Okay, I've gotten the request to begin. Welcome back to the best part of the conference. Everybody please get your snacks. This is the film and media workshop and we hope you're going to enjoy it. We are really lucky to have two rock stars in the field of addiction psychiatry as our presenters along with one of their medical students. Dr. Darryl Shorter is a board certified in both general and addiction psychiatry and serves as an associate professor at Baylor College of Medicine. He completed his residency at The Ohio State University and a fellowship at NYU and currently holds the position of medical director of addictions and recovery services at the Menninger Clinic. That's in Houston for those of you who are keeping track. He has authored numerous publications on substance use disorders and supervises fellows at the Montrose Center focusing on LGBTQ plus mental health. We are lucky to have joining him Dr. Ayanna Jordan, MD, PhD, endowed Barbara Wilson, associate professor in the Department of Psychiatry, addiction psychiatrist, and associate professor in the Department of Population Health at NYU Grossman School of Medicine. And they have brought with them Adit Ram, a second year medical student interested in psychiatry at the Baylor College of Medicine. Later they'll present the film titled Sipping on Sysop, Hip Hop Culture, Lean and Media Representations of Opioid Use Among Minoritized Communities in the South. Thank you so much. We're very excited for tonight. Dr. Shorter. Thank you. Thank you so much. Thank you. It's so nice to be here with you all. It's been a wonderful AAAP. I think one of the best aspects of my job is that I get to work alongside brilliant medical students such as Adit and I'm so excited. This is his first national conference presentation. I told him, I know, I told him we would be very kind to him, although you have nothing to worry about. So I'm going to ask Adit to come on up and get started. Hi everyone. I'm Adit. I'm a senior medical student at Baylor College of Medicine, Houston. And today we're going to be talking about hip hop culture, lean and media representations of opioid use, specifically focusing on the urban South and minority communities there. So like Dr. Shorter mentioned, this is my first presentation at a conference and of course we're going to be showing a bunch of music videos with curse words. So yeah, that's just kind of a foreshadowing of what's to come. We will be discussing all the videos though and they're all relevant to kind of the culture underlying lean use that we'll discuss. So the objectives for today with these films and media clips, first we're going to talk about what lean is, how it's made, the pharmacology of it and its impact in the urban South. Then we'll talk about images of lean use in hip hop and how those have changed historically and how they contrast with images of opioid use in society at large. And finally we will conclude with skills for psychoeducation as well as planning for assessment and treatment of lean use disorder, how this is similar and different from treating opioid disorder in general. So first just an introduction, some background on lean. So names for lean include purple drink and scissor among like the minority communities in the South. It's a mixture of codeine and promethazine which are the active ingredients of lean as well as soda, candy and sometimes alcohol. So for the active ingredient mainly it's codeine which provides the effects of euphoria and sedation and the soda and candy are meant to allow users to increase the amount of codeine in the drink allowing for high doses. So a little bit of background on lean, like Dr. Shorter said I'm from Houston originally and so that's kind of the origins of this talk and why it's relevant to our community in Houston. Lean has been tied with music from its origins decades ago in the 1960s with blues musicians. So they first noticed the euphoric and sedating effects of cough syrup with robitussin and cut this with beer and later wine for improved taste. And a couple decades later in the 1980s it was switched to codeine and promethazine as the active ingredients as these were both easily accessible at the time and still provided the same tranquilizing and euphoric desired effects. And promethazine was added later on for anticholinergic effects, additional sedation and counteracting some of the itching from codeine use. So moving into when lean really kind of became more popular nationally. So lean was popular for a couple of decades at this point already in the 1990s in Houston in particular. But broadly kind of catapulted on to a larger scale with a rapper named DJ Screw who is local to Houston. And so he produced music which was kind of like slow. He talked about lean use in his songs and the kind of desired effect was listening to the music with the additional sedating effects of the lean use. And he was very popular within the hip hop community and died in the 1990s at age 29 from codeine overdose. And so this kind of like brought to light that lean was just as dangerous as other opioids as this was the first notable overdose death. And so now we're just going to show a quick documentary about DJ Screw, kind of his impact on Houston, the local community there, the local culture, as well as how this impacted the growth of lean nationally. A local electric e-bikes brand new electric one named one of the best electric bikes of 2020. Less than 50 miles southeast of Austin, Texas, lies the quaint town of Smithfield, a farming and agricultural community with a population of less than 4000 known more for its contributions to the antique industry rather than the entertainment industry. This is where the story of the man known to the world as DJ Screw begins. Robert Earl Davis Jr. was born on July 20th, 1971, the son of Robert Earl Davis Sr. and Ida Mae Deary. Robert's family members recall life in Smithfield. We bought his first turntable from Western Auto Store for him. He was 10 years old. That's all he wanted was a turntable and some record. Each week Screw would go out and buy him a record. Whenever he wanted to find Screw, go in his room, he on the turntable. I seen all the records he had, I looked at his records, I looked at my records, I said we need to come together and do some stuff. The two young DJs formed a friendship and a business relationship that would mark the beginning of both young men's careers. This is not a dancing town, you know what I'm saying, by a long shot. This ain't like, you know what I'm saying, New York or Miami or something where it's more quick pace. It's like everything is slowing low down. You hear everything, you know what I'm saying, the clarity of it was good, then on top of that, you know, every track, you know, he's doing something different. The opportunity to freestyle on the hottest mixtapes on the streets had hustlers and aspiring MCs from all over the South Side rushing to Screw's house for a chance to wrap his hood. And as they say, the cream began to rise to the top. See, the thing about Screwed Up Clique though, man, it's a lot of members. It's kind of like some Wu-Tang type shit. From Junk, DJ Screw to Junk, you know what I'm saying, he was the number one or whatever. Screw had that quality to where when he come around, you gonna be cool with your beef until he leave. That's how much respect we all had for that dude. He was like the magnet drawing all of us to him. You gotta hear this, this boy serious, man. Prod if you got any other tapes, I'm telling you. Almost overnight, Screw's mixtapes grew from a neighborhood phenomenon to a regional craze. We have to establish order, which is where this gate comes in. He was like, OK, you know what, from now on, we're going to sell tapes at a certain time, 8 o'clock. 