Welcome, everybody, for day three of the annual meeting. Daily housekeeping. Reminders about recording availability, CME credit and slide availability can be found in the virtual conference lobby in the conference information section. Those are items two and three in that section. I'm pleased to introduce the first event of the day, our second symposium, the racial origins and impact of the war on drugs, how do we heal? Today we are presenting two differing perspectives on the intersection of race and cannabis policy. This is a polarizing topic. Today's symposium contains two scientific presentations and two policy presentations that reflect the positions of the presenters and not AAAP. Immediately following this symposium's Q&A in the same room is a brief presentation with a different position about the lessons learned about the commercialization of dependency producing products in underserved communities. Tomorrow, our final symposium will address the topic from yet another international perspective. This year, as in prior years, we also have multiple workshops, papers and posters addressing topics related to cannabis. We're hopeful the combination of these perspectives, each presenting different voices, might provide some balance and expose our audience to a diversity of perspectives. I'm now pleased to introduce the symposium chair, Dr. Brian Abenoff. Dr. Abenoff is an addiction psychiatrist who followed his retirement as distinguished professor of alcohol and drug abuse research in the Department of Psychiatry at the University of Texas Southwestern Medical Center with his current appointment as clinical professor at the University of Colorado Anschutz Medical Campus. He's published over 200 papers and book chapters on the neurobiology and treatment of addiction and is editor-in-chief of the American Journal of Drug and Alcohol Abuse. In his semi-retired status, he serves as president of Doctors for Cannabis Regulation. We will now hear the 98-minute symposium recording, followed by a Q&A moderated by Dr. Kevin Gray. You may enter questions in the Q&A box at any time, and the presenters will answer as many as they can during the live Q&A. Hi, I'm Brian Abenoff. I will be chairing the symposium on the racial origins and impact of the war on drugs. How do we heal? First, I truly want to thank AAAP for giving me and my panel the opportunity to address these issues with AAAP. I know this is a tough conversation to have, and I appreciate being able to have this opportunity. We have three excellent speakers lined up and myself. The first, Dr. Rachel Knopps, will be speaking on an untold history of cannabis, a prerequisite for health equity. Second is Dr. Howard Stevenson, racism is feature, not bug. Racial literacy for healing daily racial stress and trauma. Dr. Brenda Curtis, speaking on the language of addiction, and I will be speaking, wrapping it up, with the role of addiction psychiatrist in righting the wrongs of the drug war. And I would add that the first three speakers are from outside AAAP, so I really appreciate them joining us. We will each speak for about 20 minutes, and we should have 30 minutes left at the end for a Q&A. All the speakers will be online, and it should be a very interesting and lively discussion. Thank you. Okay. Well, greetings today. It is a great privilege to teach about the untold history of cannabis in the United States, which I consider a prerequisite for understanding the concept of health equity, and even for those pursuing careers and are related to health equity broadly today. Here's my disclosure slide. I'm a founder of or involved with organizations advancing science-informed and health equity centers in and around the cannabis space, and no products or services will be discussed during this educational presentation. Today's learning objectives are to review an inclusive but not exhaustive history of cannabis in the United States, to dissect the effects of cannabis prohibition on the resilience and well-being of the communities targeted selectively by the war on drugs, and to discuss the emerging use of the term health equity as a framework for legislative and regulatory cannabis reform. So let's begin. These words have been credited to Thomas Jefferson, founding father and third president of the United States, and he said that hemp is of the first necessity to the wealth and protection of the country. And now the wealth and protection of the United States was and is vitally important. So the question I asked myself early on was, why? It's pretty odd, right, that from 1970 to 2018, hemp itself was classified as a dangerous and otherwise useless Schedule 1 drug. So we have to ask the additional question, why, right? How does a plant held in such high esteem fall so far? And the answers make the history of cannabis quite sorted, which might be why we don't talk of it much. But there's a big but, right? With the federal legalization of cannabis on the horizon, we really have to look in the mirror to our history, lest we repeat some of these mistakes or make new ones. So let's get to it. And let's start at the beginning-ish, I like to say, when several millennia ago, ancestors across Asia and Africa, the Middle East, and Europe were using cannabis as medicine and nutrition. The documented use of cannabis as medicine dates back as far as 2737 BCE, first recorded in the ancient Chinese pharmacopoeia, the Shenan Pen Chao Qing, which detailed the agricultural purposes and medicinal characteristics of plants. And according to that text, cannabis was included as a fundamental herb for medical use. Now we know today that cannabis is made up of myriad cultivation varieties of various phenotypes and chemical profiles as a result of the crossbreeding of land races sourced from all around the world. But the cultivation varieties of cannabis that we categorize today here in the U.S. as hemp are believed to have first made their way from the East to North America, arriving in the colonies around 1606. And historical accounts confirm that Jamestown, the first English settlement in North America, grew hemp to make ropes and sails and clothing out of hemp's unusually strong fibers. Hemp demonstrated such incredible utility, in fact, that in 1619, the British crown mandated that every property owner in Jamestown grow 100 hemp plants for export for its versatility, making it illegal not to grow it. But in the same year, we saw the first cohort of West Africans arrive in the Virginia colony, effectively establishing the institution of slavery in America. Hemp production in the colonies boomed as it was vital in almost every part of the industrial society of colonial times. It was in high demand, including for its use in baling and bagging cotton, which made the cotton industry its primary market at the time. In 1760, here George Washington, who, as it turns out, farmed hemp at Mount Vernon, predicted that hemp could be more profitable than tobacco, but recognized that its high labor costs diminished its profitability, making its cultivation, harvesting, and processing ultimately dependent on slave labor. Now like Washington, Thomas Jefferson participated in hemp production, primarily at his Monticello and Poplar forest plantations. He's said to have bought his very first seeds in 1774, and acknowledged in an 1815 quote that hemp is abundantly productive and will grow forever on the same spot, but the breaking and beating it, which has always been done by hand, is so slow, so laborious, and so much complained of by our laborers. So the harvesting and processing of hemp by hand was difficult and dirty work during those days, but it also required a large labor force, and thus the ongoing exploitation of slaves, which kept costs low and white plantation hands clean. Many scholars think that without this sort of exploitation, that hemp production and really that of any crop would not have flourished so fruitfully in North America, but as we all know, they did, right? And as tobacco grew in popularity in Virginia, the bulk of hemp farming and its slave labor migrated south into the Carolinas and Mississippi, and then west into Missouri and Kentucky. And in 1775, Kentucky saw its first hemp crop and would eventually become the hemp production capital of the United States, and it's been said that if it were not for hemp, Kentucky would have never become a slave-owning state. By 1850, hemp was flourishing, and in that year, the U.S. census counted 8,327 hemp plantations, spanning around 2,000 acres each, and Kentucky production would amount to 40,000 tons of hemp at its peak in 1959, and at the time was considered the third largest agricultural commodity behind cotton and tobacco in total production, a pace that, yep, demanded free labor. In his 1951, A History of the Hemp Industry in Kentucky, author James F. Hopkins wrote a historical account of a Lexingtonian who stated that, quote, it was almost impossible to hire workmen to break a crop of hemp because the work was, again, very dirty and so laborious that scarcely any white man will work at it. Hopkins accounts further that Kentuckians sometimes referred to hemp as the nigger crop, owing to belief that no one understood the eccentricities as well or was as expert in the handling it as the negro, end quote. Now also in 1850, while hemp was experiencing peak production in the United States, cannabis was added to the United States pharmacopeia, having been introduced to Western medicine by Dr. William O'Shaughnessy in 1837, bringing his knowledge of the medicinal nature of the plant from India to England and then on to the United States. Now quickly note on this slide that by early 1900s, cannabis accounted for more than 50% of prescriptions written by physicians in the United States. It was a popular over-the-counter remedy, and it was stocked in the medicine cabinets of families across the country. Prominent pharmaceutical companies that you'd recognize by name, like Eli Lilly and Park Davis, which is now Pfizer, were the major producers of cannabis medicines from the mid-1800s to the early 1900s. But I don't want to get us too far ahead because this slide is important. In 1859, at the height of hemp production, Kentucky produced an equivalent of today's $161 million worth of hemp. But production would soon decline during the Civil War years of 1861 through 1865 as a result of the significant disruption the war caused to the institution of slavery. Now hemp's history didn't end there. There are relics of the past that do indicate to us today that hemp did thrive in high esteem through the early 20th century. Here in the Andrew Jackson $10 bill in 1914, it was printed on hemp paper, right? It also dons an illustration of hemp farming, and we know that by the length of the stalks in the rendering. Ironically, also, you'll soon find out that this bill includes the signature of then Secretary of the Treasury, Andrew Mellon. Now come the 1920s, the U.S. was introduced to smokable cannabis by Mexican farmers fleeing the conflict of the Mexican Revolution. Social consumption also made its way into the jazz community and the Black community at large, a use that has been accounted for in record by these early consumers as a form of self-medication, and particularly to the marginalized people who lived in poor and oppressive conditions. In his biography, Louis Armstrong reflected that it makes you feel good, man. It relaxes you. It makes you forget all the bad things that happened to a Negro. It makes you feel wanted. And when you're with another tea smoker, as they called it, it makes you feel a special sense of kinship. And so it's interesting that consumers associated cannabis in that way because their experiences were, in fact, being substantiated. In 1924, Dr. Charles Sajo highlighted three areas of indication of cannabis medicine in his analytic cyclopedia of practical medicine, as first a sedative or hypnotic in the treatment, and I'm going to read these, of insomnia, senile insomnia, melancholia, mania, delirium tremens, chorea, tetanus, rabies, hay fever, bronchitis, pulmonary tuberculosis, coughs, paralysis, agitans, exophthalmic goiter, spasm of the bladder and gonorrhea, as an analgesic for the treatment of headaches, migraines, eye strain, menopause, brain tumors, tic, doularo, neuralgia, gastric ulcer, gastralgia, TBs, multiple neuritis, pain not due to lesions, uterine disturbances, dysmenorrhea, chronic inflammation, menorrhagia, impending abortion, postpartum hemorrhage, acute rheumatism, eczema, senile paritis, tingling, formication and numbness of gout, and relief of dental pain, and then lastly here for other uses to improve appetite and digestion, for the pronounced anorexia following exhausting diseases, gastric neuroses, dyspepsia, diarrhea, dysentery, cholera, nephritis, hematuria, diabetes, mellitus, cardiac palpitation, vertigo, sexual