What Happens to Patients After the Prescription Runs Out | The Saving Dose Ep. 05

In the fifth episode of The Saving Dose, Dr. John Hsu and William Pedranti go inside opioid use disorder from the ground up: what it actually is, what causes it, why the people most affected by it are being failed by a system that was never designed to treat a chronic disease like a chronic disease, and why the gap between the medications that work and the patients who receive them keeps growing.

The episode opens with William's recent trip to Washington D.C., where he met with members of Congress from both sides of the aisle and visited the White House to discuss the opioid crisis facing America's veterans. What he found: unanimous agreement that the crisis is real, and a treatment infrastructure that cannot come close to meeting the need. 418,000 veterans are living with opioid use disorder. Only 6,500 are currently being treated. 44 die every day from suicide and opioid overdose.

This episode covers why opioid use disorder is a chronic medical condition and not a willpower problem, what the science actually says about brain chemistry versus environment, and why treating the addiction without treating the whole person produces a predictable failure rate that the system keeps misreading as patient noncompliance.

In this episode:

What opioid use disorder actually is clinically, why it is not the same as opioid dependency, and why the healthcare system keeps confusing the two in ways that cost lives.

Why 50 to 80% of patients with OUD also carry a co-occurring psychiatric diagnosis including depression, anxiety, PTSD, or ADHD, and what happens when clinicians treat the addiction without addressing what drove the person to opioids in the first place.

The Vietnam veteran study: why 80 to 90% of soldiers who were addicted to heroin stopped using when they returned to a changed environment, what that tells us about the role of circumstance in addiction, and why it does not mean addiction is just a choice.

Adverse childhood experiences: why a history of four or more ACEs raises the risk of developing opioid use disorder fourfold, and why that number matters for how treatment should be designed.

Why only 4 to 6% of people who misuse prescription opioids ever progress to illicit heroin or fentanyl, and what that means for the prescribing policy decisions that have left millions of chronic pain patients undertreated.

The prescription cliff: what happens when a patient leaves the pharmacy and why, in John's words, remote medication adherence monitoring stops at the patient's front door.

Why the medications work, why the stigma around them is wrong, and why a patient on Suboxone or methadone still has every right to receive opioids for acute or chronic pain.

Why opioid use disorder has to be treated like what it is: a chronic medical condition that requires sustained management, not a thirty-day program and a handshake at discharge.

William's story about a friend's brother who, after thirty years of managing addiction as a chronic disease, voluntarily checked himself back into residential treatment before relapse rather than after.

About the Hosts

John Hsu, MD is the Founder and CEO of iPill and a practicing anesthesiologist with 25 years in pain management and addiction medicine. He has taken multiple products through FDA approval and commercial launch. Connect with John: https://www.linkedin.com/in/john-hsu-md-300a8b2a/

William Pedranti is the COO of iPill, a Georgetown Law graduate, and co-founder of PENG Life Science Ventures. He has taken a biotech company from founding through FDA approval, commercial launch, and exit. Connect with William: https://www.linkedin.com/in/williampedranti/

Kendra Allen is the CRO of iPill with 20 years in behavioral health revenue strategy, payer contracting, and regulatory navigation. She founded and exited a national healthcare consulting firm. Connect with Kendra: https://www.linkedin.com/in/kendra-allen-cro/

Website: thesavingdose.com

This podcast is for educational purposes only and does not constitute medical advice. Consult a qualified healthcare professional before making any treatment decisions.

#OpioidCrisis #AddictionRecovery #OpioidUseDisorder #MOUD #MedicationAdherence #BehavioralHealth #AddictionMedicine #VeteransMentalHealth #OpioidTreatment #SubstanceUseDisorder #HealthcarePodcast #TheSavingDose #ChronicDisease #PTSD #PublicHealth #MentalHealth #DrugPolicy #OpioidEpidemic #VeteransHealth

Transcript

SPEAKER_00 0:00

There's 418,000 veterans with opioid use disorder, and there's only 208 clinics that are treating these patients. And they're able to treat about 6,500 patients. So that leaves a lot of patients without treatment. And when you don't treat patients, they tend to want to uh self-medicate. And when they self-medicate or can't get the right medications, you know, there is a problem there because 44 veterans die a day from suicide and opioid overdoses. In fact, one of the biggest, most saddest situations is that some of these veterans can't get treatment. So they go to a VA parking lot and they commit suicide.