8 o'clock, the gate will open. We sell all the tapes we need to sell. By 10 o'clock, we can close the gate. 5 o'clock, 5 p.m., the line would already be long, two or three streets down. That's why the feds and stuff thought he was selling drugs. Screw was selling a thousand tapes in 15 minutes, dog. I mean, back then, Screw Tapes was really like a promotional team without legs that was able to make it where legs couldn't go. We wasn't really worried about what was going on in the rest of the world. And when we did hear the rest of the world, it's because DJ Screw was putting us up on it. We really wasn't checking for nobody unless it was on the Screw Tape dime. Pretty soon, an appearance on the Screw Tape was better than radio. It's that crazy underground buzz that only pioneers from the street can create. So he had something that separated him apart from everybody. Yeah, you know, Screw, he invented the whole movement, you know what I'm saying? And when I slowed down my stuff, man, you know, I got the basis of how I do my stuff from listening to the art and how Screw did his thing, you know what I'm saying? I truly believe that constantly talking about the drink, constantly talking about the weed, constantly talking about the pills on the media side really sheds a bad light on who these guys really are because they are some of the most talented people I've ever met. It was a fad, man. It was right there. It was during the time when the Screw thing was popping off. It was new to a lot of us, so this is what we were doing. It was just something we were doing, man. See, that's what happens when people from the outside try and come in the inside and talk about shit that they really don't know, you know what I'm saying? It wasn't none of that, man. Screw music was Screw music and that was it. Drugs, no drugs. If you love Screw music, you love Screw music. I can't really speak for nobody else, but I mean, I've been in Screw houses many a night, many a day where we didn't have no drink, where we didn't have no weed, we didn't even have cigarettes, and we made some of the dopest freestyles in our whole career. I still listen to Screw tapes now, man, and Screw and Pat trippin' and laughin' and they born was like Batman and Robin kind of. That was just a great, tremendous amount of respect for each other, each other's space. There's a lot of respect for each other's craft. Everybody wanted to hear Fat Patty and Kiki Flo, you know what I mean? So, he felt like, he knew he was gonna make an impact. Things are crazy in this life, gotta get my smoke on, Things are crazy in this life, gotta get my smoke on, it's gettin' hard, two whole long things. I'll never forget this, man, because I looked at my watch, man, and my watch just had stopped. It's just fucked up, you know what I'm saying? It was a legendary guy, you know what I'm saying, putting it down, and it's just fucked up. It was just a fucked up day for the city. You couldn't say nothing bad about him. He was just a really, really, really cool dude. Screw built his own industry, man, for real, man. I mean, his whole thing was to let us get on the tapes and give us a boost. On the morning of November 16, 2000, DJ Screw was found dead of an apparent heart attack. It was raining real hard that day. When I gets back into the plane, my plan says I got a phone call waiting for me. And a friend of mine said, call me and ask me, man, you know, have you heard that your brother passed away? I said, nah, I said, man, you know, don't call me playing like that. I remember the day I got the call, which, to this day, still gives me chills. Some shit you just can't believe, you know what I'm saying? Unbelievable, man. I had to just see it for myself. And it was crazy. I didn't like what I heard on some of the news and so forth. It was portraying him as just a big drug user. Somebody gets shot, they don't say this father, this good man got shot. They don't say a rapper got shot. I expected that because I know they don't understand the music, they don't understand the culture, they don't understand what we're doing. They would have did that with any rapper, man. My partner didn't overdose, he worked himself to his demise. He didn't let the fame go to his head or nothing like that. He was just screwing with y'all. He was a blessing, you know what I'm saying? Everybody don't get to come across people like that. If y'all don't know he was a loving son by now, if y'all don't know that he was a workaholic, if y'all don't know that this dude was an angel because he made it possible for a lot of people to eat, if y'all don't know that he was the artist. He was an artist. He was like a Picasso. He's just missed, man, because of just the type of person he was. I don't miss him for scratching on the turntables and all that. I miss him for sitting down with Scrooge, chopping it up, we laughing and giggling and, you know, this Scrooge. I'm trying to take it where Scrooge left off at, man, to push it farther than where it's been at, man, you know what I'm saying? Just because the man is gone don't mean that the art form should die. If we could pause the documentary, please. And go to the next slide, please. Thank you. And so that documentary was just kind of like a 10-minute clip. Since DJ Scrooge was so tightly related to the national increase in spread of lean use, especially, though, in the urban South, the national portrayal of him was kind of based on that. The national kind of portrayal of him was kind of just limited to that one overdose death, but this was kind of just showing his impact on the local community and how the people around him viewed him. So now going a little bit, now that we have kind of some history and background on lean, a little bit of the pharmacology of it. So the two active ingredients are, again, codeine and promethazine. Codeine is a naturally occurring opioid, but today is derived from semisynthetic methylation of morphine. It has one-tenth of morphine strength and is a high-affinity mu-receptor agonist. For the addition of promethazine, promethazine is a first-generation H1 antagonist. It provides anticholinergic effects, and these are, again, the sedation, altered sensation that's the primary desired effect of the promethazine. So discussing some patterns of lean use. Since one of the major themes of this talk is that lean use is under-represented, under-identified, under-treated throughout the urban South, there's not a lot of good studies and good data around its prevalence and incidence. But this was one study that involved surveying people online through a Reddit forum who admitted to lean use online, and they collected 1423 adults. So 77% were male. The average age was 27 years old. And interestingly, you can see some variation in the composition of lean. So a majority, 75%, used codeine, but 60% reported only using codeine. Some proportion added promethazine themselves to codeine, and only 14% used the classic combination, codeine-promethazine cough syrup that was initially used in lean. And so this data just emphasizes that if you are treating a patient with lean use disorder in particular, you kind of need to add additional history to get a better sense of what is in the actual lean that they're consuming, because it could be codeine alone, it could be codeine plus promethazine, and you need to kind of identify the doses in which they're taking of each as well. So a little bit about the earlier epidemiology of lean use as well. So earlier studies from the late 90s to 2000s, around that same time of DJ Screw, were largely focused on Houston where this was kind of still the epicenter of lean use at the time. They were largely among young black and brown people, and they were generally associated with sexual activity, association with other drug use, especially in like a party type setting. One study from this time found that among black cocaine users, crack cocaine users in particular, codeine was associated with lower levels of education, younger age, higher likelihood of sex work involvement, and additional drug use. So kind of shifting forward by a couple of decades to the 2010s, they started to study lean use among a different setting, which was a public university. This was a study from Georgia State University, which surveyed 2,300 college students. So they still found that there was a predominantly male distribution. It was around twice as likely for males to use as females. And you see the racial distribution is different on this college campus study. Where there's more use among Hispanic and Latinx students as well as Native Americans compared to other races. And use was highest among people with lower GPA, and consistently use is higher among LGBTQ people. So this study just kind of suggests that there are some differences between kind of the original urban South community of largely black and brown people in which lean was popularized and initially formed, compared to its use in college campuses, for example, which is another common area of lean abuse. So these more recent reports are identifying more heterogeneity than originally expected in lean use. So the kind of stereotype initial image from the 90s has been largely debunked of an African American rapper athlete. Still though, it is more predominant among adolescents and young adults, as well as more predominant among males. But today there's more of an even racial distribution in lean use between African Americans, Hispanics, and whites. Although it's still worth noting that African Americans are disproportionately represented in this percentage, given their lower percentage of the population. And specifically about treatment of lean, admissions for codeine specifically were substantially lower than all other opioid uses, despite, as we've seen kind of previously, that lean is pretty prevalent in its use across a variety of settings. And so this kind of emphasizes the point that lean is under-reported, under-recognized, and under-treated because it's not often a reason for admission lean use disorder. And so it's difficult to even estimate the impact of lean aside from these limited studies. So now