what we're doing.
• 35:06
  Speaker 3: I mean on a certain level, there's a reason those are effective, right, because you're magnifying change rapidly.
• 35:12
  Speaker 3: Because you're magnifying change rapidly, that is a model of change just in a very sort of manipulative way, which isn't the goal, right, we're not trying to manipulate people, but we are trying to change people's minds, and if you can change enough people's minds, then yeah, that is sort of the answer right there, though, like that, if you can spread that message and you can change enough minds, then you can achieve that.
• 35:42
  Speaker 3: And not everybody's gonna go through the same process or go about it the same way, but people will get there.
• 35:49
  Speaker 3: It's just some people.
• 35:51
  Speaker 3: It may take time.
• 35:52
  Speaker 3: Some people may take more like direct experience where they're confronted with it.
• 35:56
  Speaker 3: That's how, like deeply sort of entrenched, my own bias was that it took years of being exposed to reverse that.
• 36:03
  Speaker 3: I don't believe that's true for everybody, and I think we as a society are starting to do better at bringing people to at least a different starting point than where I was at, I hope, at bringing people to at least a different starting point than where I was at, I hope, and we can change minds Now.
• 36:18
  Speaker 3: That isn't the only option, like an MLM isn't the only option.
• 36:23
  Speaker 1: What do you mean?
• 36:24
  Speaker 1: An MLM isn't the only option.
• 36:25
  Speaker 2: It's not the only option, it's just the best option.
• 36:28
  Speaker 1: I was told we need to make a pyramid scheme and I was all in.
• 36:31
  Speaker 3: I mean Liam.
• 36:32
  Speaker 3: If you want to talk about creating one, I'm all ears.
• 36:34
  Speaker 3: I was all in.
• 36:34
  Speaker 3: I mean Liam, if you want to talk about creating one, you know I'm all.
• 36:36
  Speaker 3: I'm all ears, I'm sure there's a model there.
• 36:37
  Speaker 1: I mean, like you said, it works.
• 36:38
  Speaker 1: It works, doesn't it, like you know, and so you harness something that's usually used for evil for good, and that's your powers for good.
• 36:47
  Speaker 3: Exactly, use your powers for good.
• 36:50
  Speaker 3: That's the answer.
• 36:52
  Speaker 1: Can we?
• 36:52
  Speaker 1: Say pyramid scheme for good.
• 36:56
  Speaker 2: Like pyramid scheme for good, like, yeah, sure, we.
• 36:57
  Speaker 2: I think we need to put it like at forefront.
• 36:58
  Speaker 2: We just need to replace the scheme like pyramid something else.
• 37:00
  Speaker 2: No, I think it's kind of evil?
• 37:01
  Speaker 1: no, but people want to be part of a scheme like I think, people like being part of a scheme, like people want to be like on the end of something.
• 37:08
  Speaker 1: You know what I'm saying?
• 37:08
  Speaker 1: Like wait, what is the scheme?
• 37:09
  Speaker 1: Why would I want to be part of that?
• 37:10
  Speaker 1: Okay, here's what we're doing.
• 37:11
  Speaker 1: Actually, that sounds pretty cool.
• 37:13
  Speaker 1: I'm just saying like listen, I, we do social media right.
• 37:16
  Speaker 1: I know, like short form social media, like the first three seconds are the most important of anything.
• 37:21
  Speaker 1: Right, you just got to hook people in, all right, so like pyramid scheme that hooks people in right away, and then we start talking about, like how we're actually trying to help people who are dealing with addiction.
• 37:31
  Speaker 3: You, can call it pyramid scheme for good, like that could just be the name.
• 37:34
  Speaker 1: Yeah, like I, social media messaging fg like pyramid scheme for good, like I don't know, we'll act, we'll acrimonize it.
• 37:42
  Speaker 1: You know I I was just saying it's.
• 37:43
  Speaker 1: It's maybe not the best option, but it's an option.
• 37:46
  Speaker 1: That's all I'm saying.
