Recovery Capital: Assets and Not Abstinence

- I'm with Penn State Extension, and this is part our program today.

It's part of a series, a webinar series that the substance use education team has developed to educate our staff, the public, and anyone about substance use disorder, what it takes to maintain recovery, and how we can reduce stigma.

So this is the second in a series that Dr. Alex Elswick from University of Kentucky has been delivering for us.

We had one on December 13th or on October 7th, on Addiction 101.

Today's workshop on Recovery Capital will build on that.

If you did not have a chance to view Addiction 101, I'm gonna post the link in the chat box shortly, and that program is available for your own viewing at no cost.

And then Alex will be with us again in February to talk about stigma and what we can do in our everyday lives and our work to help address and reduce stigma.

Our speaker today is Dr. Alex Elswick.

He is a tireless advocate for people with substance use disorders.

He currently serves at the University of Kentucky as an assistant professor and extension specialist for substance use prevention and recovery.

He's a researcher, a recovery coach, and a mental health therapist, as well as the co-founder of Voices of Hope, a peer-driven recovery community organization.

But most importantly, Alex himself is a person in long-term recovery from the chronic disease of addiction.

Alex has become a friend of Extension here in Pennsylvania because he has provided us with so much guidance and a wealth of information on how to bring hope to people who are dealing with addiction.

So I'm going to turn it over to Alex to talk with us today about Recovery Capital: Assets, Not Abstinence.

- Thank you, Denise, and good morning everybody.

I'm really excited to be back doing this again.

I'm hopeful that folks either have already had the opportunity to view Addiction 101, because where we're gonna pick up today really begins where we left off the last time.

If you haven't had the opportunity, I'd encourage you to check that out just to kind of bring you up to speed.

But for the benefit of those of you who weren't at the initial session, I'm gonna give you the quickest of background on me, but I have packed so much into this one hour presentation that we gotta move quickly.

So quick background.

I've got some clinical experience as a marriage and family therapist.

I worked for a little while in treatment, which was really good experience, specifically working at an outpatient provider of medication for opioid use disorder, you might know of as buprenorphine.

And I also co-founded a nonprofit, as Denise mentioned, Voices of Hope, which I'll mention a couple of times, not just as shameless plugs, but but as a way to kind of illustrate some examples of what recovery capital building can look like.

And then I'm currently an assistant Extension professor at UK, and being Extension faculty is the best because it really affords me the opportunity not just to do conventional teaching in the classroom and conventional research, but to do exactly this, to do research translation, and to try to take some of this information and put it in the hands of those who can do good with it.

So hopefully this is meaningful for you today.

Like I said, we're gonna kind of pick up where we left off.

I guess before I jump in, I should also mention, I'm lastly, in addition to all that experience, sort of professional experience, I'm also a person in recovery.

So rather than give you my entire testimony, just kind of suffice it to say, I got addicted to opioids when I was 18, had wisdom teeth removed and was prescribed oxycodone.

And my addiction took me to jail on drug trafficking charges and took me in and out of lots of different kinds of treatment centers and on and off the street.

And I ended up spending the very end of my addiction sleeping under a bridge in Dayton, Ohio, kind of living out the stereotype, if you will.

And when it came time for my recovery, I had access to all these things that I needed.

And people helped me with all these things that go far beyond just abstinence.

I had help with my housing and I had help with getting a job and help with applying to school and help with getting health insurance and just this long, long list of resources that when I reflected and when I got to graduate school and came to understand the evidence I came to realize actually might have been responsible for my recovery.

And so that's really what I wanna focus on today is those resources and how do we build them?

In order to get there, we gotta kind of pick up where we left off the last, and that was by talking about the brain, because we spent the majority of the time with Addiction 101 talking about addiction as a chronic brain disease.

And we talked about the implications of that.

We said, this is not actually your brain on drugs, just an egg in a frying pan.

But instead, this is your brain on drugs and this is PET scans.

And so rather than recap the entire brain science that we did in Addiction 101 in short, I would say the way that addiction impacts the brain in the short term is by causing short term increases, spikes in dopamine, hence the pleasure of the euphoria that people experience from drug use.

But over the long term, the brain habituates or compensates such that dopamine levels trend downward, downward, downward.

You have fewer dopamine receptor sites, that means less dopamine available, which means you're pretty miserable.

And that's really what's causing addiction.

And so these PET scans, you know what they're showing the brain on the left is a healthy, normal control brain.

The brain in the middle looks identical to those addicted brains that we showed you in the last set of brain scans.

They're completely bereft of dopamine.

But yet, I pointed out on this slide the last time that this brain in the middle is not actually the brain of someone who's addicted.

This is actually the brain of someone who's was addicted to methamphetamine and now they're 30 days abstinent.

And we talked about the implications of people graduating, graduating, right?

As if they're finished from treatment centers with chronic diseases that are being managed acutely and episodically.

And we talked about kind of why that's ineffective.

And so I just wanted to couch us and kind of frame the discussion today around the point that addiction is a chronic disorder.

And that means, by definition, recovery is a process of change.

It means recovery's not an event.

People don't decide I'm gonna get sober tonight, and then tomorrow my abstinence journey begins.

Right?

I mean, sort of by definition, if they could do that, they wouldn't be addicted.

So we know by its very nature that recovery is a process, which means it's often non-linear.

It's often fits and starts, two steps forward, one step back.

And it often means relapse is a part of the process.

So you may have heard it said that addiction's a chronic relapsing brain disorder, or that relapse is a part of recovery and on average for the typical recovery trajectory it is.

And so one of the questions that we're gonna explore a little bit later is, how should we react to a relapse or return to use and how should we understand that?

But before we get there, I just wanted to couch us in chronic disease.

That means our response to supporting people with substance use disorders has to be long-term, right?

So what does that look like?

Looks like recovery capital.

And so the diagram on the right, I adapted from from White and Cloud's kind of seminal work on recovery capital.

So recovery capital describes all of the resources inside of a person and outside of a person that you can leverage to support your recovery.

So generally, when we think of the things that people need to get better from addiction, our mind goes to treatment first.

And we think, well, people need to go to rehab, right?

But oftentimes we miss the totality of the human being in front of us and we forget, like this person also needs to have housing secured on the other side.

And if all we've done is get this person into treatment with no consideration for where they're gonna live, we're really doing them a disservice, right?

In the short term, we increase the likelihood that they're gonna experience a fatal overdose because that's the consequence of short term treatment.

