How is San Diego faring in the war on fentanyl?

S1: It's time for Midday Edition on Kpbs. Today , we are talking about the fentanyl crisis and its impact here in San Diego. I'm Jade Hindman with conversations that keep you informed and inspired and make you think. It's a drug like nothing seen on the streets before. And managing the crisis will require a new approach.

S2: Fentanyl is the deadliest drug we've seen on our streets. And what this means is we have to rethink a lot about how we deal with people who are under the influence and addicted to these drugs.

S1: Plus , we'll break down who's most vulnerable to exposure and the treatment options for those addicted. That's ahead on Midday Edition. San Diego is no stranger to the nation's ongoing fentanyl crisis. In fact , local law enforcement officials have gone as far as to describe the region as being an epicenter for fentanyl trafficking in the United States. But in so many ways , fentanyl is presenting challenges that are proving harder and harder to solve through conventional means. In his latest Atlantic article , author and journalist Sam Quinonez argues that the nation's approach to addressing drug related issues is fundamentally outdated and needs to be changed. He spoke with Midday Edition producer Harrison Patino about the harsh reality of the nation's fentanyl crisis and what needs to be done to address it. Here's that conversation.

S2: Fentanyl is the deadliest drug we've seen on our streets , combined also with methamphetamine. That has a dramatic effect , creating mental illness across this country. The meth that's coming out of Mexico is so potent , it seems to be doing this pretty much everywhere. And what this means is it seems to me that we have to rethink a lot about how we deal with people who are under the influence and addicted to these to these drugs. One of the things these drugs do masterfully is squelch the basic instinct for survival. You can see this in many tent encampments , people living in tents , encampments , regardless of how filthy or violent or how temperatures drop. And it does not seem to me that the folks who are in that those situations actually have control of of their own rational free will. Honestly. And what I think we've found is one example of that is that many of them , very large numbers of them , refuse treatment even when they're offered , which use housing and even when it's when it's when it's offered. Instead , it preferred to stay on the street in these kind of squalid , filthy tent comments that create this horrible public health issues as well as are breeding grounds for criminality as well as being a place where they will die. And so given the fact that that really readiness for treatment , you cannot find it in a in the in the on the street the way we're seeing it in many cities and in California , people need to be pulled out of there , it seems to me. Otherwise , they will not they will not be able to find readiness for treatment before meth drives them mad and fentanyl kills them. There's nothing compassionate about leaving people in this condition on these streets. It's awful situation for them , for the community at large , for local businesses , ET cetera. Schools and thereby all of that. And so I think that one thing we need to be thinking of is whether or not it's we can find ways of using what we already have with regard to law enforcement. And one thing I think is very important to really think about is or actually rethink is the use of jail , arresting people , putting them in jail. But in other parts of the country now , you're seeing fascinating examples of counties using jail as places for recovery recovery pods , very much like any rehabilitation center that you might get into , except crucially , you can't leave when the drugs demand that you do so. And so it's a life saving thing. Then to be arrested and put into one of these recovery pods is not the typical jail where you're just sitting there and vegetating and it's very predatory. Mostly it's very boring. These are places where people are actively involved in their own recovery. And then some counties also there is there's a whole lot of services that then lead from when you leave jail on the outside. But all of this comes starts first , I think , with with using law enforcement and rethinking some of the ways we have. We have used law enforcement in the past because the drugs on the street require it now. People are dying in record numbers. They will not survive. There's no such thing as a long term street fentanyl use or they all die. And so that that makes me think we really need to rethink a lot of what we've been doing up to now.

S3: And more on that point , you also write that America's approach to drugs overall , even though it's well intentioned , it's it's outdated.

S2: You know , all of the ideas that we're seeing used now , decriminalizing the sale of fentanyl , for example , the sale of fentanyl is when you sell fentanyl. It's very much like firing a gun into a crowd. You know , you're going to hurt somebody. You're most likely going to kill somebody. And yet we treat it as if it's somehow should be a misdemeanor as a minor thing , as if it were the same thing as , say , a baggie of marijuana 20 years ago. This idea that we should decriminalize drugs based another time , fentanyl on the street changes everything. Methamphetamine on the street , driving people to symptoms of schizophrenia , meth , and do psychosis that changes everything. These are there's no such thing on the streets. Anymore as a minor drug charge. If you're talking about arresting a guy with with a piece of foil and a fentanyl pill and a and a and a straw , that is not the same minor drug charge , as I said , like a baggie of marijuana 20 years ago , that person is going to die or somebody or he sells that pill to somebody and that that person could easily die. You're talking about life and death issues here. These are no longer minor drug charges. So all of this fentanyl and meth in the quantities and then the potency with which they are showing up all across this country and certainly in the San Diego San Diego area , without a doubt meaning that we have to rethink a lot of the stuff that that we thought were good ideas when these drugs were not on the street.