SPEAKER_01 1:08

All things addiction recovery. So whether you're a patient or a caregiver or a nurse or a doctor or a facility owner or someone who just cares deeply about addiction and the crisis we're facing in the United States, this is the podcast for you. Very excited. Thank you so much for having us here today. My name is William Pedranti. I'm one of the co-hosts here at the Saving Dough Podcast. I've got a fellow co-host, Dr. John Sue, here with me today. John, how are you doing today? I'm pretty good. Well, how are you? I'm doing great, great. It's just I'm very excited to be here with you today. Unfortunately, Kendra Allen, our other co-host, couldn't make it here tonight. But John and I have a great, great topic for you. So I'm glad you're tuning in. And that's really discussing, in particular, opioid use disorder, or as we'll refer to it today as OUD, and what causes it and what are treatments for it. So really hoping that you can learn a lot today about this condition and how doctors today are trying to tackle it. And I tell you, uh, John, before we dive into some questions on OUD, I want to tell you a little bit about my recent trip this past week to Washington, D.C. I had the pleasure to fly back there to meet with representatives on the Hill from both sides of the aisle, both Democrats and Republicans, focusing in particular on the House this time to talk about the crisis facing our veterans' community and opioid use disorder. And I tell you, it's challenging to learn about just how many of our veterans, unfortunately, are suffering from opioid use disorder. But I tell you, meeting with members on the Hill, and I got a chance, a unique opportunity I'll talk about later, about visiting with somebody from the administration, the White House as well, about how we can help support veterans who are struggling with opioid use disorder. And it's amazing that walking in there, it doesn't matter whether you're talking to a Republican or Democrat. It doesn't matter you're talking to somebody that represents a rural community or an urban area. They all understand this is a massive crisis we're facing, and our veterans are really suffering. And so got a very positive response when I'm talking about how we can try to help use technology to try to tackle this issue with our veterans' community. So tremendous support on the hill, which is great to see, but a lot of work to done, to be done. And I know you've had experience and knowledge and understanding what's going on with our veterans' community. So I just wanted to get your thoughts about what you see in this impact of opioid use disorder on our veterans' community.

SPEAKER_00 3:57

Wow, that's uh that's a really difficult subject to uh to go through because you know these uh these veterans, these American veterans, men and women, you know, they put their lives on the line for us. And, you know, they come back and if they're injured, uh they need to be treated for pain because PTSD, depression, anxiety, um it's really uh one of the cofactors or comorbid conditions that causes opioid use disorder. You know, and it's a very difficult situation because there's a lot of veterans with opioid use disorder. In one of the papers that uh the VA has put out, there's 418,000 veterans with opioid use disorder, and there's only 208 clinics that are treating these patients, and they're able to treat about 6,500 patients. So that leaves a lot of patients without treatment. And when you don't treat patients, they tend to want to uh self-medicate. And when they self-medicate or can't get the right medications, you know, there is a problem there because 44 veterans die a day from suicide and opioid overdoses. In fact, one of the biggest, most saddest situations is that some of these veterans can't get treatment. So they go to a VA parking lot and they commit suicide in order to try to send a message to the VA administration to try to get more treatment opportunities for veterans. And it's really hard because many of these veterans live in rural areas. They're two hours by bus to a clinic for uh the VA to treat opioid use disorder or to treat pain or anxiety or PTSD. So, you know, I really feel for these patients because they're putting their they put their lives on the line for us. And I really want to do something to give back to them.

SPEAKER_01 6:04

Yeah, thank you, John. That's just those numbers you cited, the statistics, the number of veterans suffering from opioid use disorder, and the number that are committing suicide or overdosing on a daily basis is absolutely tragic and astounding. And certainly leads uh that we there's a lot more we need to do. And so I'm looking forward on a future episode. I know the two of us discussed. I'd love to bring members of Congress on our podcast to talk about what we can do to support veterans. I'd love to get individuals from the Veterans Administration to come onto our podcast to talk about what we can do to support veterans. So, and that's a nice uh segue into our topic today. Again, the the topic of the episode today is opioid use disorder or OUD, as we'll talk about it here, and what that is, what's the root causes for it, why it's happening, and what we can do to try to tackle it. So, thank you. Let's dive right in. I'm I'm really excited about what we're gonna talk about here today. So, Dr. Sue, tell us a little about, first of all, maybe just for our some of our listeners who may not be familiar exactly, how do you define opioid use disorder? What does that look like?