that we have a little bit of background on lean, we're gonna kind of go into the main media components of the talk, which is looking at the ways in which lean use and substance use in general in hip-hop, videos, culture, and media have evolved since the early days of hip-hop to present day, and how this contrasts with the way in which opioid use is presented to society at large. So the next couple of slides are just taken from Google Images of Googling opioid use. And so this is kind of meant to illustrate what the public kind of perceives as the face of opioid use and opioid use disorder. So this spreads a positive message of only one in four adults who need treatment, receive medication, but we'll kind of see from the subsequent images as well, such as this one, showing two white hands reaching for each other. You see a syringe, you see pills, you see white powder. And so this is kind of the classic imagery of what the opioid epidemic has become associated with. It's not young black people at a club like drinking a bright purple drink while listening to hip-hop music. And so this kind of lends to, additionally, the under-recognition of lean use disorder among those communities because it's more difficult to identify as having an opioid use disorder. And here's just an additional image of another person who seems like they're more in despair, they're grasping for pills. And again, this type of imagery, it's just furthering the previous point of the under-treatment of lean use. So the public perception of opioid use still largely revolves around this idea of heroin injection drug use, and now rising fentanyl in recent years as well. And it still is viewed as many as a white and rural problem. But the party drink branding of lean in many communities in the urban South is really insulating these communities from understanding the danger of lean use and the ways in which it's similar, really, to consuming any other opioid, the risks of overdose and all the other adverse risks of addiction as well. And so ultimately, this contributes to an under-diagnosis and under-treatment of opioid use at large among marginalized black communities in the urban South in centers such as Houston. So now talking a little bit about hip-hop and how hip-hop culture is associated with and influences lean use. So hip-hop kind of influences substance use in many ways that many people are probably familiar with. The portrayals of media consumed by youth and young people are highly influential to their patterns of substance use. But also substance use also kind of influences hip-hop in other ways as well, that people often engage in recreational drug use generally for enhancing the effects of music. And like we saw in the DJ Screw documentary, this is especially true for lean use with hip-hop music as well. And so just as a kind of initial trend to set up the rest of this background, from 1979 to 1997, there was a six times increase in rap lyrics that referenced drugs with a greater focus on positive associations. So kind of going back to the origins of rap and hip-hop. So early hip-hop was focused largely on community empowerment and urging abstinence and distance from drugs. And so the 1970s was kind of the initiation of the war on drugs and the crack cocaine epidemic. And so hip-hop was like very closely tied to an act of resistance against these patterns of drug use that were increasingly prevalent. And so early hip-hop was kind of against substance use. And we'll kind of show an example here. This is from a song called White Lines Don't Do It. And so you can tell that the song is pretty explicitly from the title anti-substance use in general. And this is one of the early, early hip-hop songs that we'll show. How often do we end up eating alone instead of with somebody that we love? And if you get hooked, baby. And now I'm having fun baby, it's getting kinda low, I need some one-on-one baby, baby. A million magic crystals, painted pure and white, a multi-million dollars, almost overnight. Twice as sweet as sugar, twice as bitter as salt, and if you get hooked baby, it's nobody else's fault, so don't do it. Don't you get too high, don't you get too high baby, turn you on, you really turn me on and on, could you come down, my temperature is rising, when the thrill is gone, no I don't want you to go A street kid gets arrested, gonna do some time, he got out 3 years from now just to commit more crime, a business man is caught with 24 kilos, he's out on bail and out of jail and that's the way it goes Gang, shut up, gang, athletes rejected, governors corrected, gangsters, thugs and smugglers are thoroughly respected, the money gets divided, the women get excited, now I'm broke and it's no joke, it's hard as hell to fight it, don't buy it Breathe! Run! Okay, perfect. So, there's definitely a lot of imagery there related to substance use. That video is from quite a while before I was born, so I hadn't seen it before preparing this presentation, but Dr. Jordan, if you have any thoughts to share on it. Okay, you guys can hear me okay. Yeah, I mean, I really appreciate where we are so far. to how hip-hop influences what is deemed as appropriate substance use was deemed as bad or not. So, I just kind of want to go back, because I was born in the 70s, and he was born in the 2000s, but understanding really just the importance of culturally informed care and how we understand substance use. So, looking at Lean and DJ Screw, that's very kind of innate into what I understood in terms of how people used opioids and did not use in terms Have the purple drink, scissor. experience of even if you're kind of on your slow down your the music is kind of screwed up so that you're almost like having this experience of being on a on a depressant right a CNS depressant which is which is really interesting but how does that translate to now me being an addiction psychiatrist taking care of people in New York City of course I asked about lean I've written papers The demographic around how are we asking about opiate use in a way that casts a wide net, right? Not everybody is engaging in opiate use through heroin, pills, things like that. Lean is a big part of the culture. But also just seeing how hip-hop in itself is now influencing environments that necessarily would not even be exposed to lean, except for not the music, right? So looking at college campuses across our nation, away from the South, in New York City, in Connecticut, in middle America, where there is this culture of using lean, not because that's how you grew up, but it's in the music. And we'll see that as we continue the conversation, because there are many artists now who are consumers of lean. So that's one point. The second point that I think is important around this white line, and that's my jam. I was trying not to dance. I'm probably going to end up dancing because I love hip-hop music, but really thinking about the message of seeing substance use, it really being coupled with kind of seedy environments. You saw people involved in sex work, the woman, he had to open her eye because she was so out of it from using cocaine. And the underlying message during my childhood was, you just stay away, right? It was more effective than, this is your brain on drugs, just don't use drugs, their program, right? It was like, you don't want to be like this in the culture. You want to really protect yourself from this dangerous substance. We'll get into how that message really kind of goes on through black empowerment, and I love that public enemy is here, because it's really like fight the power. During that time, it was really with the rise of the war on drugs, crack cocaine in many black and brown communities, and hip-hop music was really very much like, you don't want to become involved in using substances because you don't want to be seen as someone who is a failure to the culture, but really as this is a way for you to beat the system, right? We're not going to use drugs. We're going to take back our communities, which is a positive thing, but then we'll see as we go on in the conversation in the culture that it has very much shifted from not using substances to it being a bad thing in hip-hop to be associated with being a substance user, right? Selling drugs, whatever, that's kind of different than being a consumer of substances, which now we're in this, okay, I won't give it away, so no spoilers, but so we're now in the 80s, don't use drugs, you don't want to be like this, and then moving into the late 80s, 90s, around being separated from substance use as a way to liberation, we're taking back our communities, that's where we are, okay, let's do it. that came in and said, we're just locking everybody up. If you're using substances, distributing substances, but then also really doubling down with the Reagan. three strikes you're out, right? They're folks that were literally serving the equivalent of sentences for killing someone for distributing