S3:

S2: This isn't this is not terribly I mean , I don't see why not. I think you can you can fashion a way in which we use certain aspects of harm reduction , which I think are important , Naloxone. I think sometimes needle exchange can be very , very important in certain situations , along with an idea that that it is actually a compassionate thing to arrest somebody and get them off the street. Then you fashion a system through which when they get out of jail , there's a drug court in which they can expunge the charges that got them arrested in the first place. So it won't , you know , follow them through as they try to get housing and and jobs and so on. That can be expunged very , very easily. There's all kinds of ways. And we are seeing what's interesting is not in California , but we are seeing in other parts of the country , counties really experiment in fascinating ways with combining a lot of this stuff. What I believe is necessary is kind of a third way It involves , but it does not exclusively include the ideas on the right of just throwing away the key and leaving people. And in jail , jail has a role. It's just not a place where you should be just allowed to like vegetate and and sit for months and then be let out and go back right to what you were doing. And on the left , the idea that you should be allowed to sell these deadly , deadly drugs on the street without any consequences , because the problem with that is the very people who are selling those drugs , those folks are going to die , too. They are most often selling their drugs , those drugs , to support their own habit. Anybody who's selling this stuff on the street has a very high risk of of , of of dying. And it's the record the the record overdose deaths we've seen bear that out.

S3: I think so it seems like every other headline I read involves a fentanyl bust where a large enough quantity of the drug is seized that could collectively kill hundreds of thousands or even millions of people.

S2: Exactly right. They have covered the country with fentanyl as well as with methamphetamine. Prices are so low. So they have to get rid of it somehow. And so you're seeing it just flood the country. The people who make it don't care , don't really even know what happens to it. Once they make it , they sell it to somebody who sells it to somebody else , who smuggles it across , who sells it to somebody else. So it's fentanyl is a commodity and the people who are making it don't really think too much , have no connection to anybody who would eventually use it. And so you're seeing just staggering quantities. That's why we're seeing , by the way , all these pills come across , counterfeit pills , counterfeit Percocet , Xanax , oxycodone , generic , 30mg , all containing nothing. But but fentanyl is simply so much Fentanyl is being made down there that they just have to find new ways of packaging it. And sometimes it's a powder , sometimes it's on a brick. But other times , many times , tens of millions of these pills are coming across the border now in San Diego , in Nogales , Arizona , and other places along the border. And those pills , too , are just simply covering the country. It's it's a it's a mistake , I think , to think that there is some board of directors of dope down in Mexico thinking long term thinking , man , we should plan this different. We should force price up. No , what you're seeing is prices have collapsed. You're seeing quantities of drugs flood our country that unlike any we've ever seen before. And that is because the nature of the trafficking world down in Mexico is that it's very diffuse. We call them cartels. They're not cartels. If they were cartels like OPEC , they would have gotten together , reduce supply and force the price up. What you're seeing that the very opposite happened because it's just a very diffuse organism , throbbing kind of robust organism involving many , many , many people , many regions of of of Mexico. And there is no board of directors of dope thinking long term here.

S3:

S2: Also , one thing I think is important to understand about the drug is that it's a first of all , it's a magnificent anesthetic. It's been used. I've had it myself. Many of your listeners will have had fentanyl , whether they know it or not. It's been a workhorse drug Is transformed surgery in America much better than morphine. Morphine makes you dopey , makes you nauseous. It takes hours for you to come out of the dopey state once the surgery is done. None of that is true about fentanyl. The thing about fentanyl that's important to our question right today is that fentanyl takes you in and out of anesthesia very quickly. That's what makes it such a useful drug in in operating rooms used by paramedics , frequently on on the street to control pain of the people they're dealing with. The problem is that when that is that drug is in the hands of of traffickers , that benefit turns into a real catastrophic liability. Because what what ends up happening is a drug addict needs to use them over and over and over all day long. A typical heroin addict might use 2 or 3 times a day to keep the withdrawals away. Right. But with fentanyl , you need to use six , seven , eight times a day. It's a torment for users , but you have to do it because the the the the withdrawals are so much more fierce with with fentanyl and you can never get away from it. Fentanyl is always taking you out just as it does in , in in anesthesia , which is a good thing. It becomes a torment for users. On the other hand , it becomes , of course , a bonanza for dealers because you have people who have to buy and use from you use your product repeatedly over throughout throughout the day , and that means just more sales for you.

