Effects of COVID-19 on the Opioid Crisis: Francis Collins with Nora Volkow

NIH Director, Dr. Francis Collins and NIDA Director Dr. Nora Volkow discuss how the COVID-19 pandemic may be escalating the opioid crisis and efforts to adapt research as a result of the convergence of two drastic health crises.

Video length: 39:16

Transcript

[Dr. Francis Collins speaking] Hello everyone, welcome to the 13th episode of Francis Collins at Home Edition. Yes, once again I’m coming to you from my home office in this, the 12th week of my being located here trying to manage a $42 billion a year operation called the National Institutes of Health. And depending on all of you, and with good reason, because you’ve been phenomenal to keep our momentum going, and we are moving forward in lots of different ways, and it has been great to have a chance as part of the Home Edition to interview various leaders at NIH who are playing significant roles in our ability to try and respond to the COVID-19 global pandemic. So, I’m very happy that my guest today is Dr. Nora Volkow who is the Director of the National Institute on Drug Abuse and who is a sort of a triple threat, if you want to call it that, she is after all a significant leader at NIH, Director of one of our 27 institutes and centers. She’s also a world-renowned scientist in her own right and much of what we know about the way in which drugs affect the brain is based on her own work. And she’s also, as you will soon see, a world class communicator who’s able to put forward the concepts about what happens when humans are exposed to various drugs and how that can affect their medical circumstances, their behavioral situations and their life course in a way that has, I think, illuminated a lot of people’s ability to understand why this is another public health crisis and one that we all need to get invested in and help find solutions and not blame the victims. So, yeah, here we are today talking about two public health crises at once, the crisis of COVID-19 but also the crisis which has been going on for quite some time, of drug overdoses and drug deaths. And those two have come together in a difficult way and that’s what we’re going to be talking about right now. Handling the opioid crisis is difficult in any circumstance, but you add to it what’s happening right now with the global pandemic and it becomes difficult squared. And so, it’s a really good thing that we have such a visionary leader to help us think this through and who has been putting forward initiatives, right and left, as this has been coming on us in order to try to do everything we can to help people who most need that kind of assistance right now. So, Nora, it’s great to see you, I don’t know if you brought any, sort of, family members or pets or anything to share with us as we sometimes do. Oh, you have an object, anyway?

[Dr. Nora Volkow speaking] It’s an object that symbolizes a creature; I don’t have a living creature so, as of now I’m limiting myself to the ones outside as of this one. So, sorry to disappoint everyone, but Francis hello and thanks very much for having me here and for doing this, I really appreciate it.

[Dr. Francis Collins speaking] Well, glad to have a chance to chat with you. I brought another living creature who’s at my house to say hello to you.

[Dr. Nora Volkow speaking] Hello Diane, how are you?

[Diane Baker speaking] I’m great, how are you and Stephen doing?

[Dr. Nora Volkow speaking] We are good but I’m very, very restless, I need to see people, I need to hug them, I guess they’re not going to talk anymore.

[Diane Baker speaking] Well, I’m just having a very rough bad hair day, so I had to cover up with my Children’s Inn hat to come say hello.

[Dr. Nora Volkow speaking] It’s a very good solution; I’m going to apply it to myself.

[Diane Baker speaking] You guys have a great talk.

[Dr. Francis Collins speaking] Okay, thanks Diane. Well Nora, let’s talk about this, and maybe step back a little bit, even before the pandemic hit, let’s talk about how things were going in 2019. Obviously, over the course of quite a few years the evidence of real harms that were happening because of drug overdoses and drug deaths were growing but it looked like maybe we were starting to see some progress. So, take us back a year, how were things looking in 2019 about now with this crisis of drug abuse?

[Dr. Nora Volkow speaking] Well, we started to see a turnaround from the, in the year 2017 to 2018 and it was the first year where we did not see increases in the number of people that were dying from overdoses. And what was remarkable though, was that were significant decreases in overdoses from prescription opioids and that reflect that many of the efforts from research and agencies to more properly prescribe opioids only to those who really need it, for pain management, and as well as the distribution of Naloxone, as well as the expansion of access to medication. So, we were starting to see those decreases as it relates to mortality from prescription opioids. Unfortunately, and that payed off in 2017 to 2018, unfortunately in 2018 to 2019 we’ve gone over 70,000 people who have died from overdoses and the rise is very much ascribed to two problems, one of them related to synthetic opioids, like Fentanyl, and in 2018 it is estimated that 35,000 people died from Fentanyl. But the other contributor, which is a new emerging threat, is that of psycho stimulant drugs like cocaine and methamphetamine. So, in 2019, we had 25,000 deaths between cocaine and methamphetamine. So, you add those two numbers and that has led to again to a slight increase in the number of people dying from overdoses. For the past three or four months when the COVID hit, we don’t have accurate numbers, of what the consequences are doing to the overdose fatalities, but from what we hear it’s estimated that at least there’s a 20% increase in the number of calls to the agencies reporting spikes in overdoses. So, there is concern that overdoses are increasing across the country, but we don’t have the numbers.