or possessing substances, particularly crack cocaine. So in that kind of context, I think it's important to see there was a ground swelling of like, what are we going to do? We can't rely on U.S. politics, definitely not these old white men, definitely not the politicians that are locking us up in response to substance use and distribution in our communities. Fight the power is very much like fight the power, organize government, but also what are the powers that be that are allowing these substances to come into our communities, making decisions on our behalf, taking back our own power in our communities. What does that look like, right? So even growing up. fight the power, fight these negative forces that have really impact. Fight those policies that are leading to over-representation of people in mass incarceration because of substance use. This music was ubiquitous in black and brown communities, like you could not escape public enemy. And I think the conversation around public enemy in the communities where we came from versus perhaps some of the other communities is that this was not about sort of like some of these concerns about like police brutality. I really think about like Ice-T, for example, who's on law and order right now and has been on law and order, which is just a whole other like... That's wild. Wild. Like Ice-T... Completely, like... One of the biggest drug dealers. Had a song called Cop Killer around the same time, right? Now he's playing a cop. But anyway... It's a whole thing. That's a marathon. There we go. We're just, we're gonna let you go on, but I just, I just, like these, these, that, that song was everywhere, everywhere, everywhere, everywhere. And I, and there's a kind of a question for me about like, was it everywhere for you too? Okay. Was this in the psyche of, you know, mainstream America? And then the overlap with Malcolm X, which we'll talk about, which was a Spike Lee movie that came out around the same time, played by Denzel Washington. But really the underlying theme of substances being bad, crack is whack. This is not a way towards our liberation. We do not want to be coupled with using substances, right? White lines, don't do it. Don't be a failure to communities. Okay. That's where we are. So kind of moving out of the eighties towards the nineties, this is kind of when rap started to evolve itself. And so this is kind of the first like major shift when talking about the history of hip hop and drugs is the persona shifting to drug distributor. And so gangster rap kind of incorporated like drug dealing and drug hustling, just the sale of drugs, not the consumption at this point as a means to an end. And so it was kind of seen not as something that was like necessarily respectable or something that you would want to do, but it kind of was emblematic of the struggle of black Americans that so many people had to resort to selling drugs. And so again, it's kind of the last resort to make ends meet, but one that still is not worthy of like judgment of criminalization. So our first video for that is nothing but a G thing from 1992. Michelle wasn't born, but that's okay. We were around the collective weed in the audience. So tell them how you know about Snoop Dogg. Yeah. So I didn't even know this song was from Snoop Dogg. I only know Snoop Dogg is kind of like on Wheaties, like cameos of the Olympics, stuff like that. So seeing him kind of portraying a drug dealer was not really the imagery that I associated with him, but yeah, we'll, we'll take a look at this video. The season of Audi sales event is on at Audi Naples. Choose from hundreds of vehicles, including a wide variety of all electric. One, two, three. Snoop Doggy Dogg and Dr. Dre is at the door. Ready to make an entrance. So before I have to pull the strap off, give me the microphone first so I can bust like a bubble. Captain and lone beast together. Now, you know, you in trouble cause ain't nothing but a G thing, baby. Too low def G. So we crazy. Death row is the label that pays me. Unfadeable. So please don't try to face this. But back to the lecture at hand. Perfection is perfected. So I'm going to let them understand from a young G's perspective. And before me, they got a trick. I have to find the contraceptive. You never know. She could be earning a man and learning to me. And at the same time, burning the man. Now, when she burned in the material for a minute, cause they know loving good enough to get burned while I'm offended. And that's relevant. Real deal. Holy field. And now you hookers and hoes know how I feel. Well, if it's good enough to get proper, proper chunk, I take a small piece of some of this funky stuff. It's like this. And like that. And like this. And it's like that. And like this. And it's like this. And like that. And like this. And Drake creep to the mic. Like, I'm people. And then I'm creeping. And I'm creeping. But I didn't get killed because my people can't be. But now it's time for me to make my impression. So sit back, relax, strap on your seatbelt. You've never been on a ride like this before. What if I do? So who can rap and control the maestro at the same time with the dope rhyme that I kick? You know, and I know. I feel some funky to add to my collection. This election symbolizes don't take a toke, but don't choke. If you do, you have no clue. And with me and my homie Snoop Dogg. It's like this. And like that. And like this. And it's like that. And like this. And like that. And it's like this. And we ain't got no love for those. So just chill to the next episode. Falling back on that ass. What a hell of a gangster lane. Getting funky on the mic. Like, oh, that's a collard green. It's the capital S. Oh, yes. Depression. Double O. P. D. O. Double G. Y. D. O. Double G. You see showing much flex when it's time to wreck a mic. We got to move for another one of those G hits. So straight. What up, dog? We got to give them what they want. What's that, G? We got to break them off something. Hell, yeah. And it's got to be bumping. City of Compton. It's where it takes place. So what now? Show attention. Mobbing with the dog clown. Bow, wow, wow. Dropping the funky tracks is making the suckers just mumble. When I'm on the mic, it's like a cookie. They all crumble. Try to get close, and you're bound to get smacked. My little homie Snoop Doggy Dogg has got my back. Never let me slip, because if I slip, then I'm slipping. But if I got my Nina, then you know I'm straight tripping. And I'm going to continue to put the rap down, put the Mac down. And if your woman want to trip, I have to put the smack down. Yeah, and you don't stop. I told you I'm just like a clock when I tick and I tock. But I'm never off, always on, till the break of dawn. See you wimpy till you win in the city they call Long Beach. Putting it straight together like my homie D.O.C. No one can do it better. Like this, that, and this, and a, it's like that, and like this, and like that, and a, it's like this. And we ain't got no love for girls. So just chill till the next episode. Next two videos are kind of with this like persona of the drug distributor. So the next song is Juicy by Notorious B.I.G. and then the video after that will be Can't Knock the Hustle by Jay-Z. For these two we're just gonna play like the introduction to them, like the first like minute or so. The season of Audi sales event is on at Audi Naples. Choose from hundreds of hanging pictures on my wall. Every Saturday rap attack Mr. Magic Molly Mall. I let my tape drop to my tape cop. Smoking weed and bamboo, sippin' on private stock. Way back when I had the red and black lumberjack with the hat to match. Remember rappin' Duke? Da-ha, da-ha. You never thought that hip-hop would make it this far. Now I'm in the limelight cause I run tight. And so kind of just to me, like something that stood out whenever I was watching this is like the opening line saying it goes out to everyone who called the cops on him whenever he was selling drugs just like make ends meet and feed his daughter. It's kind of still like a, it's not that he's like proud of or necessarily wanted to deal drugs but it's just that that was kind of a last resort for him. Dr. Jordan if you have any other. I mean I'm just jamming. This is the music of my childhood but you know just reflecting on nothing but a G thing that's really when you know obviously Snoop Dogg was introduced to the scene. He was definitely not the Snoop Dogg that was doing things with Martha Stewart and on Olympics but really very much a West Coast drug dealer. That was Snoop Dogg and at that point largely cannabis, some cocaine but largely cannabis and it was glorified. He was you know featured on Dr. Dre's chronic album. It was a thing like it became kind of cool to be a drug dealer. Again not from a place of like this is what we want to grow up to be but in terms of like you got to make a way out of no way and for folks who are locked up it's the product of people whose