Thank you all so much for being here. We're going to go ahead and get started. I apologize for the slight delay. I had been told it was in a different room, where I was sitting all by my lonesome, and so I'm delighted to see you all here. I want to start by thanking Petrus Livonis, who's one of the chairs at Rutgers University, where I currently am. I direct the Rutgers Addiction Research Center, which is actually the largest addiction research center in the world now. We have over 150 researchers who span all the way from basic science through to prevention, treatment, policy, recovery. My own research is in the area of genetics and understanding why some people are more at risk for developing substance use disorders than others. Today, what I'm going to be doing is talking a little bit about new advances in this field and how I think that it can benefit all of us in the field of psychiatry. I'll start with my disclosures. I've written a book published by Penguin Random House, for which I received some royalties. I am also the chief scientific officer of a company that I've co-founded recently, Thrive Genetics, and I'm on the medical advisory board for another startup, Seek, which is looking at genetic and other biomarker testing for alcohol use disorder. I've received no funding, no funds from either of these endeavors at present, though in theory I have equity in the companies and could. I'm actually going to be talking toward the latter part of my talk about why I've become involved in these initiatives. Today, what I'm going to do is really talk about what I see as some of the exciting new advances in genetics in the area of substance use disorders. I'm going to be talking about where we stand in terms of identifying the genes involved in why some people are more at risk. We've really made tremendous advances over the last five years. I'm going to be talking about our work also to understand how that risk unfolds across development, how it interacts with the environment, and then I'm going to be talking about what I see as sort of the next wave, our efforts to translate these new advances in genetics into improved prevention and early intervention. And then finally, throughout my talk, I'm going to be talking about why I think this area of research is so important, but I also think it's so important for all of us who are in this field to be informed about where the science stands. So I like to start with why, and I'm curious, by show of hands, how many folks here have read this book? I find that very few individuals in medicine or academics have. It's a business book. It was a bestseller. It's widely read in business classes. And in this book, Simon Sinek argues that most companies, good companies, focus on what they do. So Hewlett Packard makes printers, and they focus on making really good printers. But great companies, he argues, focus on why they do what they do. And so Apple's motto wasn't, we're going to make really great home computers. It was, we're going to create technology that will change your life. And that allowed them to seamlessly go from computers to iPods to iPads to iPhones to technology that quite literally has changed our lives. And I think it's very relevant to us, whether we are researchers or practitioners as well, because maybe if you are working with clients and with patients, your why feels very salient because you can see it in helping individuals. Sometimes in research, the why can feel very distant. But I think if we stay focused on why we're doing what we do, it can really inform the way that we do it. This really isn't how we're set up as a society. When you meet colleagues, you ask them, what do you do? But what I'm going to encourage us to think a little bit about today is when we focus on the why, it also requires more of us. It maybe requires us to step outside of our comfort zones, to stay on top of new advances. And I'm going to talk some about that today. So for those of us who do research in my area, in genetic epidemiology, the why is very often rooted in the precision in medicine initiative. So the idea that right now, of course, when most people go to their doctor to include in psychiatry, it's when something is wrong. Maybe some of us are very good and we go in for our annual preventative checkups each year. But most doctor's visits are for when something is wrong. And most people, of course, don't rush right off to the doctor when they notice something is wrong. Instead, they wait, see if it'll get better on its own, see if maybe they can kind of fix it doing their own things. And then it's when things get worse that they show up in our offices. The idea is that with the radical advances that we're making in genetics and in other data science areas, we should be able to move from a treatment-based model to one that is predictive, preventative, and personalized. And so we know right now that very often there's a lot of trial and error in figuring out what an individual has in terms of their diagnosis and what treatment is going to work best for them. And that entire process is incredibly costly. It's costly to the individual who is suffering. It's costly to their family members. It's costly to our healthcare system. And so we should be able to move beyond a one-size-fits-all approach to medicine to essentially be more targeted in what will work best for individuals. And so in this figure taken from a paper published in Science some years back, co-written by the director of the National Institute of Mental Health at that time, they talk about how right now, of course, what we have is an incredibly heterogeneous group of patients who show up in our offices. Even if we're limiting it to a diagnosis like alcohol use disorder or depression, it's still an incredibly heterogeneous group who likely differ in their genetic risk factors, in underlying brain activity, physiology, the behavioral processes, so behaviors, life experiences. And we should be able to essentially use these data science techniques that we have now and these large data sets and advances that we're making across these areas to be able to cluster patients into more homogeneous groups based on their underlying risk factors that would allow us to do more targeted prevention and treatment. So let's start with where we are when it comes to gene identification for substance use disorders. And what I've shown here is the current state for alcohol use disorders, which are the furthest along. And so really what this figure shows here is that along the—you all can't see my pointer, it doesn't look like—but along the x-axis there, it's essentially showing that sample sizes are increasing. Each one of those little dots is a study that was