acne in the female, and impotence in the male. But, right, but medical utility could not prevent what had already been set in motion. Here in 1930, the U.S. Secretary of the Treasury, again, Andrew Mellon, appointed Harry Anslinger as the director of the newly established Federal Bureau of Narcotics, which is today's DEA, but he did so within the Department of the Treasury, right, and he was simply appointed to address the unregulated drug market's circumvention of taxation, not to defend public health, but to address tax evasion. And by 1936, it was understood that cannabis innovations in the construction of food, fiber, fuel, medicine, and paper industries could topple the interests of industrialists like Carnegie, DuPont, William Randolph Hearst, and the like, threatening their burgeoning petrochemical, synthetic, textile, and paper empires, respectively. So, also interesting, he, as history tells it, Anslinger was married to the niece of Andrew Mellon, who was not only the Secretary of the Treasury, but a financier of DuPont. So, many believe it was politics as usual in 1936 when the regulation of cannabis evolved from a matter of taxation to one of racial villainization, aligning race with use in order to galvanize public support for prohibition. And the following year brought the Marijuana Tax Act, the first federal strike in the battle that would unseat cannabis, hemp included, as an agricultural commodity in medicine and criminalize it. This act here deemed the cultivation, production, prescription, retail, possession, and use of cannabis illegal without prior procurement of a marijuana tax stamp, which placed significant compliance and tax burdens on cannabis prescribing physicians. Prior to it being signed into law, however, interesting trivia, the American Medical Association testified in opposition to it. The AMA strongly opposed its passage for a number of reasons, including whom it taxed, physicians and pharmacists, the secrecy involved in preparing the bill, and then the dubious claims used to validate its passage, and not the least of which being the use of the term marijuana itself, because at the time marijuana was a new word in the American lexicon. The AMA thought that using the then unfamiliar term marijuana rather than the word cannabis was a ploy which would blind physicians to what the act was doing. AMA spokesperson, physician, noted drug policy expert and lawyer, Dr. William Woodward testified before Congress stating that the AMA knows of no evidence that marijuana is a dangerous drug. Now written in 1937 but published after the Marijuana Tax Act stamp was signed into law, the magazine Popular Mechanics dubbed the new billion dollar crop hemp with over 25,000 uses and applications, calling it the most profitable and desirable crop that can be grown, echoing the prophetic statements from Thomas Jefferson just a couple hundred years earlier. And just a few years later in 1941, Henry Ford presented his groundbreaking invention, a car made out of hemp plastic and fueled by hemp ethanol, which has no doubt inspired the automotive industry today, as we are seeing the likes of B&W and others shoring up their hemp supply chains. Ford's goal was specific, he wanted to grow automobiles from the soil. Come 1942, amidst all this confusion and propaganda, cannabis was removed from the U.S. Pharmacopeia under pressure from federal government, under the premise that it was a dangerous drug and that it would cause insanity and depraved criminal acts. At the same time, the USDA initiated the Hemp for Victory program during World War II after the country's supply from the Philippines had been cut off. The U.S. Navy needed hemp, they needed it to create ropes, so the tax act was lifted momentarily to allow for production. Meanwhile, the LaGuardia Committee and New York Academy of Medicine began to study the social and medical implications of cannabis use, and their 1944 report found no associations between cannabis use and drug addiction or crime. Now these dueling ideologies were not only apparent in industry, the 1960s here brought some of the first breakthroughs in cannabis science, just not in the United States. It was in Israel, with U.S. government funding, that renowned cannabis researcher Dr. Raphael Mishulam identified the chemical structures of the major active constituents in the cannabis plant, hemp included, the phytocannabinoids CBD and THC. The backstate side, we had President Nixon sign the Controlled Substances Act of 1970 into law to effectively replace the Marijuana Tax Act, ushering in what would soon be declared the War on Drugs, right? The CSA, as it is known today, classifies cannabis as a Schedule I drug alongside heroin and LSD and psilocybin, representing that it has no accepted medicinal value and carried a high potential for addiction and abuse. At the same time, Nixon appointed the Schaeffer Commission, formerly known as the National Commission on Marijuana and Drug Abuse, which he ultimately ignores when the commission finally concludes its position on cannabis in 1972, which called for cannabis decriminalization, noting a complete lack of evidence to support the notion that it was dangerous or addictive. Oregon would heed the report's direction, however, as the first state to decriminalize cannabis in some way in 1973. Now, on June 17, 1971, Nixon publicly declared a War on Drugs and dramatically increased the size and presence of federal drug agencies pushing through mandatory sentences. Now, for time's sake, I will not play this video today, but as we well know, the War on Drugs would go on to ensnare millions of people in the criminal justice system for cannabis-related activity. And this war permeated into higher education as well, as subsequently under President Ford, American universities were prohibited from studying cannabis while research instead continued abroad. Want to join me here? Here we go. On the research front, the late 1980s saw renewed curiosity amongst U.S. researchers who wanted to know how THC worked. And they were able to study this despite research restrictions by using a derivative of the already FDA-approved THC analog called Marinol. Yes, in 1985, the FDA approved Marinol, a synthetic THC, before anyone understood how it worked in the body. But despite that controversy, it was by using a radio-tagged synthetic THC derivative that the first cannabinoid receptor was revealed, as it locked into and unveiled an extensive receptor network heavily concentrated throughout the brain and body. And by 1995, researchers had identified the foundational components of the endocannabinoid system, including two primary cannabinoid receptors and the two primary endogenous human cannabinoids that work on those receptors. In 1994, Nixon chief domestic advisor John Ehrlichman gave an interview to Harper's Magazine in which he was quoted as this. The Nixon White House and the Nixon administration and their campaign had two enemies, the anti-war left and Black people. Do you understand what I'm saying? We knew we couldn't make it illegal to be either against the war or Black, but by getting the public to associate the hippies with marijuana and Blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did, end quote. In 1996, conflicting opinions about the medicinal nature and medical utility of cannabis became more complicated when legislation in several states directly contradicted federal laws and policies. California was the first state to legalize medical cannabis in 1996, and Alaska, Oregon, and Washington swiftly followed suit in 1998. In 1999, the U.S. government, as represented by the Department of Health and Human Services, filed a patent that was awarded in 2003 on cannabinoids as antioxidants and neuroprotectants, and I quote, that are useful in the treatment and prophylaxis of a wide variety of oxidation-associated diseases, such as ischemic, age-related, inflammatory, and autoimmune diseases. The cannabinoids are found to have particular application as neuroprotectants, for example, in limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer's, Parkinson's, and HIV dementia. And so it's against this backdrop that well into and beyond the turn of the century that research on the endocannabinoid system continued and is still ongoing today. But while the science is very exciting, we must recognize how controversial scientific advancement in commercial legalization is, when in 2013 the ACLU reminded us of a sobering fact. They released a study that revealed that Black people in the United States were up to six times more likely to be arrested for cannabis, despite white people using it at slightly higher rates. And moving on to 2018, we saw the farm bill finally remove hemp entirely from the definition of marijuana, and as a result from the Controlled Substances Act, paving the way for the CBD hemp boom. In June of that same year, the FDA approved Epidiolex, a CBD plant extract developed by GW Pharmaceuticals, for the treatment of two rare and difficult-to-treat forms of epilepsy. In September of that same year, the DEA classified it as a Schedule V controlled substance. All right, in 2020, the House passed both the Safe Banking and the MORE Act in an attempt to create safe harbor for businesses in good standing, erect a taxation model, and to address the failed war on drugs through automatic expungements at the federal level. Neither bills have made it to the Senate to date. And then finally, we're here at 2021, where we now have 36 states or territories in D.C. with legal medical programs, and 19 states, two territories, and the District of Columbia with legalization of small amounts of cannabis for adult use. But despite this picture, Mississippi's Supreme Court this year overturned the will of its own voters by throwing out medical legalization while simultaneously denying the appeal of a Black man named Allen Russell serving life in prison for simple cannabis possession. So with this history fresh in mind, we can begin dissecting the effects of prohibition on impacted communities. And let's switch gears to talk about health and sickness in our country, where 1 in 10 U.S. adults is suffering from heart disease, 1 in 5 from heart pain, fibromyalgia, depression, anxiety, PTSD, or IBS, 1 in 3 from insomnia, high blood pressure, or prediabetes, nearly 1 in 2 from cancer or chronic headaches, and 1 in 1.5 from some form of chronic stress. But Black adults are sicker, right? Black adults are 1.2 times more likely to die from cancer, 1.3 times more likely to be obese, a major risk factor for diabetes and heart disease, cancer, and other metabolic disorders, 1.5 times more likely to develop high blood pressure, the leading cause of heart disease and stroke, 1.6 times more likely to develop diabetes, 2.1 times more likely to die from it, 1.2 times more likely to develop asthma, 2.8 times more likely to die from it, and are 1.4 times more likely to die from COVID-19. With respect to mental health, Black adults are more likely to have feelings of sadness, hopelessness, and worthlessness than White adults, while Black youth are more likely to attempt suicide than White youth. In 2020, where we saw a 93% increase in the diagnosis of anxiety and a 62% increase in depression, we saw that Black adults had the highest average percent change over time for both anxiety and depression, and Native Americans for suicidal ideation. So as we reviewed, and as the evidence of history suggests, sitting at the root and still choking the state of Black well-being are U.S. cannabis policies. And this slide hits the point home as the ultimate summary, right? This remarkable illustration depicts the effective use of two cannabis-fueled institutions, slavery and the prison-industrial complex, to divest the Black community in particular of its access to well-being. And this is incredibly important for those of us working within medicine today to understand that for centuries on stolen Indigenous land, enslaved Black people grew hemp to peak production alongside cotton, making this country very wealthy. And that just six years after the Civil Rights Act of 1964, the 1970 Controlled Substances Act made cannabis possession illegal, ushering in an ongoing disproportionate enforcement of prohibition laws in Black and other racially targeted communities. A process that imprisoned breadwinners and heads of household to disrupt the nuclear family, to sustain a prison pipeline for profit and perpetual recidivism. It has justified disenfranchisement and depletion of community resources. It's resulted in limited job opportunities, sending the wealth building of these communities out of pace with the majority of population. It's perpetuated poverty and mental health problems and has made patients of color, Black patients in particular, all of us fearful of learning about cannabis as medicine. Now