So, they scheduled us at the last afternoon, of course, when most people are on their way out. However, we have the diehard, loyal group here who are the most dedicated to the treatment of those addicted and mentally ill. So it is a privilege, and we are among colleagues who are devoted to our cause. I'm Greg Bunt, and I'm the moderator, and I am a past president of the International Society of Addiction Medicine. We have a group here from the International Society of Addiction Medicine. I'm also the past president of the New York Society of Addiction Medicine, and I am affiliated with NYU Medical School on the faculty. And I'm going to be talking about international addiction medicine and psychiatry. But I want to introduce our panelists. I think we have a really good panel today, and I think you'll really enjoy them. So first, I want to introduce Dr. Mark Potenza. Dr. Mark Potenza is a professor from Yale, and he is an international and national authority on behavioral addictions. He's also the president-elect of the International Society of Addiction Medicine. And he goes everywhere. I mean, no matter when I try to reach him, I get connected, and he's in some other part of the world. He was just in Vienna with UNODC, he was in Majorca with the WADD. Mark is the go-to guy for those interested in behavioral addictions, and internationally, he really is authority. And he's really devoted, and he's a great guy, too. In Abu Dhabi, we were at a conference where he presented, and of course, we were ready to board, and guess what? They do the COVID testing, and the rest of us pass, and Mark has COVID. So Mark is stuck in a hotel in Abu Dhabi for, was it two weeks, was it? Pretty much two weeks. Now, I said, oh no. I said, he took this, and he was working, and he was, you know, he's unflappable. And I would have been freaking out, I said, two weeks stuck in a hotel. Oh, Mark says, you know, you got to look at the good side of things, and all the things we preach our patients to think of, I wouldn't have been able to handle Kathleen. But he's a really good guy, the go-to person for behavioral addictions, which really is emerging internationally with the internet stuff and all that. And by the way, Petros Livonis also is an outstanding speaker on behavioral addictions, and we're privileged to have him. Kathleen Brady. Kathleen Brady is a past president of the International Society of Addiction Medicine, and also a esteemed professor of psychiatry at the University of South Carolina, and has been awarded multiple honors over the years, and we're really privileged. You know, she was the first woman to be president of ISIM, the only woman to be president of ISIM, and she followed me, I actually handed over the torch. But Kathleen Brady showed the boys how it's done, and she really showed us up. Kathleen Brady is an exceptional orator. I mean, you could listen to her all day long, and never get bored. And so, you know, at a meeting like the APA, where you go to a lot of these sessions, and some of them are boring speakers, you're going to have the privilege of hearing Kathleen Brady, who's such a good teacher, because she can break down the most complicated things and present it to an audience in a way that's understandable, and you can really relate. So it's really an honor to have Kathleen Brady, and she's an expert in dual diagnosis internationally. So that is a privilege. And then, of course, we have Petro Slavonis, the president of the American Psychiatric Society, and that's an honor. And you know, there was a session, a symposium, called Badass IMG Women. That was the actual name of it, Badass IMG Women, International Medical Graduates. And I said, that's an interesting title. And so now, I'm reflecting on the way I was when I was a teenager. We have Petro Slavonis, we're badass international addiction doctors. Come on, bring it on, brothers, let's go. We got Petro here. But Petro really is also an outstanding speaker, an outstanding leader, and his leadership excels, and we're so privileged and honored to have him, Petros, at this meeting. And he's very well-known internationally. So that's the panel we have today. I'm going to be presenting a brief overview, but I'm wondering if Petros, could you have a few very brief remarks to this audience, since you're the president of the APA. First of all, thank you so much for inviting me to this panel today. I'm Greek, I came to the United States when I was 19, and I still have great ties internationally. Being president of the United States, being president of the American Psychiatric Association gave me the opportunity, I visited six continents over my presidency. So having this international angle to what we do is quite essential. The DSM comes to mind, very different takes from other parts of the world on how we view addiction, how we view mental illness, and so we have to learn from each other, and I'm delighted to have programs like the one that we have today. Just a very special shout-out to Dr. Mark Gallanter, who is not with us here today, but he was my mentor in Fellowship in Addiction Psychiatry, and he was either the founder or one of the first founders of the International Society of Addiction Medicine. He was president of the American Society of Addiction Medicine, of the American Medical Education and Substance Abuse, research in substance abuse, and also president of the American Academy of Addiction Psychiatry. So this guru of addiction psychiatry, he was the first editor of the textbook, of the American Psychiatric Association textbook in addiction psychiatry. Kathleen is now part of that textbook. Greg Bund was his first fellow. So anyway, so we have a lot of history here, and I just wanted to make sure that we acknowledge him as we embark in our work in international addiction medicine. Thank you, Petros, very much. And I can reflect. I was one of the first fellows. I think you were the first, really. Yes. I was back in 87, and Mark Allen just started the fellowship. But then Petros also followed in our program, and he was really outstanding. And I can remember doing a little bit of teaching and mentoring. I said, this guy, I talked to Mark, you know, I said, this guy, Petros, he's going to rise to really- They're making things up. They're just like, this is a restructuring. And I told Mark, I said, look, Mark, look, okay, he's Greek. I get it. But still, still, I think he's going to rise to levels of leadership that are unprecedented. But you know, it really is heartening to see Petros now the president of the APA. But that being said, I'm going to move quickly. What I want to try to do in the interest of time is to just give you a glimpse of the value and the benefit of connecting with our international colleagues. So in the International Society of Addiction Medicine, this is what we do. And I think in my experience, it's the best way to broaden your understanding of different cultural, social, and spiritual perspectives of different people when you're dealing. You know, I can remember when I was treating a patient and she said, you know, Dr. Bunt, the trouble with psychiatrists, I find, is that they're so unemotional. She said, you know what, you guys need to grow, you need to breathe, you need to expand. And I said, okay, up the dose. But you know, she had a good point. She had a very good point, and that is too many of us busy in our work and we're interacting regionally and locally, don't take the time to get connected. It's a big world out there. And there's so many different people, extraordinary people and colleagues that you can connect with and learn so much about social and cultural perspectives in addiction psychiatry. So I think that's so important and a great benefit for those of you who are interested in international work and international addiction psychiatry. And the theme this year of the APA is addiction psychiatry. And so it's fitting that this, at the tail end of our conference, is connected to international addiction psychiatry, broadening our horizons. So here in the first slide, I have, up in the upper right-hand corner, Petros received the ASAM highest distinguished award this year for the scientists and McGovern award. So I had that there in Dallas, and that was really a privilege and really enjoyable to see that. So I'm going to try to race through, let's see, I'm going to try to race through these slides in the interest of time. What I'm going to do is just to try to give you a flavor, a glimpse of what it's like to start connecting with your international colleagues abroad. So this is our United Nations, where many policies are made. This is Eric Adams, the mayor of New York City at one of our treatment sites right here in Manhattan with me. And then you see the impact of the combination of addictions and mental health on individuals and families and communities in our cities and in the nation and around the world. The number one health problem is the combined addiction and mental health. So now