[Dr. Francis Collins speaking] And what has happened during this pandemic, where all these restrictions about people’s ability to move around freely, what’s happened to treatment programs and other kinds of safety nets that would have maybe helped people last year, but aren’t so available now?

[Dr. Nora Volkow speaking] And that has been one of the first things that we’ve heard from the communities and the families afflicted by addiction, that the support systems that were there to actually help them achieve recovery are no longer present. At the same time, access to some of the treatment programs has become much harder to get by and that actually includes emergency departments. And that is something that, again, we have been hearing consistently, overall people are going much less to the emergency departments and that includes much less numbers of people that ended up with overdoses that end up in an emergency department where they can be initiated in treatment. So, we’re losing these components, access to treatment, access to support systems, including syringe exchange programs has become harder, including the support systems that are necessary, like Narcotics Anonymous that provide people with a mentor and a social support system that is fundamental for recovery. And at the same time people, obviously part of your recovery is to identify a job to build your life and as the job has actual degrees it becomes harder and it’s much more challenging. So, all of these are aspects that we are hearing in terms of support systems, this translates of course into much more stress and stress, as we know, is one of the factors that lead people to actually relapse. And it’s also a factor that leads many to actually increase the consumption of drugs. So, stress is imposing another level that they have to deal with and people that are addicted or trying to cut down on drugs or are in recovery are very vulnerable.

[Dr. Francis Collins speaking] And then what about the impact of the stay-at-home orders for people who are depending on social networks, you’ve talked about Narcotics Anonymous as an example of that, but just for anybody who has faced a degree of stress challenges, mental health issues, which we know do coexist oftentimes with drug problems, what’s the net effect basically of losing those face-to-face social connections, is that a significant factor here as well?

[Dr. Nora Volkow speaking] Indeed it is and we were just starting our interview by saying how much I’m missing people, I mean, it’s difficult for anyone of us, the isolation, we depend on others for our wellbeing. And the harder your situation, the more vulnerable we are if we don’t have those support systems. So, one of the major concerns that we have had all along is not just the enormous risk of relapse in many people, but also the risk of suicide that is always much higher in individuals that are addicted to drugs, particularly addicted to opioids, and that is, again, an aspect that there is concern that there may have been an increase in the number of suicides associated with COVID, including those among people that are addicted. One of the elements we are using right now to try to overcome that is of course virtual meetings, like we have right now, and they are fulfilling, certainly for me, I see the value. And when we’ve made surveys to patients and families to see how much these virtual support systems are helping them, we of course see in many instances that this can be life-saving and in other instances we also get the comment that it’s not the same as going to group therapy. But there is no, I mean there is an alternative that we currently have and in some instances, for example, it has enabled us to provide treatment where we couldn’t in the past, for example with Telehealth a physician now can prescribe Buprenorphine without necessarily having to see physically the individual. And that’s a major breakthrough, because it expands the number of people that can be treated. And just to give you an example, for example, that if something that has been embraced and very rapidly now with COVID, in prisons and jails one of the difficulties in instituting treatment is that they don’t have physicians, well now prisons and jails have embraced iPad through which they can provide Telehealth.  And so you can provide Buprenorphine and you can also provide with a support that someone with comorbid mental illness may need. So, there is that element that, yes it’s not the same not to be able to be with others, but we have to also recognize that with virtual technologies and Telehealth we’ve also provided a greater equity in that we are giving treatments to those that didn’t have them in the past.

[Dr. Francis Collins speaking] What’s happened to methadone clinics, just occurred to me, that’s a place where people were required to show up in person every day and yet in the current climate that’s probably not practical, what’s become of people who depended on those?