intended to identify genes for alcohol use disorder. So it's a GWAS study, a genome-wide association study. And what you see is that across time a number of studies have accumulated. The red dots are genome-wide studies of alcohol problems. The green dots are genome-wide association studies of alcohol consumption. So across time our samples have gotten bigger. And then on the y-axis, the number of genetic loci that we have identified is increasing, such that the biggest gene identification study for alcohol problems, alcohol use disorder right now, was just published last year. It has about a million individuals in that analysis, and it's identified about a hundred locations across the genome that confer risk for alcohol use disorder. Now this one clear outlier up here, which has identified over 500 loci, is for alcohol consumption. You can see three million individuals have gone into that analysis. It's easier to collect big samples on alcohol consumption because so many studies of multiple medical outcomes collect that information about how frequently people drink. But really the problem is that what we have learned is that the genetics of alcohol consumption are different than the genetics of alcohol problems. And so in fact, genes that are associated with increased consumption are also associated with increased socioeconomic status. So this is the having a glass of wine with dinner. And they are associated inversely with psychiatric disorders. So fewer psychiatric disorders. So that clearly suggests that it's only partially genetically correlated. It's only going to get us so far. What we really care about is identifying genes associated with alcohol and other substance use problems. But the good news is that we are not starting from scratch. So twin studies have been around for decades, and of course this is the idea that comparing monozygotic twins who share all of their genetic variation to dizygotic twins who share on average just half of their genetic variation can tell us about how important genetic influences are on a given outcome. And of course twin studies were critical for really demonstrating that substance use and psychiatric outcomes are under significant genetic influence. That's not all just found in, you know, risky family processes or poor mothers or whatnot. But it turns out we also learned a lot about the ways in which genes influence the comorbidity that we frequently see across psychiatric outcomes as well. And so they were good not just for showing us that something was heritable, but for really helping us learn about the genetic architecture of psychiatric and substance use disorders. Because of course one of the things that we know is that comorbidity is extremely common in our field. And so in the areas that I'm most interested in and that I focus on, alcohol use disorder and other substance use disorders, we know that they are very commonly comorbid, in particular with childhood conduct problems, with adult antisocial behavior, with personality features related to impulsivity. And what we have learned is that this comorbidity is due in large part to shared genetic influences. And so numerous twin studies have robustly shown that these outcomes share an underlying genetic liability, which is sometimes called externalizing, a term that comes out of the psychology literature, or also alternatively behavioral under control, or behavioral disinhibition. And the important thing is that this underlying genetic liability, which impacts all of these outcomes, is highly heritable, about 80 percent, more heritable than any one disorder on itself. And so what this suggests is that these really are all alternative manifestations of this underlying liability, brains that are wired toward more behavioral under control, or what we might think of as self-regulation deficits, lower self-regulation. And when it comes to substance use disorders, as much as two-thirds of the genetic variability is due to this underlying shared genetic factor that captures behavioral under control. Only as much, probably only a third tops of the genetic influences on substance use disorders are genes that are specific to a particular substance use outcome. And these are likely genes that are involved in metabolism of those particular drugs. But most of the heritability of substance use disorders is shared. And so this is really what led me to launch an international consortium called the Externalizing Consortium, in which we are working to identify genes involved in this shared underlying liability that predisposes broadly to substance use disorders, but to other disorders that are characterized by behavioral under control. And shown here are the lead analysts and the other PIs who led this project with me. And really what we did is we went out to the literature first, and we said, okay, we're going to look for big genome-wide association studies, big gene identification studies, for outcomes that are related to behavioral under control. And we arbitrarily chose a cutoff of they needed to have 50,000 or more participants in them to ensure that they were well-powered. And this is what was out there at that time and what went into the final analysis. So genome-wide studies for ADHD, for problematic alcohol use, for using cannabis, for smoking initiation, for some risky sexual behaviors, and then a general risk tolerance GWAS. And what we found, supporting all of those previous twin studies, when we put them all in a model, is that they do all load at the genetic level on a shared underlying liability, meaning that these gene identification studies converge on, yes, there is a shared underlying genetic factor that impacts all of these outcomes. So we had 1.5 million individuals in this analysis, so we're now highly powered. And so what we did is we then ran a gene identification study at the level of this externalizing factor, this factor that captures behavioral under control. So now we're not going to do a GWAS of alcohol use disorder or opioid use disorder or cannabis. We are essentially going to say, we know that these things all share genetic influences, so let's look for the genes that impact all of them. And for those of you that do not spend all of your time thinking about gene identification like I do, just quick primer, when we are essentially running these big gene identification studies, or what we often call GWAS, short for genome-wide association studies, we are literally testing millions of SNPs across the genome, so millions of locations in the genome where there's variability, and we are just stepping through all of those locations and saying, are individuals who are affected with this outcome or who are higher on this particular