I want to bring you to the International Society of Addiction Medicine. I just want to give you a brief introduction. Hamed Alghaferi from the Emirates is the president, and we have Mark Potenza is the president elect of the International Society of Addiction Medicine. Alex Baldacchino to the left is the immediate past president, and then Kathleen Brady, the president before him. And then below are some of the board members. One of them is Helena Hansen from Los Angeles, who some of you may know, an expert in diversity, equity, and inclusion. Hamed Ekteyari from Iran, who's the head of our regional council. And our regional council reaches out to trying to advance here. Hmm. Why isn't this advancing? Sorry, it was advancing before with this button here. Yeah, but it's not advancing here. Ah. The screen is not. We need some help, A.B. We're stuck here at this point in time. So we have a diverse group on the board of directors. We have Atul Ambedkar from India. Yeah, we're stuck here with the PowerPoint. Shalini Aranguri from Australia. Yasir from Switzerland. And Rishan Bhat from India. And then, let's see, we have Jiang from China. Let's see how we're doing here with the slides. It's not a slide show, though. It's a regular PowerPoint. Okay. So with the International Society of Addiction and Medicine, what I'm going to do is give you a brief historical background with the sites we have in international conference every year. And this past year, it was in Marrakesh, Morocco. Wonderful conference. Wonderful conference. And the organizer of that conference, Fatima Elomare. Fatima, could you stand up so that everybody can see you? Fatima Elomare. So tell me how I advance now. Okay. Good, good, good. Okay. Good. Yes. So it was a wonderful conference, Fatima. So back to this. ISAM has many affiliations and connections to the European Monitoring Center, the ICUDDR, which is the university consortium, the World Association for Dual Disorders. Mark Potenza is going to elaborate on that. He was at that conference in Majorca. World Psychiatric Association, a long history. Nestor Zerman was now heading that, had a conference in Majorca that Mark attended, and then NIDA and the World Health Organization, UNODC. We always have representatives attending those meetings. We also have a committee of global experts, and Kathleen and Mark both are involved in that, and they're going to be speaking in more detail about this. But you can access this information on our website. And as you see, in every continent and every nation, we have leaders that you can reach out to if you're interested in connecting with international authorities on the subject of addiction, medicine, and mental health. We also have regional council societies. And the two regional council societies in the United States are ASAM, American Society of Addiction Medicine, and AAAP, American Academy of Addiction Psychiatry. So those of you who are members of those organizations are automatically ISAM members, ISAM affiliate members. But as you can see throughout the globe, we've really developed and expanded our regional representation. And I am now a senior advisor to the regional councils. We have the regional council representatives. In the United States, it's Carol Weiss. Carol, can you stand up so that everybody can see you? Carol Weiss is an outstanding representative. And for those of you who are interested in getting connected with ISAM, she's approachable. Reach out to her and learn more about us. As you can see, we have 15 regions. And in each region, we have a representative. So this is the one, Solly Radame. I don't know if those of you know Solly. He's been at many APA meetings and is very connected to WPA in South and East Africa. We also have a number of distinguished regional representatives. Future meetings, and I think Dr. Potenza is going to elaborate on that. Next year, it's in Hamburg. This year, it's in Istanbul. And then we have Rotterdam, Sydney, Lausanne, and Helsinki. So what ISAM can do is to bring us culturally and socially in connection with colleagues who are connected with addiction medicine and psychiatry in those regions. This is Henrietta Bowden-Jones, a behavioral addiction expert out of London. And in various areas, addiction and recovery, which can be biopsychosocial, spiritual, is recognized. I'm going to go through very briefly. These are the ISAM meetings. So we have just the first one was in Iceland. And in Iceland, it was held. I attended that one. It was held at the presidential residence, the equivalent of the White House. And we had a social event there. The conference was at a different venue. And the president of Iceland officially knighted one of our addiction medicine, Dr. Sheila Bloom. You know Sheila Bloom, of course. She was knighted. And given this regalia, which she had a sign that she would give back to the government once she died. So she had to sign all these papers. But that being said, an example of how ISAM is connected with the world. And so that was the first one in 2002. And then these are various conferences throughout the globe that we've had over the years. Here in Yokohama in 2015, we had then following. In Dundee in 2015, 2014 was Yokohama. And then in Montreal. Now in Montreal, we had the Cirque du Soleil. You know about Cirque du Soleil? They had Cirque du Soleil acrobats. And the Cirque du Soleil really performed well. And in the Cirque du Soleil acrobats, we set Nora Volkow up. Kathleen remembers that well, for getting a presentation at the Cirque du Soleil event in Montreal. So we have some unique experiences. This was then the conference 2016 in Abu Dhabi. And in Abu Dhabi, the venue was at the Emirates Palace, the most incredible venue you can imagine at the Emirates Palace. And that's where the conference was held. Hamad al-Ghaffari, the current president of ISAM, had made arrangements for that. This is in Jeddah and Saudi Arabia. This is the Zayed Mosque, the incredible mosque that we got to see. Here in Busan, Kathleen Brady was the president at that time. And here were the Korean performers. Here's Kathleen in her Korean regalia. And this is then in Delhi in 2015. And I'm sorry, this was in Delhi in 2019. 2019, Paul Earley, the president of ISAM at that time. We had some interesting social events. Here's Nadia al-Ghabali. And we also had a 12-course gourmet dinner that was put together by Hemant Oberoi. I don't know if there are any Indian-American psychiatrists in the audience. But Hemant Oberoi is a world-class chef. And he was in this Hotel Mumbai, for those of you who saw that film. Yes, you've seen that? Gentleman is shaking your head. Yes, you've seen? OK, yes. So hotel, it was a true story about how this was invaded. And talk about post-traumatic stress disorder. Hemant Oberoi was cornered. And it's a film worthwhile seeing. But he prepared a 12-course gourmet meal that was outstanding at his restaurant in Abu Dhabi. And we really enjoyed that. And so these are some of the experiences. This is Hemant Oberoi. And this is Kathleen, who's going to be giving Hemant Oberoi an award and pinning the label on. Then we go to Delhi, also. This was the award for Nadi Elgabali. And here's Kathleen Brady, the president at that time, presenting Nadi Elgabali the award for lifetime achievement. And Kathleen, look at that picture. That's a picture of it. Let me see if I can hold that. Look at that. Isn't that elegant? And she's wearing her freshwater pearl necklace that got stuck in Delhi because she had relocated out of the country and then got in. This, then, was in Malta in 2022. Wonderful conference that we interacted with the University of Malta. And it was presented, this was a presentation by the Committee on Trauma and Addiction, Carol Weiss. Carol Weiss had organized that. We present every year awards to fellows. Here, Mark Potenza and I are presenting the NIDA Fellowship Awards to fellows throughout the world. This is Steve Taylor, the president of the American Society of Addiction Medicine. He was there. These are just some slides on Morocco and Marrakech, Fatima. We really enjoy the Moroccan food, the culture, the people. Great benefit to all of us. And again, it's relevant to psychiatry. And here, we are having our next Congress in Istanbul in September. And we hope some of you can join us. This is Rabia Belisi, the organizer and a representative of Eastern Europe. And she'll be hosting. I do have some brochures, about a dozen of them. So anybody who's interested, please, we'll try to pass them around. Take a brochure. We'd love to have you join us in Istanbul. And so with that, I'm going to turn it over to our next speaker, Kathleen Brady. OK. All right. Thank you. It might take me a minute to get my slides up. I'm not exactly sure how we do that. Let me help with that. Let me help you with that. OK. Thank you. And thank you, Greg, for that trip down memory lane. And I also just want to just chime in with Petros about our wonderful mentor for all of us, Mark