this slide helps us frame the negative impacts of prohibition on well-being a bit more academically. On this slide are the four determinants of well-being, and stratifying well-being in this way allows us to better understand more tangibly the depth and totality of prohibition's effects on both individuals and communities, whereby we can now demonstrate how cannabis prohibition has contributed to the poor states of economic, environmental, and social determinants of health and well-being. Which brings us to the definition and meaning of health equity, the assuredness of access to full health and well-being. We measure this, we can measure this, it's measurable is my point. Health equity cannot be achieved unless each pillar as represented here is optimized for any and every given community. And the last slide here brings us to some sort of a solution, right? Cannabis health equity, what does it mean? It's the assuredness that cannabis policies, regulations, and practices leverage the economy, taxation, research, and utility of this amazing plant to achieve health equity. And we know this to be a viable solution, giving the plants 50,000 uses and counting across its agricultural innovations, its industrial innovations, its innovations in medicine and nutrition, right? And that brings me to the end of my talk, the Untold History of Cannabis, and just a brief look into how we use the definition of health equity in applying it to cannabis to address the socio-ecological and medical, physical, spiritual, and mental well-being of the communities harmed most by the war on drugs. Hello, my name is Dr. Howard Stevenson, and I'm going to speak on racial literacy with the notion that racism is a feature, not a bug, when we think of mental well-being. So some assumptions about the work that I do around race and racism is that racial encounters are extremely important. In many respects, the work that I do is called racial socialization. And I would argue that in our society, we are all much better at learning and knowing how to dodge race and racial moments. Racial encounters, I would argue, are also more important than symbolic gestures of progress around race, like the first Black president, because they are in our face, these racial encounters. I would also argue that I'm not suggesting that systemic change is unimportant. In fact, though, I would say that without relationship change, systemic change will not last, should we actually get systems to divorce their policies and practices from segregation and distance. I also would argue that legal approaches are important, but they are not going to manage the emotional trauma of what happens daily in the lives of Black and brown people. We are more interested in competence over character, and way too long the notion of being a good person has been a substitute for actual competence in engaging in problem-solving racially stressful moments. And I would also say that our goals are to understand the proximal spaces, that if we can change racial outcomes in proximal spaces, not only can we improve relationships, but also climates in our treatment and supportive services. The way that we see race is, in a sense, both and. We see it as what we are both struggling to do, as well as not doing. And either or, right, wrong, reasoning, is what I would argue is debilitating to humanity in the sense that we can't see each other or know each other's stories. And part of the idea is we're proposing, what if we took a both-hand approach to our struggles in race relations? What if we saw each other as both and, both blind and visionary, where we want and argue for change, but also resist it at the same time? So when we think about racial encounters, we're talking about Shelley Harrell's notion of how we are overtaxed and don't know how to regulate our emotions, our bodies, our thoughts, which all affect our engagement or voice. And that sometimes these encounters are so intense, they're threatening to us. And if you look at the literature on racial threat, you'll find that racial threat distorts our perceptions. In the work of Claude Steele, racing mind is when our brains go on lockdown and we lose peripheral vision and hearing, that the onslaught of both historical trauma over generations and across the lifespan leave us fatigued, and people of color in particular, perseverating on the past experiences of dehumanization related to race, but also fearful the future experiences. Then there is a notion of the presumption of dangerousness in every place that people of color walk in. That has to be considered. We also have to understand that in some neuroscience research, the notion of racial threat, the face in this case, just showing the faces of black and brown men in this article, identified the fear response as so primitive that it matched the same response we have towards spiders and snakes. And if you realize a moment is a long period of time, this threat reaction of fight, flight, and fright is not a small thing. This same reaction of fight, flight, and fright is true towards black boys compared to white boys at 10 years old, according to Philip Goff's wonderful work. He identifies this as a form of dehumanization where we don't see children about as they are and exaggerate their age perceptually, but also true for five-year-olds. When I think about the issue not only for boys but also for girls, the notion of perceiving children to be more adult-like is justification for not providing protection, nurturance, and support. This adultification is not a good thing. When I ask people around the country, which grade do you think students of all racial groups are expelled the most, most people say seventh and eighth grade. And I think that's primarily because they hated their middle school years and hated how they looked and how people looked at them. The answer, though, is pre-K. And this is a racial problem. This is an adult problem by my good friend and colleague, Walter Gilliam from Yale University, who's been studying pre-K expulsion, where the rate is three times that for K-12 students, but it's greater for children of color and that it's the way that adults misperceive or overreact or are stressed by these children as young as preschool. Racial stress not only harms our perceptions, but it harms our health. And this is where the importance of understanding the impact on substance use is very important. The same way that we think about racial stress and threat affecting how we see people and whether we are presuming dangerousness of them, we also, it affects the lives and experiences around health, cardiovascular disease, breast cancer, Black women, poor sleep quality in teens across the racial spectrum, that this is not a simple matter of what happens in a face-to-face encounter. This stress lingers with us. If we look at the history of racism in substance use, stress is an important factor. If you look at some who've argued that racism and discrimination are not only linked to substance use among subgroups of youth, but subgroups of adults of color, the treatment availability for these services for Black, Latinx, and Indigenous people is less than that of whites in this country. A key dynamic for communities of color is the underappreciation of historical trauma on substance use and the underappreciation of Indigenous culturally responsive healing practices by clinicians and mainstream service agencies. This has hampered the treatment and resolution of some of these notions and issues. Some of the recommendations to reduce these gaps in addiction treatment include more training around unconscious bias and stereotyping. In our work, we have been more interested, again, around racial literacy. Not only does racial stress and threat affect our perceptions of others, our physical and emotional well-being, it affects our recovery when we are actually trying to get help, as well as those who are healers. Now, in our work, we think the narratives of Black and brown people have been so distorted, it affects our treatment services. It affects how we see them as human. This proverb, the lion's story will never be known as long as the hunter is the one to tell it, is really about how much we know our own racial stories. The point that we want to make in our work around racial literacy is that everybody has a powerful and important racial story. My racial story is not better than yours, and yours is not better than mine, but it is a problem if we do not appreciate or know our own racial stories. We can't blame the left or the right. In that sense, there's something powerful about healing and storytelling if we are embracing a narrative that fits our people, our community, and our culture. How do you combat racism? Well, sometimes you've got to recognize that not everybody's going to love your story. This wonderful poem by Nayyirah Y. Eads suggests that some people, when they hear your story contract, others, upon hearing, expand. This is how you know. This is referring to the importance of a treatment or healing approach that involves how do we deal with those who do not appreciate our humanity or our children. This work is rooted in a lot of research for years that I and others have done around racial socialization. We've learned a lot about does it matter when parents talk to their children about race, and it does. In fact, talking about race in general has some positive benefits, including how preschoolers think and behave in competent ways compared to those preschoolers who haven't gotten feedback about navigating the politics of race. Racial socialization is also linked to greater self-esteem, anger management, anxiety management, all of which are related to academic progress in young people and adults. Even parents who are getting very good at talking to their children around race receive a bump by reducing their parental worries, because parents of color worry incessantly not only about parenting, but parenting children of color who might be perceived as monsters. The worrying about racial profiling is a measure we created, and we found that those parents who are better at talking to their children about race tend to be less worried if they've done that job well. We've looked at some of our research in different professions, but in particular around teaching, when you compare white teachers to teachers of color, there's a disparity in not only how much socialization those teachers had around race during their childhood, but also how much they understand racial discrimination or have experienced it, how they navigate the politics of race in a school, and how they also pick up on how the climate in schools are dehumanizing to students of color. teachers of color are better prepared to see these things than white teachers, and in general, even are significantly less threatened when a face-to-face, in-the-moment racial encounter happens with their students. Now, in many respects, while race is a disparity, we also know that racial socialization is a better predictor of positive interactions with teachers and students over and above race. How much do I know how to navigate these issues? We can also assume that in other professions, not just education, psychiatry, psychology, therapy, face-to-face encounters, the more that those professionals have support when they're navigating the politics of race and facial encounters, face-to-face encounters, the more stronger they are gonna be in engaging people of color and helping them navigate the challenges that they are facing. Now, the theory behind our work, it's called Racial Encounter, Coping, Appraisal, and Socialization Theory, RECAST for short, and what we think of as healing and a part of the notion of racial socialization is we ask why does racial socialization seem to be linked to these positive outcomes? And one of the reasons is in the case of children or teenagers or young adults is that when they have had more conversation about what to do when somebody comes at them because of their difference or dehumanizes them, having had some exposure and skillsets taught, they are less stressed. And by being less stressed, they don't have the fight, flight, or threat reactions. And that also means over time, it builds their confidence to engage rather than run, fight, or freeze during a face-to-face racial encounter. But key elements of a competent racial socialization approach, which we think of in families, but also can happen in social media, can happen in psychiatry, can happen in substance use treatment, has to have some elements that challenge dehumanization. One of those elements is humanity affirmed. Are folks feeling protected from both physical and mental harm? Is there a way in which there is approach to redirect self-destructive thinking and hold people accountable for dehumanization? And whether or not we can connect patients, clients, children