outcome, depression scores or alcohol use, are they more likely to carry a particular variant at this location than individuals who are unaffected or who are low on the trait? This is the exact same method, by the way, that we use for all biomedical outcomes, cardiovascular diseases, cancers, etc. So we essentially conduct tests across these millions of places where there's genetic variability. We then do a massive multiple testing correction, and we essentially identify those locations that are significantly associated with the outcome, where individuals who are affected are more likely to carry a particular variant. And so this is what, if you look at these scientific papers, produces what we sometimes call Manhattan plots, because we want them to look like they have lots of skyscrapers, because what all of those peaks represent is every one of these dots here is one of those genetic variants that we tested. So the colors at the bottom are all the non-significant things which run together, but what you can see is that everything above that dashed line there, the top dashed line, indicates a genetic variant that is significantly associated, after all this correction, with the outcome, with externalizing. These are genes that are involved broadly in behavioral under control. So we identified nearly 600 loci, and if you compare that to, at the time, the biggest studies that were just looking at one of these individual disorders by themselves, we had only identified 29 loci significantly associated with alcohol use disorder, two with cannabis use disorder, one with opioid use disorder. We're identifying nearly 600 that broadly confer risk to all of these outcomes, and these other kinds of child behavior problems, etc., as well. And as you would expect, we find that there is an enrichment of genes that are involved, that are expressed in the brain, and that are involved in neurodevelopmental processes. So what we can then do is essentially add up all of these variants that are associated, weight them by their effect size, and create what we call a polygenic score, poly meaning many, genic of these locations in the genome, that indicates, and we can sum them up, we weight them by their effect size, and so we can create a genetic risk score for any individual, and when we take these genetic risk scores into independent samples, we find that they account for about 10% of the variants in an externalizing factor score, and what that means is we're essentially summing up for each individual information across their childhood behavior problems, ADHD symptoms, antisocial behavior, all the different forms of substance use, the things that went into our gene discovery. So we are at the point now where we actually have genetic risk scores that rival the size of other really important, for example, socio-environmental factors that we know contribute to substance use outcomes, and what this looks like, just to give you a sense, is that in this graph, what we've done is broken up what is a continuous bell-shaped distribution of genetic risk. We divided it into quintiles, so at the far left are individuals in the bottom 20%, so the lowest levels of genetic risk, and on the far right are individuals at the highest level of genetic risk, and then this is just looking at some substance use outcomes, for example, so the top line, meaning individuals who essentially meet criteria for either moderate or severe alcohol use disorder at the lowest levels of genetic risk, about 28% of them do. At the highest levels of genetic risk, nearly 50% of those individuals do. Part of the reason it's so high in this sample is because it's a sample enriched for alcohol problems in the family members. If you look at something like ever using opioids without a doctor's prescription or not as recommended by a doctor, it's about 13% among those carrying the lowest levels of genetic risk, but it's about 30% among individuals at the highest levels of genetic risk, so you see these very clear, linear trends with increased genetic risk more likely to display these different substance use problems. So what we did next is we actually took those genetic risk scores into a big electronic health record database. We partnered with colleagues at Vanderbilt and looked at the Vanderbilt Biobank, and essentially what we were looking at is, okay, so what are these genetic risk scores associated with in individuals' health records? So we're essentially scanning all the different types of health outcomes that might be associated with carrying this genetic risk towards self-regulation deficits. And though I know you cannot see any of these labels on this figure, which you're not intended to, but the point is this is a figure that's kind of flipped on its side from what we were looking at, except instead of before we were looking at individual genetic loci that were significant. Now what we're looking at is these are all of the medical outcomes in those electronic health records that were significantly associated with genetic risk. And so in addition to substance use and psychiatric outcomes, it was also associated with suicide attempts, but it was also associated with worse health across nearly every bodily system. So individuals with higher levels of genetic risk, so more behavioral under control, were more likely to suffer from heart disease, HIV infection, type 2 diabetes, obesity, cirrhosis of the liver, lung cancer. And of course, what I'm sure is immediately becoming obvious to you, as did to us, is that these are all medical outcomes that are mediated by behaviors related to self-regulation. Eating too much, drinking too much, smoking too much, risky sex. And so I think this is really important as we think about what individuals who are carrying genetic risk are really at risk for in a broader health holistic sense. So they might be in our offices, for example, for alcohol use disorder, but if they're carrying this genetic risk disposition, they're also at risk for all of these other kinds of outcomes related to self-regulation deficits. Now, maybe you're sitting there thinking, okay, aren't all these things confounded? Because we know that, for example, individuals who have more severe substance use disorders might have more challenges holding down a job, then they're not going to have health insurance, and so all these things are just going to end up correlated. Well, to try and look at that and make sure it's not all just confounding, we actually looked at sibling samples, and we found that all of these associations hold up within siblings as well, too. So within a sibling pair, the sibling who is carrying more genetic risk was more likely than their other sibling to have all of these