And they're not gonna be able to get access to the things that they need.

And I like to put this beside Maslow's Hierarchy of Needs because you all will recognize Maslow as like foundational sociological theory.

And Maslow pointed out to us like, hey, you can't begin working on higher ordered needs like belongingness or self-esteem.

You surely can't reach your full potential until your basic needs have been met.

And so I like to put these beside each other because they're very similar.

And also because Maslow uses the language of reaching one's full potential to describe what he called self-actualization.

And that's actually the same language of the definition of recovery because Samson's definition of recovery describes a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

So in many ways, you know, you can think of this like your hierarchy for recovery, and we can't ignore physiological needs and safety needs and belongingness needs and focus exclusively on sending people to treatment.

So for the most part, people come to this point and we go, okay, we agree that people need access to these resources in order to support a holistic kind of meaningful recovery.

The way that these resources support recovery in short, is by reducing stress.

And you know, when we talk about stress as you good scientists know, we're not talking about like, I had a stressful day at work.

Today we're talking about bio psychosocial stress.

So we're talking about poverty, we're talking about homelessness, we're talking about trauma, we're talking about, you know, undertreated or untreated mental disorders.

We're talking about all the things that create real stress, family conflict and all those things.

And so what recovery capital does when you improve someone's housing, when you improve the nutrition that people eat, when you encourage people to engage in physical activity, when you get people connected to a new social network, when you do any of those things, what you're doing is reducing biocycle social stress, which in turn is increasing the likelihood that people experience remission or recovery, right?

The problem it begs a really important question when you're doing this work on the ground, it's not quite so simple because you have to answer the question of when are we gonna begin to provide these resources for folks?

And I think every social service provider that we work with in Central Kentucky is having to grapple with this question every day.

When do we start to provide the resources?

Do we wait until people go to treatment and become abstinent?

Or do we start providing them today?

And in my community, we've largely answered this question and we've decided that before we're gonna provide people access to recovery capital, they have to be abstinent first.

So we demand abstinence as a precondition for housing in my community.

And we don't have any housing at all for people who use drugs.

So if you're a person who has a substance use disorder and you're active in your addiction, we don't have a place for you to go.

The emergency shelters won't allow you to be intoxicated or possess drugs.

You know, halfway houses or sober living is a place where you can go if you're already sober, which necessarily means people who have substance use disorders, who are also experiencing homelessness are invariably going to be get getting PIs like public intoxication charges because they have no choice but to be intoxicated in public, right?

As a matter of pragmatism, there's nowhere to go.

And so what we do is we actually prevent people from accessing the very housing that they might need to support their recovery.

Think about the consequences of let's say someone goes to sober living, they're already abstinent and after two weeks or two months that chronic disease that they have rears its ugly head and they experience a return to use, probably in 95% of those cases, the response is gonna be to kick them out, to take away from them the recovery capital, the basic needs that have to be met, right?

To take away from them the very foundation of every healthy human being.

We do the same thing with caregiving.

And I always wanna be a little more gentle as I say this because I don't wanna sound like I'm being critical of family members.

What I'm really being critical of is, is the advice that we give to family members and concerned others, is we tell them, your loved one has to hit rock bottom.

And we tell them, don't enable, don't enable, don't enable.

And the literature's done a really poor job of defining that and operationalizing that in any meaningful way that families can actually use.

So, right before I got on here, I was doing an interview, collecting some research with one of my graduate students, a kind of a qualitative study of family members experiences of supporting versus enabling, because we know that we have to support our loved ones and we know that we can't enable them, but we have no idea what the difference is.

And so what it does is it leads to family members withdrawing the support that their loved ones might desperately need.

We require abstinence as a pre-condition to access lots of kinds of mental health services.

And one example from my own experience is the clinic where I was trained had a policy that if a family or a couple came to us and alcohol was any part of their presenting problem or drugs, they would have to show evidence that they had completed a treatment program, an abstinence-based treatment program in order for us to begin doing work with them.

And so you think from the perspective of service provision, the incredible barrier that we're putting in front of families and we're saying to them, you don't deserve to begin working on your family cohesion until we address the addiction.

The abstinence has to come first.

And we can't imagine that that reducing family conflict might improve someone's drinking outcomes, might make it easier, might reduce the biopsychosocial stress, right?

Maybe the most egregious example of this, like over-prioritization of abstinence is once people are in treatment and they experience a return to use.

So way back in 2005, William White wrote a paper and the title of the paper was something to the effect of, It's Time To Stop Kicking People Out of Addiction Treatment.

And his point was very simple.

If we're all going to agree that addiction is a chronic relapsing brain disorder, then why are we holding people accountable?

Why are we blaming people when they're experiencing returns to use?

Right?

Either it's a disorder or it isn't and we can't have it both ways.

And then frightfully for me, for my folks, people in recovery, abstinence has become synonymous with recovery.

It's become a precondition for being accepted in recovery, such that if you're a person who had a problem with opioids and now you drink alcohol, you're not considered in recovery by the majority.

If you're a person who uses medication as a part of your recovery, many people consider that not really in recovery, right?

And this does a lot of harm because it's making the umbrella a lot smaller and preventing the kind of belongingness and connection that people really need as a part of their recovery.

So what I kind of am trying to suggest is that if we keep pushing this idea that people need to hit rock bottom, that we can't enable, that we can't begin to mitigate harm or to provide services for people until they're abstinent, then we don't really believe what Maslow taught us 'cause we got Maslow right upside down, right?

Because in other words, what we're suggesting is people have to somehow do the work of reaching their potential of recovering from a substance use disorder without the benefit of the very foundation of recovery.

So we're saying, yeah, you need to get abstinent, but you need to do it without any help with your housing or your mental health or without ever processing the trauma that's led you down this path in the first place.

Like I think we've got it upside down.

I think we're getting the cart before the horse.

And so I just wanted to give you, these are anecdotal examples, but from my own experience about what happens when we're so myopically focused on abstinence, that we forget that recovery's a process and that we neglect to allow people the space to be in that process of fits and starts, that kind of non-linear process.

So the first example is a really disappointing example for me personally.

My best friend since I was very, very young, his name's Bobby, and I shared this with his permission.

Bobby has a substance use disorder.

He has experienced kind of some short periods of abstinence, nothing that he considers himself to be like meaningful recovery.

And he caught a charge not too long ago, about 18 months ago, actually a little while ago.