[Dr. Nora Volkow speaking] Well, it became very rapidly evident and you saw it in pictures of methadone clinics at the beginning of March, I mean, all of these people conglomerated together because the spaces are small, there’s not enough staff and that was a very, very high risk. So, they started to curtail the number of people that they could see in a methadone clinic, the staff was getting sick, so they lost capacity So, one of the things that is positive is that there was a change in the policy, so now a methadone clinic can provide take-home methadone for the patients, whereas in the past they had to go daily and many times at a very restricted time, which made it incredibly difficult to comply. And it was very penalizing; we don’t do anything like that for any of the other diseases that they say you have to go to the doctor on a daily basis from this time. And by the way, your methadone clinic may be one or two hours away, you may not have transportation, but you’ll figure it out. So, it was a really non-sensitive system to the needs of those afflicted with addiction that are really struggling. So, this has been unprecedented, because for many years this was one of the questions that was going about, do we really need to have this support system to provide methadone. And one of the questions that we’re now trying to answer from a scientific perspective is to evaluate the outcomes when people are given take-home methadone, because if we can show from evidence that the outcomes are as good as when you go daily, then we hope that that should help transform these policies.

[Dr. Francis Collins speaking] So, there’s a silver lining in a few places here in terms of ability to do treatments without requiring very onerous steps that many people don’t have the ability to carry through. I’m glad to hear there’s something we can say about this that’s positive. In terms of people who do suffer from drug use disorders, are they also at increased risk of getting sick from COVID-19, I mean, you mentioned if they’re forced into small spaces to try to get treatment, that would be a risk, but are there other aspects of that population that’s placed at a particularly high risk of getting quite ill from this virus?

[Dr. Nora Volkow speaking] There are many factors that place them at very; very high risk and I like to divide them into pharmacological, structural and social. Pharmacological, because these drugs basically negatively affect multiple systems in your body and one of the main targets is the pulmonary system. And as you know, if your pulmonary system is already has pathology because of prior conditions, it’s much easier for the virus to actually infect you and lead to negative outcomes and that pertains to of course cigarette smoking that produces COPD and pulmonary damage as well as very, very toxic drugs like methamphetamine that produces pulmonary hypertension. Or opioids, which actually produce hypoxia, they depress respiration and you can see that the combination of respiration and having a viral infection that attacks your lungs is not going to be a very positive one. And indeed it is very likely that that combination lowers the threshold for people to die from overdoses or to die from COVID. But these drugs also affect the cardiovascular system and they also affect the metabolic system, so all of the factors that we’ve identified as conditions that make you more vulnerable are affected by drugs. So, from that perspective individuals that have a history of substance use disorder are at greater risk. But then there are the structural systems that we have, and we were discussing the methadone clinics, that actually puts people, together, in very close spaces. In general, one of our main priorities with HEAL and before that was to bring the treatment of substance use disorder and the screening to the healthcare system, but now the healthcare system is saturated and individuals who have gotten their treatment in healthcare systems no longer can access them. So, that also restricts their ability to actually seek help. In our country, we basically criminalize people that take drugs, and many of them are in jail systems and prisons, where infections can rapidly occur. And so that is another element where they are at much higher risk. Another aspect of it is because you, most people, even though now there is parity, the number of individuals with substance use disorder that have insurance is much less than that of the general population and by default just not having any medical insurance is associated with a greater likelihood of having chronic medical conditions, which again is another element. And so this mixes the structural with the social and in the social of course you have stigma. And stigmatizing individuals with addiction makes them very vulnerable, because, first of all, they are afraid to seek help, they don’t want to be discriminated, and secondly, if they are in a situation where decisions are being made about providing treatment, when treatment is limited, that can actually make them much more vulnerable. And two, I think that we cannot ignore as we’re looking at everything that’s happening right now in our country, where we are dealing with COVID, where we are also being faced with the disparities that exist in our society, recognizing if there is, and COVID has made it very clear how horrifically disparate outcomes are between groups of people in our country. And a lot of it explained on the basis of socioeconomics and lack of opportunities. And people with substance use disorders are not any different. So, those elements, incarceration, homelessness, lack of jobs, all of those aspects are the social ones that make people very vulnerable.