S3: Now , you've written in the past that skyrocketing fentanyl usage is a root cause of the nation's worsening homelessness crisis.

S2: These are drugs that are , I believe , major drivers of our of our homeless problem throughout the country. First of all , you find them there in intent encampments very , very commonly. Now , methamphetamine is a is a drug that drives people now in the current state is coming in with immense potency that's being produced down in Mexico , 99% purity , just just remarkable amounts of that stuff that it's very quickly driving people to symptoms of schizophrenia , meth induced psychosis , inability to live with anybody. But both of these drugs , once you're on the street , regardless of why you initially became homeless , both of these drugs served to kind of keep you homeless , particularly in the supplies and the potency with which they're now on the street. It's very difficult for people to to find the desire to leave these drugs. As I said , most people seem to refuse treatment when they're on when they're on the street. And so it's it's also the prevalence , the potency of these drugs is so intense that when you're on the street , regardless of why you initially ended up there and there could be many , many , many reasons why that would be , they serve to keep you there mired to the street , both in addiction and sometimes certainly in the case of methamphetamine , driving you to to a state of of mental illness that you're incapable of kind of perceiving reality. So all of these both of these drugs , particularly in the in the potency and the supply in which they are now covering our country , it's not like a like a regional thing anymore. Everywhere I go , I talk to people and everywhere I go , the story is the same. What's the big problem ? Fentanyl and meth or methamphetamine , depending on on , on whatever your your your region is. But it's always the same. And I think when you get down into it , you find very often the people who are who are most mired in homelessness , they are addicted to one or both of these drugs. These drugs are not the only cause of homelessness. But but they do serve to keep people mired in it in a very intense way because of how prevalent and potent they are across the country.

S3:

S2: The situation really has only recently become apparent to people as a critical because we were for two years really involved in in Covid and that took up all our budget and. Our attention and all that. And so it's only been recently that you've seen that I would say that the trafficking world covered our country with these two drugs just about the time Covid hit. And at that point , you know , the entire focus was naturally on a worldwide pandemic. I do believe that there are places in the country which are understanding that this has to be a community response. I talk about the importance of rethinking jail. I talk about the importance of rethinking jail because it's as part of a larger community response , using every tool that we have available to us. That's jail , that's drug court. That's a lot of services on the outside. Once people leave. To me , I think what what this is making clear is that it's so important now to think in terms of a community recovery , ready community kind of response. You we I don't think we can really have the luxury anymore of saying , no , we're not going to use that. You know , we got the problem with the drug war was not that we used law enforcement. It was the what ? We only used law enforcement. The problem today , I think , is that we're saying no , a law enforcement because of the drug war should be sidelined. We're not going to really that should not be part of the equation. I think that's foolish. I think that's delusional. Law enforcement has a number of very , very important roles to play. I think one of them that people aren't thinking of , the reason I write about this or mention it a fair amount is because people are not thinking of the idea of how you might change jail to make it a positive in in people's lives. And I think that's happening in certain counties in the Midwest where they've been at this a lot longer than we have out in the out in the in the on the West Coast. And so to me , that idea , that realization that we need to use a variety of services , a variety of community assets is something I think is gradually becoming more apparent as the crisis itself gets gets more severe. The problem is political will to do that. And in some parts of the country on the right , you find no political will for changing how jail should be on other parts of the country , like on the West Coast. You see that on the left ? No , no support at all for saying , you know , maybe law enforcement really has a good a bunch of good roles to play in all this. And but always as part of an orchestrated community response , not alone. We try that during the drug war , it didn't work. We also tried , by the way , of of of eradicating pain. It also , like drug addiction , derives from the the brain , our brain chemistry. We decided that we could somehow eradicate all pain by prescribing one kind of narcotic painkiller for the entire every single human human being. Anytime you try to use a few or one tool to to deal with something that derives from from our brain chemistry , the most immensely complex organ that we know of is the brain. You are going to get into trouble. We did that with drug war. I think we did that with the opioid epidemic as well. And I'm afraid I see too many examples of people saying now let them rot in jail or no , it's okay to sell fentanyl on the street. It should be a misdemeanor because why ? Well , the drug war.