• 37:47
  Speaker 1: I mean the whole thing with like I will say like the whole thing with like drugs.
• 37:50
  Speaker 1: I've always found it really interesting, especially like looking at other countries and like the completely different ways they'll go about it.
• 37:57
  Speaker 1: Like I don't, I don't know all the ins and outs of everything, like I know just stuff to be dangerous, all this stuff.
• 38:01
  Speaker 1: But like you, look at one place like the philippines which is like basically just anyone who's seen a drug is murdered, like they, they, they have the harshest laws of like anything right, like I'm sure you've probably seen some of this stuff right, like um, and then on the on, yeah, on the flip side, you have portugal, who?
• 38:19
  Speaker 1: I was just gonna say like actually portugal and I've seen like switzerland even have done like, not made drugs legal, but they've decriminalized drugs right and so they've made it.
• 38:29
  Speaker 1: So, like you, it's easier to seek treatment.
• 38:32
  Speaker 1: It's more see it's.
• 38:33
  Speaker 1: It's seen more right as like as a medical issue, right, so that that needs to be treated, than it is a crime that we have to lock you in prison for many years for Correct In.
• 38:44
  Speaker 3: Portugal.
• 38:44
  Speaker 3: So Portugal put their entire sort of money and effort behind this idea that decriminalization could work in hand in hand with, rob, like you mentioned, the idea of improving access to treatment and that if people come and you give them a safe space, they may want to pursue treatment and you need to have the availability there.
• 39:06
  Speaker 3: And so I know when I talk about Portugal and that they dramatically rate they spent about 20 years doing this.
• 39:14
  Speaker 3: I think now they've cut overdose deaths down to essentially like negligible compared to our over 100,000 for a couple of years.
• 39:24
  Speaker 3: Yeah, the people will potentially point to Oregon, and Oregon decriminalized small dose possession of all drugs for a brief period over the last couple of years, but they didn't put the money and the sort of enforcement ability to create all the treatment spaces and the bed availability and all that to low barrier treatment which is kind of necessary.
• 39:53
  Speaker 3: That's the key part, and so they, they people will say it failed because they repealed it after a couple of years, two or three, because they're like oh, there's public drug use has gotten way up and now the police say they can't do anything about it.
• 40:06
  Speaker 3: Blah, blah, blah, well, people can't access treatment.
• 40:09
  Speaker 3: It blah, blah, blah, well, people can't access treatment.
• 40:11
  Speaker 3: Then, like, what good are you doing?
• 40:13
  Speaker 3: If you are just like oh, yeah, sure, anybody can use drugs anywhere and it's legal.
• 40:19
  Speaker 3: Well, it's decriminalized, so it's not illegal, we're not going to necessarily take them to jail for it, but you like, well, you can't help.
• 40:26
  Speaker 3: Then what are you then?
• 40:28
  Speaker 3: What are you doing?
• 40:28
  Speaker 3: Right?
• 40:29
  Speaker 3: So the difference between Portugal and Oregon was that Portugal, like, invested heavily in this idea and it worked.
• 40:38
  Speaker 3: And if you don't invest heavily and that may be part of the political will problem is, people want to take that half measure.
• 40:45
  Speaker 3: They want to say, well, it's decriminalized, at least, but they don't put any money into it.
• 40:51
  Speaker 3: Then that's because we see, these people as criminals already.
• 40:55
  Speaker 1: So you know, it's basically like hey, let's spend a bunch of money to help people that you've already othered.
• 41:00
  Speaker 1: Yeah, you know that's a hard sell.
• 41:02
  Speaker 1: That's like you know.
• 41:04
  Speaker 1: You know selling whatever I don't know, one of those analogies You're selling the sand to someone in a desert, whatever I don't find.
• 41:11
  Speaker 1: I don't do analogies, I don't know.
• 41:13
  Speaker 1: But like I don't feel, like it's not gonna go super well, right, like that's all, that's hard that's hard and and that is part of the political problem is you.
• 41:24
  Speaker 3: You have to be able to overcome that and that is as much more complex or political answer than than just just like hey.