Gallanter. I think it's, you know, I love the idea of thinking about him as we all present in this wonderful symposium. And the ISAM meetings are great. So I hope that we have convinced some of you guys to come. I am, hang on there so I can get ready. Thank you. And I also, yeah, just a slide. Great. Thank you. All right, great. And also want to thank Petros for all the work he's done to bring addictions to the forefront in psychiatry. I mean, I have been at this for a long time. And I think it's been a bit of a struggle to, you know, there's so much comorbidity of psychiatric and substance use disorders. And substance use disorders are a psychiatric disorder. But so often, it's been sort of in the shadows. So it's wonderful to see this highlighted in this meeting. And when we talk about comorbidity, this is an area in terms of an international perspective where really what you're going to find as I move forward is what we need is more data and more information. So let me just start by saying I'm going to begin with the prevalence of substance use disorders and then other psychiatric disorders worldwide and our general comorbidity knowledge. And let me tell you what our general comorbidity knowledge is. And that is that there's really only three countries that have actually done. It's hard enough just to get prevalence estimates internationally for substance use disorders. And PTSD is probably the comorbidity that's been the most commonly studied internationally. But talk about studying comorbidity. There's only three countries that have actually published several comorbidity studies. United States, where we have the epidemiologic catchment area study, the national comorbidity study, and then NISARC. Canada has a few. They aren't nationwide, but a few survey studies where they've looked at comorbidity in Australia. So all sort of pretty developed nations. But I'm going to also talk about differential trauma exposure worldwide, differences in access to care, and then conclusions and future directions. And let me just talk about the caveats to everything I'm going to say. And that is that there is paucity of data about substance use and psychiatric disorders for many countries. As you can imagine, there's a lack of funding for large scale surveys. And WHO is probably the one group that has done most of the large scale surveys. And as I said, they have done some substance use surveys. And then there's surveys that have also been done, just search and seizure sorts of surveys, where they look at legal interdictions in various countries and can tell us something about drug use in those countries from that. But there are many assessment instruments also that are not multilingual and many assessment instruments that are really not culturally sensitive. So they may not really apply, even if we're trying to do a survey study in other countries. In addition, there is difference in the definition of what's a disorder. Something that might be considered aberrant drinking in one country may not really be considered to be out of the realm of normal in another country. And then marijuana use in this country, it's different from state to state. So you can only imagine what that's like country to country. And then there's really not only going to be difference in how we define things, but also differences in the acceptability, culturally, of reporting different signs and symptoms of various psychiatric disorders. So with that in mind, I'm just going to go through some maps, global maps, that show you really the variety and the differences across the world in terms of various substances of abuse. And let me also say that this data is not done, well, liters of consumption is actually World Bank data. So this is probably data that we can sort of count on from where they have data. And you can see USSR pretty heavily, Australia also one of the countries with the largest consumption, United States and Canada also very high. You can see not quite so high in the African nations and in some of the Asian countries. And this is, of course, 2015. Some of this data is just not, we don't really have current estimates. But here is the share of the population with alcohol use disorders. So this is a different way of looking at it. And again, these are estimates for all the next four or five slides I'm going to show you. Estimates from a combination, these are WHO estimates, but it's from a combination of sources. They use medical records, they use epidemiologic data, they use survey data where they have it, and then they use meta regression models to sort of then fill in the blanks where we don't have data. But you can see for alcohol use disorder, we have this is actually, I think, Uzbekistan. This is Mongolia here. I don't trust this. I think Greenland must have had a survey or something because I just don't trust it that it's that high. Anyway, United States, as you can see. Brazil, parts of South America. But certainly, the United States and Europe is where we see. And Australia, probably highest, high prevalences. and of course USSR, of alcohol use disorder. Okay. How about death rates from smoking? Very, very different picture. You can see we've had big prevention efforts in the United States and Canada, our numbers are down. Look at the Asia and the USSR and a lot of these, and the Middle Eastern countries, lots of European countries with very high death rates, relatively speaking. How about just the share of population with alcohol or drug use disorders, either one or the other? You can see the United States sort of stands out when you add both together. Again, USSR, this is Mongolia again, Australia also sort of stands out. Again, I'm not trusting this Greenland data. I tried to actually look it up and see why those numbers were so high. And I have a feeling they may have sent some survey data that indicated high rates, but, and then opioid use disorder death rate. This is something where the United States, including Alaska, really does stand out. We see a lot less in, a little bit less in Canada, a lot less Australia. Canada and USSR are really around the same. So what you can see from all of this, I think that may be it, is that we have very different rates of various substances of abuse, depending on country. But one of the things that all comorbidity, even though we haven't got comorbidity studies from, from every country. Every comorbidity study that's been done to date show us the same thing, and that is that drug and alcohol use disorders co-occur with substance, with other psychiatric disorders at a higher rate than you'd expect by chance alone. And this is just an, an old study. This is from the National Comorbidity Study, but what you can see is for those with alcohol use or dependence, 52% have another psychiatric diagnosis. And for drug abuse and dependence, 71% have alcohol use disorder, and 59% have another psychiatric disorder. So it's not exactly the exception to the rule. It actually probably is more like the, a, a small by, but it's a majority have, this is lifetime. Some other psychiatric disorder at some time in their lives. And so again, while we don't have data from every country, the data that we have from the, the, that, studies that have been done are all fairly consistent in showing this risk, and another way to look at this risk is to look at odds ratio. So what's the likelihood that an individual with, let's say, antisocial personality disorder has lifetime drug or alcohol dependence compared to somebody who doesn't have antisocial personality disorder, and you can see it is 18, and an odds ratio of above 2 is considered at risk. And you can see for every disorder in here, it's pretty high. Antisocial personality disorder, there's probably a confound because some of the, some of the actual criteria for antisocial personality disorder sort of, drug, drug and alcohol use can lead to some of that. But when you look at things like bipolar disorder, schizophrenia, PTSD, this is one that I've spent a lot of my career studying. People with PTSD are four to six times more likely to have a psychiatric disorder. I mean, to have a substance use disorder compared to those without PTSD. And when we look at our other anxiety and depressive affective disorders, the risk is still twice normal. So these, no matter what part of the world we're looking at, we can probably assume that psychiatric disorders and substance use disorders are going to co-occur at a higher rate than than one would expect by chance alone. And one of the things we know, PTSD is not the only sequelae of trauma, and early life trauma in particular. We know that depression, GAD, PTSD, there are many, many psychiatric disorders, including substance use disorders, that can develop as a sequelae of traumatic exposure. Particularly exposure during childhood. And traumatic exposure is extremely common in the lives of individuals with substance use disorders. And every epidemiologic survey study, every study, and in this area, there