S1: That was author and journalist Sam Quinonez speaking with Midday Edition producer Harrison Patino. What do you think would be helpful in addressing the fentanyl crisis ? Give us a call at (619) 452-0228. You can leave a message or you can email us at midday at pbs.org. Coming up , the conversation continues with Dr. Luke Bergman , director of San Diego County's Behavioral Health Services , on how people are being exposed to fentanyl.

S4: It continues to be the case that there are greater rates of fentanyl exposure coming from unintentional fentanyl use.

S1: You're listening to Kpbs Midday Edition. Over the past few years , fentanyl has fast become one of the defining issues that communities across the nation are trying to address. In the last year alone , the CDC recorded more than 100,000 deaths from the drug nationwide. Here locally , San Diego faces a number of key challenges in tackling the crisis. Given its proximity to the border , the San Diego region faces a unique challenge in the sheer amount of fentanyl from Mexico that circulating within the community. Joining me now with the regional outlook is Dr. Luke Bergman , the director of behavioral health services in San Diego County. Dr. Bergman , welcome to Midday Edition.

S4: It's great to be here. Thanks.

S1: Good to have you. So overdose deaths from fentanyl are on the rise nationwide.

S4: People have been dying in unprecedented numbers as a result of fentanyl related overdoses. The the most recent year from which we have full data is 2021 , in which over 1200 people in the county died of opioid related deaths overall and over 800 from fentanyl specifically , which was around 64% of the total number of of overdose deaths. The preliminary data from 2022 suggest what looks to be a potential leveling off in the the rates of mortality , which isn't the best news possible. What we would , of course , like to see is a precipitous decline given the heights of these numbers. But a leveling off is better news than we might have seen , which would have been ongoing increases in rates.

S1:

S4: What I think is a really good question that that you're asking. It continues to be the case in data that we see from across the country that there are greater rates of fentanyl exposure coming from unintentional fentanyl use , that those would be cases where fentanyl is mixed with some other substance that users are intending to use and that they do know that they are using , though we also see the numbers of folks and the rates of folks who are intentionally using fentanyl continue to increase. So it's not most of the people , but that does seem to be an increasing pattern. It is a kind of a growing phenomenon that there are people who are meaning to use fentanyl and identifying themselves even as fentanyl users in greater numbers.

S1:

S4: I suppose , you know , an issue that is on a lot of people's minds is the relationship between fentanyl use and other social determinants of health or other sort of indices of social vulnerability such as homelessness. We've seen , you know , pretty long standing and relatively high rates of of potentially harmful substance use among people who are chronically homeless , especially I want to make very clear data suggest pretty clearly that substance use disorder is not the primary and maybe not even a significant driver of homelessness. But because of the hardships of homelessness , we do see higher rates of substance use and substance use disorder among cohorts of people who are chronically homeless than the general population and among folks who are using substances in risky ways. Fentanyl is , of course , a significant part of the picture and you know that has impacts in that it increases the overall health and wellness vulnerability of our homeless population. And it also can contribute to to challenges with getting people who are experiencing homelessness , chronically access to the right kinds of. Care use disorder is is a. It is probably the most significant chronic illness that we face as a nation. And entering treatment into it in particular can be very challenging for people with severe substance use disorder. And so a lot of what , you know , frontline workers aiming to address homelessness experience are challenges reaching people with substance use disorder and navigating people with substance use disorder to care. So I would say the the the frequency of fentanyl use , we see , of course , most vividly in the number of deaths that have resulted , but also collateral in how it creates some service access complexity for for other cohorts that are particularly vulnerable.

S1:

S4: The the central region of the county , not surprisingly , is is the region where there are relatively speaking , highest rates. So it's about 1.2 times higher. We see a 1.2 times higher overdose death rate in the central region than in the than in the rest of the county. We also see particular vulnerability to mortality among non-Hispanic American , Indian and Alaska native populations , as well as among non-Hispanic black populations , where in particular we see two times higher rates of overdose mortality than the county rate generally.