And he was offered either a year in county jail or a drug court.

And without hesitation, he said he wanted to take the year in jail.

And that's because he knows from his own experience that he's not gonna be able to be abstinent in drug court.

He just knows this about his own life.

And so he told me, I'm just gonna take the year and I meddled more than I should have.

And I said, "Bobby, I really want you to consider drug court because a year in jail is not gonna do anything to help you with any of the problems that you have.

At least in drug court, we can get you help with the things that you need and you don't have to sit in a jail cell all day." And so I kind of did my piece and I convinced him, and we got him into drug court.

And I know the drug court prosecutor and I asked her, you know, can we give him some room?

Can we give him some space to be in this process?

'Cause he's really terrified that he's not gonna be able to be abstinent, particularly because what my friend has sort of at the root of his addiction, or is a part of his addiction, is experiences with gun violence.

And he has post-traumatic stress disorder that's been diagnosed but hasn't been resolved or processed or treated in any meaningful way.

And so here's what would happen.

Bobby got into drug court, he was abstinent about 10 days.

He tested positive for the first time on a drug test and they put him into an outpatient program.

So better than sending him to jail.

But then a week later in his outpatient program, he tested positive again as he told us he wasn't gonna be able to stay abstinent.

So now they sent him to an inpatient treatment center.

And so it went over and over again.

He just kept going in and outta treatment, in and outta treatment, in and outta treatment, testing positive over and over again.

And the reality is that Bob knows what he needs and he knows that part of his problem is this gun violence that's given him post-traumatic stress disorder such that he can't sit still in his own skin, he's not getting anything out of treatment 'cause he can't sit in a group and engage in a meaningful way with the people all around him.

He's just having to figure it out on his own.

And it just seemed so unfair that, that what Bob really needed was some continuity of care.

What Bob really needed was an opportunity to work with a therapist over time because he, this is a process, resolving his trauma is gonna be a process, but instead there was such a myopic focus on abstinence that it put a barrier between Bob and the care that he needed.

And as a result, he ended up going and just doing the year in county.

I experienced the same when I worked with MOUD providers.

So these are medications for opioid use disorder.

And in particular my experience was with buprenorphine.

And what I experienced was you would have people who had severe opioid use disorders and, they would come to the clinic, they would start taking buprenorphine and their lives would be stabilized and you would see reductions in all substance use.

And you would see that they would start going to work and they would start rebuilding relationships and start to get some traction.

And then someone would test positive for THC or maybe for some other substance, and in some cases they would be kicked right outta care.

And more than once we received reports that a person that we had kicked outta care had overdosed and died within days or weeks of being kicked outta that care.

Again, such a myopic focus on making sure that people are abstinent, that we're forgetting that there's a whole human that's gotta be treated and a whole process that they've gotta go through.

The last example I give you goes back to families and concerned others.

And I have a family friend, a close family friend whose daughter has a substance use disorder, and she went to treatment and as a part of their treatment experience at Family Week, they encourage them to write up a contract, which is a really common practice in the field contingency contracting, right?

And according to the contract, it demanded abstinence in order for the daughter to be allowed to live in the parent's house and to be able to be supported.

And a few days after leaving treatment, her mom caught her smoking a bowl of marijuana in the garage and she did what the contract said she was supposed to do, and she kicked her daughter out of the house and she overdosed and died on fentanyl that night.

And so, just, those are extreme examples and in some ways maybe that feels exploitative, but I hope what it does is it illustrates the point that there's such a myopic focus on abstinence, that we're forgetting that this is a process and that people need room to be in the process to accumulate the resources, to resolve the trauma, to address the mental health conditions in order to get traction towards abstinence or towards whatever their recovery is gonna look like.

So let's take a step back and my fear whenever I present on recovery capital is that people think, okay, he's telling us people need resources to get better, whoop-de-do, right?

Like, and it's actually a lot more nuanced than that.

I'm not just saying people need resources or people need housing or to address their co-occurring conditions.

It's really more nuanced than that.

And so I think going back a step helps to explain the nuance.

So William Cloud was working on his doctoral dissertation in the 1960s, I think, and he was, he was looking at college students who had severe addictions and he noticed a couple of things that were unusual about this population.

One is that they seemed to be recovering at a higher rate than the general population, which he found curious.

But secondly, he noticed that these students were recovering without ever going to treatment, even though they were using heroin and they were using, you know, cocaine and they had severe addictions in college, they were graduating college and they were going back kind of to their families of origin.

And they were just sort of getting a job and buying a home and moving on.

And it was really curious kind of phenomenon.

And he started forming this idea that it was because they had the support of their families, that it was that critical social connections and maybe some of the privileges associated with that.

And then he met Robert Grandfield, and Robert Grandfield kind of filled in the rest and said, it's not just these social connections, it's also about these tangible resources that people have access to.

Basically what it is, is you had these college students who were so well privileged, they had access to so many of the things that they needed that they just sort of got better organically.

And so they wrote a paper called The Elephant No One Sees, Natural Recovery among middle class addicts.

And of course, if you attend our session later on in February where we talk about using destigmatized language, we'll tell you that the word addict is a really stigmatized term, but we didn't have that science back in 1996.

So we certainly don't blame Grandfield and Cloud for that.

And what their article showed is they're saying, hey, there's this phenomenon happening that none of us are talking about.

And the phenomenon is there's a large swath of people in recovery who are middle class, who are recovering without any formal help.

They're not going to treatment, they're not going to therapy, they're not going to AA, they're just getting better.

And if that sounds totally ludicrous to you, it sort of did the first time I heard about it because up to that point, my limited experience had been with abstinence based programs and everyone around me had gone to treatment in order to get better.

I didn't know anyone in natural recovery.

And it turns out not only is natural recovery a phenomenon, it's the phenomenon.

It's actually the rule in recovery and not the exception.

And I think this is really important to understand, it's important to center ourselves on this point.

So natural recovery is sometimes called unassisted recovery.

It's also sometimes called spontaneous remission in the literature.

But I really dislike that term because I think that is misleading.

It suggests that people just outta nowhere and for no apparent reason recover spontaneously.

And that's of course not what's happening.

The reason that people are able to recover naturally is precisely because they have recovery capital.

So 46% of people with substance use disorders and 75% of people with alcohol use disorders recover without any formal help whatsoever.

And I think what that helps to point out is sort of the nuance behind recovery capital.

We're not just saying, hey, people need resources to get better.