are a number of international studies looking at rates of PTSD. And I'll show you some of those. Very few of those actually look at PTSD plus substance use, but the WHO has actually, because of all the trauma in the world, WHO has had a focus on PTSD and trauma. And one of the things we know is that people with PTSD have a high co-occurrence of addictions. In terms of treatment seeking individuals, 30 to 40% have substance use disorders. It could be higher in people that have developed their PTSD from being in combat. In substance use samples, so you look at people seeking treatment for substance use, somewhere between 20 and 60% have PTSD. This is higher in women and higher in cocaine and opiate users. And again, epidemiologic data, as I showed earlier, show much higher odds ratios. If we just look at, even though we don't have data about PTSD and substance use from all parts of the world, we all know that there is a tremendous amount of chaos and trauma related to not just wars, but refugees, migrants. So there is, you know, we read about it every single day in the newspaper. And in this study right here, they looked at, this is a world map of countries and regions who had a history of war, at least one war between 1989 and 2015, one war on their soil. That was it. And so what they found was that approximately 1 billion adults between 1989 and now have experienced war or displacement. Now think about that, you guys. There's 5 million people in the world. That is one-fifth of the people in the world. That's like, to me, that was like a just a mind-boggling number. And of that 1 billion, actually, they did a survey study with about 15,000 participants based on 24 different surveys. And they extrapolated that to what they thought the toll of these wars and displacement in the world are. And they figured that we have about 354 million people with PTSD and or major depression as a result of war or displacement. So it's about a third, about a third of people that experience war and displacement in their country who are directly affected by it end up developing either PTSD and or major depression. And while at the time of all that chaos, they may not have access, actually, to substances of abuse. So maybe the substance use doesn't develop immediately at the time. But as what we found often is that people with PTSD, once their lives, maybe they get into a situation where substance use is available and treatments are not. That's when we see the development of that sort of comorbidity. This is just, again, from WHO, a cross-national. They have developed. Now, WHO has done, as I said, a pretty good job in PTSD specifically developing instruments that have been translated into 20 or 30 languages. And also developing some that are more culturally, that have a little more cultural sensitivity in terms of the questions asked. But you can see the cross-national prevalence of post-traumatic stress disorder from this. And believe it or not, even though there have not been any wars in these countries, Canada, Australia and the United States have all had pretty high rates. I'd say in the United States, that's probably a lot of that is crime related, you know, personal trauma. But so what about, again, back to this worldwide data, again, all the same caveats. What about the share of individuals who report lifetime anxiety or depression? This is data from 2020. And you can see it's actually fairly high in South America. United States and Canada are about the same at, you know, somewhere between 20 and 25%. USSR and some of these Eastern European nations a little bit higher at 30 to 35%. So, but this is probably, as everybody can imagine, an underestimate because depending on an underestimate for some countries in particular, because it does depend to some extent, at least in the perceived comfort in speaking about anxiety or depression. Again, this was another 2021 study where they looked across countries and just did survey analysis and asked people how comfortable they felt. And you can see, sort of surprising to me, but in Egypt, we have 56% of individuals feeling very comfortable talking about anxiety and depression. Whereas in Japan, we have somewhere around 2 to 3%, United States 7.2%. So you can see there's going to be lots of variability in reporting based on just people's perceived comfort in talking about it. And again, this is just looking at that data in a different way. Perceived discomfort speaking about anxiety or depression. Again, you can see it is in some parts of Africa in particular, lots of discomfort with that. United States is sort of in the mid to severe range in terms of that. But let's just say, even when individuals are comfortable talking about their substance use and or their other psychiatric symptoms, even if you can get them to walk into the light, what about access to care? And this is two graphs that actually deal with that. One is psychiatrists working in the mental health sector in 2017. You can see in some parts of the world, there is either no information or no psychiatrists, I'm not sure which, in many parts of the world. We have lots in Argentina, you can see. United States does pretty well and Europe does pretty well. But you can see generally that the per capita number of psychiatrists, considering the amount of trauma and trouble in the world, is not particularly high. And this is just percentage of respondents reporting specialty mental health care by country income level. And it's exactly what you'd expect. The lower income level is the lowest access to specialty mental health care. High income has higher access, but we're still only talking about 30% or so. So that is still not exactly what you'd call universal care. So I guess in the face of all this, I'd like to say we are developing, I mean, we're here at the APA meeting. We've all been listening to multiple sessions about exciting new developments in terms of psychosocial treatments, cognitive behavioral therapy, contingency management, mindfulness, 12-step recovery, all kinds of interesting treatments for pharmacologic treatments as well. We've got the new psychedelics, we've had our old standbys, antidepressants, mood stabilizers. So there are lots of treatments available, but the question is, how do we get these to the people that need them? And so let me just conclude by making a few conclusions slash recommendations. One is we know that we have global, cultural, and regional influences on people's access to drugs and alcohol and the type of drug that they are likely to be using. Because people are going to be using the drug, most often they'll use substances that they have the best access to. And then regardless of access, there is going to be differences in use that's based on cultural norms and societal and regulations, legality, illegality. There's also vast differences in the acceptability of reporting drug or alcohol use in psychiatric symptoms, which really speaks to our need to develop these culturally sensitive instruments and ways of getting at this information. And then vast differences in the access to treatment. So I'd have to say in terms of conclusions and challenges, I think we know that trauma and psychiatric illnesses are common throughout the world. And that substance use disorders are common throughout the world. But the predominant substances probably differ a great, great deal. We don't know this for a fact, but every piece of data we have leads us to conclude that the comorbidity of psychiatric and substance use disorders is likely to be high. It's been high in every place that we've looked to see whether it was high. We see high comorbidity. So I guess my thoughts are what we really need are some large scale prevention efforts that are in high risk areas because we really want to prevent what we can. And really when you think about prevention efforts in both the substance, the ones that we know are effective in both substance use disorder and in terms of PTSD and trauma related sequelae, they're very similar. It's a lot of it is about education. A lot of it is about early intervention. A lot of it is about providing psychosocial support. That is once you get a roof over people's heads and you make sure that they have something to eat and drink. You know, once you get past that, and I'd say this is really close to the top of the hierarchy of what people need, is that social support and education and trauma informed education about what the sequelae are. And I'd say especially addressing children who are in these situations. We also need culturally sensitive assessment instruments. And then for those that end up needing treatment, and no matter how much we do for prevention, there's going to be some we need treatments that are feasible, generalizable, acceptable, and accessible. And with that, I will turn this over. Thank you very much, Kathleen. That's wonderful, wonderful. So our next speaker is going to be Mark Potenza. But what I'm going to do is see if we can, while we're