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← Evaluating the Therapeutic Potential of Ayahuasca for Substance Use Problems - Brian Rush

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  1. [Psychedelic Science 2013]
  2. [Evaluating the Therapeutic Potential of Ayahuasca for Substance Use Problems]
  3. [Brian Rush, Ph.D.
    April 20, 2013]
  4. BRIAN RUSH: I'm new to the study of ayahuasca, but not new to the study of addictions.
  5. Thirty-seven years in the field, and I just feel to
  6. make a contribution in this area
  7. by bringing some of that experience into this context.
  8. And I... It's late, so I also wanted to
  9. thank you for being here.
  10. You're either hardcore addiction researchers,
  11. or clinicians, or you're
  12. hardcore ayahuasca researchers,
  13. or clinicians, or both.
  14. So thank you for staying.
  15. So without further ado, let me figure out how to do this.
  16. You can see the title:
  17. I thought a lot about what I could contribute,
  18. and I framed the title this way.
  19. What do the prevailing models and methods of
  20. alcohol and drug treatment and treatment research,
  21. what can they bring to the study of ayahuasca
  22. and its therapeutic potential?
  23. But also I'd like you to think about the reverse of that,
  24. which I've spend quite a bit of time thinking about.
  25. What does the study of ayahuasca - what is the
  26. potential to bring to the study of alcohol
  27. and drug treatment in other contexts?
  28. I think that's a more reciprocal way
  29. to look at the work that we face.
  30. Okay.
  31. Nope.
  32. Help me out.
  33. AUDIENCE MEMBER: Point it at the projector.
  34. BRIAN RUSH: Ah.
  35. HELPER: Maybe the battery's died.
  36. Is there a way to move it forward?
  37. BRIAN RUSH: I guess also by way of introduction,
  38. while we're getting started,
  39. I'm not a psychiatrist, a clinician, a physician.
  40. I'm an epidemiologist,
  41. so I bring a public health perspective to this as well,
  42. which I think is interesting, to see how we can
  43. contribute to something kind of in a clinical context,
  44. but also both aware of the potential risks
  45. in public health contexts, but as you'll see,
  46. I'm going to just raise questions for you about
  47. the role of ayahuasca in treating the full spectrum,
  48. or supporting the full spectrum of substance use
  49. and abuse, including its role in prevention.
  50. I'm from Canada, so this is kind of a Canadian
  51. afternoon with our colleagues. So, I'm from Toronto.
  52. We are on the cusp of being in the Stanley Cup
  53. Playoffs for the first time in the last century, it feels.
  54. So we do play hockey, and
  55. we are a very multicultural society.
  56. I thought I would just point that out,
  57. because everything I'm going to talk about including use
  58. of ayahuasca in its therapeutic context
  59. is really all about cultural context,
  60. so this is a little bit of my cultural context.
  61. So I'm going to start,
  62. just the way the presentation's organized --
  63. What are some of the things we've learned
  64. from the study of alcohol and drugs and treatment,
  65. and then what are some of the implications
  66. of that for the study, for the therapeutic potential
  67. of ayahuasca. So the first thing we've learned
  68. over the last while, is that the treatment system,
  69. and I'll go on to describe what I mean by that,
  70. really needs to address the full spectrum.
  71. It doesn't exist in an either/or phenomena,
  72. not like the good and bad spirits (Jacques?).
  73. Alcohol and drug use in the community exists
  74. along a full spectrum, and we now see the need
  75. to see how the specialized services for the treatment
  76. of addictions actually can be distributed
  77. through the community to address the full spectrum
  78. of risks. And this asks us to look at the relationship
  79. between treatment and prevention.
  80. And, to point out, the afternoon has been about
  81. the use of ayahuasca for treatment, but just as a
  82. reminder, in many cultures it's used in a prevention
  83. context, and we should also have that in mind.
  84. It's not the focus for today, necessarily, but the children
  85. are the future.
  86. This is what's often referred to as a
  87. population health pyramid.
  88. Many people who are coming into
  89. alcohol and drug treatment, and for sure,
  90. my visit to Takiwasi, the people coming to the center
  91. are really very severe, and quite complex,
  92. but we have to recognize that's kind of
  93. the tip of the iceberg.
  94. These people emerge from a history
  95. of use and abuse. And if we think about
  96. Gabor Maté's presentation,
  97. a history of a wide range of trauma.