[Dr. Francis Collins speaking] So, yes I’m glad you’re getting into this area of health disparities, because it is such an important issue for us to all try to look at unflinchingly and see that these disparities have been there, but they’re having a particular bright light shined on them right now as we see the effect of COVID-19. And on top of that of course we have as a nation looked much more closely in the last two or three weeks, at the evidence in our culture, in our society of what you might call structural racism, particularly in the law enforcement instances, the deaths of George Floyd, of Briana Taylor, of Ahmaud Arbery and others. And these are all, kind of, linked up, aren’t they, because you have a circumstance where there is a connection between drug addiction and criminal activity. Oftentimes an individual trying to seek out a way to support this compulsion, it comes along with the addicted situation. And yet we have a law enforcement situation that tends to overly stigmatize and perhaps particularly target those of less represented races and so our prisons are full of circumstances that are heartbreaking, of individuals who have gotten trapped into a drug use problem, then have gotten into the criminal justice system. Oftentimes if you look at the distribution of individuals it is heavily dominated by those of minority races. This seems like a really difficult circumstance that deserves attention and it’s maybe one of those moments where we can ratchet up that impression. So, Nora, say a little bit more about your view because you’ve been a real leader here on what we might do to try to bring the effort to pay attention to helping people with drug use problems in the criminal justice system, which is oftentimes where an opportunity rises, but unfortunately, oftentimes where that opportunity is missed?

[Dr. Nora Volkow speaking] Yes, I mean, one of our priorities as we address the opioids crisis is to actually do research in justice settings in order to be able to identify the models that lead to the best outcomes and to understand how to implement them. And this has resulted in the creation of a research network that enables us to actually connect across the justice and the healthcare system. The network has started to emerge before COVID hit and it has put us in an opportunity to actually from that network get direct information about what’s happening out there. And what we know, which is again a research opportunity to answer your question, is because prisons and jails are so high risk for infection, many of the States, if not all of the States, are releasing people, that are not violent, into their communities. Many of them have a substance use disorder and to the extent, and again it’s like everything else, you cannot just, if someone has a long history of a substance use disorder and you release them into the community without a support system, and in the midst of the COVID epidemic, where it’s hard to find a job, where the families are rejecting them, you can predict the outcome and the outcome is going to be very, very poor, including dying from overdoses. So, the challenge is, and I look at this way, we have an opportunity to show that treating these people in their community with provided support is going to lead to much better outcomes than leaving them in jail or prison. So, what we are working with our researchers is to figure out, and with the agencies, how to provide that support that’s necessary as these individuals with substance use disorders are released into their communities. Because it can go both ways, without support the outcomes may be very poor, with support we have the opportunity of transforming the way that we deal with addiction in this country, such that in a much more systematic way we provide treatment as opposed to putting someone in prison or jail. And if for whatever reason that crime that was committed does deserve jail or prison, then to ensure that that person is given treatment and opportunity to rehabilitation, because otherwise they are going to get back into the system, they are going to actually relapse.

[Dr. Francis Collins speaking] And I think what a lot of people may not realize is that treatment does exist, treatment is effective, treatment has been demonstrated to change lives and improve outcomes over the long term. I still think there’s a lot of folks out there that think, oh you know, it’s just hopeless or else if this person just had a little bit more willpower, they’d be able to take care of this. You of all people have studied this intensively, so just say a little bit about what the current treatment options are and what the evidence is that they’re needed if you’re going to help somebody recover from a substance use disorder.

[Dr. Nora Volkow speaking] Well certainly, particularly for opioid use disorders we have actually quite effective medications. There are medications for alcoholism and there are medications also for nicotine use disorders, but by far the most effective are for opioid addiction. And this has been, again, very frustrating, because the medications work, but they are not necessarily given to patients and sometimes even given to patients they reject them, and part of it is because of the stigma against the medication, there’s not just a stigma against the person that’s addicted, there’s stigma against the medications. The opioid crisis has helped smooth that out somewhat and so has there been a greater acceptance of medication. And two, in partnership with the pharmaceutical industry, what we have been working towards is developing extended release formulations that make it much easier for people to take these medications. And also, in parallel, not just for opioid addiction, but for other addictions, we have built up evidence of behavioral interventions that can improve outcomes for people with substance use disorder in general. While also recognizing that since there is a high risk of comorbidity with mental illness, we need to provide the treatment that is necessary to address those psychiatric disease problems or symptoms as well as the addiction process. And so, a lot of the work is right now in creating models that are allow this comprehensive treatment that is tailored to the needs of the person. And that is very important, because as I say and as we are facing, for example, right now the crisis of methamphetamine addiction, we don’t have currently any FDA approved medications for methamphetamine, which is an extremely addictive and toxic drug. But we do have behavioral treatment interventions that have been shown to be effective. So, we need to ensure that they are provided in a way that actually is effective, that it follows the procedures that are necessary that are the active ingredients of that intervention. And now, again, like with anything, sometimes, something as tragic as what was happening to all of us leads to rapid change, so that there has been an expansion in terms of what insurances are willing to support and one of the treatments that has been shown effective in methamphetamine addiction is contingency management. Where I will check and give you a little bit of money for being able to show milestones. But insurances in the past were not very open to pay for that, now that has changed. So, there are advances that have happened as it relates to being forced to modify the way that we provide the treatment and the way that we supported it, because it has become clear that if we don’t it our patients are going to be left with no support systems.