on the theme of trauma and addiction, which Kathleen expressed so well. The committee on trauma and addiction that's led, ISAM committee that's led by Carol Weiss, had put together a short three minute video, which I don't know if we can project this. Can we have some help from the audio visual? I don't know. It's a three minute video based on the trauma in Ukraine. And we have colleagues in Ukraine right now. There's Igor Kutsenov from California. I don't know if you know him, but he's a Ukrainian-American. But he's over the ITTC, the International Technology Training Center, and does a lot of work in Ukraine. We have Olena Zybenko. There's no sound. Where's the sound? Sound. Okay. So we have Olena Zybenko, who... Is there any sound coming? I'll tell you the story, nevertheless I'm used to it, it doesn't work on TVFolk. She was young, her heart was pure and white and every night had its price. Thank you for watching. and I'll see you in the next one. Two, three, four, eins, zwei, drei, na, es ist nix dabei, na, wenn ich euch erzähl die Geschichte Nichtsdestotrotz, ich bin es schon gewohnt, im TV-Funk, da läuft es nicht Tja, sie war jung, das Herz so weil und weiß, und jede Nacht hat ihren Preis Sie sagt, to the sweet, you can rap to the heat, ich verstehe, sie ist heiß Sie sagt, babe, you know, I miss my fucking friends, sie meint Jack und Joe und Jill Mein Fachverständnis, ja, das reicht, so not ich immer reiß, was sie jetzt dreht Ich überleg bei mir, ihr Nasen spricht dafür, währenddessen ich noch rauch Die Special Places sind ihr wohl bekannt, ich mein, sie fährt ja U-Bahn auch Drei Zinger, sie trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, er wird sie anschauen Und du weißt, warum, die Lebenslust bringt die um Alles klar, Herr Kommissar Hey, Brunner weiß im Stift, ne, ne Did you ever rap that thing, Jack, as her rap comes to the beat? Wir treffen Jill und Joe und dessen Bruder Hip und auch den Rest der coolen Gang Sie rappen hin, sie rappen her, dazwischen kratzen's ab die Wände Dieser Fall ist klar, lieber Herr Kommissar, auch wenn Sie anderer Meinung sind Der Schnee, auf dem wir alle Teilwärts fahren, enthalte jedes Kind, jetzt das Kinderlied Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, er hat die Kraft Und wir sind kleine und dumm, und dieser Frust macht uns stumm Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, wenn er dir anspricht Und du weißt, warum, so gern der Glück bricht die um Alles klar, Herr Kommissar Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, er hat die Kraft Und wir sind kleine und dumm, und dieser Frust macht uns stumm Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, wenn er dir anspricht Und du weißt, warum, so gern der Glück bricht die um Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh, la Trat ihnen um, oh, oh, schau, schau Der Kommissar geht um, oh, oh It was a 12-year-old prodigy artist from California, Ukrainian-American, 12 years old. Model after Guernica So, Mark Potenza on behavioral addiction. So, I'm going to be talking about some international efforts with respect to both substance and behavioral addictions, not only with respect to ISAM, but World Health Organization and other organizations. I have a series of disclosures with respect to pharmaceutical, gambling, gaming, nonprofit and legal entities. We heard some of the history of ISAM, which was founded in 1999, but I thought I would go over briefly that it has multiple mandates, including an educational mandate to advance education, training, clinical care, and public health, and to really address, through working together with other organizations around the world, to address the burden of addictions and try to help people globally with respect to advancing prevention, treatment, care, and workforce development. So one of the initiatives of ISAM over the past several years has been a global expert network. And this global expert network involves 20 different leaders around the world who are then have a group of other individuals, so that there is a large network of people. And this global expert network was in a good position at the onset of the pandemic to try to gather information and understand how the pandemic was impacting substance use and addictions globally. So some of the initial efforts of the global expert network were to have webinars during the onset of the pandemic to share experiences that different care providers and individuals in public health were having with respect to substance use and addiction, and then really to utilize scientific methodology to gather information from around the world so that we could fill some of the gaps that Dr. Brady had mentioned in her presentation. So we've generated a protocol paper for the global expert network, and during the onset of the pandemic, there was a survey conducted one week into the pandemic to ask a number of addiction medicine service providers from around the globe what their experiences were. And this resulted in several peer-reviewed publications regarding the impacts on supply price and use of illicit drugs and alcohol, as well as how treatment services were being impacted and how people were adopting to the pandemic to still provide care to individuals. Since that time, there's been a large focus on dual disorders or dual diagnosis, particularly with respect to Kristen Schutz and Marta Torrens, for example, leading a psychosis and substance use disorders effort. We've been working together with the International Collaboration on ADHD and Substance Abuse, ICASA, about, in conjunction with Diana Gibbs, to investigate ADHD and co-occurring substance use. But there are multiple other initiatives with respect to trying to understand how addictions are impacting people. We also have been active not only in the annual meetings that Dr. Bunt had reviewed, but also with regional meetings. And we think that it's important to have these regional meetings to gather people in different jurisdictions to address addictions in their region of the world because of the cultural differences. Some of these are language-based. So several of the recent regional conferences have been francophonic, meaning the meetings were conducted in French. And then other jurisdictions, like several that have occurred or are being planned are occurring in Asian jurisdictions, which have multiple cultural differences. We try to communicate our activities through not only the website that we heard about, but also through the bimonthly ISAM Bites, which communicates the happenings within ISAM. And then there are a number of topical interest groups and committees in which people can become involved. And this may be particularly helpful for early career investigators. So ISAM has the ISAM NEXT group, which is the New Professionals Exploration Training and Education group. And ISAM also has initiatives to help support early career investigators to attend the annual conference. So the ISAM NEXT group is currently led by Dr. Jiang Long out of China, but he's also worked internationally, including with the World Health Organization. And the prior chair, Roshan Bhat, is now on the ISAM board. So this may be a mechanism by which individuals can gain experience in ISAM and progress through the organization. So ISAM NEXT was established as a committee for early career addiction medicine professionals or ECAMPs. There are currently 30 members from different 20 organizations and societies globally. And this is for early career investigators. The working groups of ISAM NEXT are listed here. And these dovetail with some of the other working groups, special interest groups that are in ISAM generally. So these are the special interest groups within ISAM. And they cover behavioral addictions, neuroscience, practice and policy, philosophy, anthropology and human sciences, and spirituality in 12-step aspects. And some of these dovetail nicely with ISAM NEXT. For example, the In Love with Addiction Neuroscience series of webinars interview a number of established investigators to provide their description of their career paths and the potential hurdles and the ways that they have developed into their careers. This is also a mechanism for generating information and position papers such as the spirituality in 12-step group when ISAM dropped spirituality from its addiction definition. The ISAM spirituality in 12-step group commented upon this. So there have been a number of ISAM NEXT initiatives that include webinars as well as publications. These publications cover a wide range of topics including different drugs that are used in different parts of the globe, as well as treatment considerations, particularly during COVID-19, as well as behavioral addictions. ISAM in general has generated through its special interest groups a number of different publications in leading journals, for example, in Lancet Psychiatry and in JAMA Psychiatry focusing on telemedicine delivery for opioid use disorder, as well as the changing landscape with respect to