• 41:32
  Speaker 3: We need to help decrease stigma for towards people who use drugs and help support the political will towards allowing things like overdose prevention sites.
• 41:44
  Speaker 3: We could do that we could do that and that could still work without sort of decriminalizing everything and then requiring treatment beds and all that.
• 41:54
  Speaker 3: Uh, that would be sort of another layer to that, that piece of the puzzle.
• 41:59
  Speaker 3: Um, but I think we can get there, we.
• 42:04
  Speaker 3: We just have to, we have to start somewhere.
• 42:06
  Speaker 1: Right, I was just gonna say, like I think the way, maybe one of the one of the ways to try, besides a pyramid scheme, is to try and tell people like the situation we have now is, but like it's not good, like we have we, our system is literally set up to cost basically the most amount of money where people have to go to the emergency room and that's incredibly expensive.
• 42:28
  Speaker 1: And we're constantly talking about how much we spend on, you know, medicine in general.
• 42:32
  Speaker 1: Right, like, because we do, we spend like a crazy amount.
• 42:34
  Speaker 1: This isn't the only reason, but it's just not not helping.
• 42:37
  Speaker 1: So, like I, I feel like maybe one of the best ways to go about it's just like hey, this is what we have right now and it's terrible.
• 42:43
  Speaker 1: So, like, would you be willing to try something else that would maybe also save money, because you like that sound?
• 42:51
  Speaker 3: probably, yeah I mean, and that's the thing, they will save money and they like you can save money, you can save lives and you can take people away from using in public.
• 43:03
  Speaker 3: Like that.
• 43:04
  Speaker 3: It seems like a win, win win yeah you have to say doing drugs is okay.
• 43:10
  Speaker 1: I feel like that's the one that it's like for some people.
• 43:12
  Speaker 1: There's like they're never thought the war on drugs has gotten too deep into their skull, or just like.
• 43:18
  Speaker 2: Just say no, like reagan said, and then it's not a problem well, another thing we need to do is rehumanize these people that are yeah and like that's not going to work for the people who are far right and they only care about the money.
• 43:31
  Speaker 2: But I mean, like it was mentioned earlier, we get them with the money, Like just those people.
• 43:37
  Speaker 1: we just focus on the money, but everybody else we try to humanize.
• 43:39
  Speaker 2: There we go.
• 43:40
  Speaker 2: It was mentioned earlier that these people, a lot of them, are probably going through stressful times and stuff.
• 43:55
  Speaker 3: And the more you beat them down, the more that they are going to withdraw from society and rely on drugs to get by.
• 43:57
  Speaker 3: I use the term.
• 43:58
  Speaker 3: You know people use drugs to save their life, right, like.
• 44:01
  Speaker 3: Ask a person who uses drugs why they use drugs and you will hear many people say drugs saved my life for a variety of reasons.
• 44:12
  Speaker 3: But if you are in a situation that is deeply uncomfortable, traumatic, stressful, what have you just?
• 44:21
  Speaker 3: Like you said, rob, like people are going to use drugs as a means of escape, as a means of finding some level of whether it's tuning out or finding some level of joy, whatever it might be that like saves their life, that prevents them from dying or dying by suicide or whatever it may be.
• 44:44
  Speaker 3: When you have people say drugs saved my life, like, it's hard to look away from that and say but we should never allow people to use them I find it interesting you say I used to say, like you said, die by suicide.
• 44:57
  Speaker 1: I feel like that's it's a change that I actually do, like I try and say, instead of saying committed suicide, as everybody says, because when you commit something, generally you commit, you know, arson, burglary, a crime, whereas like did you really you took your own life, is that we, we criminalize even the act of taking your own life.
• 45:14
  Speaker 1: That seems, boy, that seems real rough, like so you die by suicide.
• 45:18
  Speaker 1: So I think it is a nice thing if people could start saying that in the future.