SPEAKER_00 7:11

Well, the diagnosis is, you know, classically it's called a opioid use disorder. It's a clinical determination that an individual has a problematic pattern of opioid use causing significant distress, distress, or impairment. And it in, you know, opioids can include drugs like heroin, synthetic opioids like fentanyl, and prescription painkillers like oxycontin or morphine or hydromorphone is uh uh as well.

SPEAKER_01 7:45

Yeah. So when somebody gets opioid use disorder, right? And so somebody is um and and is addicted to, or and and what does that look like from a patient? I you I said addicted to, but what does that actually look like? When somebody has an opioid use disorder, how does that present it to you, John? Is it somebody that's taking too many opioids? It's somebody that that can't stop taking them. I mean, what does that exactly look like? And or maybe it presents on a spectrum uh of what it looks like when somebody has an opioid use disorder.

SPEAKER_00 8:18

Well, it starts from the person themselves. Usually there's something that's happened in their lives where um it's called adverse uh child events, uh ACE for short. Um, they've had something in their childhood that causes them to have uh trauma. And that leads to depression and anxiety, and with uh what uh some of the veterans have gone through in getting injured or in the war in different wars, they end up with PTSD. And in those patients, many of those patients have continued pain, and they're really seeking relief of pain. And when they don't get treated, they have they have this unire to just try to get something to relieve their symptoms, and that's when they start to go to opioids, because you know, doctors prescribe opioids because they think that's the best drug to treat a lot of the depression and anxiety and PTSD that these patients have. 50 to 80 percent of these patients have a psychiatric comorbidity, like I just described and listed. And if they aren't treated, they want to go to opioids to really try to find some sort of relief. And when I prescribe opioids, they take the opioids more than I prescribe. And then the next thing that happens is that's all they think about. They they have opioid cravings because they don't feel good. There's a brain change, there's an environment change, their environment's not very conducive to getting treatment, and they just uh become unhappy. And really unhappy patients, they they begin to try to use opioids to make them feel better. There's a dopamine response, meaning that uh they they have anxiety, they have depression, and they they want, they become so desperate to try to heal themselves with opioids that they that's all they do. They they they they don't think about work, they lose their family, they lose their job, and all they want to do is feel better, and the only thing that makes them feel better is opioids at that time.

SPEAKER_01 10:45

Wow, God, there's a lot of really good stuff in there, John, that I want to focus on and ask to follow up on. One of the things that you mentioned was the cobormidity that the situation where most of these patients, sounds like almost all of them, also have a co-occurring psychiatric diagnosis, depression, PTSD anxiety, ADHE. So that is that right? Are you seeing almost a correlation between somebody that's got opioid use disorder and is also dealing with a psychiatric diagnosis?

SPEAKER_00 11:16

Yeah, 50 to 80 percent, like I said, have some sort of diagnosis of you know depression or anxiety or or ADHD. I mean, if you look at, if you split it apart, you know, I mean, these numbers are they they roll in my head. It's it's so it's so distressing. 36% have depression, 30% have anxiety, 18% have PTSD, 20% have ADHD, and it's the same. And it goes across political lines: Democrat, Republican, men, it's male, females, young, old, it really crosses the whole spectrum. If you're human, you can get opioid use disorder.

SPEAKER_01 12:10

Yeah, gosh, that that's incredible, that correlation. And so if that's a big piece of it, right? Somebody's like you said earlier in your conversation, somebody that's struggling, maybe it's childhood trauma, I know, as you mentioned as one example, or a lost job, or a failed relationship, or a financial situation that they've got stuck in. So they're dealing with something else that's challenging in their life that's causing some of those things that you mentioned, depression and anxiety, PTSD, whatever it happens to be. That is an important piece to note because it I assume that if you only say, hey, I'm here just to treat the opiate use disorder, I'm just trying to target the fact that they got this addiction to opioids, you're missing a key underlying condition that it sounds like you've also got to try to target and treat, to try to help on the addiction side. Is that right?