cannabinoids and what addiction medicine physicians should know. So another way in which ISAM is working together with other organizations like the World Psychiatric Association and the International Society for the Study of Behavioral Addictions is through the gambling webinars, this international webinar series on gambling. And as one of the recent presentations reflects, this covers multiple regions of the globe including Australia, Europe, and China to gather together people with experience of, in this case, providing care to people with behavioral addictions so that information can be shared in an international community. Some of these same individuals have been involved in some of the World Health Organization efforts to consider internet use and behavioral addictions, and a group of us had been meeting annually in anticipation of the 11th revision of the International Classification of Diseases, or ICD-11. And one of the areas that was controversial was whether or not gaming disorder should be included as a formal clinical diagnosis in the ICD-11. So there were groups of scholars who believed that it was premature to do so. A group of us wrote back that we thought that this was important for diagnostic management and prevention purposes. The same sort of debate was being played out in the general media. So on back-to-back days, the Times published that game addict disorder is a moral panic, and then the following day, the National Health Services are to open an addiction clinic for young online gamers. And this was happening in the setting of headlines about children engaging in oppositional and defiant behaviors when limits were being set on video game playing. And so we, again, wrote about the importance from clinical and public health perspectives to include gaming disorder in the ICD-11. When this was being proposed, the day that this was released, the gaming industry came out against the World Health Organization's proposal to include gaming disorder in the ICD-11, saying that they believed that the evidence for its inclusion remained highly contested and inconclusive. And we wrote back, and this gaming industry response consortium is over 120 individuals, we wrote back a piece in Addiction asking whether this might be a corporate strategy to disregard harm and deflect social responsibility, remembering that it was only about 30 years ago when the CEOs of tobacco companies went in front of Congress and testified that they did not believe tobacco was an addictive substance. So these sorts of debates internationally, I think, are important to consider. What happened when the World Health Assembly met in May of 2019 was that gambling and gaming disorders were included as disorders due to addictive behavior, so this was a reclassification. Hazardous gambling and hazardous gaming were included, and this is akin to hazardous or harmful alcohol use and is meant to define an entity for public health considerations. And then compulsive sexual behavior disorder was included as an impulse control disorder. The central elements of gaming disorder are listed here as involving impaired control over the gaming, increasing precedence such that the gaming takes the place of other interests and activities, and the continuation or escalation of gaming despite negative consequences. The hazardous gaming is a mutually exclusive entity and it is a level of gaming that is harmful, but not reaching the level of a disorder. And in line with what was said about the importance of culturally valid and empirically supported instruments across different jurisdictions, current efforts of this group involve generating valid diagnostic assessment and screening instruments based on past work of the WHO, things like the audit, doing this work for gaming disorder and hazardous gaming. Compulsive sexual behavior disorder, while classified as an impulse control disorder, does share many elements of the core features of addictive disorders, including the continued engagement despite adverse consequences. There is also the, like with gaming and gambling disorder, the significant impairment in one or more major areas of life functioning. So some of the other efforts that I think are noteworthy to mention about ISAM are some of the educational efforts. And one of these educational efforts is a master class leadership, so how to train the individuals who are training the next generation of addiction medicine professionals. There is also the ISAM textbook that is now in its second edition. And there is the international certification examination. And the eligibility follows the eligibility that organizations like the World Health Organization have laid down. And there's more information that's available on the ISAM website. Basically the examination itself is a four and a half hour examination divided into two sessions with a small break in between the two plus hour periods. There are 225 questions that covers a wide range of domains that are listed here, including with respect to co-occurring disorders, both medical and psychiatric, as well as behavioral and substance addictions. So to date there have been over 380 individuals who have applied for certification with over 320 individuals who have passed, successful completion has been done by individuals from 25 different countries, and the certification examination will next be offered at the meeting in Istanbul. And Greg ran through the meetings. This is now a world map of where the meetings have been globally over the past 25 years, 25 to 30 years. And one can see that there is a good global representation of the sites of meetings. As I mentioned, ISAM does try to promote the attendance of early career investigators at the annual conference. Greg has been the PI on a conference grant, an R13 conference grant from NIDA, now in its third iteration where he and I are multiple PIs. And this mechanism has in part contributed to the over 100 travel awardees that have been given to help early career investigators to attend the ISAM annual conference. Also, there are reviews of the content of the ISAM conferences going back about a decade or so that are published in peer-reviewed journals, including substance abuse, most recently in drug and alcohol dependents. And then we have the annual conference coming up in September in Istanbul, as well as the next conference, the 2025 conference that will be a bit earlier in May of 2025. So all in all, ISAM, I believe, is doing very important work with multiple organizations globally. A lot of this work is to help develop the next generation of addiction medicine professionals, as well as to address addictions globally. And if there are any questions, please feel free to contact me or Marilyn DeRozia, who has been integral to the operation of ISAM over the course of decades, really an important person to acknowledge. So thank you for your attention. Thank you, Mark. And we're gonna have time for some questions and answers, but I'd like to have Petro say a few concluding remarks right now. I think I have exhausted my wisdom and my remark-making abilities throughout this conference. Just, I continue to learn things from Mark and Kathleen and Greg, of course, every day. So wonderful presentations. And yes, every time we go to Capitol Hill, we fight for things here in the US. Having that international perspective makes it that much powerful and that's much more effective. So thank you so much for this award. It does have very, very direct consequences, positive consequences for our work here in the US. Thank you. Thank you, Petros. So why don't we acknowledge this gentleman here? Go ahead with your question. Yeah, Mike Johnson, Boston Medical Center and VA Boston. Involved pretty heavily with training addiction medicine, addiction psychiatry fellows and interprofessional fellows at VA. Just curious what, from the ISAM's perspective of the certification exam in particular, what that scope is in terms of developing for skill sets when they take the exam, how that's gonna improve their practice, their scholarly work, and how does that overlap with the ASAM exam and the addiction psychiatry exam? Because that's kind of where our mindset is of, so what is the added value of that exam? Oh, of the international exam? Yeah. I'd say there's a couple of things. One is that, you know, now, well, I'm not sure, I know that ASAM sort of morphed into the American board so that to take both of those exams, you have to actually do training in the US. So that's- Fellowship, yes. Or grandfathering. I've actually taken both the addiction psychiatry and addiction medicine boards. There's about 85% similar, but the question is, what's the intent of, what is that preparing people to do? What added skill sets? Oh, to practice, it is a certification that is actually very meaningful in countries that do not currently. So a lot of the people that have taken the exam are Canadians, Egyptians, I'm trying to think where else. So in countries where we've got a