S1:

S4: I think that has a lot to do with overall exposure to social determinants of health and and and to health and wellness vulnerability that are born very unequally across this country by communities of , you know , different racial and ethnic identity. And this is the thing we talked about. I think really importantly and consistently in the context of the Covid pandemic , that it was very clear in that context the different communities of geography and identity were being impacted differently. Um , I think it's very important that we in San Diego County in particular , where there's a relatively small African American community by total population , right ? Remind ourselves that that community is bearing the brunt of the homelessness crisis very disproportionately. And , and think that's some of what we see playing out with respect to vulnerability to to overdose death as well. Right. We know that people who are homeless are much more vulnerable to overdose mortality. Right. If somebody does not have a consistent place to live , they are at greater risk of substance use disorder. They are at greater risk of mortality from substance use , and it is more difficult to get them care. And that is a condition that we know impacts the black community in San Diego County kind of wildly disproportionate to to other populations here. So that alone think would contribute pretty extensively or pretty significantly rather , to to the disproportionate numbers of overdose deaths here.

S1: So much of this is intertwined. And so when we talk about tackling fentanyl , it's not just the drug we have to worry about , but the host of other issues. It makes worse like you were just talking about.

S4: And , and I would say relative to to a lot of other jurisdictions , San Diego County has really been leading with that model of response. There are long standing efforts highlighted by convenings , um , the strike force , for example , the prescription prescription drug abuse task force , also that involve balanced membership across public safety and and public health. So we've seen that in this county for quite some time. And I think it's through the ongoing. Ramping up of an acceleration of that kind of collaborative. Collaboration that we're that will be in position to do the most good. So our our emphases are in ensuring that our community has access to the right kinds of overdose prevention resources. That most significantly is the medication lock lockdown about which listeners to of course heard a great deal. This is an opioid antagonist that can reverse an overdose. It is effective with fentanyl and at the county we've really just taken a , you know , a determined approach to to saturating the county with this medication. So , you know , ultimately we hope that it is , you know , so accessible that one would almost have to work to avoid it. Some efforts that have been particularly noteworthy in this county have been the the distribution of naloxone vending machines , which we've accomplished over the last number of months. We now have around 12 vending machines distributed across the county , the distribution of naloxone through community based organizations at county clinics , um , increasingly through school systems at the outset of our efforts to really ramp up naloxone distribution , when it was becoming clear that , you know , that we needed to pay particular attention in this moment to making this medication available , we we set a goal of getting 33,000 doses out to the county. We have now allocated through our county of San Diego and a lock zone distribution network between July of 2022 and and and May actually the end of May of of 23 close to 60,000 doses. Um , so we we feel like we are achieving success in our efforts to distribute naloxone. That's one piece of what we need to do , right ? That's , you know , that that will help us avoid the kind of gravest consequences which are , which is overdose death. We also need to continue to expand treatment and continue in particular to expand and make more accessible medication assisted treatment. So we do that through opioid treatment programs that the county supports. These are clinics where people have access to to medications like methadone , but also buprenorphine , both of which have demonstrated over and over again to be extremely effective in treating opioid addiction. And and more recently , those efforts will be complemented by additional efforts kind of in the the harm reduction continuum. Um , so we are , you know , in the process of launching additional harm reduction service centers where we will really take a , you know , kind of health and wellness first and foremost approach , a very low threshold approach , right ? It's a it's a facet of substance use disorder that people are often reluctant to get addiction care , um , even if they intellectually understand that , you know , that , that it would be helpful to them because it's an extremely physically and emotionally painful process to go through for a lot of folks. So making care settings like those that are harm reduction oriented , lowest threshold is really important , making them welcoming for people even if they are not ready to stop using substances is really important. And that's what the county's harm reduction center effort will be all about.

S1: I'm speaking with Dr. Luke Bergman , the director of behavioral health services in San Diego County. Coming up , the conversation continues with new treatment options for people addicted to fentanyl.

S4: The most important thing I would want to emphasize is that care is available and that care absolutely works and that its effectiveness is something that we need to be both committed to and patient with.

S1: You're listening to Kpbs Midday Edition. You're listening to Midday Edition on Kpbs. I'm Jade Hindman , joined by Dr. Luke Bergman , the director of behavioral health services in San Diego County. We're discussing the regional outlook on the ongoing fentanyl crisis. So I want to ask you , in the 80s , there was the crack cocaine epidemic. The use of that drug was criminalized and never treated as a public health issue.