fathers literally are in a prison. A lot of families are broken up and so what do you do if you don't have access to education and like parents who went to college and the professors like you sell drugs and that's the way you bling it out. You know one of the reasons why I wear gold in my mouth, diamonds in my mouth stays me connected to the culture but that is what was happening right and the people that I looked up to my rock stars to kind of really show that you've made it. So when I got my first attending check I was like I'm blinging my mouth out. I'm wearing my gold to Harvard you know that's what is like the currency of you've made it right. That's the sign that you made it. So there's a real coupling of substances now not as the using substances and not even as evolution of like don't do it it's bad but like oh it's okay to sell drugs as a way to kind of make it in your hood but also take care of your community. That was introduced with Snoop Dogg as a young drug dealer mainly through cannabis but then with Biggie now from the going from the west coast to the east coast. Biggie in New York City particularly in Brooklyn, Bed-Stuy and he was selling crack cocaine and like you're saying that opening nine juicy he's like this goes out to all the police officers that caught my daughter I'm out here just trying to make a living. His mother people knew Biggie right he was a big-time drug dealer who happened to rap who ended up legitimizing himself because of his his rap music but one of the things that I'll never forget about Billy Biggie is in a 10 crack commandment the name of the song he said never get high on your own supply right so that was a big deal in terms of yeah you can sell drugs but you don't use them. If we go to the next slide please and this is just the intro again to the Jay-Z video. Can't knock the hustle. Chilly with enough bell money to free a big Willie. High stakes I got more in state than Philly. Shopping sprees, copping three. Deuce fever, I guess it's fully loaded. Bouncing in the Lex Luger. Tire smoke like Buddha. 50 G's to the crapshooter. Niggas can't fade me. Chrome socks demon. Through my peripheral I see you scheming. Yeah so again this is very different from the Jay-Z that I know in like current pop culture like who's married to Beyonce billionaire and so this kind of again shows like the roots of Jay-Z from the 90s that this was his in this video too there's kind of some different imagery like he's kind of dressed up like Godfather style like looking like he had like an empire already and so this shows like kind of the power the masculinity those like associated things that become the begin to be associated with drug dealing and like a drug empire almost. So now the next shift as to where we are now in terms of, okay, people who take care of those with substance use disorders is understanding the behavior of how we kind of got here and what people are doing and how it really is acceptable in a lot of minoritized communities in the South, but also, quite frankly, nationally around using drugs. And hip-hop has a huge influence on that conversation. And so now, like moving into the 21st century, like Dr. Jordan was saying, this is the shift, the next big shift from drug distributor to drug consumer. And so we kind of discussed with Jay-Z that this was the transition to this drug use association with toughness, masculinity, sexual prowess, a lavish lifestyle, one of luxury and wealth. And so this kind of shifted that drug from drug dealing to drug use associated with all these things, and with that, the public kind of had a large criticism towards hip-hop also shifted. During the, like, 90s, the criticism was more that selling drugs was causing damage to communities by increasing drug use among them. And now, towards the 21st century, the criticism of rap music and drug use is more that it's like glorification or a positive portrayal, which is damaging communities in that way. So this is another song where the title kind of speaks for itself in many ways. On the shift towards drug use, this is Hate Being Sober from 2013 by Chief Keef and Wiz Khalifa. The season of Audi sales event is on at Audi Naples. Choose from hundreds of vehicles, including a wide variety of all. Okay. So we're moving a little bit quicker through some of the videos now, just for time. But this, in this video as well, they are, like, drinking lean, smoking marijuana, drinking alcohol while driving these, like, ATVs through a desert, kind of. And so thinking about, like, intended audience of this video, this is kind of shown as, like, a fun recreational activity. It's combined with driving. And so this is kind of moving towards some of the more harmful portrayals of lean use. And so discussing kind of a study that, like, analyzed the hip-hop lyrics involving lean from 2020. So some of the, like, specific themes that have been more consistent in more recent times is combination with other drugs, used for sexual activity enhancement, used while driving, like we saw in that last video. And then interestingly, also just for relieving mental distress. And so we'll kind of circle back and talk about that a little more as well. Lean is not just a party drug, but also one for coping as well. So this is the, this is the music video, like, that's the title of this talk. And so the portrayals of lean in this are kind of the most apparent and glaring, I think. So we can watch this, sipping on some syrup from 2000. Come on man, you're always slow. What in the world happened last night? What happened last night? I'll tell you what happened man. You know what I'm saying? Get us something to eat. I'll tell you. Boy don't know. Man, it's going down. Okay, perfect, and so kind of some of the imagery that stood out to me watching this, you see like the bright colored drinks that are presumed to be lean in baby bottles, kind of consumed by everyone at this club that they're all at. So this, kind of with the theme of lean being viewed as an innocent drug rather than a drug of abuse or misuse, this is kind of emblematic of that, like a baby bottle is almost like a symbol of innocence for them to be consuming lean in, and you see now that it's consumed in this party setting, in a variety of settings as well, like on the beach, at a restaurant, and so that's kind of my takeaways from this music video. Okay, and then now, moving a little bit further in the future, 2017 with Gucci Gang, so this is by Lil Pump, this song came out when I was in high school and I remember watching it at the time, it has I think billions of views at this point, yeah, so 1.7 billion views to this video, and Lil Pump at the time of this song being released was 17 years old also, so just thinking about an intended audience while watching this video as well. Okay, so kind of some more themes here. So this entire music video takes place in a high school, I didn't mention it before, but the double stacked styrofoam cups is kind of like a common representation of lean, where it's understood that that's there, and they show at one point a lunch lady pouring like a purple drink into it as well, you know, he has like a tiger on a leash, he's carrying around like huge bags of marijuana, and so this is kind of again like him flaunting this as a sense of lavishness, and again to his peers as fellow teenagers and young adolescents as the intended audience. And I think it's important to see this shift, right, so the kind of accepted behavior is not that you're selling drugs, or that's how you get the girls, or that's how you're cool, but really like you are the consumer, right, like this kind of blows my mind, 1.7 billion views, but like, yeah, you know, teenagers want to be cool. They want to learn how to make lean, drink lean, take lean, smoke weed and have the tiger walking down the hallway. I mean like whatever but you know like this is a real shift so really thinking about demographics, the nature of hip-hop being so really worldwide how people are seeing this one emulated and who are we asking about their substance use and what how are we asking it in a way that makes sense. We may not be able to ask about opioid use but you can definitely ask about lean right understanding we have to do the interpretation that that is an opioid. You may not be able to ask about cannabis use but we can ask about chronic or dro or other names that are like you know for for weed. Okay. Go to the next slide please. And so now another song from the same year. The song is Bad and Boujee and again thinking about like intended audience while we just show the initial part of this clip. You know, young rich. You know so we really never had no old money. We got a whole lot of new money though. Bad and boujee. Cooking up with a Uzi. My niggas are savage, ruthless. We got 30's and 100 rounds too. All set. Woo. Woo. Woo. Woo. Rackets on rackets. Got backers on backers. I'm riding around in a coupe. I take your p*** right from you. I'm a