concentration of people that have taken it, it is actually a recognized certification for the practices of very clinically oriented. I was used to be on the group that wrote questions for both ASAMN and for the American board of psychiatry and neurology. So, and now I'm the chief examiner for this one. So I'd say there's substantial overlap. It's, you know, but there's also a real international perspective to a lot of these questions. And it is really simply, you know, it's very clinically oriented. It is designed to test somebody's sort of knowledge and ability to practice addiction medicine and certify that there's a certain level of expertise. If I could just elaborate a bit, and that is the utility of the certification varies in particular regions. And in fact, in certain regions, like in New York state, there are requirements that you have to have a certification either in addiction psychiatry, or now in addiction medicine through the preventive medicine board. But there are requirements that you need that certification to become a medical director of a large treatment program. So I have to be board certified in one or the other in order to remain as the medical director of an OASIS funded treatment program. In academic centers, sometimes the requirement, certainly if you are in training in a particular division of addiction psychiatry or medicine, of course, it is expected that you're gonna be board certified. But it varies depending on region and state and internationally, that certification, the ISAM certification can really be critical to them in then gaining academic positions or particular official positions in leadership in addiction medicine or psychiatry. And some prefer it just because it represents an elevated standard of expertise so that they might find it a value in their whatever, an endeavor, private practice, or in a clinical position in the community. But the ISAM exam does not require this fellowship and extensive training. And so therefore, that's an advantage. Many doctors, many addiction oriented doctors in the states have inquired whether if they take the ISAM certification, can that qualify, for example, as the medical director of an OASIS funded facility. And that's something we've engaged in discussions about with the OASIS commissioner. And related, is there a review course or anything like that in preparation for the exam? It's based largely on the textbook, but we are on the international textbook, but we are considering a review course. I think that would probably be a really good idea. But in many of these countries that folks that are taking, this is the only exam that they're eligible for that actually provides some objective measurement of their knowledge base in addiction medicine. You have to be an MD. There's certain qualifications just to take the exam. They have to have a medical degree and board. And of course, with ASAM and AAAP, there are review courses. And that can overlap actually from preparation for the ISAM exam, because a lot of the material is the same. Thank you. I want to thank you for your great representations. I'm Dr. Mary. I'm coming from Turkey. I'm from Istanbul. And I want to say a few words about the ISAM Congress. I'm also a local committee organizer in Istanbul. I want to say you come and see Istanbul. And I think that we're gonna have a great conference. And I want to invite you and all my colleagues here. And thank you. Thank you very much. Thank you so much for your efforts. I did pass some brochures around. And also, you can access them on the website. You just go on the ISAM website or the ISAM Congress website. And you can access the information about the Congress and the details in the application. Yes, young lady. Thank you, doctors, for all this really helpful information. I have lots of questions, actually. But my first one is, as a follow-up from our doctor's question, how can you delineate the scope of practice between addiction medicine and addiction psychiatrists? Okay, that's, I think, Kathleen, you can. Well, I can start, but I am sure that other people on this stage have something to say about that. I do think we expect, from addiction psychiatry, a much better grasp of comorbidity in psychiatric disorder and psychiatric diagnosis. So I think that's one really clear differentiating factor. I don't know. Yeah, go ahead. Yeah, that's exactly right. The idea was, at least originally, that addiction psychiatry people would specialize in psychiatric comorbidities, addiction medicine people would specialize in medical and OB-GYN and pediatric comorbidities like HIV, Hep C, and the like. What is fascinating to me is that the original idea, again, with the fellowships was that the psychiatrists would become even more entrenched into the psychiatry of addiction, and the addiction medicine fellowships would really concentrate on neonatal abstinence syndrome, make the OB-GYNs even better at pregnancy and addiction, and so on. And actually, what we found, it was exactly the opposite. The people who are non-psychiatrists and attracted to an addiction medicine fellowship, they can learn complicated withdrawals, they can learn neonatal abstinence syndromes, they can learn all that within a matter of a couple of weeks or a month at the most. They're not gonna spend 12 months doing this kind of work. What they're really coming to the fellowships for is to learn motivational interviewing, to learn CBT, to learn psychiatric comorbidities, to learn how to talk to people, and so had to really kind of shift our attention. I've started the addiction medicine fellowship a couple of times, actually, and I've been amazed how much psychiatry the non-psychiatrists want to learn rather than the very specialized medical aspects of addiction medicine. Historically, addiction psychiatry certification started first, and it was many years afterward that addiction medicine doctors who are not psychiatrists wanted that board certification for the various reasons we explained. So that developed more recently. Some doctors are certified in both addiction medicine and addiction psychiatry. Dr. Carol Weiss, you wanna just say a couple of comments about why you're board certified in both and what advantages that bring, Carol? Oh, okay. All right, so, yes. Yeah, my follow-up question is, like, how about for prescribing psychotropic drugs? Like, are addiction, like, medicine physicians allowed to prescribe? Yeah, to prescribe psychotropic, yeah. I mean, there's no restrictions. Okay. My next question is, can we just let the other people have it back? Go to the end of the line and then we'll get to the others, and then we're going to get back to you. Thank you. No, you can go to the end of the line. We'll get to you. Go ahead. Yes. Thank you. Good day. My name is Irimide. I'm a medical student, and I'm originally from Nigeria. And although I schooled in the Caribbeans, I did some elective rotations in Nigeria and just growing up in Nigeria generally. And I was looking at some of the data that was put up, and I think there's a heavy underrepresentation of data of substance use disorder in Nigeria. I can't speak for every other country, but I could say for my country specifically. And I think it's important that there is representation, because if these people are not even seen, how can they be helped? So is the ISAM doing anything maybe in collaboration with WHO to at least get more data? Because even going to the store to buy wine, there's so many local ways we make our own alcohol back home. And we see old men, they wake up in the morning, they go to the palm trees, they ferment it, and they drink it early in the morning. And according to CAGE questions, I think that's an eye-opener, right? So very good question. I'm glad you raised that, because we do have a Nigerian chapter, and you can access communication with your colleagues in Nigeria if you're a member of ISAM. Membership in ISAM, I think it's $150 dues a year, or even as a resident or fellow, they're much lower. But you ought to contact Carol Weiss, who's the ISAM USA representative, and she can put you in contact with the Nigerian chapter of ISAM. And that applies to everybody who has an interest, based on various reasons, or you have roots or relatives or colleagues in different countries, ISAM might have a chapter in that respective region. But thank you for that question. And I just want to add a little something about the data on those slides. I would say, if anything, with the exception of Greenland, which just stood out to me, any of those numbers were probably an under-representation, because of the means of data collection. But also, when it was clear or white or hatched, that could either mean no use or no information. And I think in the case of Nigeria, it meant no information, not no use. So I didn't really point that out in the graph, but, you know, as I said, there's lots of problems with that information, but it's the best we have right now. And I'll also add that there is unequal