• 45:23
  Speaker 3: But like, still, sometimes I'll catch myself saying it because it's just so ingrained in us, you know absolutely, and, and, and it speaks to the whole point about humanizing, right, you're just like trying to humanize people's lived experiences of whatever they are experiencing, um, and, and sometimes it's, you know, deeply difficult, and it's okay that we reconcile that with the ability of drugs to create opportunities for people to continue living, um, and, and that is okay right like, like.
• 45:56
  Speaker 1: I think we collectively agree that people continuing to live is generally a good for the most part, I feel like we can come together on a few things and be like you know less people dying.
• 46:08
  Speaker 1: Can we all give a thumbs up?
• 46:10
  Speaker 1: What do we do?
• 46:11
  Speaker 1: How do we feel about this?
• 46:13
  Speaker 1: I would hope most people would be on board.
• 46:16
  Speaker 2: I imagine another potential benefit to these harm reduction sites is just the ability for, or the potential for people to find others in similar situations and feel less alone.
• 46:32
  Speaker 3: Yeah, absolutely.
• 46:33
  Speaker 3: Drug use and substance use disorders in general are surrounded with shame and stigma and internalizing social stigma, and so people often end up in situations where they're using alone, they're using in isolation, they don't understand that there are other people in the same place where they are and finding that community can be incredibly.
• 46:55
  Speaker 3: I mean not only can be an incredible relief, but is incredibly important to them being able to form a self identity, to be able to move forward, regardless of whether they want to be, you know, become abstinent in their you know, in their like recovery process, or if they want to be, you know, become abstinent in their you know, in their like recovery process, or if they're just like oh man, this is getting out of hand and I need somebody to hold me accountable, to moderate my use, or whatever it may be.
• 47:20
  Speaker 3: That is incredibly helpful.
• 47:23
  Speaker 3: I mean just community building in general.
• 47:24
  Speaker 3: We are social beings, right Like that's useful for any of us but that.
• 47:29
  Speaker 3: But I think that is a specific thing.
• 47:31
  Speaker 1: That is like isolated right and stigmatized what you said, though, like really gets to the heart of the issue.
• 47:36
  Speaker 1: We with the drugs are an escapism, you know, like there's the the people have are dealing with their lives and things are shitty, and you know you turn to drugs.
• 47:47
  Speaker 1: It makes sense, right, like that's what humans have been doing, that since we've had drugs.
• 47:50
  Speaker 1: Right, like we've, like you said, you've been doing drugs since we've discovered drugs.
• 47:54
  Speaker 1: Like you know, we find, oh, this frog, if I lick it, if things go weird, then I'm gonna keep doing that.
• 47:59
  Speaker 1: Like it's kind of tough to just be like, ah, don't do that.
• 48:12
  Speaker 1: So, like I think you know, just overall, just trying to improve people's lives.
• 48:14
  Speaker 1: You know it's got to be like one of the answers there.
• 48:15
  Speaker 1: And like you know you look at any like drug treatment facility, center, rehab, whatever it is.
• 48:18
  Speaker 1: They try, and you know, show the people dealing with addiction like other things, right, like there's just like, hey, what there's, there's this and that and there's other reasons, and you know that's, I mean, that's when you're fighting.
• 48:31
  Speaker 1: You know heroin, that's gotta be really hard, man, I should for anybody dealing with addiction.
• 48:34
  Speaker 1: I'm so sorry, like that just has to be.
• 48:36
  Speaker 1: So the absolute, fucking terrible.
• 48:38
  Speaker 1: I'm just going off on a tangent here, but it's you know, just basically yeah, we're trying to improve people's lives.
• 48:44
  Speaker 1: I feel like it's one of the best things you can do certainly and certainly a worthwhile goal, in my opinion you know.
• 48:51
  Speaker 1: But then it gets into the like okay, how do we do that, this and that like you know?
• 48:54
  Speaker 1: That's you know when you're looking more for like, what can we do in the you know right now?
• 48:59
  Speaker 1: I think you know, like you said, creating these places people can go that are safe seems to be one of the better things we can do, as opposed to, you know, again, having a terrible system that we have now.