We're saying it's so critical to be building this kind of infrastructure and giving people access to these kinds of things that it might preclude the need for treatment in many, if not most cases, recovery capital's really important.

So let's step back from recovery capital and contextualize it just for a second in kind of the last 50 years or so of addressing addiction.

So I would argue beginning with the Harrison Narcotics Act in 1914, but most of the world would argue starting in 1971 with Nixon's declaration of a war on drugs, we started waging a war on drugs.

And as a consequence, we waged a war on people who used drugs and we got mass incarceration, prison industrial complex, et cetera, and an opioid epidemic, things not working, right?

And so beginning about 2000 to 2010, what some have called the age of the brain, we started to uncover in the research that actually addiction's a brain disorder, that something's happening in the brain here.

And as a consequence we started to address addiction in treatment centers.

And so you saw progressive alternatives to incarceration and the advent of drug courts and mental health courts and veterans courts and all the specialty courts.

And this is definitely a step in the right direction, definitely a more humane approach, definitely an approach that follows the evidence some more.

But the problem is, this is sort of the paradigm that we have have today and this paradigm, as we said last time, is these 30 day stints to address this long-term disorder that people have.

So it's a really inherent mismatch.

And so where we want to go, the direction in which we're trying to move is toward what are called ROSCs.

You all might be familiar with these, they're called recovery oriented systems of care.

And furthermore, I'm just gonna call them ROSCs 'cause I have a really hard time saying oriented right after saying recovery.

So ROSCs, what you notice that's distinct about ROSCs, first of all, the focus of a ROSC is a person at home in their community.

And that's important to point out because the focus of the first approach was a jail cell, an incarceration, and it didn't work.

And the focus of the second approach was providing people all these meaningful supports in treatment, but then sending them on their way after 30 days, right?

What ROSCs aim to do instead is provide those resources right at home where people live so that they don't have to keep going back to treatment to access the things that they need so that they can get it right at home where they live.

And so you see that treatment and rehab is still a really important component of a ROSC.

And so please hear me clearly.

I'm not saying that treatment or rehab are not important.

What I'm saying is that the research shows majority of people will recover without formal intervention.

But the majority of those folks, the research would show are people who have mild or moderate SUD.

So it seems that the majority of people with severe SUDs will require some form of treatment.

So treatment's an important part of ROSC, but it's not the central focus, it's not the be all end all, right?

Because when folks leave treatment, they have this bevy of resources at their disposal right at home where they live.

So my analogy, well, before I get to my analogy, sorry, I forgot, I don't normally love putting a bunch of words on the screen, but I think this is a pretty straightforward quote to explain what we wanna explain.

And it comes from William White, who I think is just the addiction thinker in my mind.

He said, given the chronic nature of addiction and the scarcity of funds for treatment, neither a single nor serial episode acute care will ever meet the vast need that exists.

In other words, sending people to treatment once or sending people to treatment over and over and over and over again is never gonna meet the need that exists.

And I think I can speak to this at least in part because I was in treatment many, many times myself, in and out with no continuity of care, but I was in treatment with guys and women who'd been to treatment 15 and 20 times, right?

And parents are dipping into their 401ks and their siblings college tuition, college funds to pay for these episodic treatment that's never going to match the nature of their disorder in the first place, only a focus on ongoing recovery support and recovery management can effectively address the chronic nature of this illness.

So here's my analogy for that.

My first job when I got in recovery, which by the way I was very grateful for, was working in the College of Ag at UK doing tobacco research.

I tell people that really, I was doing manual labor and other people were doing tobacco research and we would gr develop these varieties of tobacco in a greenhouse.

And the curious thing about these greenhouses is they're these climate controlled environments where the plants just absolutely grow and thrive.

It's like they have perfect air quality control and perfect sunlight and constant access to water and nutrients and the plants just shoot right up.

And then when they'd reached a sufficient kind of level of maturation, we would transfer these trays onto trailers, we would drive them out to our field and we would set the tobacco.

And if we set the tobacco in a field that had good, good nutrients available, plenty of sunlight, not too much rainfall, the plants would do just fine in the transition, they would perk right up and they would grow and thrive.

But alternatively, if we took those plants that were getting pretty healthy, but planted them in soil that had poor nutrients, one time we planted in a low lying area that collected too much rainwater, and so we got a disease, then they wilt and they die, right?

So this is my analogy for thinking about the difference between treatment and recovery.

So treatment is a lot like a greenhouse because it's this perfectly climate controlled environment, where people have access to all the nutrients, all the recovery capital, all the things that they need.

You think about it, when you're in treatment, you have this regimented day, you've got all this structure, you've got peer support, you've got mutual aid groups three times a day.

You've got educated counselors who are doing counseling to address the issues that you have helping improve your coping.

You have more nutritious meals, you might have built in physical activity.

This is recovery capital, right?

So in in Kentucky we have Fort Knox, which is where we keep all the gold in the United States, right?

So I think of treatment centers like Fort Knox for recovery capital, right?

You have a wealth of recovery capital.

And it's no wonder that people tend to be on a right path in recovery when they're in treatment.

The problem is, unlike the plants, which were sufficiently matured, when we transition them to the field, we take people whose brains are still very much addicted.

We transition them back into communities.

We don't give them any of the nutrients that the science is screaming off the page and telling us that people need access to, namely housing.

And as a consequence they're wilting, you know, and they're relapsing or god forbid, like a lot of my friends, they're dying.

And then we're blaming them and we're blaming them and we're framing it around choice and relapse and telling people that they wanna use drugs more than they love their kids.

And really horrible things that just really aren't fair.

So we have to get recovery capital into communities.

Recovery capital can't just exist in treatment centers, otherwise all we're ever gonna have is an an episodic model of care where people have to keep going back, right?

Can you imagine what it would be like if we treated diabetes that way?

If you had to go into intensive care every, it's crazy.

Okay, so what can it look like to build recovery capital?

I'm gonna give you all six kind of examples of ways that you can build recovery capital in communities.

These are by no means an exhaustive list.

There are so many more, but we've only got an hour, so we gotta do our best.

I thought it was really important to start with mutual aid organizations.

And part of the reason it's so important is there's this really cool science that shows that that social interaction is vitally important to recovery.

And not just in the sense that people need social support, it actually directly impacts their brains.

So if you remember, when we talk about brain science, we talk about dopamine down regulation.