representation of the world in a lot of these surveys. And also, ISAM is making efforts to include different jurisdictions that are currently under-represented in Africa, South America, and other jurisdictions. So it's an active effort. It applies not only to substance use, but also behavioral addictions, particularly given, for example, the gambling problems at a number of jurisdictions in Africa, where there's sports gambling that is really a concern. So trying to understand how the different jurisdictions are addressing these concerns from policy and public health and clinical perspectives is really important. Thank you very much. Next, gentleman. Hi. Good afternoon, everyone. This was a very timely presentation. Dr. Brady, the global graph that you had up there, I was particularly intrigued by the prevalences that we're seeing. In particular, I'm a psychiatrist that works in the University of the West Indies in Jamaica, and I kind of noticed right there in the West Indies, the prevalence rates were very much similar to what you would see here in the Americas and further up north, aside from probably the opioid issue. My question really is, one, the university that I'm a participant to has many campuses in the Caribbean, and is there a scope for perhaps a Gen X or an expert sort of network being created within that sort of territories, considering they represent one of the lower and middle income countries that we see a lot of the substance use issues happening worldwide? And the second question is possibly more personal and for some of my residents who are interested in addiction training, further addiction training. Our program has a very strong component with regards to addiction because of our heavy burden regarding cannabis and alcohol. So there's a very, I said, prolonged program or rotation in our residency training. But in terms of a fellowship, we don't have an addiction fellowship, and I noticed one of the criteria was that you would have had to complete a year of addiction fellowship. Is there any exception to that rule? Oh, yes. It's either, I'm sorry, it's either a year of addiction fellowship or work in the field that's documented. So you can get a letter from people saying that you've worked in the addictions area. And we do, I think we have a regional representative from the Caribbean. Mark has the map up. I was just going to ask him to fill in, but we would love to connect with you around that. Don't we have a regional representative? Yes, we have a regional representative for the Caribbean, Ayanna Gibbs, and Carol can give you the information on that. We'd love to connect you with that. Thank you. Appreciate it. Good afternoon. Thank you very much for this insightful presentation. My name is Dr. Okoye, and I work in a correctional facility. Thanks for all you've done over the years. Mode, opioid use disorder medication assisted treatment is being used in the population. And my second comment, my fellow Nigerian had raised what I wanted to raise about the under-representation of the data. And I thought possibly it's because, I don't know, but data there, you know, might be limited. But I'm glad that you mentioned that we have a representative council in Nigeria. So it would be good for us to know about that. So that we can also send to other associations, medical associations that we belong to. And my last question is, for medical students, or maybe those aspiring to go into medical school, do you have any pathway or program to help them in research, those interested in research, learning more about addiction research? Well, that's a great question. First of all, I want to thank you for your comments, and just thank you for your interest and for enlightening us about the different areas where you practice, because this is how we all learn from each other. So you know, I know some residencies have, you know, some residencies have research tracks, some medical, almost all medical schools in the United States, there is an opportunity to spend one summer at least in research, and some of that is funded by the NIH. So I think it just varies school to school. Yes. And you have you have one more question, yes. Oh yeah, I'm sorry. If you have more time, then I have a question. Yes, yes, go ahead. In terms of, like, the difference between DSM-5 and DSM-4, like, the updates, about the diagnosis of PTSD, since it's, like... Yeah, it became its own. Yes, so right now, like, PTSD can be diagnosed at one month, more than one month? Yeah, I think it's longer than a month with a certain constellation of symptoms. And then there's delayed onset diagnosis, more than six months, and there's complex PTSD as well. So how do you, like, diagnose, like, those things? What are the criteria? Well, gosh, I don't know if I'm going to be able to go through them all right now, but I know there's three different clusters. There's the arousal cluster, there's the avoidant cluster, and then there's the re-experiencing cluster of symptoms. And you have to have some from each, and re-experiencing is nightmares, flashbacks, you know, feeling like you're back in the situation again. Avoidance is things like people just who really shut down, they don't. And then hyperarousal is when you see reminders of it, your heart rate goes up. Yeah, so those are the three symptom clusters that make up. But, of course, the first thing you have to have is an index event that meets criteria. And you're right, the symptoms need to have been persistent for at least a month, because otherwise it's an acute traumatic stress reaction. Yeah, and beyond the diagnostic criteria, I think also the particular cultural experience that could be dependent on region or affiliations. So, for example, now, we have a program for veterans, military veterans, right here in New York. And their shared common experience of the trauma is a very important part of the therapeutic process, and they relate to each other in that way. In Morocco, there was an earthquake with earthquake victims. So when we were there, we touched with them. And, of course, in Ukraine. So depending on the region, there can be shared experiences and emotions in relation to certain traumas, which are important to incorporate into your understanding, evaluation, and treatment of those clients. Yes, because my concern is more off the timeline. Because we just had a capstone project in Bellevue, since there's ASD as well, and adjustment disorders. And these are, you know, timeline-based. But thank you for your answers. My third question is, how do you deal with, like, post-substance abuse? Like, if there's a patient who comes in with alcohol, nicotine, cannabis, opioid-like disorders, like, how do you treat them? Like, do you prioritize one of the other? Or do you treat them, like, all of them? If I could respond, yes. So it depends on perspective, of course. And in the states, that would take a full day to explain what our perspectives are. But in different cultures and different countries, they have different angles and viewpoints and perspectives on how to treat, you know, polysubstance abuse and dual diagnosis in particular, where they treat one first. And there's a lot of psychosocial therapies that really go across the board. You know, contingency management, cognitive behavioral therapy. So there's a lot of things that you would do regardless. And then I think in the other, in terms of what you might prioritize, I think acute lethality would be a, you know, probably, you know, a prioritizing factor if you thought somebody was really likely to overdose and that, you know, they had very dangerous opioid use, for instance, or methamphetamine. So I think it, yeah, it's just sort of a clinical, it's clinical. So thank you all for running out of time. But, oh, do we have one more question? Related. Does ISAM have any funding mechanisms or points in the right directions for international medical graduates that want to train here or some connection that are interested in addiction, psychiatry, addiction medicine? No funding mechanisms of which I'm aware. There are some who are interested. And we've had some who are interested in coming and do get some kind of internships training by a mentor. But that's not funded. But, you know, NIDA has some pretty good mechanisms for that. What's the, oh, I'm trying to think of that. The Humphrey Fellows come from all over the world. So there's a couple of federal mechanisms to fund international people coming to study. Were you a Humphrey Fellow? So you must have, Bob Balser was my thesis advisor. You must know Bob. Yeah, yeah. So I think the Humphrey Fellows are fabulous. I mean, that's a great mechanism and really wonderful group. So thank you all. Okay, thank you. Thank you.

international addiction medicine

psychiatry

Greg Bunt

ISAM

behavioral addictions

dual diagnosis

global collaboration

substance use disorders

cultural sensitivity

education and research

global expert network

addiction treatment

certification exams