elevated problems across all these different outcomes. So we go back to, okay, so where are we in terms of the genetics of substance use disorders? This is the picture I showed you before, where we started, and this is now where our study puts us. So clearly, by moving beyond thinking about each of these as, quote, different outcomes, alcohol use disorder, opioid use disorder, cannabis use disorder, et cetera, and thinking about what have we learned about the ways in which genes act, we can really radically advance our ability to identify these specific genes. And so I've been talking right now about genes that influence alcohol problems via this broad externalizing factor, but we can, of course, then also look for genes. In this way, we can separate out, we can tease apart the genes that are more directly influencing a particular outcome. So genes that are specific to alcohol problems that aren't operating through broad self-regulation. And of course, what we find there when we run that study is the whole series of genes involved in alcohol metabolism, as you would expect. And so really, what we've learned is that there are multiple genetically influenced pathways that impact risk for substance use problems. And I find that one of the biggest misconceptions when I talk to the public and to many medical doctors is they'll say, okay, yeah, I understand now. I know that there's genes that influence risk for substance use disorder. Some people are more at risk than others, but they are thinking of just the genes involved in the physiology of it, that they think, okay, some individuals, if they try a particular drug are more likely to become physiologically addicted to it, that their bodies are likely to respond to it in a more addictive way. And yes, there is some truth to that. There are those genes that are involved more specifically in a particular substance use problem. But really what we've learned is that the vast majority of genetic risk for substance use outcomes is not related to the way bodies respond to a drug. It's related to the way brains are wired. And so we know that these are actually the much more important genetically influenced risk pathways, externalizing being the big one. That's the one that I've talked about. So related to the way brains are wired to process rewards and consequences. Some individuals are carrying genetic dispositions that make them more excited about what's right in front of them. They don't have brains that naturally think through all the long-term consequences. And when you see this behavioral under control, it clearly influences not just risk for substance outcomes, but for all of these other outcomes as well. And then we know that there are also genes that are involved in internalizing, in depression, anxiety. We're making some progress there too. And substance use outcomes then are likely a sort of secondary piece of that if there are not effective coping mechanisms or the anxiety or depression is not effectively addressed, then substances might be used to cope. So that's another more indirect genetically influenced pathway. And so if we go back to kind of where we want to go with all of this, the idea that we can take our heterogeneous group of patients and better understand the risk pathways, cluster them into what are the underlying risk mechanisms, we can see we're getting much closer to this. And so we know that some individuals are going to carry genetic risk related to externalizing, to behavioral under control. Some of them will carry genetic risk related to physiological response to particular drugs. Some of them may carry genetic risk related to this more internalizing pathway. And of course, these are not mutually exclusive. So individuals could carry risk across any of these pathways. So what we have done next is essentially go into large longitudinal databases that have followed kids from early in development until, in this case, in the mid 20s. So we used data from the UK, a couple of samples from the United States, a sample from Finland so nearly 20,000 individuals in this analysis. And so we essentially had data starting at six months all the way through to 26 years. And what we see is that genetic risk associated with behavioral under control shows up in all kinds of ways from very early in development. So in temperament and little kids, it shows up as high approach and high activity. And then as they get a little older, now it's showing up as sensation seeking and impulsivity and ADHD and oppositional defiant. And then it starts showing up as more delinquency, risk taking, conduct disorder as their adolescence. And then when substances come on the line and come into the picture developmentally, we see them being more at risk for substance use disorders as well. And so when we think about prevention, early intervention, I think this kind of information really can get us to start to think about how we can capture individuals who might be at risk earlier in that process. And then, of course, we can layer on the environment as well. And so what this graph shows is this is one of those samples looking at delinquency and adolescence. And what those three lines are is we've grouped them into three groups here. The red line is individuals who are one standard deviation or more above the mean in terms of their genetic risk for externalizing for behavioral under control. The yellow line is individuals at the mean. And the blue line is individuals who are carrying lower levels of genetic risk. And you can see, and this is looking at delinquency as a function of genetic risk and parental monitoring of adolescence. So when there's low levels of parental monitoring, parental engagement, we see the expected association. Kids who are carrying more genetic risk who are more dysregulated are more likely to be getting into trouble. But as there is more parental engagement, more parental monitoring, you can see that the effects, it's good for everyone, first of all. Delinquency goes down across the board for all kids. But it goes down fastest for the kids who are genetically most at risk. And so at higher levels of parental engagement and monitoring, there's no difference in delinquency as a function of genotype anymore. And so this really speaks to how when we understand someone's genetic risk, the environment also plays a powerful role here. Okay, so now I'm going to shift gears and talk a little bit about how we can actually translate all these things that we're learning about genetic and environmental influences on substance use outcomes into practice. So, returning to the Precision Medicine Initiative and this idea that we can move to personalized treatment and prevention, very often genetics