• 49:10
  Speaker 3: That it's just, it's awful yeah, it's tough, but I appreciate you guys having me on to to talk about this.
• 49:18
  Speaker 3: I mean that is one of the answers.
• 49:20
  Speaker 3: Right is like trying to spread this idea.
• 49:23
  Speaker 3: It's the, it's the mlm.
• 49:24
  Speaker 3: Uh, if you will, I still listen, I like the pure.
• 49:30
  Speaker 1: Why don't?
• 49:30
  Speaker 1: We could also call it a cult.
• 49:31
  Speaker 1: It's a cult we're trying to get people into and then people are very confused and they find out why and they're happy.
• 49:39
  Speaker 1: Then they're like, yes, less you know, less, less deaths from drugs, that's good.
• 49:44
  Speaker 1: I like that.
• 49:45
  Speaker 1: I'm part of this pyramid scheme.
• 49:46
  Speaker 1: Now I'm just saying it's not the worst idea.
• 49:48
  Speaker 1: It's not the worst idea, oh shit.
• 49:51
  Speaker 1: Well, I mean also, I guess like, do you have any?
• 49:54
  Speaker 1: We?
• 49:54
  Speaker 1: But here we talk a lot about nutrition.
• 49:56
  Speaker 1: Do you have anything to mention about, like, drugs and nutrition?
• 49:59
  Speaker 3: here I need a combination I think nutrition in in addiction context is really interesting.
• 50:06
  Speaker 3: Framing um, speaking of sort of how nutrition relates, there are things that also leverage the same things that cause addiction to drugs, that cause addiction to food, right, like food can be an escape, it can be pleasurable, it drives dopamine release.
• 50:24
  Speaker 3: People can use food in a way that helps them with that escape and release, and so people can develop sort of eating disorders or disordered thinking around food, the same way that they develop substance use disorders, disordered use of drugs, right.
• 50:44
  Speaker 3: So it's something to think about and be mindful of as we seek to approach addictions is like food can be used as an addiction.
• 50:55
  Speaker 3: Food can be addictive in that sense.
• 50:58
  Speaker 3: And so I don't and I use that word a little bit cautiously because I don't I don't think like drugs themselves are the addiction forming problem.
• 51:07
  Speaker 3: Like the vast, vast, vast majority of people who use drugs don't develop an addiction Um, same thing is true with food.
• 51:15
  Speaker 3: So it's not the like substance itself, it's the way that it's used, it's the context with the you know I.
• 51:21
  Speaker 3: So substance use disorders form in people in sort of like a three fold um model.
• 51:30
  Speaker 3: I guess you'd say like there are three factors.
• 51:31
  Speaker 3: It would be like.
• 51:33
  Speaker 3: We know there's some genetic component that people are more predisposed to develop addictions or substance use disorders.
• 51:41
  Speaker 3: They have to have an environment that creates the necessary circumstances where that drug becomes that creates that positive feedback.
• 51:50
  Speaker 3: Circumstances where that drug becomes that creates that positive feedback.
• 51:54
  Speaker 3: And then you have to have the exposure.
• 51:54
  Speaker 3: And so, even though I am generally on the side of like reducing harm, I'm not on the side of like let's make everything legal and increase exposure.
• 52:02
  Speaker 3: I'm okay with providing people informed consent and putting warning labels on things and like telling people that smoking can kill them.
• 52:09
  Speaker 3: Like people are like, oh, but what about you know?
• 52:11
  Speaker 3: Like, isn't that part of?
• 52:13
  Speaker 3: Like harm reduction is like just letting people use drugs?
• 52:15
  Speaker 3: It's like, well, I mean, yes, in so far as we should provide people help where and when they need it, the way they want help.
• 52:24
  Speaker 3: But we know that if the later, the more people delay their exposure to drugs, the less likely they are to develop substance use disorder.
• 52:32
  Speaker 3: So the same thing is true with food.