to thriving relationships outside of those of us who have their best interests at heart. So racial literacy, addition to racial socialization is based on this. When we talk to parents about, when they talk to their children about race, some were very clear, but some were very vague. And the vagueness left a lot of young people telling us across the country, being proud to be Black is nice, but I don't know how that's gonna help me when somebody is really mistreating me in a negative way. And so racial literacy is defined as the ability to read, recast and resolve racially stressful encounters. And it's more skills-based. It's more about social and emotional learning, about emotional regulation in the context of a threatening moment. And it's really, how do I reduce my threat in a moment where I can come out of the situation feeling like I have more agency? And so three skills, reading racially stressful encounters about do I see the racial elephant in the room? And do I accurately interpret the meaning of that elephant moment? Recasting is, do I see, not only see the elephant, but do I also notice the impact emotionally, stress-wise of that elephant racial moment on my body, my thoughts, and my emotions? And so how do I positively reframe an impossible racial encounter, which could last literally 30 seconds into one that is possible from a tsunami to a mountain climbing experience from on a scale of one to 10, from eight, nine and 10, how do I bring it down to a five, six or seven? And we use a mindfulness approach called calculate, locate, communicate, breathe and exhale. Calculate is about what feelings I'm having right now and how intense are they? So I'll give you an example. Let's say I'm angry that someone has just called me a racial slur and I realized I'm angry at a nine for that slur. And let's just say that the person who's called me that slur is somebody I thought I could trust. So I'm angry at a nine, I'm sad at a seven, calculate. Locate is where in my body do I feel those feelings? I feel the anger on the back of my neck, like my neck is on fire, that's how angry I am. And I'm sad at a seven in my gut because I thought I could trust this person and feels like betrayal, kick in the gut, that's locate. Communicate is what am I saying to myself through self-talk and what am I saying to myself through images that come to mind? Let's say self-talk, I said to myself, I can't believe this dude called me this and I thought we were friends, self-talk. And memory or imaging is around to what degree do I remember the last time somebody called me that? I can see in my mind's eye, I was in college, they were playing, Roots was on the whole week, the whole campus was intense. Calculate, locate, communicate, breathe and exhale. Breathing in very slowly and exhaling out even slower allows oxygen into my brain, opens up that racing mind that's Claude Steele talks about, the peripheral vision that I've lost, the peripheral hearing that I've lost and so that I can see and hear better and make better decisions. So reading is around seeing the racial elephant in the room, recasting is reducing the stress of that racial situation and resolving is do I make a healthy decision that's not an underreaction or overreaction during the racially stressful encounter? An underreaction would be when I pretend that the situation of the racial moment didn't bother me when it really did bother me. Or overreact and that's when I curse at everybody including the cats, the dogs and inanimate objects and they had nothing to do with the racial moment. Resolving racially stressful encounter is not about solving racism, it's about managing the stress and anxiety within me so that I can make a socially just decision, not just talk about social justice as many of us do but don't know how to behave in a social just way in a small period of time. So reading, recasting and resolving are the skill sets that we teach anyone from third grade into adulthood. In several projects we've been doing this work, can we talk around teachers and students in schools? We've used African-American barbers as health educators, amazing counselors and they do this work while cutting the hair of their patrons of black men between the ages of 18 to 24. We've used basketball as a site for managing stress in the moment in real time as well as training around these issues in a nonprofit we call the Lion Story Village where we abuse racial literacy approaches and train professionals, students, educators across justice, health and education settings. We've even supported and advised to Sesame Street where we understand even very young children need practice in how to speak up for themselves. So in some of our work we'll also ask large groups of people to begin some of the notions of managing the stress of racism. And we think again, this is useful in the substance use arena because knowing your racial story is important. When we ask people to give some indication of what they remember racial socialization while growing up and we'll just give them a very short period of time, most people are frightened to death. They have threat responses around sadness, shame, anger, guilt and embarrassment. And we ask them to do it again either with themselves or with a partner. Like let's say you had a do-over and if you wanted to change some of the narrative of that racial socialization growing up, what would you do? And the answer comes out very differently. Five minutes later, relatable, some sadness but understanding, some pride, curiosity. Now imagine if we can change how people think about going back to their racial narratives and see not just the ugly or the rupture that Wayne Noble's beautiful psychologist has talked about but the splendor as well that we can maybe in a short period of time make differences in how people perceive or take the risks of engaging in their racial narratives. We also see that this work comports with a lot of the work of finding your voice to speak up against injustice, wherever you find it because that speaking up can prevent future injustices. Now, what am I saying to sum up? Racial literacy is around in many respects it stresses us out, right? Racial moments can stress us in our bodies, feelings and thoughts. Racial threat impairs our ability to perceive others accurately in decision-making and behaviors and feeling threatened as human, we could say but avoiding that threat as if it does not exist will leave us engaging in unethical and incompetent behavior. I would argue that we can do something about racial stress in the moment, but only if we face it. This is about being courageous, asking for help and practice. It is not about blame but it is about accountability and preparation. So the questions we ask folks, are we prepared or not? I would just remind you of Martin Luther King was also at one point his letter from a Birmingham jail not a prophet or preacher, but a parent where he got stressed when he thought about saying when he said, you suddenly find your tongue twisted and your speech stammering as you seek to explain to your six-year-old daughter why she can't go to the public amusement park that has just been advertised on television and see tears welling up in her eyes when she is told that Funtown is closed to colored children and see ominous clouds of inferiority beginning to form in her little mental sky. We are living in a time like Fred Douglas described there are those around us who profess to favor freedom and yet depreciate agitation are men who want crops without plowing up the ground. I think our struggle is a moral one, a physical one but also a relational one. And in the area of substance abuse we cannot discount the historical trauma or the particular practices of indigenous cultural healing that has storytelling at its center. So the question we ask everybody is what's your racial story? Thank you. Hello, I'm Brenda Curtis and I'm Chief of the Technology and Translational Research Unit at the National Institute on Drug Abuse. At the NIDA Intramural Research Program my research pairs evidence-based novel methods and emerging technologies to address the societal needs for empirically validated drug use interventions. I also co-chair the NIH Stigma Scientific Interest Group using natural language processing, digital phenotyping and big data methodologies. I focus on enhancing precision assessments for substance use and behavioral predictors using intensive longitudinal data and integrating passive smartphone sensor data. I have no relevant disclosures and what I'm going to discuss today are based on current research in the academic literature. Today I will focus on the intersection of stigma, racism and substance use disorders and the role that language plays. So what is stigma? And discrimination. So stigma is a multidimensional construct that can manifest in a variety of ways. Stigma is defined as a label and a stereotype. For example, the label calling someone an addict links a person to a set of undesirable characteristics. For example, them being a criminal and being dirty or untrustworthy. And that works to form a stereotype which are beliefs held about a group of people such as people with a substance use disorder believing that they're criminals. Discrimination is the actual manifestation of actions that people take when they believe a stereotype and then associate the label with others. I have to pause here and I like to discuss briefly the war on drugs. Over 50 years ago, on June 18th, 1971, President Richard Nixon addressed America and declared that drug abuse was America's public enemy number one. Despite Nixon mentioning rehabilitation, research and education in his speech, the war on drugs has been offensive with military interventions, storing arrest rates and aggressive sentencing predominantly on black, indigenous and people of color. So when people ask me what has the war on drugs got us and ask many other people, we'll say it's been a war on people of color. Blacks and whites use cannabis at similar rates. But black people are nearly four times more likely to be arrested for cannabis possession than white people in the US. Unfortunately, the increasing number of states legalizing or decriminalizing marijuana has not reduced national trends and racial disparities which remain unchanged since 2010. Every single state in the US, black people were more likely to be arrested for marijuana possession. And in some states, black people were up to six, eight or almost 10 times more likely to be arrested. And again, remember blacks and whites use cannabis at the same rates. Whites and blacks do not differ all that much on their other drug use. However, blacks are subjected to having their substance use criminalized to greater degrees than their white counterparts. In the US, blacks and Latinos account for about a quarter of the population, but make up about 75% of the people in federal prisons for drug offenses. Also in the federal system, the average black defendant convicted of drug offenses will serve nearly the same amount of time, almost 60 months as a white defendant who would be convicted of, who's been convicted of a violent crime. People of color account for 70% of all defendants convicted of charges with a mandatory minimal sentence. Prosecutors are twice as likely to pursue a mandatory minimal sentence for black defendants than a white defendant charged with the same offense. And black defendants are less likely to receive relief for mandatory minimums. On average, defendants subject to mandatory minimums spend five times longer in prison than those convicted of other offenses. Picture a thousand words, I think that's the phrase. How we illustrated opioid use and crack cocaine use provide great visuals for my point. Opiate use became a problem when we felt it impacted white people. White women who had children and use opiates were seen as victims. We did not do this, we did not penalize them for their use of prescription opiates, which was used more by whites at the same degree as we did heroin, which was used more by an urban population. Now we contrast this to how women were depicted during the crack cocaine epidemic, specifically black communities. We had much harsher penalties were imposed for crack as compared to free-based cocaine, and free-based cocaine was typically used in the white community. Also, there were higher rates of African-American women being portrayed in the media with negative images. Black mothers who used crack were not portrayed to elicit sympathy, they were vilified. These are just a few examples of the kinds of racial discrimination and stereotypes that we've seen that have been long embedded in our drug laws, our policing, and the impact of the US and how we've decided to treat individuals. We as scientists, we've been silent too long, and silence is like a cancer, it