is discussed in the context of finding genes, advancing our understanding of the underlying biology, and then hence being able to develop better treatments, better pharmaceutical treatments, more targeted pharmaceuticals. And I'm involved in those efforts, and they are moving forward, and I'm not going to talk about those today. They are still in a younger, earlier stage, but underway. What I'm going to talk about, though, is this other piece of precision medicine as well, that we can use this information to prevent problems, ideally, before they start. So, when it comes to substance use prevention and treatment, very often, we're focused largely on the environmental side, on risk factors that are found in neighborhoods and families, in peer groups, and that's obviously incredibly important. So, I want no one to come away from this thinking that I have suggested that we should not be doing all of those things and thinking about those things. But we are essentially leaving the other half of what we know influences why some people are more at risk than others on the table. We're not addressing it. These are incredibly challenging problems. We need all the tools that we can get in our toolkit. And so, I think what we can do is use these new advances in genetics to also incorporate that information when we're thinking about prevention, intervention, and treatment. And we don't even need to measure individuals' specific genotypes, though we're moving towards some of that, and I will talk about that at the end. But because we have learned a lot about the pathways, the early behaviors that represent genetic risk, we can use that information to essentially help prevent problems before they start. And so, the first place that we worked on building out some of these prevention programs is in a study that I ran called Spit for Science. When I was on the faculty at Virginia Commonwealth University, we worked with the leadership to run a university-wide initiative focused on substance use and mental health. Of course, these are big problems among emerging adults. We enrolled about 70% of all incoming students for five years, about 12,000 students. And then the idea was the commitment that we made to the leadership of the university is that we would essentially use these results to think about how we could feed them back to benefit our students. Because, of course, the challenge on college campuses, and again, with young adults more broadly, is that we know they engage in high rates of risky substance use. We also know that they are highly unmotivated to do anything that sounds like substance use prevention programming. And universities have all kinds of creative ways to get around this. Sometimes they require them to do online programs before they allow them to register for classes. One year, we relaxed that requirement, and we found that exactly 40 out of the 4,000 incoming students even went to the recommended website with resources for them. So we have been working on creative solutions, or what the mom in me calls chocolate-covered broccoli. How do we get something that is good for someone to them in a way that they actually are excited about and want to take part in? And it turns out that while young people hate doing anything that sounds like adults making them do substance use prevention programming, what they love to do is fill out surveys about themselves. So we build this not as substance use prevention programming, but about learn about you to get the most out of your college experience. And they filled out a short questionnaire, and essentially what these questions were are the items that load most highly on the things that we know are most predictive of developing substance use or mental health challenges. So they fill out these 20 or so items, and this was a program that was developed with interdisciplinary expertise from those of us who work in genetic epidemiology, in prevention, in our counseling centers. And so they fill out their items. They get a little bit of psychoeducation about how you all have unique genetic codes, and combined with your lived experience, it influences the way brains are wired, which impacts your natural tendencies and your personality styles. And then we essentially have it set up to be gamified. They can personalize their avatar. We worked with students to ensure that there were diverse hairstyles, skin colors represented. And then we give them feedback across four dimensions that we know from our big studies of those college students have been correlated with substance use and mental health challenges. So those are sensations. So the extroversion and the introversion. And knowing that extroversion tends to be even more important in this age group, we have three of those dimensions and one on the internalizing. So sensation seeking, extroversion, impulsivity, and then neuroticism or worry, kind of anxiety sensitivity. So they get their feedback, and then what we do is we walk through the good, the not so good, and then level up. We give them resources that are tailored to their particular profile. And what we're doing here is we're, of course, connecting this literature about all the things that we have learned about genetic, the genetic epidemiology of substance use and mental health outcomes with best practice, evidence-based cognitive behavioral principles, harm reduction. And so the big question is, would it work and do the students like it? Well, it turns out the students loved it. And so what these blue bars represent is these are a whole series of satisfaction items. The dark and light blue are strongly agreed or agreed to all of them. So, you know, along things here at the bottom, for example, is I enjoyed the program. I learned new information. I'd recommend it to a friend. It was helpful to learn about the good and the not so good aspects of my personality. So they liked it, but does it work? So we ran a small RCT. We got a grant from NIAAA to do this. And we essentially enrolled a sample of about 250 incoming students, and then we assigned them to four different groups, a control group, which just got a list of university resources. The BMI group is a brief motivational intervention. So it's an online, short, brief motivational intervention. This is considered the gold standard right now. It's what NIAAA recommends for college students. The personalized feedback program, so the one we developed where we're not focused on substance use, we're focused on understanding yourself and your particular risk profile. And then we ran a combined condition because we thought maybe if we give them information about themselves, then they'll be more interested in learning about the substance use piece too. I'm