[Dr. Francis Collins speaking] Nora, it occurs to me that maybe people watching this who have a family member or friend who is suffering from substance abuse disorder in the midst of COVID-19, trying to struggle with how to cope with it, maybe looking at some glossy brochure that has lovely photographs of a 28-day detox program, which all too commonly is what’s offered without any medication assistance or sometimes even very effective behavioral therapy. Those aren’t the answer, but what would be a place where people could go and get reliable evidence based information about the kind of treatment programs that somebody needs who’s struggling trying to deal this difficult situation?[Dr. Nora Volkow speaking] Both the NIDA website and SAMHSA website, and SAMHSA is of course the organization that provides the services to most of the treatment for substance use disorders. What we are aiming to do, and I’m glad you’re asking this question, because it is, many people have found themselves reading these are the recommended places, but how do you evaluate. And one of the problems is that in the substance abuse treatment there has not been any way of assessing the quality of the treatment. Whereas in medicine you can check what are the track records of this or that hospital for this or that surgery, that does not exist for substance use disorder. So, we have been funding researchers to develop metrics that can predict good outcomes on treatment programs that can be based on, one, the experiences of people and family that actually took these services, and the other  one, from the structural characteristics of the program that ensure that they do have the evidence-based components that have been shown by research to deal with better outcomes. So, there are, I mean, researchers that are now developing those, I call, report cards that hopefully will do two things, first of all as a family member being able to get a sense of how others are rating it, and importantly to incentivize their treatment program to get better scores. Because everybody’s looking at you and you want people to choose you and so if they are actually being assessed in an objective way, that can serve as an incentive to improve the quality of care that you provide.

[Dr. Francis Collins speaking] That would be wonderful, to have more of that data for people searching for good answers. So, Nora, somehow we’ve talked about drug abuse and substance use disorders and we haven’t even mentioned the acronym HEAL. H, E, A, L, which stands for Helping End Addiction Long-term, a trans-agency initiative funded by the Congress to help us conduct research to try to address these multiple problems from multiple different directions that relate both to addiction, but also to the problems of chronic pain and how do we come up with better solutions for pain that are not addictive. You and Walter Koroshetz are the co-leads amongst institute directors, although there’s a whole Executive Committee that oversees this. And Nora you and I meet every week to talk about how we’re doing on this program, trying to be sure we’re using those resources as best we can. How does the existence of the HEAL Initiative need to kind of adapt to the current health crisis of COVID-19 and what’s your institute doing to try to address some of these really significant problems that have emerged in just the last two or three months?

[Dr. Nora Volkow speaking] Yeah, and I think that that question also relates to, I would say, to basically most of our, some of the general ones that are afflicting all of our grantees, right, when you cannot do research because the IRB closed or because they are not recruiting patients, and that is the problem of course that has directly affected the HEAL initiative as well as other programs. And that has put us in a very slow trajectory, because, for example, one of the programs that we were very interested on was expanding the use of the emergency department for the screening and initiation of treatment to medications for opioids use disorder and that’s really now on hold. Another program actually that does not relate to the healthcare system, but to the justice settings, which is another major HEAL program for us, where we were going to start to do clinical trials to evaluate the outcomes of different types of medications for opioids use disorder, they are all basically on hold. So that is a major challenge. On the other hand, I have to say that having built these large programs, and there are three that are very notable, the one that we’ve been discussing about the justice setting that enables us to understand how justice is dealing with these issues. And then of course based on that knowledge we can derive and identify priorities for research. The second one is our projects with the healthcare system that are basically driven through the clinical trials network that has given us scans in terms of this healthcare systems including Telehealth and access to rural communities, for understanding how they are dealing which substance use disorders out here and in combination with COVID, including pregnant women. And the third element is the healing community story, which is the story that looks at four States with very high mortality rates, Massachusetts, New York, Ohio and Kentucky, and randomizes communities to do an intervention that is tailored to their needs and based to access rapid access of data of their outcomes versus those that are just as usual. And of course, the implementation of many of the programs, like expansion of Naloxone or expansion of medications had been slow, because their systems are overwhelmed with dealing with patients with COVID. But they had given us; again, the opportunity to understand what is happening out there in rural communities or in communities that have been devastated by the opioid crisis. So, whereas we’re not able to move as swiftly and as rapidly as we had hoped, in the goal of the story itself, this infrastructure has given us a very powerful tool to understand what’s happening, because this is a new world and we don’t have data and so it has enabled us to do that.