only grows. Dr. Volkow just recently published a paper on the need to stop criminalizing addiction, and I will quote her. We have known for decades that addiction is a medical condition, a treatable brain disorder, not a character flaw or a form of social deviance. Yet, despite the overwhelming evidence supporting that position, drug addiction continues to be criminalized. The US must take a public health approach to drug addiction now in the interest of both population wellbeing and health equity. And while considerable progress has been made in recent decades in reducing stigma associated with psychiatric disorders, such as depression, such change has been much slower in relation to substance use disorder. People with substance use disorders and psychiatric disorders oftentimes experience a double stigma. When we refer to a double or a triple stigma among people with a substance use disorder, we're talking about the intersection of being a member of a stigmatizing group, for example, race, gender, sexual orientation, criminal history, or having a mental health condition. It's basically how all the stigma from all of those different categories or groups that you're part of intersect. But today, I'm sure people are wondering, well, why are you talking about language? Why is language so important? Well, how a disease or condition is discussed also impacts help-seeking behaviors. It impacts treatment outcomes, policies, specifically policies, right, and funding. Do we put money on research, treatment, prevention, or do we put money on putting people in jails? Stigma is a direct barrier to accessing substance use disorder treatment among individuals who have that concern. Stigma also results in a lack of general public support for legislation that provides meaningful reform and fiscal support to prevention, treatment, and recovery. It impacts quality of healthcare delivery given by medical professions, and most recently, in the midst of the opioid crisis, can result in death. I'd like to go through some of the literature, and I'd like to start off telling you about a study that inspired a lot of the research that I've conducted. There's a study done by Kelly and Westernhoff that started us off on this, my research team on this endeavor. The study population consisted of 728 medical healthcare providers who were part of two mental health addiction conferences. So they were attending a mental health addiction conference. Just at the start of the two addiction-focused talks, a survey was handed out. There were two survey forms representing the two levels of the independent variable. A survey form either talked about a person being a substance abuser or the person having a substance use disorder. And when we talk about a person with a substance use disorder, we often refer to that as person-first language. One of the two substance-related terms were embedded in a vignette describing the individual with the substance-related problem. The questionnaire distributed with the vignette asked participants to rate the extent to which they agree with various causes of the character substance-related problem and whether the character should receive more therapeutic or punitive action if the person was a social threat and if the person was capable of regulating his substance use behavior. There were no differences detected between groups on the social threat or victim treatment subscales. However, a difference was detected on the perpetrator punishment scale. Compared to those in the substance use disorder condition, those in the substance abuser condition agreed more with the notion that the character was personally culpable and that punitive measures should be taken. Even among highly trained mental health professionals, exposures to these two commonly used terms evoke systematically different judgments. Former graduate student in my lab, Robert Ashford, and another graduate student, Austin Brown, we embarked on a set of studies to examine if we could quantify the amount of stigma words produce around substance use disorder. In our first study, we had 44 adult participants were recruited through groups on popular digital media platforms. People who were either impacted, people who were either impacted, had a substance use disorder, or were interested. Majority of these people, if they were interested, were kind of like pure support for providers. In the study, we administered two different measures. We did the vignettes and we did a go-no-go association test, which are designed to measure bias toward individuals with a substance use disorder. The go-no-go test involved classifying two objective categories here, substance abuser versus a person with a substance use disorder, and evaluate the categories of good versus bad. We also used a social distance scale to assess the comfort level of participants in response to other individuals that differ from them. The scale was originally developed to assess comfort toward individuals of different ethnicity and racial identities. In the current study, we administered it to address the comfort level of being around a person in those two conditions. Both terms had negative association. However, substance abuser plus bad had the strongest negative association in this test. Next, we examined the words addict and person with the substance use disorder. The main finding here, again, both terms had negative associations. However, addict plus bad had the strongest negative association. We did a couple of more studies, but the one here I'd like to tell you about, this was our biggest one. We had 1,300 people, and we, again, did the go-no-go association test with the vignette-based design. We examined seven groups of labels, which are listed here, basically using terms like addict, abuser, alcoholic, compared to, again, the person-first language, a person with a substance use disorder, a person with an opioid use disorder. We also examined words like relapse and compared that to recurrence of use. The main findings here are that, not to be surprised, it is associated with what others have found and what we've found in the past. Terms like addict, alcoholic, opiate addict, substance abuser were strongly associated with negative and significantly different than their positive counterparts. Relapse and recurrence of use were strongly associated with negative also. However, the stressors associated with negative and the strength of reoccurrence of use positive association was higher and significantly different from that of relapse. Pharmacotherapy was strongly associated with positive and significantly different than medication-assisted treatment. So let's go with pharmacotherapy. Both medication-assisted recovery and long-term recovery were strongly associated with positive. People like using the word recovery when we talk about substance use disorder. In many recovery pathways, the use of negative labels serve a purpose. The identity of being an addict or an alcoholic can serve as a mechanism of change and empowerment. It reminds people who they once were compared to who they are now. And for many, that is believed to be a necessity to remain vigilant in the recovery process. People will say, I am an addict. I am an alcoholic. And this right to self-identify and self-label exists and should be supported. People should be able to be called what they want to be called. But we have this preliminary research that we found that show that people in recovery have greater levels of implicit bias towards these labels. And, but yet we also want people to have the right to self-identify. What do we do? And how might this internal implicit bias affect recovery outcomes? So we have these two pieces of information, right? Language that we know, certain language is stigmatizing, but people right to self-identify. While it's studying, we examined the usage of two labels. We wanted to keep it simple. Addict and a person with a substance use disorder among people in recovery. And we looked at recovery outcomes. We had these research questions. How often do individuals in substance use recovery use labels such as addict and a person with a substance use disorder? What settings do they use these labels? And are there group differences between individuals using different self-labeling language on common recovery outcomes? Things like recovery capital, recovery length, self-esteem, flourishing, internalized perceived stigma and internalized shame. Again, it was a pilot study. We had about 44 participants and we recruited these participants through online measures of people in substance use recovery groups. Both participants use both labels at high rates, labels like addict and person with a substance use disorder. So mutually exclusive use was lower, like addict alone or a person with a substance use alone. So typically people use them together or would use both at different times. Common label use settings included mutual aid recovery meetings with friends and family and on social media. So people were using these in various locations. Glad to find out there were no significant differences between people who use the various label groups on recovery capital, self-esteem, internalized stigma, shame, flourishing and length of recovery. Now up to now, we've picked the terms to study and everything, as we pointed out, basically had a negative association, had a negative sentiment. We're just looking at ones which are more positive than the other, but almost every term we looked at outside of like just saying recovery had a negative sentiment association. So how do we identify what words may be associated with recovery that are positive? So we decided to let people tell us what was positive and negative. We had three distinct stakeholders, individuals in recovery, family members who had been impacted and loved ones and professionals in the treatment field. We use a digital Delphi type of setup where instead of looking to achieve consensus, we explored the levels of disagreement and agreement with words that were viewed as stigmatizing negative and non-stigmatizing positive. First round of participants listed 10 words or phrases, and they also listed up to 10 words or phrases that were positive and 10 words or phrases that was negative. In the second round, participants were then asked to rank each of the words or phrases from a one to 10 scale with items stigmatizing given a one for most stigmatizing and 10 for the least. And then they also looked at our listed words or rated words that were considered empowering with one being the most empowered and 10 being the least. The third round, we rank listed the negative and positive words that were from round two, as well as any comments that were left in round two were given to participants. And participants were encouraged to review the location in the rank list and the mean range associated with the words. Participants identified 60 different terms that were considered stigmatizing or positive. And as we've seen before many times in many studies, people previously identified stigmatizing terms like abuser, addict, crackhead, were present for all stakeholder groups as stigmatizing. Additionally, stigmatizing terms for all groups included things like junky, alcoholic, dirty, words like that. All stakeholder groups included persons with a substance use disorder as positive and additional positive terms related to long-term recovery. Other research findings we present today, this research suggests the continued use of terms like addict, alcoholic, abuser, and junky can induce stigma in multiple stakeholders. Words matter and yes, let's use the right words. I would like to thank you and I'd like to thank my amazing research team and lab who have helped me do all of this research. And I'd like to thank my collaborators. Finally, I'd like to give a special thanks to a wonderful set of mentors and individuals I regularly consult with on my research and my career, as well as my scientific director and the director of NIDA. Thank you very much and have a great day. Hi, I'm Brian Adnoff. I will be speaking on the role of addiction psychiatrists in righting the wrongs of the drug war. I'm a clinical professor at University of Colorado Anschutz Medical Campus, editor-in-chief of the American Journal of Drug and Alcohol Abuse, and I'm president of Doctors for Cannabis Regulation. Disclosures include I'm a scientific advisor at Demorex, and this is a company that is investigating the effectiveness of Ibogaine for the use in addictive disorders. And I've done consulting for Jazz Pharmaceuticals. Mentioned, I'm the president of Doctors for Cannabis Regulation, and AAAP has asked that I state our mission statement, which is, DFCR serves as a global voice for physicians and other health professionals to advance legalization and sign-based regulation of cannabis. In this talk, I will be discussing