not even going to talk about that condition because those students actually did the worst. And we think it's because, you know, for anyone who's a parent out there, you know, if you talk too much at your kids, at some point they just tune out and take away nothing from it. And so we think there was a bit of an information overload going on there. So we then, we did a baseline survey before we essentially assigned them into their condition. And then we followed them up 30 days and three months later to look at substance use outcomes. And I want to point out, this isn't a high risk sample. In fact, this is a sample coming out of the pandemic. So about 75% were reporting little or no drinking. They've been at home with their parents, but we know they're now entering a high risk environment. So we're trying to prevent uptake of risky substance use. And to cut to the chase, the students who completed the personalized feedback program, it was highly effective. They were 54% less likely to use alcohol. Three months later, the effects actually got stronger over time. And 71% less likely to use cannabis than the gold standard, not than the control group. And so that little figure at the bottom just shows you the percentage of students in red in the PFP who are using alcohol and then cannabis on the right as compared to in gold, the gold standard and in blue, just the control condition of giving them a list of resources. So we think these look very promising. We're currently writing a follow-up grant to run a bigger study from the National Institute of Drug Abuse. And of course, the idea behind this line of research is that we know that this child, the impulsive one who's dangling from trees, who's ending up in the ER, who's giving parents a heart attack, if you fast forward a decade, this child is more likely to be this child. But not necessarily. There's no reason that same disposition can't get channeled into this. Or into this. And in fact, for full disclosure, that little risk taker is my little risk taker who comes by it honestly. His father, my father, my brother are in fact all fighter pilots. He is currently 17 and applying to the Air Force Academy. So what I want to turn to now in the last part of our time together is talking about why I think this information is so important for all of us as a community, not just as researchers, to understand. And this is because I truly believe that genetics is poised to shape the future in ways that are likely to be far-reaching and that we are not even imagining right now. To give you an idea of why I think this, I want to take you back about 30 years to one of my favorite films to come out at that time, Gattaca, a science fiction movie, and this is one of the opening clips from that movie. Ten fingers, ten toes, that's all that used to matter. Not now. Now, only seconds old, the exact time and cause of my death was already known. Neurological condition, 60% probability. Manic depression, 42% probability. Neurological condition, 60% probability. Manic depression, 42% probability. Attention deficit disorder, 89% probability. Heart disorder, 99% probability. Early fatal potential. Okay, so clearly they didn't get everything right. We obviously are not going to know the exact time of someone's death. But think about what I was talking about today. This was purely science fiction 30 years ago. Today, with this genotype, 30% probability. With this genotype, 50% probability. This is actually where the science is right now. Now, it's not fully out into the medical community. It's something us scientists are all talking about. But to give you some context for that, I want to take you back to that same time 30 years ago in the mid-90s to something else scientists were just starting to talk about back then. This crazy concept called the internet. Back now at 56 past, I wasn't prepared to translate that. As I was doing that little tease. Oh, that's right. That little mark with the A and then the ring around it. At? See, that's what I said. Um, Katie said she thought it was about. Yeah. Oh. But I've never heard it around. I've never heard it said. I don't see the mark, but never heard it said. And then it sounded stupid when I said it. Violence at NBC. Yeah, I heard it around the lunchroom. There it is. Violence at NBC. G.E. com. I mean. what Allison should know what is internet anyway internet is that massive computer right the one that's becoming really big now what do you mean that's big way how does one it not what do you write to it like mail no a lot of people use it and communicate it I guess they can communicate with NBC writers and producers Allison can you explain what internet is 30 years ago what is the internet something something you know those scientists and folks were talking about of course now what we have is a world that has been entirely changed by that technology we have an entire generation growing up that doesn't even know a world before having the ability to connect with anyone or anything and something they can put in their pockets it's something that we clearly were not thinking about 30 years ago and what made that happen is that there was exponential growth in computing technology our brains have evolved to think linearly it's served us really well for the last hundreds of thousands of years we cannot think exponentially exponential growth is what led to this when it came to computing now consider this the only field that has advanced at a pace that equals computing not only that that outpaces computing is genetics genetic technology is advancing at a pace that is faster than the exponential growth that was witnessed in computing so what this graph shows is the white line is Moore's Law so Moore's Law captures this exponential growth Gordon Moore who is the Intel co-founder was one of the first folks to observe that they were able to double the number of transistors on a square inch of computing space every other year and that's what led to exponential growth he observed this in the 60s so computers exponential growth curve started in the 60s and before now this line white line is Moore's Law it looks linear because you'll if you look at the y-axis you'll see it's an exponential axis so it's going from 1 to 10 to 100,000 to a million to 10 million etc now the white line is Moore's Law that's how fast computing was moving the green line which you can see drops off even faster is the cost of genotyping sequencing so advances in genomics technology consider that it took 13 years and three billion dollars to sequence the first human genome one 13 years three billion dollars we can now sequence a genome in a few hours for less than a hundred dollars that's exponential growth and it's not