dog. Beat her walls loose. Hop in the fall. I tell that p*** to come comfort me. I swear these n****s is under me. And so kind of like the thinking about the intended audience of this video. It's pretty different from Lil Pump's intended audience. You can see that there's a little bit more like the the group is older. There's some more maturity. They're popping like gold bottles of champagne. But there still is kind of also like he's holding the styrofoam cups. They're like hanging out still in a local diner. They're eating ramen. And so one of the lines I think like stands out too is we came from some from some we came from nothing to something. And so I think that's again like Dr. Jordan was saying like a way to show that you made it. And kind of the associations that go along with that and how that's shifted from earlier videos to now like like explicitly showing that. And like by popping bottles by like drinking the lean still there as a constant association. Yeah. And just also to like what are the activities of the rich. And he says in the beginning Offset who actually talked very publicly about his addiction to lean and how it actually ruined his life and how nobody actually really asked him about it or helped him. Anyway, he's doing better now. But the point is he says like we never had any old money. Now we got new money. Right. So the ways in which. Yeah. Like a lot of black and brown people don't have generational wealth. Right. So the way in which they have made their money whether it's through new money and newer generations. What are those activities that they want to do to celebrate that. And a lot of it is coupled with substance use but it's very different. It's not necessarily cocaine but it is smoking a lot of weed with a very high THC content. It is having access to lean, sipping on it constantly throughout the day and having beautiful women. I'll just say that. I censored myself. Having beautiful women around you in that way. And so this continuum of yes teenagers but now we're getting to the new money. Those who are the YouTube stars, the hip hop artists, whatever, they want to kind of pop their collar and substance use has a lot to do with it. All right. We have one more and then we're going to have discussion. I'm so excited. I want to know if anybody in the audience know what G and G thing actually stands for. It's nothing but a G thing. OK. We'll get to it. OK. So now kind of continuing this at hip hop culture at large. So this slide is just kind of showing that hip hop culture expands beyond just the music. And so a little bit of this shift. New Jack City is a movie from the 90s about kind of similar to the Jay-Z imagery of a drug empire. Kind of like similar like mafia undertones and then kind of transitioning now to more modern times. This is a Soulja Boy song called Xan With That Lean about taking Xanax and lean together. And so that's again a very explicit encouragement of co-occurrence of drugs. And then now in present day there's a show on Netflix called Top Boy about kind of a similar culture but within London just to show the global impact of this culture. OK. And then now for the last objective. This is kind of about psychoeducation and how to address patients who might be struggling with lean use disorder. So this is a show on Netflix called Mo and came out in 2022. It's kind of what first got me interested in this topic about lean use and from Houston in particular. I spoke to Dr. Shorter about. And so this is a show about a Palestinian man who's undocumented. He's a refugee and he moves to Houston. And the show kind of chronicles some of his struggles with lean addiction as well as other things. And so just a quick trailer for this. Mo, hi. No, no, we don't have to do that. You can keep your shoes on, Mo. No, that's gross. Well, come on in. How you doing, brother? Let me show you something. Why do you need to sell that crap? Selling merch is the only thing I can do without papers. I need to support my family. Petro-emotion. It's my last one. It's my last one. Last one. Islam is real practical. You can talk to G.O.D. anytime. You should go to church with me someday. What is the trinity, though? Please explain it to me. What is it? No, no, don't do that. No, no. Astaghfirullah. Don't do that. She said she really loves your hair. Thank you. She wants you to take your shoes off when she wishes you weren't Polish. Joking. A lot of jokes. You know what? I don't want to talk to you anymore. I don't want to talk to you anymore. I've never been to Palestine. I don't have citizenship there. I don't have citizenship here. I'm like a refugee free agent. Would you like to try some chocolate hummus? You said chocolate hummus? You just insulted my grandmother. Osiento, I did not know that hummus was Mexican. You keep thinking that you have to do all this stuff alone, and you don't. You got us, and you got your family. Who the hell are you? I got drugs in the car. I got drugs in the car. Where I come from, olive theft is a huge problem. Next slide, please. Okay, perfect. Now we just kind of wanted to present Mo as a case of someone with lean-use disorder, kind of how to think about how to approach treatment. This is based on his presentation from the show. Imagine a young man named Mo walks into your office. We kind of talked a little bit about his background, but he started drinking lean recently to manage his pain after a gunshot wound. He recently was laid off from his job, and he does not have health insurance, so he cannot seek medical attention for it. He also is undergoing some recent stress because he has an uncertain asylum case coming up. His lean-use has been progressively increasing, and he's also been using it to cope with stress in addition to managing pain. He's buying the codeine-promethazine combination syrup from a friend who's been concerned about him, and he's only admitted his addiction once in a religious context and feels intense guilt about it. So for his previous substance-use history, the lean-use is his only current substance-use aside from smoking cigarettes. And some relevant family history, his father was tortured prior to his death, which he only recently found out through his asylum hearing, and so now he has a much more complicated grief resurgence decades after his father's death and has these recurrent vivid visuals and flashbacks of his father. So some questions to consider that we kind of wanted to open to discussion are how would you approach treating Moe? What are some additional points of history you might want to collect, any additional considerations or challenges in managing his opioid use in particular? Thank you. Thank you. Round of applause for him. So, so good. You did so good. So we had really not intended to end up with only about 17 minutes of time for Q&A, but we got to jamming on the thing, me and Dr. Jordan, and so we didn't cut off the time, and we apologize about that. So right now we want to open up for comments and questions from the audience, if you have thoughts about what you've seen today. Certainly I can, I can talk about my own experience and journey with hip-hop. I mean, Dr. Jordan and I both, as well are all hip-hop fans, and I can really think back to seeing these images, but also I think in some ways not necessarily thinking about them as deeply as I do certainly now at this age. I think a lot about intended audience and who not only the music is trying to speak to, but also what the images are trying to communicate. I think it's really important with the Chief Keef video, for example, that these are guys that are hanging out, riding in ATVs in the desert, and how aspirational that can be for somebody who's grown up in the hood. I've never even seen a vehicle like that, I've never taken a vacation to a place like that, and there they are, they are engaging in this behavior that looks wild and amazing and fun and fantastic, and there's a hot girl in the passenger seat, oh, and they're also using lean, and what that communicates about how okay it is or how desirable it is to really engage in that kind of behavior. And when I see them in the diner eating ramen, popping gold champagne bottles, I'm like who wouldn't want that? So we have to really think about what that communicates to people about the desirability of engaging in certain types of behaviors, particularly around substances. So why don't we start over here, yeah. This was really wonderful, I really enjoyed it. I was also born in the 70s, so I was like the music from the 90s was awesome, and it was fantastic, but all the new stuff, I thought this was ridiculous and I don't understand it, but my question is, how would you recommend that I ask about it without sounding like a middle-aged white woman who doesn't get youth culture? Yeah, that's a great question. Dr. Jordan, you want to get in? Yeah, I love that. I mean, I'm a middle-aged black woman, so I'll tell you how I approach it, and is it right or is it wrong? It