That's what addiction is, is dopamine going down, down, down, down, down, down, until people have no dopamine, basically that, you know, they experience anhedonia, that inability to experience pleasure.

And so what recovery is, if addiction is down regulation of dopamine, then in maybe oversimplified terms, what recovery is, is upregulation of dopamine, right?

And so an important question we might ask in recovery is what are some strategies that we can invoke to sort of expedite the process of upregulating dopamine to sort of expedite brain recovery?

And it turns out that research shows that social interactions do exactly that.

So this is an article published in 2010 in Frontiers and Behavioral Neuroscience, and the title says it all, the rewarding nature of social interactions, pro-social activity upregulates dopamine in the brain.

Not only do you get like the short term acute maybe spike in dopamine, which precipitates pleasure and enjoyment and bonding and connection, but you also get the chronic benefit, the long-term change to your brain, the actual neuro anatomical change, which is increasing dopamine such that you can enjoy life around you.

So connection is so important to people in recovery, not only because of social support, but also because of what it does to people's brains.

And if you think about it, we've done a a fairly poor job of doing that in our societies of connecting people, particularly people who use drugs.

We make lots of effort to disconnect people who use drugs from others, from their families, from their society, which prohibits that kind of healing.

So we know that people need community, they need social interaction, they need mutual aid organizations.

Mutual aid organizations are beautiful because they're free, ubiquitous resources.

So in one of the presentations, not in this series, in a different one, I levied a couple of criticisms about AA only because they're not really criticisms of AA, it's just the fact that most communities only have AA available, because AA is an abstinence based program.

And that means for the minority of people who are addicted, who are interested in abstinence, it's gonna be a great program and it works really well for them.

And please don't hear me say otherwise, the problem exists because the majority of people who are addicted today are not treatment seeking and they're not abstinence seeking.

And that's a reality that we have to deal with.

And so the reality is, if they're not abstinent seeking, they're not gonna get support in an abstinence-based program.

That means other types of support have to exist because it's so critical that we get people connected.

So at Voices of Hope, we offer dozens of different kinds of mutual aid organizations that meet week after week.

You'll be familiar with all the A's, all the anonymous programs to the extent that we actually have what they've called themselves a secular AA program.

We also have refuge recovery, which is based on mindfulness-based stress reduction and kind of Eastern Buddhist principles.

We have smart recovery, self-management and recovery training is based on cognitive behavioral principles.

And it's sort of, it's my favorite.

It's very pragmatic.

You make pro-con lists and things like that.

I'm a type A kind of person, so it fits my line of thinking anyways.

We have all recovery meetings, which are kind of non-denominational.

We have MARA, which is a dedicated space to people who use medication as a part of treating their opioid use disorder because they experience so much stigma in other groups, a dedicated space for them.

Harm reduction works, which is my, I guess I just called ARMs my favorite meeting.

But I think actually harm reduction works is my favorite meeting, because it's a meeting for everyone, but really a focus on people who are actively using.

And prior to this time, we haven't really had spaces that are genuinely supportive of people who are actively using.

You know, the third tradition of AA says that the only requirement for membership is a desire to stop using and or desire to stop drinking.

And if you don't have that desire, then you can't be a member, right?

But you can be a member of harm reduction works and you can get support and connection.

And then we also provide support groups for affinity groups and reference groups like LGBTQ+.

And so kind of our ethos, kind of our, one of our core values at Voices of Hope is that we value all pathways to recovery.

It's like roots to a tree.

We really aren't the arbiter of what's good and bad recovery.

We don't decide what's best for you.

We just support you on your journey.

Second thing I wanna mention is peer-based recovery support services.

So at Voices of Hope, at our Recovery Community center in Lexington, all of our 100 staff are people in recovery who use their lived experience to help other people in recovery.

And what's so cool about that, and what just dawned on me a couple of months ago is that we quickly became one of the biggest employers of people in recovery, which is never something that we set out to do.

We wanted to be hiring people to help people in recovery.

And it just so happens that in the process of doing that, they're getting help to themselves.

So recovery community centers and peer-based services are so cool because it creates these like self-sustaining ecologies of people in recovery, helping people in recovery.

And it's the coolest thing.

So one example is telephone recovery support.

And it's simple, but it's kind of elegant.

So it takes the idea of sponsorship and flips it on its head.

So instead of having to pick up the thousand pound phone and call your sponsor when you're feeling tight, you can say, you know, frequently people say things like, I work a nine to five job and then I go pick the kids up after school and I put them in bed at 7:30 and I don't have a single craving to drink until 8:30 at night.

But after I'm sitting at home alone and the kids are in bed and the house is quiet, I start to get cravings.

That's a perfect time for a telephone recovery support call.

And our volunteers, most of whom are in recovery are gonna call and they're not gonna say, are you sober?

They're not gonna say, when was the last time you drank?

They're not gonna say, here's what you need to do.

What they're gonna say is, how's your recovery going today?

And how can I help you with your recovery today?

Sometimes we connect people to treatment, sometimes we connect people to various forms of recovery capital.

But the real explicit purpose of the call is just connection, is just a touchpoint in someone's day.

Another anchor that's based on recovery.

Kind of the main intervention that we run on site through our brick and mortar locations at Voices of Hope and also through our mobile unit is recovery coaching.

And recovery Coaching is where our coaches who have lived experience in addiction build recovery capital with and for people who are in addiction or people in recovery, and you know, they do it irrespective of whether or not someone's abstinent, people don't have to earn access to our resources.

You don't have to pass a drug test, you don't have to show evidence that you've graduated a treatment program.

You know, you're just welcome.

You're just welcome.

And our coaches do incredible, incredible work.

They understand the barriers that people face on the ground at a really granular level.

And so they actually kind of lead the creation of some of our programs.

So we realize that because methadone is so tightly controlled, and yet it's a really critical medication to have in the context of an opioid overdose epidemic, we had a problem, which is that people were having to drive two and three adjacent counties over to access methadone.

And it's a huge barrier.

So we started our, at the behest of our coaches, a methadone transportation program, and our coaches go and pick people up on a daily basis, you know, 4:30, 5 o'clock in the morning going, picking people up out in the counties and taking them to their appointments to make sure they access life-saving medication.

And oh, by the way, while they're on the way, they're talking recovery, you know, they're connecting, they're having that social connection that's contributing to their recovery.

The last kind of peer service I would mention is family based peer services.

So we offer a variety of different kinds of meetings for family members, family members who are grieving the loss of a loved one, family members who have a loved one in active addiction or in recovery.