  98. So there's a personal trajectory, often, here.
  99. But most of the people are here.
  100. If we put some numbers on that,
  101. in the Canadian context,
  102. and if you have the right epidemiological data,
  103. you can do this in most of the developed countries.
  104. This is really a very small percentage of the overall
  105. population, whereas most of the people are here.
  106. And then if we ask what percentage of these
  107. people are actually going for help related to their
  108. alcohol and drugs, here very few people go for help,
  109. but even here most of the people with very,
  110. very severe problems, are not going for help.
  111. The emerging view in the alcohol
  112. and drug treatment literature,
  113. is that this kind of microsystem of alcohol and drug
  114. and mental health services is just not sufficient
  115. to address this population. It's just not big enough,
  116. and not enough people are going for help.
  117. So the emerging view is that these services need to
  118. be working in concert with other health services.
  119. There's a wide range of collaborative care models,
  120. and this is the system of support for those folks:
  121. schools, workplace, um, the social assistance.
  122. I've added spiritual resources.
  123. Most people would not put them there.
  124. I'll come back to that point.
  125. Traditional healing, most people would not
  126. put them there, but I'll come back to that point.
  127. So this is the alcohol and drug treatment system.
  128. That picture looks quite different in many countries.
  129. This is the system of healing, and you can
  130. see I added question marks here, because in some
  131. communities in developing countries,
  132. low-income countries, theres really very little of this,
  133. and there's really only this.
  134. So the implications: alternative healing needs to
  135. be recognized as a legitimate part
  136. of the community treatment system.
  137. And I say that's a fundamental principle,
  138. whether you're in downtown Oakland, San Francisco,
  139. Chicago, Toronto, Inuktituk in our Arctic --
  140. there are community healers there.
  141. They are doing a lot of good work but they are
  142. generally not seen as part of our health care system.
  143. We need to consider the role of ayahuasca and other
  144. plant medicine for prevention and early intervention.
  145. And this one is a big challenge --
  146. we need to see the treatment centers
  147. as part of this system, but they need to be linked.
  148. You heard from Anya, Gabor,
  149. everyone talking today,
  150. that ayahuasca is not a panacea,
  151. but also for the treatment of addiction,
  152. it needs to be connected to some followup.
  153. So it's raising the question:
  154. "what is the relationship of the retreats,"
  155. "of residential centers, even like Takiwasi,"
  156. "what is the relationship, for discharge,"
  157. "where are those people going, and,"
  158. "what's the connection when they go back home?"
  159. So, lesson learned number 2:
  160. the paradigm of treatment.
  161. The paradigm of addicton drives, obviously,
  162. the design of the intervention,
  163. but the design of the intervention
  164. will drive the choice of evaluation.
  165. There is no one paradigm has been shown to be
  166. superior in guiding the development
  167. and evaluation of treatment.
  168. Indeed, these paradigms are essentially
  169. competing with each other.
  170. We don't have time to go into this.
  171. I think this is very similar to this
  172. slide that Jacques showed...
  173. Um, different ways to explain addiction.
  174. These paradigms lead to different kinds
  175. of interventions, different focus,
  176. the structure of the treatment,
  177. the interaction between the person.
  178. The point I'm trying to make
  179. is that the paradigm drives the intervention.
  180. That's not news, but the question is
  181. whether there's enough acceptance here
  182. to accept a spiritual paradigm for treatment
  183. of addictions - to be successful in getting
  184. funding, to be successful in moving the
  185. project forward.
  186. Of course the sentence has 3 errors, because
  187. the sentence itself is incorrect.
  188. In other words, you will see what you
  189. look for. We do have I think,
  190. a Bio/Psycho/Social. But sometimes we have to
  191. whisper the word 'spiritual'.
  192. Bio, Psycho, Social, [whispers] Spritual...
  193. [scattered laughter]
  194. ...paradigm for treatment.
  195. It's like putting it in brackets in the grant.
  196. So, the dynamics of a paradigm shift...
  197. ...and I won't dwell here, but where this is
  198. leading is that I do not think we can evaluate
  199. ayahuasca - it's therapeutic potential - without
  200. including a spiritual component.
  201. Paradigm shift, when something is not going well.
  202. But we do have a dominant paradigm, and there's
  203. often a competition to get space for
  204. particular models, or measures.