• 52:36
  Speaker 3: Right, Like all of those things, from a nutritional standpoint that matters, we should be thinking about how we label food, how we approach food, how we allow people to be exposed to it.
• 52:48
  Speaker 3: Because I'm sure, if you broke it down and I'm not like an expert on the on the, you know, nutrition side, I'm not like a dietician, but like I'm sure there are other ways to approach exposure, in the same way that we approach exposure to drugs and and and yes, I'm all for the ideas of like, if something is found to truly be harmful or have potential negative consequences, we should label that, we should provide warnings for that, we can ban things.
• 53:17
  Speaker 3: I'm okay with all those things.
• 53:18
  Speaker 3: But to try to reduce people's consumption of harmful things.
• 53:22
  Speaker 3: I think, like in Rob, to your point also about community, like there are community support groups for these things.
• 53:29
  Speaker 3: Right, Forming community and recognizing that you're not alone in your own, like food addiction, is also valuable in terms of forming that self-identity and decreasing the self-shame and stigma.
• 53:40
  Speaker 3: All of that, all of that is important, and so we can view them sort of through the same lens.
• 53:46
  Speaker 3: Like food is not inherently bad but it can be used in harmful ways, drugs are not inherently bad, but it can be used in harmful ways.
• 53:53
  Speaker 3: Drugs are not inherently bad, but they can be used in harmful ways and they can lead people to dying.
• 53:57
  Speaker 3: Just like food can lead people to die, like poor nutrition can lead to bad outcomes, drugs can lead to bad outcomes.
• 54:03
  Speaker 3: We can recognize those things but also, try to, like improve the lives of the people who use them In moderation.
• 54:11
  Speaker 2: Brad Bobby Reduction Center coming soon to a city near you.
• 54:12
  Speaker 2: Reduction Center to like improve the lives of the people who use them in moderation.
• 54:12
  Speaker 2: Brand bobby reduction center coming soon to a city near you reduction set.
• 54:16
  Speaker 1: I think we have to spend our money a little more wisely.
• 54:18
  Speaker 1: But like we'll throw it on the list, um, that's how successful that mlm is.
• 54:22
  Speaker 1: Yeah yeah, and that's the thing you know with people, with food, you know you're surrounded by food all the time, like you need to eat, you need food.
• 54:29
  Speaker 1: So when you have it around you, you know you always have that exposure right to it which, yeah, for a lot of people can be really difficult.
• 54:36
  Speaker 2: Yeah, absolutely so.
• 54:39
  Speaker 2: If we have somebody in our lives that could use going to a harm reduction center or something, yeah, what would be a good way to approach that to get them?
• 54:51
  Speaker 3: That's a great question.
• 54:52
  Speaker 3: So one thing I will say to start is, like I generally think of interventions in the context that like the sort of classical context that we think of as interventions like sit down and everybody's going to like basically shame this person, tell them how bad they are and they need to seek help, as inherently problematic.
• 55:12
  Speaker 3: Are there ways to do that more ethically?
• 55:15
  Speaker 3: Sure, um, but I think you can just approach the conversation and say hey, here's an issue that I see, right, um, I've seen that you struggled with food.
• 55:28
  Speaker 3: I've seen that you struggled with your heroin use getting out of control.
• 55:32
  Speaker 3: Are you interested in talking about that?
• 55:33
  Speaker 3: And if they're like, yeah, I know I'm really having a problem then you can say hey, like, would you be open?
• 55:40
  Speaker 3: I know that there's a place that it's not going to shame you or stigmatize you about your use, but they'll be willing to talk to you about this.
• 55:49
  Speaker 3: They're they might be better than me at having this conversation about how we can go about helping you in terms of your use so that it's not out of control, so that your life doesn't feel out of control.