SPEAKER_00 13:04

That's right. You know, if you're only treating the addiction part of it and you're not treating the person, you really only you can only be successful 50% of the time because as humans, we have a mind and we have a body. The mind is 50% of the body, and the body is 50% of the mind. So if you only treat one part, there's a high rate of failure. If we're only treating uh OUD with medications, the failure rate's fairly high. You know, relapses are fairly high. And if if if you're not treating the whole person, you're not really gearing the chance for a successful treatment. I mean, any patient with uh adverse childhood experiences, they have a they have a four times higher chance of developing an OUD. And if you have four more uh adverse childhood experiences, you have a three times higher chance of opioid misuse. And with all those things being said, you know, uh it you have a history, and the history of in your life can lead you to using opioids so you can relieve some of that pain in your history. You know, most people when they when they take opioids as prescribed, most people don't have a problem. That's why we have uh confusion between opioid dependency and opioid use disorder. Only four to six percent of people who misuse prescription opioids ever progress to illicit heroin or illicit f uh fentanyl. You know, uh it's really quite low, but you know, it's it's important to understand that if you don't treat the underlying cause of opioid use disorder and treat opioid use disorder as a primary problem, a chronic medical condition, you're not really gonna be successful in treatment. It's really a complicated situation. As humans, we're complicated creatures, and you can't just treat one part of it. You have to treat the whole body, the whole person.

SPEAKER_01 15:29

Yeah, gosh, there's some great, really good things you said in there. And I want to pick apart a couple, but I want to reinforce one point, and because the stigma, unfortunately, that exists out there, that people that have opioid use disorder and may be struggling with opioids is the idea, well, they're just an addict and they're weak and they can't control that situation. And I think this is so important what you said, that almost incredible correlation between these underlying other psychiatric conditions, depression, anxiety, PTSD, other things that are there. That's so important to remember that when you run across somebody that's dealing with addiction, there's a really good chance that there's something else in their life that's creating all these challenges that's causing this other condition to happen, uh, that's caused them to migrate into the, you know, using these medications, as you said earlier, to try to feel better. And that's so important, I think, as caregivers, as clinicians, as people out there in the public, who may have a friend or a colleague or somebody they know that's suffering from addiction to recognize hey, there's a really good chance there's something else going on here with this person where they're struggling in life and looking for ways out of that struggle to try to feel better. So I love that. Thank you so much for making that point. I think that's really important point to keep hammering home through our podcast. But I want to catch another piece that you said I thought was really important. It was the low percentage of people that get addicted to opioids after prescribing in a legitimate situation. So when somebody has surgery or chronic pain or an injury or something, and the doctor writes an opioid, how often, if somebody taking their prescriptions as prescribed, the doctor writes them as they should, and the take patient takes them as prescribed. It sounds like from what you said, that's actually a really low percentage of people that end up with opioid use disorder. Is that right?

SPEAKER_00 17:28

That's correct. If you look at the CDC report death rates, um the amount of prescriptions that we write for opioids is roughly about 137 to 142 million prescriptions per year, and 13,260 roughly patients die from prescription opioid overdoses, whereas 70,000 plus die from illicit opioids. And it's fentanyl, but you know, recently most of the issue is fentanyl in a polypharmacy or fentanyl plus other drugs altogether. 67% of patients who die from fentanyl overdoses had other drugs, Tranc, xylazine, uh doxid uh dexidomidate, um, in their system, which causes their death. I mean, it could be benzodiazepines, cocaine, speed, alcohol, pot. There's a lot of drugs that are out there, but you know, everyone keys in on the fentanyl, the the opioid, and you know, again, people get confused between opioid dependence and opioid use disorder, and they just combine the two and say, because opioids are bad, um, we're not gonna allow doctors to give opioids to patients, and that causes opioid use disorder, causes sorry, causes pain to be left untreated, which causes patients to begin to try to self-medicate to relieve some of that issue.

SPEAKER_01 19:03

Right. Um I want to ask a separate question, it kind of following this line of thought. So somebody is likely has an underlying psychiatric conditions or struggles in life, they end up, you know, try to m self-medicate and end up in a situation getting uh addicted to opioids or other some of these illicit drugs that you mentioned. How much thinking about you know the the clinical aspect of it, is opioid use disorder more of a disease of brain chemistry or is it a disease of circumstance and environment?