And you know, it's because we recognize that family is a really important part of social recovery capital.

I know that from my own experience I've benefited, it's just hard to describe the extent to which I benefited from having a family that supported me the way that they did.

Sober living.

And really what we should talk more broadly about is housing in general.

But you all may be familiar with the Oxford House model.

The Oxford House is sort of a democratic model of halfway houses that's run by people in recovery for people in recovery.

They are abstinence based models.

And what you see here is one paper published in 2006 that shows that they're really effective in terms of reducing substance use, helping support employment, reduce the likelihood of recidivism and reincarceration.

And I think some of this is not just a consequence of the Oxford Model of care.

Some of this is the consequence of being housed, of recognizing housing as sort of a public health intervention.

But there's also some things that are unique about making it a democratic process and really returning agency to the people in the house.

So sober living is a really important resource to have in communities, but it's worth mentioning that not all sober living is good sober living.

And so this is a good paper that was published in 2019 that kind of looked at the characteristics of recovery residences.

And something that I thought was worth noting, number one, sort of like student to teacher ratio, sober living or halfway houses, recovery residences that had kind of a middling residence capacity seemed to be the most effective, the better student to teacher ratio you had, rather than the kind of places that are just trying to house as many people as possible under one roof.

Also, I think it's noteworthy that places that required 12 step meeting attendance led to increased abstinence.

And so I think it important, that we require not specifically 12 step attendance, but mutual aid attendance maybe more broadly, but I'm glad to see that there.

Also to two important points to point out about housing and recovery residence is the first, there's very limited housing for people on medications.

So there's this huge push from SAMHSA and from organizations like us at Voices of Hope to try to change the narrative around medications, to try to improve access and initiation and retention on medications.

And yet once we get people on medication, we face all these barriers, like they can't get housing, they can't get housing because most sober living and halfway houses are abstinence based programs that don't recognize MOUD as sort of a valid kind of recovery in at least one case in Lexington, one of our service providers does allow MOUD, people on MOUD to be housed, but they're housed separately, you know, which is I guess in some sense understandable, but in another sense, clearly stigmatizing, clearly othering by its very definition we're othering the people separately, right?

And furthermore, there is no supportive housing for people who use drugs.

And I sort of pointed that ear out earlier on, but to drive home this point, something to think about, this is sort of a tautology or a truism or something, but everyone who's in recovery today was once upon a time a person who uses drugs, right?

So instead of viewing people who use drugs as categorically different than people in recovery, I think it's a much more helpful lens to recognize that these are people in pre-contemplation, these are folks who are in the very earliest stages of change.

And so these are folks that we want to engage, folks for whom we want to build capital so that we can motivate them through the stages, right?

But unfortunately, we simply don't have a model of care for that, at least not in my community.

Clinical models.

So I have to talk about medications.

We've been talking about it for five years now, really thinking that we would get to stop talking about it.

But I think that the conversation is still, there's just still too much stigma surrounding the use of MOUD.

And I see it not just through the lens of the research, but pragmatically through the way that it impacts the people we work with every day.

Frankly, the way that it impacts some of our employees who experience stigma.

So it's a fight, it's a mantle that I've taken up personally, even though I didn't use medication as a part of my recovery.

So Rhode Island had a problem.

They had a lot of people who had been incarcerated who were leaving the jail and overdosing quickly.

And that's a problem that we see everywhere, right?

Incarceration increases the risk of experiencing a fatal overdose.

And they started this program where they initiated the people who were incarcerated on buprenorphine prior to being released from jail and they immediately saw a 60% reduction in mortality.

It's just such a success.

I don't know if this is true, maybe you can tell me it isn't.

It seems like if you had another condition and you had another medication for which there was a 60% reduction in mortality, that that would be like, you'd get a Nobel Peace prize, seems like a really, really effective medication, right?

So for every 11 inmates who were treated with MOUD a death was prevented.

The graph on the right is another study looking at a specific kind of MOUD.

So this is looking at opioid agonist treatment that really means methadone in this case.

So comparing the effect effectiveness of methadone versus mutual aid organizations and outpatient counseling in terms of engendering abstinence.

And it might surprise you to find that the folks who used the opioid agonist treatment, the methadone maintenance, were more likely across all time points to be abstinent from all other substances than people who were going to 12 step meetings or mutual aid organizations or doing outpatient counseling.

So the medications, there's no question that they're effective and definitely there's work to be done in terms of improving, you know, preventing, what's the word I'm looking for?

The diversion of buprenorphine.

I hear a lot about the concern of that people who get in clinics and cell their buprenorphine.

But my response to that always is, I stole this from somebody, but I think it's brilliant, if there's a medic, I mean obviously we don't want medications diverted into our communities, but if there was one medication that you would want diverted into your community in the midst of an opioid overdose epidemic, it's probably this medication.

You know what I mean?

So ironically the one that helps prevent overdose, it kind of is the one that we want getting out there.

One more just nod to the research on medications.

So in 2020, Sarah Wakeman and colleagues undertook a study to really compare the effectiveness of these medications for opioid use disorder against other treatment pathways in particularly in terms of reducing the odds of overdose mortality, which seems like a really worthy kind of research to undertake in the context of the opioid epidemic.

And so they examined six mutually exclusive treatment pathways, a control inpatient treatment, intensive outpatient treatment, regular outpatient treatment, buprenorphine or methadone and naltrexone.

And they found that only treatment with buprenorphine or methadone was associated with reduced risk of overdose at the three month and the 12 month follow up.

So that means that inpatient rehab didn't do it, outpatient treatment didn't do it, counseling didn't do it, even naltrexone didn't do it.

It suggests that naltrexone probably shouldn't be mentioned in the same breath with buprenorphine and methadone, even though it's an FDA approved medication, it doesn't have the same efficacy as the other two medications, particularly in terms of keeping people alive.

So it's a shame that at a time when these medications can be so effective at at least saving lives and giving people a shot at recovery, that there's so much stigma.

So I've been including these in a lot of my presentations recently and I almost went back and updated them, but it's too gross of an exercise.

So what I'm gonna show you all are some memes that I took from Facebook that really try to stigmatize people on medication and I just want you to know before I put them up that I'm not putting them up cause I think they're funny.

I put them up because I think it's having a really negative impact.

So this is, you know, Leonardo DiCaprio and "Django Unchained" and the suggestion here is that the doctor's doing something inappropriate by prescribing buprenorphine, despite the fact that all of the literature would suggest this is actually the gold standard for treating the condition that you have.