• 56:01
  Speaker 3: I think driving like isolating them more and shaming them more is just going to be more problematic and they're going to reflexively basically want to tell you to f off and and like I can do it myself or whatever it is, or I don't want to do it your way because, like you're making me feel ashamed, you're making you're an asshole, yeah, um, and so if you can approach it just from like a friendly, like hey, I want to help, tell me if you want help and if and they may say no and then you just kind of like beat that drum a little bit, say like I'm, or even offer like hey, you know, I took another friend to this place and like they seem like they really have these conversations well, or whatever you want, however, you want to approach it, but like not a confrontational way, right, um, I like to think about those sorts of things in the like, like I I I'm not a person with a substance use disorder but like I have a problem with using my phone too much and using social media too much, and I've had to have conversations about, like you know, like with my wife, like hey, um, I like this is a time that, like I need you to really like not use your phone.
• 57:23
  Speaker 1: It's like okay.
• 57:23
  Speaker 3: If that was presented in like a super confrontational way, like hey, you're a dick, um, and you're ignoring me or whatever.
• 57:29
  Speaker 3: Like I'm not going to respond to that, well, um, but just approaching it from like hey, this is a thing that I think is an issue right now and we can talk about it more later if you want.
• 57:40
  Speaker 3: But, like, I would like to see this happen this way because of and frame it in the context of like this is how I feel about it, not about them, not about like hey, not, I feel like your life is out of control, but like I feel like I've seen this happen to you and I want to help.
• 57:57
  Speaker 3: Can I can't, like can you allow me to have a conversation with you about that?
• 58:02
  Speaker 2: so not last semi-charmed life and then be like hey, speaking of drugs for those of you who don't realize it yet, uh, semi-charmed life is about doing crystal meth yeah you go back and listen to that song, you're like, holy shit.
• 58:18
  Speaker 1: I listened to this when I was younger and I was just like singing along with the lyrics.
• 58:21
  Speaker 1: But now, god damn, what is this?
• 58:23
  Speaker 1: Was this lyrics always like this?
• 58:25
  Speaker 1: Yeah, yeah, everybody after this episode is gonna go listen to semi-charmed life.
• 58:30
  Speaker 2: Yeah, huge spike in listeners.
• 58:32
  Speaker 1: I know Spotify it's a bunch of listeners Well, is there anything else you want to touch on that we didn't mention, or anything that you want to get across to people?
• 58:41
  Speaker 3: Uh, if you're interested in this kind of discussion, um, I host a podcast with a friend and colleague, um Macaulay Sexton, called Recovery Reform and basically is all about reframing the way we talk about recovery and talking about it in a non-abstinent, non-stigmatizing way and wanting to support people where they are in their journey and recovery.
• 59:07
  Speaker 3: So, yeah, plug that.
• 59:11
  Speaker 1: Where else can people find you Do all the pluggables, all the plugs.
• 59:16
  Speaker 3: I don't use Twitter anymore.
• 59:18
  Speaker 3: I'm on X or not on X?
• 59:21
  Speaker 3: I'm off of X.
• 59:22
  Speaker 1: I'm not on Twitter.
• 59:22
  Speaker 1: Elon Musk is happy that you called it X.
• 59:25
  Speaker 3: I'm on Blue Sky and my profile is tnicholsmcom.
• 59:30
  Speaker 3: Um, I don't know.
• 59:33
  Speaker 3: That's pretty much it.
• 59:34
  Speaker 3: I stopped using social media.
• 59:36
  Speaker 1: In general, I get it, oh yeah.
• 59:39
  Speaker 3: Yeah, it's a.
• 59:39
  Speaker 3: It's not great right now, anyways.
• 59:42
  Speaker 1: Uh yeah.
• 59:42
  Speaker 1: Well, don't worry, the next four years will be a lot better.
• 59:44
  Speaker 1: It's fine.
• 59:48
  Speaker 3: Thank you guys.
• 59:48
  Speaker 3: I appreciate you.
• 59:49
  Speaker 3: Thank you for having me and, yeah, I look forward to more of these conversations.
• 59:54
  Speaker 2: And I look forward to us organizing our MLM.
• 59:58
  Speaker 1: MLM.
• 59:58
  Speaker 1: I want pyramid scheme.
• 59:59
  Speaker 1: I want to have a pyramid scheme.