is what it is. I think the most important thing is that we're having these discussions to recognize that the ways in which we think about substances is not universal to everyone, and so we have to consider the ways in which different audiences use substances, but also really understanding that we are approaching it as this is bad, whereas for many cultures it may not be necessarily bad. It's very aspirational, and it gets them close to something that they may never have. Experiences and liberation and things like that. So the way I ask about it is this. I'm so happy you're here to see me. I'm going to ask you the same questions that I ask everybody else. I am a child of hip-hop. I love hip-hop music. These are the things that I'm seeing. I know about lean, Xanny's, popping, da-da-da. Do you do any of those things? What are some other substances that you do use? Tell me some of your favorite artists. Do they do any of these? And then we start a conversation. Back in the day, I'll say Biggie was a big thing for me. Ten Crack Commandments. Don't get high on your own supply. I know right now there's a big song at the time. I'm in love with the Coco. So that is saying that I'm in love with cocaine. Very different than how I was raised, right? But I have a conversation of, I ask everybody about this. This is what I understand it to be. This is what I know, because I don't know everything, and the landscape has changed. You tell me what people are using, right? And then, you know, I found out, you know, folks are putting Jolly Ranchers and all types of stuff in their substances to make it taste better, to make it look different, and I learned that way, and we have a conversation, right? Right now I'm the cool doctor. I love it, but I cannot keep up with the times, so I just come from a place of, this is what I know, and then you tell me. What are the trends? What are people doing in school? Things like that. Yeah. This was awesome. I've been texting people the whole time. This was amazing. Okay. I just feel like Tupac wasn't on your list. I don't know why there wasn't. I'm sorry. I just felt, and I also was wondering about, like, films, Menace to Society, Friday, like, you know, those things that kind of also permeated around that same time when it was coming up, like, if you had thoughts on that. I'll let you, but the other thing about the case is also, I always look at, like, protective factors, because I love Mo. I watched the series as well, but, you know, he had a very strong family. You know, like, there's a lot of, like, there's risk factors, but also looking at the protective factors as well. Now, I think that what you're speaking to is exactly what was presented, like, we've evolved from hip-hop, not just being in the music, but it's the culture, right, and television, and film, and movies, all of that, so it's very pervasive, and it would be really limiting for us as providers not to have an understanding to bring this into the room, right? It's important, so how do we educate ourselves informally? It's not going to be in the New England Journal. You've got to, like, be in the world, right? So that's an important point, and the other thing that you said around protective factors is huge, right? Understanding that for a Mo, like, it was funny in the trailer, like, the Polish lawyer who didn't take off her shoes, there are certain things that understanding the culture and the commitment to family and the deference for his mother is important, so in ways in which I am kind of outside the culture, I don't understand, I will say, what are the things that are important to you that can be a part of your treatment plan, you know, that can help us have you live a better life? So that has led to bringing imams in the room, right? I'm not Muslim at all, but I've had imams come into the room because that is a protective factor, or having aunties come into the room. I'm an auntie, so I'm at every single appointment, right? What are the ways in which your family or your culture have been able to survive? Usually I say, as a black and brown person living in a racist America, how can we bring those things in the room to help you? And I think just being able to say that is important. Yeah. Yeah. Great talk. I really appreciate this. I have a lot of different thoughts. I'll try to be succinct about them. I'll say, anecdotally, I went to undergrad down in Dallas, specifically SMU, it's predominantly white, but obviously it's in the middle of downtown Dallas. And so I saw a lot of these things, like, firsthand in college. And one comment that I'll make as it pertains to the Sip and Scissor music video with the baby bottles, that's actually utilized because it's how they measure the lean, because it's a liquid. And baby bottles, I mean, if you have children, maybe you don't, but it's actually measured, has measurement increments. So you can actually be definitive, same way that you buy cocaine or weed in gram increments and you weigh it out, that's their measurement because it's a liquid. So they are very much synonymous, although I'm sure the psychological, the youthfulness and things like that is also a role in it. It does play an actual purpose in that. So what I'll say, anecdotally, is being able to talk about lean, Percs, Zannies in that way explicitly, I think is really important because, especially even looking back at my college experience, like, I didn't know that lean was an opioid, or like, I wouldn't know how to classify in that way at that time. And I know that that's a pervasive thing even now, moonlighting, I'm an NYU resident at the CPEP in our emergency department, obviously, you kind of tell a little conversation to the patient, but when you're asking about, okay, do you do heroin, fentanyl, they're like, oh, no, I don't do that. But they don't recognize that's the same class as these other things. So I think being able to have that colloquialism and being able to communicate in that way is really effective. So, but thank you. It's a great talk. Thank you. Hey. Yeah. So since y'all asked for a little bit of a self-disclosure to our exposure, well, first for a disappointing self-disclosure, no, I don't know what the G in the G thing stands for. Ah, somebody. Does anybody know what the G means for? Gangsta. Gangsta. Okay. That's a little gangsta thing. Thank you. Okay. We're doing okay. We're doing okay. We got something. Yeah. But what I can say is I did grow up in Houston. So I really found it helpful, you know, kind of shining the light on that part of Houston and its history, you know, growing up, you know, born in 92, high school, like early 2000s. We definitely, you know, you know, suburbs, you know, white, predominantly white area, you know, high school, basically, you know, we did know about like chopped and screwed music and there was kind of a sense of Houston pride there. And then college at UT Austin, you know, I went to, you know, music festival there, fun, fun, fun fest and Public Enemy was one of the headliners, surprisingly enough. Not known for being the most diverse of an audience that, you know, Austin Music Festival, but still was great to see. Did have two questions. One more kind of concrete and logistical, you know, I remember one of the early slides about Lean, like the Reddit survey, I think it was showing that it was like 75% were reporting it containing codeine. And so what I was curious about is like, you know, when you're talking about these epidemiologic like prevalence studies, is there like a concrete like case definition of like what Lean is? Like are we talking about dextromethorphan as well? Like does it have to contain codeine or like how do we define like Lean? That's a really great question. So Lean in many ways is what you call it. So people might be using promethazine only, but they have it in a styrofoam cup with soda and Jolly Ranchers and that for them is Lean or drank or seserve. So I think we are probably a bit more exacting about the chemical composition and the makeup of it than sometimes people who engage in Lean use are. But that's a really good question because I was, we were sort of surprised when we came across that to find that so few people were using the actual defined combination that we sort of know as Lean, that codeine plus promethazine combination, it's a good question. But I think it's important for what we know and there's not a lot written about Lean, right? Like literally we did the rapid review, there's not a lot written about Lean, but what we do know is that the majority of the time there is the codeine but not necessarily so. So I think the most important thing is to say this is my understanding of it, what are you using and do you know what it is? And a lot of times people will know because they make Lean, they make their own Lean or they know the person who's supplying it, but I love that at least we have a scaffolding of like for the most case it's going to have codeine and the minority