SPEAKER_00 19:37

What is it we're dealing with here? Well, that's a really complicated question. The way to frame it is to think about it in terms of the mind and the body again. Okay, and uh many many people just want to they just don't have the time to think about the whole person because uh, you know, doctors they just want to they don't have time anymore. They they want to give a prescription and have the patient go on their merry way and not get treated, but that's not the complete treatment. The complete treatment is to treat the mind and the body. So uh a classic study that was done uh with Vietnam veterans, 80 to 85 to 90 percent of the Vietnam veterans who were uh addicted to heroin came back to the United States and were actually uh stopped using heroin because their environment became much more positive, much more conducive to their personality, and they stopped using heroin. So that's an environmental cause. But you know, some of their brain changes were present in the brain changes, is that um we have dopamine receptors in the brain, and those dopamine receptors are upregulated, and we really want those opioids to um address the uh upregulation of the of the dopamine receptors. So the brain is always craving opioids and opioid use disorder because of the dopamine reward feel-good um feeling that people get when they take opioids. So it's a combination, and it's a very tricky situation, to have patients with brain changes in a bad environment. That's really a setup for continued relapsing opioid use disorder. In patients who have a good environment and who are adequately treated for uh opioid use disorder with suboxone or methadone or notrexone, those are the three FDA approved medications, plus they are treated for their uh underlying psychiatric. Comorbid conditions, there's a higher chance that these patients are not going to relapse and are actually going to change from a chronic medical condition to a manageable condition that can be uh allow these patients to get back into society. And that's really what we want. I mean, it's like high blood pressure. You know, if you don't manage it well, you can possibly die of a heart attack or a stroke. But if you manage it well, you can live a pretty good can uh uh life, and you can have all uh an uh a uh an equivalent longevity to a person without hypertension or high blood pressure.

SPEAKER_01 22:49

Yeah. So as you said, it sounds like a complicated answer, but but certainly the brain chemistry piece is there. These people have these receptors that have that need for an opioid, and that would be something they're gonna live with their whole life. And so it'd be a chronic condition their whole life. But environment matters. Environment, a supportive, good environment can help somebody that may be struggling, may have that brain chemistry that makes them predisposed to potentially getting hooked on an opioid. But with a good supportive environment around them, it sounds like something that they can try to try to better manage and control over their lifetime.

SPEAKER_00 23:30

Yeah, no, that's very true. And one of the biggest barriers to care is transportation, because it's hard for these veterans who live so far away from the select few VA treatment facilities that they can't get to treatment. They can't get their medications because some of these pharmacies they they don't stock these medications because it's expensive, it's difficult, and they're subject to burglaries uh of their uh pharmacies. And many of these um many of these pharmacies don't like treating these or don't like dispensing medications to these patients because of stigma. You know, some of these patients may not appear uh uh uh as um uh members of society. They may be look disheveled, they may be unemployed, they they're different. And it it's unfortunate because we have to treat these patients as as people uh as well. And if we if we do that and we get them care, we can get them back into society uh uh as you know, members of society that that we just need to take care of. These are the people who have given their lives for us, these veterans. For the other uh pop parts of the population who have opioid use disorder, you know, they were they were members of society before, and we get more of those people into society. Uh, you know, there's so many benefits because, you know, many patients who have opioid use disorder, that's all they uh that's all they crave is the next opioid. And once they run out of the money they they have for opioids, you know, they lose their jobs, they lose their housing, they lose family support. And and many of those patients are on the streets uh and they're homeless. And, you know, perhaps, you know, there's some other things that we can do for these patients besides treat the opiouse disorder, but you know, treat their underlying psychiatric homorbic conditions so that we can treat the whole person.

SPEAKER_01 25:51

Yeah, and I want to that's so important, just what you just said. I want to come back to that just a second, sort of recap some of the things that you mentioned. Uh understanding this is a chronic condition, a chronic condition that people live with. For those, for many that are it's a brain chemistry situation, and so no fault of their own. So there shouldn't be this stigma that, oh, they're an addict and they're weak and they can't beat this thing. But it's a chronic condition that's a brain condition that they don't have very little control over. And so, like you said, going in with that to knock that stigma out that provides support to people, understanding, respect. And then that last piece, you know, I just want you to expand on because I think that's so important. If OUD, opioiducisis, or is a symptom of pain and trauma and mental illness and other social conditions like the environment, what does that mean for how we should be delivering treatment to those who are suffering from this?

SPEAKER_00 26:50

Well, we need to treat both. We need to treat the mind with the memories of those traumas, of those uh adverse childhood experiences. Uh, you know, because if you have adverse childhood experiences, you have a four times higher occurrence of developing uh substance use disorder or opioid use disorder. And if you don't treat that, you're just treating the body, you're not treating the mind. And that induces a higher chance of relapse. And you have to treat both. You have to treat the mind and the body. And treating all those things together is where you're going to get successful treatment and change it from a chronic medical condition to a manageable uh medical condition.