S4: And of course , the ways in which those were very unequally borne by people from different races and ethnicities. Right. Minority communities much more dramatically impacted by law enforcement related policies during the crack epidemic. I think that has a long with , you know , the advent and evolution of better and better medication assisted treatment regimen for substance use disorder helped to shift the discourse really significantly over the intervening years so that so that it's it's much more publicly acceptable now to have a primary response that is public health rather than law enforcement. Though imagine you're asking the question in part because recent efforts some local many across the the nation have highlighted opportunities to enhance law enforcement response to to fentanyl , to fentanyl dealing and , you know , to to to illicit transactions and involving fentanyl. I can't speak for the , you know , the progenitors of of that work. I would just say that , you know , those efforts kind of notwithstanding or irrespective the predominant response that that really needs to be marshaled if we're if we're going to address this , this issue effectively needs to be about enhancing care , making it more and more accessible and more and more shaped around the particular nature of substance use disorder , which is that it is a chronic relapsing disease. So so treatment has to be structured in a way that accommodates the virtual inevitability of relapse and takes an approach to ongoing engagement of people in care that is much more consistent with how chronic somatic illness is treated , right like diabetes. And this is a , you know , an analog that's often pointed to , right ? We don't kick people out of diabetes treatment if they eat too many Snickers bars. And we do need to take , as you know , kind of cartoonish as that can sound. We do need to take a similar approach to our our our systems of care for for people with substance use disorder. Our commitment needs to be to ongoing engagement through thick and thin as people are doing well and also as they are are struggling. That's what that kind of commitment , which of course carries with it , needs to carry with it an obligation to fight stigma around substance use disorder. That kind of commitment is the one that's going to get us the farthest.

S1: We hear all the time about just how deadly impotent fentanyl is from a public health perspective.

S4: I think the the way in which we are leaning more and more towards a public health approach and proportionately away from , you know , an approach characterized by supply intervention or or law enforcement. And that's because the the potency is , you know , is so strong , so little , in other words , of fentanyl , you know , is necessary to to really saturate communities with it. That trying to blockade it from entering communities is really futile. It's you know , it is it can have in very small quantities A. Dramatic impact , not just at the level of a single person or at the level of a family or the level of a network of friends , but at the level of an entire community and certainly in an entire county , it's not going to work for us to devote our energies to trying to keep it from being here. It very likely will be here for quite some time. What we need to do is enhance our efforts to make harmful substance use , a thing that is talked about , that is understood as very widespread and a thing for which people can get care and treatment. And and I think that's you know , that's owing in part think the you know , the the the leaning in that direction is owing in some part to the fact that there there has to be broad acknowledgement because of the potency of fentanyl because it is colorless and odorless and appearing in all kinds of different forms. A supply side approach isn't going to work with it.

S1:

S4: It may not work right away , but it's very likely if if the commitment to it is sustained , it's very likely over the long haul to be effective. Only 10% of people with substance use disorder ever get access to addiction care in this country. And that's owing in part to the fact that the disease is so stigmatized and care for it is stigmatized and sometimes dismissed as something that doesn't work anyways. It's incredibly important that people understand that it does work. Access to it is a huge problem. But for those who do get access and for those who get sustained access in particular , it can be very effective.

S1: You know , earlier in the program , we spoke to a journalist who argues that America's approach to drug treatment is just fundamentally outdated.

S4: I think that there is a lot of room for us to continue to evolve addiction treatment in this country. I think the thing that it's most important for us to focus on is how we can further and further integrate addiction care into overall health care. Traditionally , addiction treatment is mostly accessible through a specialty care system that is very siloed from the rest of health care. We don't tend to consistently screen people for addiction or addiction risk in primary care settings , for example , we don't tend to , in primary care settings , offer care for addiction. We do offer care for other chronic illnesses , but not for for addiction. We we have anticipated traditionally that people would get care for those issues someplace else , even though addiction is probably the most harmful chronic illness that we face as a country. And even though it it is very well established that there are very strong connections between addiction and other physical health issues , that kind of health care integration focus in our efforts to evolve addiction treatment in this country I think will be incredibly meaningful.

S1: I've been speaking with Dr. Luke Bergman , the director of behavioral health services in San Diego County. Dr. Bergman , thank you so much for joining us.

UU: Thanks so much , Jay.