  205. These are the two fundamental goals of the
  206. treatment system: coverage, and remember,
  207. that even the most severe problems,
  208. people do not go for help, so coverage
  209. is a major problem.
  210. But also quality. Even well-funded, well, uh, uh,
  211. resourced programs still struggle to get very
  212. successful rates, especially with the kinds of
  213. people Gabor Maté is seeing in the downtown
  214. Eastside, and what I think is going to Takawasi.
  215. So a competing paradigm must contribute
  216. and improve upon those two goals.
  217. Will a spirituality-based approach grow and
  218. be supported? Yes... if it improves coverage.
  219. In other words, it will not be supported if we
  220. are only seeing a very, very small number
  221. of people, and if the results are not really good.
  222. No one will pay any attention if you don't
  223. solve those two problems.
  224. So, the implications - we need to be open to
  225. multiple perspectives, we need to fit the measures
  226. to the model - spirituality needs a place in the
  227. measurement model, and we don't have time
  228. to go into it here, but almost everything I say
  229. may not be true for the evaluation of
  230. indigenous programs, it needs its own
  231. paradigm, and its own model.
  232. So lesson learned number 3: no one type
  233. of therapeutic intervention has shown to be superior.
  234. It's basically, 'different strokes for different folks'.
  235. What are the factors related to improvement?
  236. 40% of the variance in treatment outcome is related
  237. to what the person brings - their severity,
  238. their context, their family, their community.
  239. 15% is related to what we will do with them -
  240. and this quite humbling for people.
  241. 15% or so is based on expectancy.
  242. And 30% is based on having a good relationship.
  243. So, it's very difficult to find the one best
  244. techique, because you're really only operating
  245. with a small percentage of the variance.
  246. And it's also important to note that
  247. while there's lots of room for new approaches,
  248. there are some common elements that relate to
  249. therapeutic relationship, belief, expectancies,
  250. and so on - and this calls for a holistic
  251. approach to the evaluation, something, I think,
  252. similar to what, um, has been promoted through
  253. all of the presentations today.
  254. It cannot be biological alone, it cannot be
  255. psychological alone, it cannot be social alone,
  256. these things need a holistic model.
  257. So, the implications: treatment with ayahuasca
  258. needs to be seen in a stepped care model,
  259. in some case, it could be the initial stepping stone,
  260. and needing some extended treatment,
  261. back to what Gabor was saying.
  262. It may be a second stage intervention.
  263. In other words, it's not just one approach,
  264. it needs to be part of a continuing care model.
  265. Long-term residential ayahuasca-assisted treatment
  266. may be effective, but it needs to be reserved
  267. for the most severe.
  268. Lesson learned number 5: what actually is
  269. evidence based practice? What standards
  270. of evidence are being held up for us?
  271. They're pretty high, but are they really appropriate?
  272. Um, the literature around 'EBPs', as they're called,
  273. evidence-based practice, is evolving, and are now
  274. distinguishing between practice and the process,
  275. in this case, the actual intervention from the
  276. process of delivering it.
  277. We also hear language coming out of the
  278. study of indigenous practices, in particular here
  279. in the United States, um, formal definitions
  280. of practice-based evidence, and community-defined
  281. evidence. And we're likely to find some support
  282. there in moving work in the area of ayahuasca
  283. forward if we're looking to that literature and
  284. the success that the American Indians, and our
  285. indigenous people in Canada - and in New Zealand
  286. in particular - are being very successful in promoting
  287. their work, in getting funding for their programs,
  288. by redefining evidence.
  289. There's also work underway in the evaluation field,
  290. for some people this is a bit of a no brainer,
  291. but think about it.
  292. Intervention plus context equals outcome.
  293. There's a whole range of new methodologies
  294. being developed for synthesizing literature
  295. and so on.
  296. So for sure, and I guess following up
  297. on the last presentation in particular,
  298. there's a need to build upon the existing
  299. database, our existing knowledge.
  300. There's a need to learn from the progress
  301. being made in other indigenous healing practices.
  302. And, this is something I really had to deal with
  303. myself, we need to resist, or at least
  304. carefully consider, our tendency to deconstruct the
  305. ayahuasca experience. We have a strong therapeutic
  306. relationship there, we have, in a shamanic context,
  307. or a religious context, we have a group experience,
  308. we have belief, we have a biological component --
  309. so our first inclination is to want to kind of
  310. pull that apart. But that's just how our Western
  311. brain kind of thinks.