just happening in science it's happening in the private sector as well too so this is we're seeing exponential growth and direct-to-consumer DTC genetic testing so this is the number of people who had engaged in direct consumer genetic testing it also is showing an exponential growth curve so ancestry.com 23andme those kinds of companies you used to be able to upload your raw genotypic data to a public website called impute me interestingly this was the picture that was on the front of it and what this little graph shows is that there was exponential growth and the number of people who were doing that and what you could get on this free website is you could download your polygenic scores the things I was talking about at the beginning of the talk for over 1,500 medical conditions half of the top 12 most requested genetic risk scores were for psychiatric and substance use disorders so you could pull from a drop-down menu of over 1,500 medical outcomes half of the top ones psychiatric and substance use disorders alcohol use disorder which was the only substance use disorder that was available at that time was the third most requested outcome people want access to this information the genetic testing industry is right now an 18 billion dollar industry it's expected to double by the end of this decade and if you look at much of the innovation that has shaped our lives over the last two decades it has come from the private sector it has essentially changed the way that we move through the world the way that we shop the way that we drive the way that we book hotels the way we move through the universe and it has come for genetics and in one of the stranger collaboration requests of my career I actually had the CEO of a heavy metal rock accessory company reach out to me and this company was is called unchanged brands and he partnered with slash on this he lost his father to alcohol use disorder never developed problems he's the vice president of a software company but became a musician because that was kind of his outlet as he was growing up and they partnered to create these chains they have a special meaning related to care compassion computer courage community and compassion and they essentially give all the proceeds to music cares which is the nonprofit of the Grammys for which one of their primary causes is supporting families with loved ones with addiction and essentially in the context of this what they had was many people reaching out to them saying I wish I'd known I wish I had known that my loved one wasn't going to be one of the people who could use alcohol or other drugs recreationally but it went on to destroy their lives it's an interesting puzzle that we have taken on as a society we know that about 85% of people choose to use alcohol or other drugs recreationally but a subset of them are going to develop fairly devastating disorders that of course can really have profound impacts on their lives and the lives of those individuals who love them so I give a lot of parent talks and this is the top thing that parents also say to me I wish I could know I wish I could know if my child is going to be the one to develop problems is more risk and it would drive me crazy because I would think you can tell me about your child and I can tell you something about how at risk they are we have learned a tremendous amount about what are the factors that indicate which individuals are more likely to go on and develop problems and so I talked today about our advances in genetics that we can now create genetic risk scores but in addition of course we know a ton about the early behaviors and the environments that also confer increased risk and so this is a figure taken from this particular paper and if you just look at those little purple triangles what it's showing is we created a behavioral environmental risk index with these factors which based on huge longitudinal samples are consistently associated with an elevated likelihood of going on to develop substance use problems and that's the rate of developing any substance use problem as a function of the more risk factors that you carry and in fact when you put these things together the genetic risk and the behavioral environmental risk they independently add to the prediction and so in this little chart down here at the bottom we essentially this is just showing individuals in the upper and lower quintiles of the genetic risk the polygenic scores and the clinical environmental risk how many of these risk indicators they have and it's really interesting that in fact this measured genotypes still predict they add predictive power above and beyond this behavioral environmental risk index considering that we know that some of those things early externalizing behaviors early use of substances are actually a reflection of genetic risk but you can see that we can pretty powerfully differentiate individuals who are at the lowest levels of risk so 4% of individuals who have low genetic risk and low environmental and behavioral risk go on to develop substance use problems as compared to 84% of people carrying the highest levels of risk both genetically and behaviorally environmentally and these are based on data from about 20,000 individuals followed across time and so one of the things that I care deeply about is how can we get this research into the hands of people who can use it into the hands of practitioners who can use it with patients and directly to individuals to families and to community members and so this is really what we are working on right now so we are building out this online platform to create these personalized risk profiles and so it's based on all of this research so my own history of 20 years and 50 some million dollars of you know NIH funded grants that have gone into this and the way that it works is essentially an individual goes online creates an account they fill out a survey with those behavioral and environmental factors that are most predictive of who develops problems and then we essentially mail a saliva kit to their house they spit into a tube mail it back to the lab we scan the genome we create those polygenic scores based on those big analyses I was showing at the beginning and then we essentially combine that genetic and behavioral and environmental information to give people a risk profile to essentially help them understand the extent to which they're carrying genetic behavioral and environmental risk and we've done research around how do you present that information to ensure that they do understand it that they don't adopt deterministic mindsets they know what it means but also what it doesn't mean because we know that of course DNA is not destiny and we don't just