But what you see when you go on the internet, what you're hearing from your friends, what you're hearing from your community is that you're doing something that you shouldn't be doing, something shameful or something sneaky.

It obviously undermines access and retention.

It's a SpongeBob meme, that's SpongeBob's seeking medical help for his crippling addiction to opiates.

And Dr. Patrick slaps a bandaid on a bullet wound or so the cartoon would suggest, eight milligrams of Suboxone three times a day.

And I just think about my friends who, you know, the reason we have 12 step meetings in church basements is because we're stigmatized by society at large.

So we go to church basements so that we can be in a safe space where we can experience support and not be judged and not be stigmatized.

But imagine what it would be like if you were retreated down to your safe space only to find that they judge you and they criticize you and they don't accept you there either.

What it means is you don't have a home and that's a really dangerous thing for a person in recovery.

So I think it really important that we dedicate some attention to fighting this stigma in particular.

A note to mention about medication, the clinical guidelines as I understand them, would suggest that people don't need to come off the medication at any time.

We don't have a lot of research on the long-term effects, but the current clinical guidelines don't suggest people should only be on them for X period of time.

Substance use disorder is a chronic disorder.

It stands to reason that like other chronic disorders you would take your medication in so far as it's been effective.

But one real utility of medication that I saw in my experience working at an MOUD provider was when you were working with clients who had really low recovery capital.

So when you had clients who had housing insecurity or they were in abusive relationships or they had unstable mental health when they had these really serious risk factors that made it really difficult for them to get any traction, to put any time under their belt to build meaningful recovery.

That's why I saw medication be really effective because what it did was it helped people get a foundation, just sort of a layer of stability that they could build upon such that now they can start going back to work and they can start building up their income, their savings account now that they can get a house they can get out from under, you know, a rental agreement or whatever it is.

It reduces stress, it reduces bio psychosocial stress is what I would argue.

And it's been particularly effective for my clients who face lots of barriers.

However, I think it's reasonable to assume that the medication could be useful for lots and lots of people who have opioid use disorder.

Okay, last two, and I gotta move kind of quickly 'cause I'm running outta time, Recovery Community Centers.

This is what Voices of Hope is.

This is what we are, we're a recovery community center.

We're at, we actually have two locations, 450 Old Vine Street and then we're also at 644 North Broadway right next to Indie's Chicken in Lexington and we are the hub for recovery in our community.

So when I gave you that example of the tobacco and transitioning from treatment to recovery, we are the transplant where we take all the things, all the recovery capital that was so effective in treatment and we transplant it into our community so that now people don't have to go spend 30 day stints in treatment centers to access support for their recovery.

People can just come to their community center and they come to meetings and they come to do yoga and they come to work with recovery coaches to have their barriers reduced, like getting records expunged, getting job opportunities.

The list goes on and on.

It's a really cool model of that ecology, people in recovery helping people in recovery.

The last one that I'll mention before I go to kind of my parting examples are recovery supports in educational settings.

And I got the opportunity to help start the UK collegiate recovery community.

This is the CRC circa like 2000.

It's a really old picture, 2016 maybe.

And we had just a couple handful of a common core of students who kept coming back to the meetings week after week.

And one really cool example of that, we had a student named Alexis Patterson who was working with us in the CRC and years later she ended up winning one of our scholarships through Voices of Hope that helps people in recovery go back to school.

And I tell you all this to tell you, she said something to me that I thought was really interesting.

Our sponsor had actually reduced the amount for the scholarship the year that she won.

And so I was apologizing to her before we presented it to her and just said, I'm sorry that it's not the amount that it was previously.

We wanted to help you as much as we possibly could.

And her response was number one, as you'd expect from someone in recovery, very gracious, very humble.

But secondly, her response was, you know, every little bit helps because it seems like every little bit that I get makes the process just a little bit easier.

And I thought that's profound because that's recovery capital.

What she's describing back to me is the impact of focusing not on her abstinence, but on her recovery capital, on helping build with and for her the things that she needs to reduce stress so that she can enjoy a sustainable remission.

But I also think it important to recognize that all of this recovery capital building needs to happen in the context of harm reduction.

And so with my last five minutes, I wanna think about harm reduction.

So what is the value of harm reduction?

Why harm reduction beyond the obvious, which is that it reduces harm, reduces harms like the likelihood of overdose, the incidence of, you know, viral diseases, things like that.

But beyond that, there's a much more important but more subtle reason why harm reduction is a really important approach to adopt.

So it's really helpful to think about this in terms of the trans-theoretical model.

You all, hopefully maybe a lot of you have seen this, Francesca De Clemente said, in order to change any behavior, you have to go through these stages, right?

And under the current treatment paradigm that we have today where we say people have to get abstinent first before we start building resources for them, we can only be effective with people who are right here.

This is where our current treatment paradigm is situated.

We have treatment centers, brick and mortar locations that are stood up waiting for people to show up, not doing outreach and engagement, not not working with people who are in pre-contemplation or contemplation 'cause they're still using, right?

Instead just hoping and praying that people are gonna show up at our doors and get care for the things that they need.

And that's a huge problem because as I've already told you, the research shows the majority of the people on this spectrum who have substance use disorders are not treatment seeking.

They're not interested in treatment at all.

Which means what are we gonna do?

Whether we like to acknowledge that or not, it's still a burden.

They're still gonna, you know, show up at the ER with endocarditis and show up at our jails committing crimes to support their addictions.

It's still something that has to be addressed.

What harm reduction allows us to do is to connect with people across the spectrum, and we do it every day.

You can have somebody in pre-contemplation, somebody who has a severe substance use disorder and doesn't even think that they have a problem.

Traditional models of care don't have a clue what to do with this person because they're only focused on abstinence.

But what harm reduction allows us to do is to begin connecting with that person through our coaching, through a syringe service program, through telephone recovery support, whatever it is, start building rapport, start building relationship, get them on the path, right?

And so what's the value?

The value is engagement.

What harm reduction allows us to do is engage the otherwise unengaged, engage the majority of the people with substance use disorders in our communities who are not being engaged by traditional models of care.

And so here's what it looks like, with our current model of care where we don't meet people where they are, we just demand abstinence.

Here's what you got.

You got 23 million people in the United States who have a substance use disorder and only 10% are gonna receive treatment this year.