drug use and addiction as a brain disease versus a criminal act. I will explore the growing acceptance of drug legalization and decriminalization and review the relevant policies of AAAP, explore possible reasons for the medical establishment's continued support of drug criminalization, and present a way forward for AAAP. Now, as an addiction psychiatrist, and the rest of you here, most of whom I assume are probably addiction psychiatrists, we tend to go by the eye, buy into the idea that addiction is a brain disease. This has been around for a long time, for certainly most of my career. And here's a couple of somewhat random reviews on the subject. The first is by Alan Leshner, Addiction is a Brain Disease and It Matters in Science. And Alan Leshner was the director of NIDA before Nora was. And Nora, George Kube, and Tom McClellan. Nora's the director of NIDA. George Kube is director of NAAA, and Tom McClellan is one of the giants in our field. In this article, we found neurobiologic advances from brain disease model of addiction in the new in the journal of medicine. This is just to highlight that this idea of addiction as a brain disorder, a brain disease, has been around for quite some time. And I mean, I buy into it. Now switching to the idea of looking at the issue of criminalization of drug use disorders. The criteria for substance use disorders changed a little bit from DSM-4 to 5. And for those who maybe are new to the field, I just want to review those because they're very important. One is that we added on craving to the alcohol abuse independence. Craving was added. And the only criteria that was dropped was the one at the bottom, recurrent substance-related legal problems, like arrest for alcohol-related disorderly conduct. And the reason for that is if you look at this, Deborah Hassan and her group, looked at four drugs here, four substances, alcohol, cannabis, cocaine, and heroin, and looked at how well they hung together with the relationship that the R value was between all of them. And as you can see, cannabis is probably the best example where all the criteria hung together very nicely. If you had one, you had the other, except for legal problems. As you can see in all four substances, the relationship between legal problems and the other criteria was very low. The idea was thought that the problem was using a socially constrained phenomenon to define a disorder may be problematic. And what that means is a white male, if I'm walking down the street, particularly dressed nice, is befitting a physician, and I have a briefcase full of cocaine, it's unlikely that I'm gonna be stopped or questioned. If a young black male, particularly dressed in a hoodie, walked down the street with a couple of joints, the odds are reasonably well that he might be stopped and arrested for having cannabis. I mean, I'm in Colorado now, so not so much, but certainly historically. There's a lot of consequences to being arrested, even for cannabis. And we talk about, I just listed off, I had the criteria up, the consequences of having a substance use disorder. There are equal, if not worse, consequences of being arrested for having substance use. For having substance use, whether you have having a substance on you, an illicit substance, an illegal one, even if you're not having any problems from your use. These include disenfranchised and incarceration of people of color. You've heard a lot about that today. A loss of employment, inability to gain employment, loss of driver's license, loss of housing, loss of child custody, immigration status, deportation, a loss of nutrition due to lifetime bans on felony drug conviction, people with felony drug convictions getting assistance, increased risk of overdose following incarceration, increase in illicit drug use following incarceration. I could go on. Oh, and I love this term at the top, politicogenic effects, meaning these consequences are not due to substance use. They are due to the politics of substance use. This is from Aleska Hubley, a colleague in Finland who passed this along to me. Nora Volkow has recently addressed this issue very nicely. She brings up arguments that I've certainly been hearing for a long time, but she puts them together very well. And one of her comments is, it's worth quoting here, these disparities, the racial disparities she's referring to are particularly stark in the field of substance use and substance use disorders where entrenched punitive approaches have exacerbated stigma and made it hard to implement appropriate medical care. Abundant data show that black people and other communities of color had been disproportionately harmed by decades of addressing drug use as a crime rather than as a matter of public health. Now, there's been a sea change, not only in hearing from Nora, but certainly in the way the public is viewing the war on drugs. This is most overtly seen with cannabis legalization. 36 states or 71% of the US population now live in states where medical cannabis is legal. Adult use, people refer to it sometimes as recreational, but I don't really know. People use it for all sorts of things. Adult use is now legal in 20 states, which is closing in on almost half of the US population. The picture on the left shows that the majority, kind of sizable majority of people in the US now approve of cannabis legalization. And this is across parties. This may be one of the only bipartisan issues we have in this country that people agree on. A majority of Republicans also feel this way. And on the right, you can see all the states that have legalized cannabis. Dark green is for adult use. Light green is just medical. Orange is those that don't have anything. Now, and coming from a prohibitionist perspective of cannabis, you wonder what's going on in all these states? Why are they doing this? Are they anti-science? And I think it's a reasonable question, but I saw this slide on the left, and it reminded, it looked very similar to the cannabis slide that I just showed at the state, but the opposite. This is less in July of less than 50% of adults fully vaccinated. And I put red dots on the right of states that have legalized cannabis. And as you can see, with the exception of Wisconsin, every state that has high rates of vaccination for COVID, almost all of them are actually adult use legal states, but at a minimum, they are medical legal states. Decriminalization is drug decriminalization where you have a minor fines or criminal penalties for possession. People wonder what that would look like. Well, Portugal did it in 20 years ago now. They've seen a dramatic decrease in drug arrests and people incarcerated. That makes sense. That was the idea, but also a fourfold decrease in overdose deaths, 18% decrease in social costs of drug misuse and no increase in drug use. Closer to home, Oregon recently passed this drug decriminalization quite overwhelmingly, 58%. Small amounts of drugs are a civil violation. It's a $100 fine can be avoided by agreeing to health assessment. Selling and manufacturing remains illegal. And really important is $300 million has been set aside over the next two years towards recovery treatment efforts. So the idea is to take money that we choose to police substance use and incarceration and everything that goes with that and put it into recovery. Now, where is AAAP been on this? And I'm putting in harm reduction with decriminalization is a way to reduce the harms of substance use. So looking at harm reduction efforts, clean needle exchange and syringic change, AAAP has come out for that beginning in 1994, a long time now and reaffirmed it 2002, 2018. Opioid overdose education and naloxone distribution, 2018. Little late, Texas actually supported widespread distribution in 2014, but we got there. Buprenorphine treatment in 2012 and the policies in 2015 and 2018, criminal justice and substance use disorder treatment, state substance use disorder treatment is a more appropriate intervention than incarceration for nonviolent drug offenders. That's awesome. But they have us, they have, we have a policy we have a policy, legalization of drugs beginning in 1990 and it's persisted and re-upped through the years. States AAAP maintains a position that the position that any new legislation supporting recreational drug legalization, taxable sales must concurrently provide robust research and development of public health safety policies to prevent substance related harms and substance use disorders. It must also provide adequate funding for prevention of such harm and treatment of substance use disorder that may expand with greater legal access. That is a heck of a bar to jump over. Regarding must concurrently provide robust research to prevent substance related harms. What about a policy that says any new law criminalizing substance use must have concurrently provide robust research showing that it's not worse than what we have now, that it doesn't lead to harms. This criminalization law doesn't lead to harms. Adequate funding for prevention of such harms. We don't provide adequate funding now for substance use disorders. So it's asking for something we're not even doing from the get go. The cannabis policy, let me just jump to, it really starts off with all the bad things that cannabis can do, which is fair enough. I mean, these are important. These are harms from cannabis. What it doesn't do is address the harms that are due to cannabis prohibition. And these are critical. I would refer AAAP to ASAM that has a very comprehensive cannabis policy and they do include the consequences of cannabis prohibition and try to balance that out. AAAP does not take this into account. And AAAP is not alone in this. There's only a couple of organizations that I can think of, American Heart Association and the California Medical Association that have come out for cannabis legalization for adult or medical use to my knowledge. Why is the medical established, where is so much of the majority of people in the US have moved on and recognize the harms of the war on drugs? Why is the medical establishment so behind on this? And as addiction psychiatrists, why we are unique in medicine in having the condition that we treat every day criminalized. There's all sorts of behaviors that lead to long-term lifetime problems. Certainly alcohol and tobacco use, sports, high caloric carbohydrates, cars. There's all sorts of things that as a society we have chosen to regulate rather than criminalize and drug use stand out. We should be the ones in the forefront of trying to stop the criminalization of this. Why are we okay with the criminalization? So I've wondered about this and here's some thoughts I have. First off, most physicians are not experiencing the harms resulting from the war on drugs. We are white and we are wealthy and are certainly comfortable and we come from backgrounds that are more than comfortable. This is from the Association of American Medical Colleges and it's looking at the quintile of incomes, of parental income of incoming first-year medical students, 2017. 50% of medical students are coming from the top 20, top quintile in income. 