SPEAKER_01 27:40

Yeah. Well, and we're just about out of time here, John. Um, but I I love what you said. That last piece is so important. And in looking at this, this is a chronic condition, that this is an individual that's dealing with a lot of things in their life, maybe struggling with financial situations, work situations, family situations, childhood trauma, trauma in the military, as so many of our veterans that are suffering from PTSD. So, yeah, those underlying conditions that it sounds like as a physician, you need to understand what is going on completely in a whole basis of what's going on with this patient, to really get at the root of that, to understand how did this end up to where this person is now taking opioids or other illicit drugs that their brain chemistry is hardwired to need. And as soon as they get hooked on, and get then now all of a sudden they're heading down a road that's you know, a disaster situation. So I love the fact that you said that. We've really got to treat the whole person, and that's so, so important to try to help tackle opioid use disorder. So, but we're just about out of time. I don't know if you have any final thoughts that you want to uh part with John before we read today on opioid use disorder, how we think about it, how we treat it, or veterans or anything else before we wrap up here today.

SPEAKER_00 29:00

Yeah, you know, I just want to highlight the fact that, you know, if we leave pain untreated, that there's a high correlation of untreated pain with opioid use disorder. And if we don't treat pain and we don't treat opioid use disorder, we're gonna allow these patients to die. And I think that's really unfortunate because we as physicians should be treating patients, not allowing people to die. We really need to go ahead and treat patients.

SPEAKER_01 29:36

Yeah. Well, thank you for saying that. I know on a previous podcast that you and I, I think it was episode two, we're talking about there isn't enough physicians out there that specialize in addiction recovery. And even chronic pain, I think you said before, physicians are still a little nervous about using opioids and things like that to treat chronic pain. But I'm glad you said it at the end, because that is a key piece of it, in addition to all these other underlying conditions that somebody may be dealing with. If they have chronic pain of a situation they're dealing with, that it doesn't get treated, they're gonna take their own avenues to get to feel better. As you said before, they're desperate to try to feel better. And so they're gonna use their own avenues to try to do their own self-medication if physicians aren't treating it.

SPEAKER_00 30:21

Yeah, and the difficulty is, you know, when I write a prescription for opioids and I give the prescription to the patient, and the patient goes and gets it this uh goes to the pharmacy to get it dispensed. That's pretty much the end of the control and my ability to monitor how well the patient's taking those medications. You know, remote medication adherence monitoring is non-existent today. It stops right at the patient's front door. When the pills go into the patient's home, however they use a drug is how they use a drug. And right now, today, 75% of patients don't take medications correctly. And that leads to a huge amount of unnecessary deaths, uh, medic, you know, medication abuse, disuse, diversion. There's just a lot of things in the whole picture of opioid use disorder that we really need to address. We need to address the patient, we need to address control of the drug, we need to address medication adherence. There's just a lot of things we really need to do because if we let this go on, it's gonna get worse and worse and worse. And I know some people will say that opioid overdoses have dropped over the last two or three years. Uh, but you know, opioid use disorder uh uh has not dropped. In fact, some states have seen an increase in opioid use disorder, they're just not dying. Yeah.

SPEAKER_01 32:05

So, well, thank you. And that last point, highlighting this is still a massive issue. We still have a crisis going on in our country in dealing with opioid use disorder and other substance abuse disorders. And with there's more we need to do, and and some of the key highlights, you made point about there's good, really good medications out there that work, that can help people to help tackle and get it as they're going through addiction recovery. But you're right, there are gaps in the healthcare system about how to get that medication to the patient, help them take that medication and keep the doctor informed and caregivers informed that that patient is following their program. So that I agree is a massive gap that we've got to look at solutions uh as a country and of people to support, whether it's in the VA system or in the correctional facility systems or in our private communities to try to help tackle that issue. So thank you for bringing that up. I know that'll be an opportunity for a subject matter for another episode to do a deep dive on. But we're out of time, uh, Dr. Zue. And so thank you so much for our time today. I want to thank all of our listeners out there today for listening to us. If this is the first time you've you've listened to the Saving Dose podcast, please subscribe to it. Please like it, please share it. If you have ideas uh on other topics and things we can discuss, please send some comments on our website or through. We're on YouTube now. We just launched on YouTube. We're loading up the social media. We've got Instagram and Facebook, other social media so we can get the message out. And that's what it's all about is on the saving dose is all things addiction recovery. We want to be a source for people to help learn more about addiction recovery and how to help people deal with this crisis. So thank you. I hope you guys learned a lot. I know I did today about opioid use disorder. Thank you for following us. We look forward to seeing you again on the Saving Dose.