  312. I've been advised by others to not go there
  313. right now, but to try to study the experience
  314. in it's totality, and also to make sure we're still
  315. focused somewhat on toxicity.
  316. So, bringing it all to bear:
  317. I'm a health services guy, this is natural for me
  318. to say, "okay, small-scale clinical studies are
  319. one thing", but I think it's time,
  320. or maybe time, to kinda kick it up a notch,
  321. and what I describe as a health services agenda,
  322. placing ayahuasca-assisted treatment in a larger
  323. context of a health service.
  324. Not small-scale clinical studies.
  325. So, one approach are really finding people
  326. in the community who are not in contact with any
  327. formal services. There are methodologies available
  328. that we can do this. I think we need to
  329. understand why they're using ayahuasca,
  330. and also, what benefits they're getting,
  331. and how they're complementing that experience.
  332. Secondly, and this is a study I'll describe
  333. very quickly, what we call a panel study,
  334. or some might use the word 'descriptive',
  335. but it's a not-controlled, it's not a randomized
  336. controlled trial, I don't think they're there,
  337. but I think we can do larger scale studies
  338. following people out, looking at a variety
  339. of outcomes, and also understanding the context
  340. in which ayahuasca is being used.
  341. So, we have a project in development,
  342. we are not funded yet.
  343. It's a multicenter study being planned to describe
  344. various approaches, the outcomes being achieved,
  345. and their context.
  346. At present the 3 countries involved are
  347. Peru, Argentina, and Brazil.
  348. A few of us here to keep talking about this.
  349. Um, we are proposing a common
  350. baseline description using validated
  351. assessment tools. At this point it's not likely
  352. to be the ASI, uh, we have another option
  353. that we're looking at. But whatever tool
  354. we use needs to have its outcome measures
  355. embedded in that. So it's a common quote-unquote
  356. 'clinical assessment' across a number of centers,
  357. and a number of countries.
  358. Um, one- or two-year followup --
  359. this will depend a lot on funding.
  360. So, it would be a quantitative assessment of
  361. outcomes, this is the tool we're looking at.
  362. We're now translating that into Portuguese and
  363. Spanish, this would be the range of measures.
  364. Some of them in the GAIN, the spirituality-based
  365. outcomes. Um, I've done my own literature review
  366. on that, and I got a stack this high,
  367. so nobody can tell me there's no spiritually-based
  368. research being done -- you have to look in, uh,
  369. social work, and other branches, for example
  370. in cancer care, they're studying, um, end of life kinds
  371. of work, and so on.
  372. There's a qualitative narrative component
  373. that will be needed. We are open to explore
  374. other, uh, innovative evaluation techniques,
  375. but essentially, it's a clinical study
  376. done in naturalistic settings. There's a variety
  377. of challenges - one I've been thinking about here -
  378. I would appreciate kind of feedback on,
  379. and we're gonna be talking about in the group.
  380. Um, some people are coming - I don't know if this
  381. is the right word - but are we talking about the
  382. treatment of local people? Or are we talking
  383. about the treatment of people who have come
  384. from Europe or North America into a Latin American
  385. context, and should we separate them in some way?
  386. Should we have two different samples?
  387. I'm not sure, but I think it's different in some way.
  388. The belief system, the expectancies, everything,
  389. are going to be different for that population.
  390. Um, this is an interesting question.
  391. Jacques was good enough to introduce me to
  392. Sacha [?] in uh, Runa Wasi, in Buenos Aires, uh,
  393. they use ayahuasca in the context of mental health,
  394. generally, not just addiction.
  395. So is our study about addictions, is our study
  396. about something broader?
  397. There are a wide range of infrastructure
  398. requirements to do this. To do this in one center
  399. is difficult enough, but to do it, for example,
  400. in the Amazon, if we find a place, do we need
  401. an infrastructure, for not just paper and pencils?
  402. Computers? Data quality? Monitoring fidelity, of the
  403. interventions, and the, and the data collection?
  404. Sample size - Jacques wil be the first to admit -
  405. Takiwasi is, how many people a year? Fifty?
  406. So, we need three or four times that.
  407. The power in these studies is in the numbers, and
  408. for statistical controls, and statistical manipulation.
  409. It's how you can kind of, get away, sort of,
  410. without a control group.
  411. But you need numbers to do that.
  412. We will be able to compare the data,
  413. depending on the measure we choose,
  414. to international benchmarks of outcome.