25% of medical students are coming from the top 5%. If my kid got caught with a drug, even as adults, I'd help them out. I mean, I'd get a lawyer. It's most likely they would not land up in jail. There would be consequences, but the main thing I would try and do is get them in treatment that I can afford. If you can't afford a lawyer, if you're black, if you're brown, you are gonna be more likely to not be able to afford these. Blacks are still, even recently, American Association of American Medical Colleges has stated that blacks are entered in medical school at about half of their presence in the population. For Hispanics, it's a third. There's an availability bias. We tend to know what we experience. So working with substance users and people with addiction every day, we see the harms to the people. We see the harms to their family. We don't see the harms, unless we're working in a prison system or jail, we don't see the harms of putting these people in jail. So again, we see that it's harmful that they're using. We don't see the opposite side of the coin. I think we miss things in our disclosures. Cannabis practice-related disclosures are required. Dr. Knox, even though she's not really speaking on cannabis as a medicine, she was asked to, she was required to give her disclosure as practicing a legal cannabis practice. But practice-related disclosures profiting from drug prohibition are not required. The largest opposition to the Oregon decriminalization measure came from the Oregon Council of Behavioral Health. Oregon's voice, as they describe it as, Oregon themselves as Oregon's voice for addiction treatment and recovery. They get a ton of money, or they got a ton of money, I guess, from the government, from people that were arrested and then referred to treatment through drug courts. This is, to me, a disclosure that's necessary. And I've never, and a lot of us in the organization work for organizations that do get these referrals, but this is not required as a disclosure. Commercial disclosures are required, but not government or foundation grants. When you're getting money from NIDA, you are getting money from a organization that has been promoting, has not until recently, with Nora coming out, has not really been supportive of drug decriminalization and a lot of harm reduction measures. And I've worked with, I have several colleagues that like to be more involved with DFCR, Dr. Cannabis Regulation, but they don't feel comfortable doing it. And they've been advised by colleagues not to. Regarding medical cannabis, physicians have a true faith in the FDA approval process, even though there has been so many problems with it. They do great. And I look for FDA approval for drugs that I'm gonna use myself or for my family. But there are significant problems, and there have been, I have a picture of my dad. He was, I think he was 81, but he was healthy, but he had some chronic pain, post-traumatic neuropathy. He was taking COX-2 inhibitors, and he suddenly died from a heart attack. It later came out that the pharmaceutical companies had well-known knowledge of the dangers of cardiovascular effects from COX-2 inhibitors. The opioid epidemic was started with doctors overprescribing opioids, FDA approved. So the FDA is not perfect. Yet we're waiting for FDA approval for any cannabis before we think it should be legal. For cannabis in particular, it's very difficult to do cannabis research, even though we keep calling for more research. It requires approval from FDA, DEA, U.S. Public Health Service, and NIDA. No other drug research, even if you're doing LSD or heroin, do you need all those regulatory procedures? Nora has talked about this quite a bit. The DEA really doesn't want medical cannabis research to take place, and has done everything to stop, they can to stop it. Cannabis, unlike all other Schedule I drugs, is not commercially available for research, still just available from the University of Mississippi. Funding is actually still really limited. How much more research do we need? There's always this other bar. And the fact is cannabis, medical cannabis flower, is never going to be approved. Each chemo bar, each strain must be approved individually. It's extremely expensive. It can take a hundred million dollars to bring something through the FDA regulatory process. If you have one or two strains, maybe making it through, but you're not gonna have the wide variety of strains we have presently. And finally, physicians underestimate the effectiveness of prevention in education, taxation, and regulation. I think one of the primary benefits, the successes of public health over the last century has been the decrease in tobacco use. Slide on the left, 51% of adults smoked in 1965, presently 19%. That's amazing. That's hundreds of thousands of lives saved every year, really. And in adolescence, we did the same thing. 30-day prevalence use in 12th graders, 29% to 7%. Again, pretty amazing. So these interventions are very powerful and we should be used maximizing these for all substances. So what can AAAP do to move forward? Needle exchange I mentioned, opioid agonist therapy, increased naloxone access. They have approved all that. Good Samaritan laws seems to me a no brainer, supporting the ability of someone to call 911 without getting arrested. Drug checking is becoming increasingly common. Dan Safe does this at raves all over the country. Safe consumption rooms, also called harm reduction centers, opioid overdose centers. There's pilot programs approved in Rhode Island. The AMA strongly supports the development and implementation of harm reduction centers in the United States. New York has just approved it. And I mentioned ASAM, they have a policy supporting it as well. And actually, while I'm thinking of it, ASAM also has a really nice policy on advancing racial justice in addiction medicine that we should take a look at. And where it really discusses the harms from drug prohibition on people of color. Heroin substitution is used in many countries in Canada and Europe, and I've discussed legalization and decriminalization. I'd like to end with a really nice quote from Melissa Moore in Drug Policy Alliance. It was on a psychoactive podcast. It is kind of my go-to podcast nowadays. She says, how do we switch from a criminalization approach to drugs, to one that is much more rooted in providing people with the care and resources they need if they are experiencing problematic use and leaving them alone in dignity and peace if they are not experiencing problematic use. Thank you very much. And I look forward to your questions. Hi, good afternoon, everybody. I'm Kevin Gray. I'm at the Medical University of South Carolina on the AAAP board and really grateful for this excellent panel. I think we want to jump into Q&A on this. I think certainly a lot of really important content, timely, thought-provoking, and I think no better opportunity than now to take advantage of having the expertise on this panel to engage in some questions. So I'll do my best, probably imperfectly so in terms of going through the Q&A box. I already see that Dr. Curtis has been diligently answering many questions. So grateful. I actually hope to get some discussion on those items as well. I think I may start bottom and go upward a bit. And one is actually one that engages. Let's see if I have this right here. Let's see. So actually jumping around a little bit. So Dr. Stephenson, I want to make sure I get to engage you on this, is there is a question about research to guide clinicians on how to communicate kindly and effectively with patients of another race, recognizing the thought-provoking presentation and clinicians wanting to make sure they engage appropriately and kindly. I'm really interested in your feedback on that. Sure, thank you, Kevin, for that. I actually, there's an exorbitant amount of information about not only the disparities that happen in both medical, psychiatric, psychological counseling sessions. So face-to-face encounters mean a lot to people who are overwhelmed by difference in those encounters. But there's a lot of research actually on how to improve patient care with an acknowledgement of one's own unconscious bias, but also understanding how clients of color might misperceive physician judgments or trust those judgments. So to answer the question, there's a lot out there in that regard. And we've just been more interested in having professionals be aware and acknowledge their own, both not only unconscious, but subconscious biases, as well as just basic anxiety in the moment. Thank you so much. I appreciate that, Dr. Stephenson. And I don't want to miss, I know that Dr. Curtis had answered really kindly within the chat, but I'm curious about addressing, given that our own organization, American Academy of Addiction Psychiatry, includes the word addiction and really getting thoughts in terms of benefits, in terms of destigmatization, positively balanced responses to persons, people with substance use disorder. I'm interested in your thoughts about the term addiction. I think you had a really elegant response that I'd love to elicit some discussion with the group as well. So for people that didn't read the response as quickly, the kind of idea is that a lot of the words around substance use disorders and substance use are rated negatively. And the question becomes kind of the, what's more positive than the others? We believe, as we normalize the condition, as we understand more about substance use disorders and people that use drugs, we'll have less dehumanization and less stigmatizing valence that the words will cover. And again, people, everyone wants to know about NIDA, SAMHSA, NIAAA, and the federal agency's name change. Just a reminder, something that I had to learn myself, Congress is the one who changed his name. But looking at what Dr. Volkov and NIAAA and NIMH recent, kind of push about accepting language and changing language, I foresee that there will be a push to asking Congress to make some of these changes. Thanks so much, Dr. Curtis. I know at the top of the Q&A, there's a question for Dr. Knox. I want to thoughtfully address the question in terms of utilizing the term cannabis use disorder within DSM-5 and understanding the context of the presentation. It's important for us to think about brain disorder, but also really understanding social context. The question was really thinking about whether it may be a construct of racist politics versus chronic brain disease. Obviously, it's a provocatively worded question. I'm interested in your thoughts on that because I think underlying the theme of today, I think understanding brain disorder, but also understanding we can't ignore and we actually have to really thoughtfully address social context around substance use. I'm really interested in your thoughts on that question. The social construct existed before any of us were born. I think it's inextricably bound to how we diagnose SUD, unfortunately. The rates of true addiction to cannabis are inflated. We know this to be true. We know that many folks have had to enter into rehabilitation, not because they actually bore the criteria for addiction, but that they wanted to agree to a lesser charge. This 9% addiction rate, we believe in our industry is absolutely conflated. When we're thinking about the pros and cons or the potential benefits and risks of legalization, commercialization versus remaining in prohibition, we really need to start weighing the degree of benefit people are receiving. I'm a clinician. I wasn't speaking as a clinician in this space, but I can tell you after my family seeing 60,000 unique visits for cannabis use when managed by a competent healthcare provider, we are seeing people titrate their use up to the perceived benefit and no more. Under clinical management as a harm reduction tool, we are simply not seeing the criteria for SUD when people are appropriately using this. I don't think we spend enough time head to head examining all of the benefits of cannabis use next to the potential harms and for some people, direct harms. I do. I think we've conflated the issue quite a bit. That does not mean there is a legitimate brain disorder. I just think we have to be very careful in this day and age in assigning that diagnosis to folks, especially without identifying the root cause of use. I regret not knowing enough in residency when I was entrenched in the hospital setting and we were admitting people for SUD due to cannabis. I didn't know to ask them, why are you using this? For what purpose are you using this? Are you dependent on this because it's treating pain or PTSD? We're not asking those questions of folks and thereby, unfortunately, labeling them with diagnoses. I think from this point on, I would challenge everybody to examine their evaluation and diagnosis through that social construct and ask themselves, is there something else I'm overlooking as a result of the constructs that have been set up before I even came into this practice? The last thing I'll say about that is, we healthcare providers need to depersonalize ourselves from the decades and really centuries of stigmatization around this plant. It is not our fault that we've been misinformed. It's not our fault that we weren't taught about the historical use of cannabis in this country, that we don't know that cannabis was removed from the US pharmacopeia. It is not our fault. I also ask us to take our ego out of this and recognize that it was them. It was the establishment who taught us a way, but it is up to us to change our own minds. Thank you so much for the thoughtful response. I know it's not my place to comment within this, but I think it is one of the challenges we face as addictions providers or substance use providers is that the bulk of our most recent training and ongoing practices around substance use disorder. Oftentimes, there is the tendency toward focusing on disorder versus thinking full spectrum of substance use. Cannabis is a really interesting example here where there is a full array of benefit and harm. Multiple voices are needed to understand that to contextualize that appropriately. I think we're coming to terms with that as a country, but also as treatment providers is trying to weigh pros and cons without polarizing any one substance as either all good or all bad. It's a complicated mix, but we can make thoughtful decisions when weighing pro and con. I think that's just something, at least as clinicians, we're trained to do that well, but I think we also have to have enough humility to really