of cases not always, right? But oftentimes it is combined and even if it's just only the codeine, it's often mixed with something, like whether it's taken with Xanis or something else, right? Yeah. Okay. Thank you. I have a second part question if I can ask. So I recently read When Crack Was King from Donovan X. Ramsey, which I found really informative and helpful. One of his arguments was basically that Dr. Dre's The Chronic Album was kind of part of a heralding of almost a harm reduction or help protective switch to making cannabis like the kind of cool thing to do for the generation after, you know, or like the generation who kind of was suffering under like parents who were suffering from the crack cocaine addiction primarily. And, you know, of course he saw, you know, Snoop Dogg and, you know, we all know Snoop Dogg and cannabis, but, you know, had the cannabis leaf on his hat there in the video. So I'm just interested in y'all's perspective on, you know, if you think that theory holds weight or not. I mean, listen, I think that, and I'll try and be brief because I want to get to all the questions and be done, but yeah, I mean, I think that there has a lot to do in terms of acceptability of what substance was deemed okay. And the reality is, and still to this day, that there are lasting negative impacts in terms of crack cocaine, specifically on many historically excluded communities. And so I do think that not only was it a virgin away from, I don't want to be a crack kid. I would never use that word, but this is, you know, I don't want to be seen as a fiend, but this is cooler and it's not going to lead to kind of the devastation, what we saw in our communities. Right. We're shifting now, even away from cannabis, I mean, people are using it, but the kind of cooler thing to do is pop pills and other things like that. But I think from that perspective, yeah, it makes sense. I just want to add real quick that the intersection of this type of substance use with music just really cannot be underscored enough. Like this is really intended to enhance the overall experience of listening to a certain type of music. And one of the questions that we also should pose to people, if music has been a big part of your life, for many of us it is, how can you continue to engage in listening to that type of music in the absence of lean, in the absence of chronic or dro? So really sort of thinking about that as part of our overall treatment plan and our discussions with patients who engage in substance use alongside their consumption of certain types of media. Thank you for this presentation. It was awesome. I loved your song picks. I wanted to ask, with regards to the White Lines song, in your personal perspective, what do you think it would take to get back to that kind of message in the community? And you think that's in, like, I guess, what are your thoughts on that? I'll go quick. I think we are shifting. I think we're shifting. Future just came out with a new song. And Future, most of his songs are about taking drugs. And with the increase in black and brown folks dying, he felt really guilty about it and was like, I can't do this. So anyway, I say all that to say, in his new video, he has, like, naloxone and these tricked out cards with buprenorphine on it and, like, all this stuff. And you have people like Offset from the Migos who was featured singing about bad and bougie who's like, this is not cool. Like, I don't want to be doing these drugs. You have folks like Lil Wayne, who I love, you know, who went to the Essence Fest, and he's like, I almost lost my life next to Lean. And people are trying to figure out how to take care of community through their music and still figure it out. So I think we're shifting. I really do think we're shifting. And I hope it continues. Yeah. I'll try to get one more. This dovetails with what you're saying and also with the lady that just recently spoke. Looking at the videos through the lens of an addiction psychiatrist, I think the part that I enjoyed the most, just because it felt so subversive, is the mixed messaging. Don't do this wonderful thing where I'm having a lot of fun. Make sure not to do it. And I think reflecting on that, that ends up becoming a big part of the conversation that I have with my patients. Like, look, I get it. To pretend that drugs and alcohol don't do good things for you is ridiculous. Of course they do. Otherwise, you wouldn't do it. But here we are, letting go of these tools that you've learned to utilize, and where do we go from here? And then kind of leaning into that. But it was just, it was really interesting to watch the videos and hear the words for, say, you know, white lines saying, don't do this thing. And clearly the imaging and all the messaging is the complete opposite of that. And again, I think going forward, I think good music demonstrates a tension between two different things. You know, being pulled between two different things. So, yeah. No, Ashe, I think you're right on with that. And I think for us as psychiatrists to pretend like there is not that dichotomy is silly. And I think we need to speak to that while also tapping into what are some other things that maybe can't make you feel as good as lean, but can still get you the access to those feelings that remind you of being alive and free. And it's okay to miss it. And it's okay to want that feeling when you are existing in a space where your very presence can be quite painful, right? So, how can we tap into the music without the substances and tap into the community and all of those things? I love that point. Yeah. We have to... I'm sorry. We are over on time. Okay. Well, these are the last two. Okay. You and then we'll end with the black woman. Yeah. As long as she makes sure she gets a chance. First of all, thank you. I somehow had a misconception that dextromethorphan was part of it too. And I don't know why. I had that misperception, I think because of the robo-ing. It used to be an earlier concoction. It used to be. It has now shifted. So, it's not commonly used anymore. Okay. Oh, that was quick. Awesome. Yeah. I'm glad we got it. Mine is really quick too. First of all, I did not know that Flavor Flav had a good era. Oh, yeah. Mind blown. Mind blown. Thank you. I now have something cool to talk about Thanksgiving dinner. But I think my question kind of, you've partially kind of answered it with the other lady. I'm thinking if hip hop had an era where it became very problematic, do you see it as being an avenue or a vehicle to use for like risk reduction and, you know, trending towards more like, okay, this is high risk behavior. I don't know. Maybe a rap battle with Kendrick Lamar. I don't know if... Yeah. I mean, I think about it the way that I think about it, like gospel rap. Like people are going to like gospel rap, but it's only going to get so far. I think that... And that's not very far, actually. Yeah. Listen, I think that hip hop is problematic. We saw it in the videos. It's extremely misogynistic. You know, the girls on the... Whatever. It is what it is. And it's amazing as well. Right? It's the reason why hip hop is as global and as big as it is and like hip hop stars are now rock stars, you know, you go into literally every place in the world, they know a hip hop artist. So I think that I don't want to spend so much time in terms of what are the problems within hip hop, but understanding how can we use hip hop as a way to understand the trends, what people are doing, how people are interacting with substances, and really thinking, is there a way for us to engage in hip hop without necessarily having all of the substances that go along with it? Some folks are figuring it out. Future is a big, big guy. And I say that because he is super successful and he does not use substances at all. Right? So I think that we have to be able to disclose, listen, one of the biggest hip hop artists of our time only talks about using substances and he himself doesn't use it. Lil Wayne, who was also really big, has stepped away. Beyonce, who was now married to Jay-Z, who's a drug dealer, talks about this ain't it anymore. So I think that there's ability to use hip hop as conversations for making change. And I think that's pretty awesome. But do I want to take away the chronic from Snoop? No. So it's the push and the pull. And how do we negotiate that? Yeah. But first we have to be aware. Okay. I'm done. I'm done. Oh, no. This could go on forever. It's so wonderful. Thank you so much. What rock stars, all of you. And Adeek. Wow. That was amazing. Well, the Fellowship Forum is happening now for any of you who are thinking about doing a fellowship. And for the rest of you, have a great evening. And thanks so much to our team.

hip-hop culture

Lean

opioid use

marginalized communities

urban South

addiction psychiatry

codeine

promethazine

DJ Screw

substance use

media portrayal

culturally informed care

psychoeducation