  415. So, it's not completely uncontrolled,
  416. it's not completely observational.
  417. Um. And the other one, I think I should've, uh,
  418. thought to put on, is that only in Peru
  419. is it really wide open and legal,
  420. unless we did include Colombia I suppose.
  421. So, is there some risk to the centers to be involved?
  422. Um. How are we going to get approval?
  423. If we looked at the Canadian example
  424. that was presented today, it's uh... observational
  425. studies, so maybe we don't need all those approvals.
  426. But, in each case, we have people associated
  427. with university. We need an ethics review.
  428. So it's a little complicated - the logistics about it.
  429. And I had lunch with Anya today to talk about that,
  430. and some of the pros and cons, maybe,
  431. of involving Mexico,
  432. which we'll talk about as a group.
  433. So I think that's it. Um, right now,
  434. it's a staged approach. We are... we got caught up
  435. in trying to get funding from Senado [?] in Brazil...
  436. which ran into its own problems,
  437. and its own kind of drug wars at the moment.
  438. So we are still unfunded, but, uh, I think
  439. we've got a variety of funding options
  440. we'll now pursue. Um, either in Brazil, or Peru,
  441. through kind of traditional
  442. government research funding.
  443. Especially for the first meeting, which is not
  444. going to be super expensive,
  445. we just need to come together to really
  446. finalize the protocol. We may have other
  447. philantropic options, and I'm starting to consider
  448. using crowdfunding through the internet, cause
  449. it's really not that much money.
  450. If the 1600 people enrolled in MAPS each
  451. contributed 10 bucks, we're halfway there!
  452. [scattered laughter]
  453. Thank you, and good luck in your own
  454. personal work. Thank you.
  455. [Applause]
  456. CHAIR: Thank you, Brian. Uh, question.
  457. AUDIENCE MEMBER: Yeah. I have two questions.
  458. First question: Being in Canada, are you aware --
  459. I'm from Arizona -- and in New Mexico they're having
  460. like a traditional healing consult team, in, in Gallup, New Mexico, in the Navajo area, in the hospital.
  461. Does that kind of thing exist in Canada?
  462. BRIAN RUSH: Um. Not to my knowledge. An indigenous healer working in the context of the center?
  463. AUDIENCE MEMBER: Yeah. That's what I've, uh, come across.
  464. That they have like a hogan, you know, in the back, and they can, the patient can ask to participate.
  465. So, I'm just wondering, that's an interesting kind of thing that's happening...
  466. BRIAN RUSH: Not in Ontario... Canada's a big country...
  468. BRIAN RUSH: ...and if it's happening, it would be happening probably in Saskatchewan, or Alberta, where the indigenous population is larger.
  469. Um, we were close to hiring an indigenous, very spiritually oriented psychiatrist at our center, but at the end it didn't...
  470. ... I think they were just not brave enough. But, so I think the answer is not.
  472. BRIAN RUSH: There's good relationships, but not in-house indigenous support.
  473. AUDIENCE MEMBER: Okay. And then the next thing is... you know, I have my center there in [garbled] in the middle of Peru, with the MD,
  474. we have computers, and stuff, and we'd love to participate.
  475. BRIAN RUSH: Yeah, I was happy to meet you. We have to talk, and I'm sure you have...
  476. AUDIENCE MEMBER: Yeah, you guys are gonna schmooze me, you know, and take me out, or, you know...
  477. [laughter]
  478. ...yeah, but we want to participate. I do. Yeah.
  479. BRIAN RUSH: By the way, it was during your presentation that I started to wonder about the challenges including,
  480. are we talking about local people? Mestizos or indigenous people, from Peru, for example?
  481. Or, your family from Norway? It's a different context, but, we should talk, yeah.
  482. AUDIENCE MEMBER: Well, uh, I mean, just so you should know, I mean, our focus is neurotourism.
  483. You know, we're treating foreigners, because that's how we can run a sustainable business.
  484. BRIAN RUSH: I understand.
  485. AUDIENCE MEMBER: And, I think it is an intriguing model, because that would apply here... to the individuals.
  486. BRIAN RUSH: Yeah.
  487. CHAIR: Next question.
  488. AUDIENCE MEMBER 2: Thanks a lot, Brian. Um. When we finished our study with Canadian First Nations,
  489. we started thinking about what the challenges might be in moving on to clinical research,
  490. and I'm so glad to hear that you're looking at those challenges,
  491. but one of them that was tough to work around, was whether... how to deal with, um, dose response issues, a standardized dose, et cetera.