think through and be empathic and understand where people are coming from with it. I appreciate your thoughtful response. There's another relatively provocative question, but I think is a really good one, is one for Dr. Adanoff around legalization of, quote unquote, harder drugs around heroin, methamphetamine, thoughts around that and potential effects on substance use disorders as compared to cannabis legalization. Interested in your thoughts on that. I know that you're well read in terms of international policy with legalization and decriminalization. I'm really interested in your thoughts. Yeah, it's a great question and it's a very difficult question. It's actually why I didn't talk about legalization for so-called harder drugs. Cannabis does seem to be safe enough for legalization. What we probably will see, number one, is there's an increase in use likely with legalization, but it depends on, at least that's what we've seen with cannabis, but number one, we have not seen an increase in cannabis use in adolescents or those less 18 and younger. That's been because as predicted, when you go to the drug dealer, they really don't care whether you're 11 years old or 50 years old. When you go to a dispensary for anyone who's tried, most of them are very, very careful about who they let in. If you're under age, you don't get in. Most, by and large, studies show that, in fact, adolescent use in legal states has not increased. If anything, it's decreased. With other drugs, it's unclear. That's why what I was... We'll see, number one, we'll see in Oregon what happened. In Portugal, we did not see an increase with decriminalization. We'll see what happens in Oregon, but actually with decriminalization, I would not expect to see an increase. What's important really, I want to get this point in, is that removing... We've talked so much about stigma, not only in this symposium, but in every symposium I've been in so far, including workshops. It always comes... It's always discussed in terms of the opioid epidemic, the stigma with substance use disorder. As long as it's criminalized, we're not going to be able to get away from the stigma. We are saying as a country that this is a criminal act, so there's going to be stigma attached. I mentioned, for instance, heroin substitution. That is a form of legalization. It's been used in Europe. It's been used in Canada without untoward effects. Actually, what you see is people getting into treatment more so when they get into a heroin substitution program than if they are not. Clearly, having dispensaries for something like methamphetamine or fentanyl, I don't see that happening, but heroin substitution is an excellent way that we can monitor its use, make sure the right people are getting it, and having pathways to treatment. Thank you, Dr. Adenoff. A question from Dr. Weiss in the audience, Dr. Gerard Weiss, commentary, and then a question, I think, around some of the nuances around legalization. One is while there may be legitimate uses, medicalized uses, et cetera, there also may be the challenge of someone who may have a use disorder seeing legalization as blank justification that, oh, well, then it's fine. Again, falling into this, it's either all good or all bad. I think this is a question for the panel around is how does one navigate these nuances in a doctor-patient relationship when there may be use that is problematic at the same time where there is this interpretation of endorsement that it is good, benign, et cetera, when in an individual case there may be challenges. That's not for a specific panel member, but I think it's an interesting question. Whenever I hear that question, I always wonder, well, how do we do it with alcohol? Alcohol is legalized. Legalize and really perpetuate it. Try to find a movie that doesn't have alcohol use. Luckily, we've removed a lot of the smoking out of movies, but movies, TV, every form of media shows alcohol use. If we can do it with alcohol use, we can do it with other substances. I'm just saying that's the point that we're going to say if you legalize something, how do you then treat it? I think we do have one example. That's an excellent comment. We really can. Ages in terms of legalization oftentimes parallel those with alcohol. We have similar media contexts, narrative contexts, which parallel that. Really, a lot of wisdom to be gained. Another question in terms of potential change that might come with legalization, the arguments around reducing the risk of obtaining drugs contaminated with fentanyl or other adulterants. Interested in the panel's thoughts on that. Again, with a complicated nuance of pro and con, but the thought about the idea that contaminants are a real issue in the current drug supply. I'll comment on that. I agree completely. That's why I mentioned things like drug check. There's many, many things we can do before we just say everything's legal, but taking away the stigma by allowing people to get their drug checked. First of all, with cannabis dispensaries, we do know what we're getting. I think there's a lot we still need to do in terms of making sure that the testing that's being done is actually accurate by third party labs, but having fentanyl strips so people know if there's fentanyl or not. Being able to send your or bring your drug that you're going to use anyways to see what's actually in it. Again, something like heroin substitution, where you know that what you're getting is good. These are not big steps from where AAA, where the field is now. There were the same arguments about opiate agonist therapy. These are opioids that have particularly methadone has the same effects as illicit opioids, but the government has decided that it's legal and to give it out in a controlled way. We're already doing this. We're just trying to decide on do we do this with some other substances as well as methadone and butadone. There have been a couple of comments. This is for Dr. Adanoff around rates of youth and young adult use of cannabis in states with legalization versus not. One commenter around the National Survey of Drug Use and Health citing increases in use and youth in those states versus those not legalized. There was a question about your source of data for lack of increase in use in those states. I said less than 18 years old. I don't have all the data offhand, but even Nora has recently said in a podcast, Nora Volkow has said that she expected to see an increase in adolescent use and we haven't seen that. There is a great deal of data on that. I can refer you to the dfcr.org website where under education I list some of that data, but monitoring the future has shown no increase in use. There's been multiple large studies looking at adolescent use that does not show an increase in use. As I said, if anything, a decrease. This has been looked at very, very carefully. My understanding is it has increased in young adults 18 and over and adults in general. I know there's been change in attitudes toward acceptance of use rates. I think there has been differences in different surveys that have had different outcomes, but I'd appreciate that response. Another question comment for the group was around striking a balance if one is thinking of using cannabis as a therapeutic or if there is a patient that comes to you that endorses that there's been positive effects, say for a condition such as PTSD in their case, but you're also concerned about potential initiation or worsening of psychotic symptoms and knowing that there's potentially both pro and con psychiatrically with cannabis case by case. Someone was asking about the nuances of managing the pro and con within a treatment context. I would love to jump in here to answer this question. First, I want to say it is so incredibly important that knowledgeable healthcare providers get involved in the policy making around cannabis and in the rules, the design of these regulatory frameworks around cannabis because we are uniquely positioned to understand the harms that we're trying to mitigate. But on the flip side of that is that yes, in all beneficence and our commitment to doing no wrong, no harm with our patients, we have to be open to the possibilities. When we think very practically about applying cannabis into the clinical setting, we're going to do so no differently than we do pharmaceutical drugs. We're going to start with the lowest derivative of dose, maybe that's a half of a serving size if we're talking about the commercial market, and we're going to monitor. It's no different than how we manage patients on conventional pharmaceutical drugs. We start with that lowest dose, we see how they're doing, we follow up with them, we ask all the questions to address harm and benefit, and we increase incrementally until we see a perceived benefit. We call that the minimal effective dose in cannabis, and why that's important is because no one person is alike. We all have different endocannabinoid systems with different endocannabinoid tone. That means a product that might work for one patient might not work for another, even if they have the same condition. We have to apply the standard of care that we are so familiar with in the conventional setting to medical cannabis. That really begins to help us shed our own stigma and get more comfortable with working with these products that people just bring into us. I've had patients bring in a bag load of product, dump it out on my desk, and say, I don't know what to do. In part, that's because they got their information from the dispensary and are just super confused. Me and clinicians like me have taken on what we consider the responsibility and our due diligence to do our best to understand the pharmacology of these products, the physiology and the body these products work on, and then work with that patient to find something that works best for them, mitigating any risk, lowering that burden of harm while still addressing their needs. I made a comment in the chat here in response to a question around PTSD. PTSD is considered a clinical endocannabinoid deficiency syndrome. It's one of the few syndromes, fibromyalgia is one as well, that shows a clinical deficiency across folks who have all been studied. They've had spinal taps. People have assessed their endocannabinoids. They've all had a remarkable reduction in anandamide. What is very interesting is that THC of all the cannabinoids is most analogous to anandamide. To make this real simple, we might use exogenous synthetic vitamin D most often to treat vitamin D deficiency. We do. We see THC as an appropriate therapy for an anandamide deficiency. Does that mean we're prescribing Marinol, isolate out the gate? No, it's not, but it was no surprise to me after learning that why so many of my patients with PTSD were seeking cannabis products that had some THC in it. The science helped me make sense of a trend I was seeing in consumer use. That's how deliberately we need to be at the clinical level. This sort of knowledge is exactly what policymakers and regulators need to hear from us because this information is going to help inform operators around what doses, what serving sizes are appropriate for the public and whatnot because people are using cannabis for medical purposes, whether we like it or not. I do challenge us to get a little bit more comfortable with having these clinical conversations with our patients as, again, like I said, a harm reduction tool. I greatly appreciate your response. I know we're, I think, right at time. I'm really grateful for this group and I probably need to defer over to Dr. Weiss. Really thoughtful discussion. I wish we had more time with this group. There's more cannabis-related content to come within this meeting and in future meetings, certainly. I think this was really helpful in terms of really opening up our thinking caps. Maybe that's not the right metaphor, but opening, broadening our thoughts in terms of cannabis and in terms of social context and understanding more broadly in terms of therapeutics and harms. I think this was a really helpful discussion that we've had as well. I appreciate everyone's expertise and time within this. We know that these are complex discussions. Thankfully, we're making advances in our understanding of the neuroscience of endocannabinoids and exogenous cannabinoids, therapeutics, harms, et cetera. We're learning more and more at the same time. We can't endlessly wait until an endpoint of learning to act now as we're addressing things in a doctor-patient relationship and also at the policy perspective. With that, I will send over to Dr. Weiss.

annual meeting

war on drugs

racial origins

symposium

Dr. Brian Abenoff

historical racial disparities

cannabis policy

Dr. Howard Stevenson

mental well-being

Dr. Brenda Curtis

stigma

substance use disorders

addiction

language

help-seeking behaviors