[Dr. Francis Collins speaking] Nora, you’ve given us a lot of information about how all these efforts are being organized around trying to deal with this double public health crisis, what’s your hope, going forward over the next few months, about what NIH can do to try to address this situation in a most effective way possible? What would you like to see us invest in, even as some opening up and starts to happen?

[Dr. Nora Volkow speaking] You know, there is a word that I saw in this light of Bob Kali that just resonated in my brain, and that is purpose. We have a purpose and we are embracing that purpose, all of us, and I think with all of our commitment and creativity and I think that we’ve proven ourselves, I mean, in terms in general, that when we do that, when we all have a common purpose that we can solve it. So, I am optimistic and not just because I’m wishy-washy, but because I can see how science can solve extremely challenging problems and I think that this is the time for science to shine again and show us that methodologies aimed to actually identify objectively and develop optimal solutions can resolve problems. So, the concept that in my brain goes around is, how long it’s going to take and I also had been very impressed about how these devastating circumstances can lead us to question the timing at which we moved projects in the past. So, we will just get on these things, oh it’s going to take so much time to get this done, and now we know it’s not that case, we can do things very, very rapidly. And, to me, I think that is a wonderful thing that has happened, recognizing that time is a luxury, that we need to move everything rapidly. So, that is the question,: how long will it take? With respect to the issue of substance use disorder, I would hope that as we as a nation become aware, because we are in all of this together, of the suffering that this pandemic is putting in all of us, that we become more emphatic for the suffering of others. As I see the movements across the country and the support of the injustices that are happening I would hope that that also goes through to diseases that have been stigmatized and that it actually touches them so that we can modify our stigma and embrace it and provide the same level of importance to treating these diseases and supporting the people afflicted, than others. I think that science will prevail, what is going to be important there is we also allow for our humanity to use that science in a way that everyone can take advantage of it.

[Dr. Francis Collins speaking] That’s a wonderful way to wind up what we’ve been talking about and I’m glad to hear you focus on purpose, because that is, I think, what drives all us who have the privilege of working at this time in the largest supporter of biomedical research in the world. Our purpose is clear to find answers for all of these difficult problems that cause suffering and early death for people who deserve better. And I think our eyes are particularly strongly now on those most vulnerable populations right now, COVID-19 has pointed us to that, our discussion now about those who suffer from substance use disorders also focuses on that.
The focus we have right now on our structural racial discrimination problems are also, I think inspires us to get beyond where our mindset has been and do something that might actually result in some actions. And I’m always one who likes to talk about hope, because after all it drives a lot of us, that’s what we get up in the morning thinking about, is hope that our efforts are going to lead to a new vaccine or a new treatment for COVID-19 or a better way of helping people who have been afflicted with drug problems. And yet I think, somebody once wrote, one of my favorite quotes, that hope is a privilege that attaches to action, that means that you can’t just say well I hope for something, unless you attach that to some actions you’re going to take. Nora, your institute has been living that out; you don’t just hope that something good will happen to turn the tide of this terrible crisis of deaths from opioid overdoses, you’re all about action. And I appreciate the chance to chat with you about this and for your continued devotion to those individuals who need our help and who’ve been stigmatized and badly treated and for whom maybe science and evidence can provide the best possible rescue from a circumstance that has been far too unfeeling and too harsh in the past. So, thank you for your incredible dedication to the science and to the people who we are trying to serve and reminding us about our purpose and for being my guest.

[Dr. Nora Volkow speaking] Francis, thanks very much for your support and actually your battle all along. So, we have a purpose in life.

[Dr. Francis Collins speaking] We do. And so do all of you who are watching this. So, with that we will wish you well.