  492. It was clear that none of the ayahuasceros that we worked with wanted to use the freeze-dried version of ayahuasca.
  493. And otherwise, if you're doing a long-term clinical study with, with hundreds of participants, you almost need to make one huge dose,
  494. and have that either frozen or otherwise, to be able to make sure that everyone's getting a similar product.
  495. Not because we think it makes a difference in bioavailability,
  496. but because for the scientific community, it will, and so... what are you thoughts on that?
  497. BRIAN RUSH: Well, there may be some of those things we need to try.
  498. I don't think for this project we'd go there. I think it's part of the descriptive thing. Where's it made? What is the dosage? Uhh. Et cetera.
  499. How is it being used is more of interest right now. I think at another stage, is more of a controlled kind of research thing.
  500. And then, as many people in the room will know, you can have the same tea, in the same cup, in the same room, with 5 different people, and it's all different.
  501. And it's gonna be different tomorrow. So even controlling the substance is not controlling the experience.
  502. But, I think it's... for the credibility of the work, in another stage, I think we do have to go there.
  503. AUDIENCE MEMBER 2: Thank you.
  504. AUDIENCE MEMBER 3: Thanks. Uh... very interesting talk. So... trying to think about the cultural context in Canada,
  505. with the work with the First Nations, I mean this is a context in which addiction is intimately linked with ongoing colonial violence,
  506. with dispossession, and with questions of sovereignty. And... to talk about translation, [indistinct] to translation of, of outcomes.
  507. How can we kind of think about that, and also kind of complicate the way in which spirit is being deployed... in this context?
  508. I mean, to kind of echo Max Weber, even, and Slavoj Žižek--
  509. the relation between liberal capitalism, and spirit, and the way in which that's being deployed, in this context,
  510. where really, what we're trying to heal from is an ongoing colonization.
  511. BRIAN RUSH: Yeah, these are all good issues, and we wouldn't dream to go too far without a lot more consultation with our First Nations population.
  512. We have the one project in BC, where they've followed a really good process.
  513. But that's, um, one small community in Western Canada. I'm working with a group at a more national level,
  514. uh, reviewing culture-based, uh, intervention. We're going through a systematic review of culture-based intervention for indigenous people.
  515. I've put your... it was nice to have the publication in press, at least put that there, so the issue of indigenous plants from the South, being used
  516. in a cultural context in the North, it's emerging as a discussion point, but it's not, not quite there yet.
  517. I think it's a very serious topic. Um, you can have a lot of perspectives.
  518. My own is that it's maybe too early. And, and, it's not the right time to introduce it. But it's there anyway.
  519. [Brian chuckles]
  520. So, I appreciate the question a lot.
  521. AUDIENCE MEMBER 4: I'm just curious. In regards to substance abuse, what are the 3 top addictions that you treat normally?
  522. BRIAN RUSH: I'm sorry. Just do it one more time for me?
  523. AUDIENCE MEMBER 4: In regards to substance abuse, what are the 3 top addictions that you normally treat? Like is it heroin, cocaine, alcohol...
  524. BRIAN RUSH: In... In Canada? It depends a little bit on the province and the, and also urban versus rural.
  525. Uh, alcohol is still top of the list. Prescription opiates are emerging as number 2.
  526. In our treatment centers in Ontario, it's sixty, seventy thousand people per year. Um, prescription opiates have now outpaced cocaine,
  527. as the drug of use coming into treatment. So if you just get your head around that it's a little bit scary.
  528. Um. Cannabis is also very high, but we look a little bit suspiciously at the statistics, because many are young people that have been kind of...
  529. ...moved there, either from the criminal justice system, or, uh, the school system. So it's not necessarily 'in treatment'...
  530. ... the kind of, 'in the treatment program'. But, there are still, there are many people in treatment for cannabis-related problems. Seriously.
  531. So, alcohol, cannabis, and now prescription opiates would be the top 3.
  532. But that's kind of on a large scale. In Vancouver, crystal meth and opiates, and you name it. It's a pharmacy, downtown Eastside.
  533. CHAIR: Okay, we're right at six o'clock, so I'd like to thank Brian again.
  534. BRIAN RUSH: Okay. Thank you all!
  535. [Applause]