We call this the treatment gap.

So we say, oh my goodness, 90% of people who need treatment won't get it.

But it turns out the reality is that the majority of those people don't want treatment 'cause they don't wanna be abstinent.

So this is cool.

There's a recovery community organization like Voices of Hope in Florida that also distributes syringes and does other harm reduction services.

And a paper that was published a few years ago showed that 87% of their participants had used substances in the past month.

And I love citing the statistic because I think most people would look at that kind of the untrained eye and say, my goodness, everyone who's going through this program is still using drugs.

This program isn't working.

But what I see when I look at this is the engagement of the unengaged.

This 87%, these are the folks who stand in the gap.

These are the people who exist in the gap who aren't getting care of any kind.

And it's precisely because this RCO, this organization has a harm reduction orientation that they're able to engage folks in care.

So I realize I am right up against time now I've got one minute I'm gonna share with you my last example, my favorite example and we'll get outta here.

And I put a smiley face up to remind me to do this.

So early in our work with Voices of Hope, we had a guy come to us, let's call him John.

John came to us.

He had really poor mental health and he also had really poor dental health.

He needed work done on his teeth.

And so he came to us and said, I want some help with my teeth.

And we said, John, we'd love to help you but we gotta get you sober first.

And so we did a warm referral, got him to a treatment center and he wouldn't go and he left that day.

And so you can imagine if any of you all have done service provision, you know how some of those kind of stigmatizing conversations are starting to happen behind the scenes.

Well, he's not willing to do the work.

Well I guess he's not ready yet.

Guess he doesn't want it enough, right?

All that kind of stuff.

And then John comes back a couple weeks later and he says, you know, I wanna help with my teeth.

And we're like, John, we have to get you sober first.

So we set him up with a therapist and a female therapist who is a friend of ours, an acquaintance.

And he went to one session and he wouldn't go back.

And so now we're getting furious and we're having the most stigmatized conversation behind John's back about how he's not willing to do anything.

John's just looking for a handout.

And so finally John comes back, asks for help with his teeth.

Again, we don't know what to do.

So we relent.

And it's this really complicated procedure where he has to have some teeth pulled other teeth inserted so that he has something to affix the dentures too, right?

So really complicated procedure, John disappears and we don't see John for four months and you can guarantee that the conversation we were having behind the scene was John just pulled one over on us, looks like John just got a free set of teeth on us.

And it turns out we were completely wrong because not a month after that, about five months after his procedure, John came back around and not only had he been abstinent from the day of the procedure, but he'd been employed for four of those five months.

What John knew that he needed that I couldn't understand is that John needed to deal with his teeth first.

I was so obsessed with getting John abstinence and trying to be a good steward of this recovery capital that I didn't realize that John is the expert in his own life and he knows exactly what he needed.

John knew that he went, when he went to treatment, he was too self-conscious to open his mouth and share in a group, which meant he wasn't gonna experience support.

And when he sat down, especially across from a female therapist and had to open his mouth and betray the part of him that he's most self-conscious about, he said, I'm not gonna do that.

John knew that he had to feel okay about himself before he could start doing any of the other work.

And that's one of my favorite examples of why recovery capital comes before abstinence.

You have to build the foundation first.

So I know we're up against time, I gotta stop there 'cause I know you got places to go.

I'm sorry I didn't leave time for questions.

If you have specific questions or wanna banter back and forth about something, I love that.

Here's my email, I'm gonna throw references up.

Also, there's an evaluation that I dropped in the chat at the very beginning.

I'm gonna try to drop it just once more here for you.

- I just did Alex. - Thank you. Perfect.

You're on it.

- If people do have questions, we do have a few minutes and if you wanna hang on, if you're able to Alex, please feel free to do that.

Alex, I think there was a request for your email again.

If you could post that in the chat.

A question that I have, I wanna go back to your friend Bobby.

And you know I don't know a whole lot about this topic.

I do know that I could listen to you all afternoon, but that was the fastest hour of my life.

Bobby chose to spend a year in prison as opposed to going into the drug court because he felt he couldn't maintain his abstinence.

Was he able to maintain abstinence in prison?

And what did they do?

Did they give him what, explain how that works?

- Well no, definitely he wasn't abstinent in prison.

So like oftentimes family members will say, you know, there's some relief when my loved one's incarcerated because at least they know they're safe and nothing is further from the truth, because your loved ones are being traumatized while they're incarcerated.

They're at risk of lots of different kinds of harms and they have access to substances.

My friend Bob certainly did, and that that wasn't so much the reason that he chose it.

He wasn't choosing incarceration because he would be able to use, he was choosing incarceration because he knew he can do that year and then he's free and clear, and when he gets out on the other side, he's not caught in the complex web of the system.

But what he knew that I didn't know, 'cause he's the expert in his own life, right?

He knew that his abstinence was gonna prevent him from graduating drug court.

And what it meant was it was gonna turn a one year sentence into a five year sentence.

And so, you know, I don't wanna pretend like I have the answer, I know that's a dangerous thing to do, but I do see the flaw.

I think it's pretty clear to see that there's the problem there and that there has to be some sort of a system that permits people to be in process.

Particularly if we're gonna acknowledge that the reason that my friend Bobby, or part of his addiction at least is this trauma that he's experienced.

I mean, it's the kind of PTSD that's visible on someone, right?

Where you can see that he can't be comfortable in his own skin when other people are in the room that obviously needs to be managed before he's gonna be able to find any kind of recovery that works for him.

So it's a great question.

- Thank you so much for clarifying that for me.

Does anyone else have any questions, thoughts, comments before we leave?

Host them in the chat or the Q and A?

I always appreciate, I've learned so much from Alex about this topic and it's really helped guide some of our programs.

Thank you, Michelle.

This model and the awareness of stigma will then come back in February, February 7th, Alex will be talking about stigma and what we can do to be ambassadors for reducing that stigma.

And you know, sometimes I think the best education we do isn't on a Zoom or in a classroom setting, but it's like sitting in someone's living room and they make a comment and we can respond to that based on like this great information that we have.

We really appreciate your completing the evaluation.

Gives Alex great feedback, and us as well.

And again, if you didn't get to view Addiction 101, it is on the Extension website.

I posted that earlier in the chat.

I can put that again.

And anybody have any last minute comments?

Well, I so appreciate all you do for us, Alex, thank you so much for taking your time to help us grow in our knowledge and understanding.

- Very welcome, thanks for having me.