want to tell people they're at risk though ultimately we then want to connect them to evidence-based resources to reduce risk and so what we're doing right now is we're actually enrolling a subset of emerging adults so 18 to 25 year olds so the idea being that they are adults so we feel more comfortable giving them their personalized risk profiles but they are still early in that risk phase that the onset period so that hopefully we can catch individuals before they develop problems and so we're in the process now of essentially enrolling individuals to get feedback on the platform and to test a variety of different types of resources so to include a condition where they get access just to online information one where they get access to a psychiatric genetic counselor to talk through and process their results one in which they get access to interactive best practices so CBT MI mindfulness based modules etc so that is coming soon so not only do I think genetics is poised to shape the future I think the future is here this train has left the station when it comes to private industry genetic testing it has left the station and it is going with or without the researchers and I believe that we all have a role to play whether that's us as researchers thinking about what's out there so some of you all may have seen that the FDA recently approved the avert D test those of us who work in the psychiatric genetics community immediately were concerned because it does not represent best practices in genetics and in fact we ran tests and found it predict predicted no better than chance we of course don't have their exact algorithms but we have their published these are the the genes that are included in the test unfortunately what it does predict is ancestry and so it looks like it in fact could be discriminatory and because it's picking up on ancestry and in their studies there were more individuals who were black in their affected group than in their unaffected group and so a group of us have you know written a letter to the FDA about that but this is coming and it's going to be increasingly facing our profession and I think that whether you're a researcher or a practitioner who might have patients clients who are going to be showing up in your offices and asking about these products that it's been a lot has changed since many of us were doing our degrees there's been huge advances in genetics it's hard to keep up but understanding where things are where they're going I think is going to be increasingly important for all of us it often requires us to step out of our comfort zones and so one of the things that I did that I never imagined doing is I published as I mentioned a popular press book from Penguin Random House called the child code and this was because I found myself oh the irony raising the high-risk child that I study the highly impulsive highly emotional one and knowing the research was so helpful for me in my own parenting and I looked around and I realized how many parents were really doubting and judging themselves when their kids were struggling and so this book is intended to be a not sciency very user-friendly introduction to parents about understanding how kids behavior is genetically influenced how the environment interacts with that there's essentially some surveys and quizzes for them to understand you know where their child falls on these key big genetically influenced dimensions and then there's information about what parenting strategies work better or worse for kids with different dispositional styles because we know that all kids are wired differently and so hence they respond differently to different things and so sometimes I still in the mail open around of my favorite things as I will open my mail and think what did I order from Amazon and it's a box penguin owns world rights and I opened a box and it was Japanese versions of the child code the other day so you know I think thinking about what are the ways that we can help educate the public about this what I see as the new future the new integration of genomics into psychiatry because if it's not us people are going to get their information from somewhere and it's likely to be some one less informed than us I mean I love the rock as much as the next person but I'm not sure I'd want to be getting my mental health and genetics advice from him so if not you then who with that I want to acknowledge that everything I've presented today has been made possible by these huge consortia that have collected all of this data by funding from the National Institutes of Health for this work as I mentioned I run a large addiction research center at Rutgers there are many many individuals who have contributed to all of the work that I've presented today and one of the things we try and do is put information on the Rutgers Addiction Research Center website which you can access here we put resources for community members about substance use disorders new trends blogs addiction in the news events etc and with that I'm going to wrap up here is where you can find me some of the work that I do to try and get the latest scientific findings to the public in very user-friendly digestible kinds of ways on my website at Danielle dick calm through my book thank you for having me and I'm happy to answer any questions that you might have thanks so much I've moved from academics into community psychiatry working primarily with homeless people doing a lot of addiction treatment and I've been profoundly moved by the stories of our patients who struggle with addictions and how much universally they experienced challenging life life events as they were growing up the other side of genetic loading on an individual basis is the heritability of these things and how much these congregate in families making it even more challenging to introduce preventive strategies sometimes in families that have a very hard time navigating in the world and something that I'm interested in seeing going forward is how this kind of information is used in the service sector in the schools in health clinics and those kinds of things to help better inform families where sometimes the genetics of this is all over the family yes I really appreciate your comment and obviously these are complex challenges and and so I really think of this as kind of a multi pronged approach for how we can use this information and so we are the personalized feedback program that I was mentioning where we're giving personality based feedback we are essentially developing a version for use in schools and for essentially adolescents and younger kids with the idea that the earlier we can catch individuals and talk to parents about these kinds of things about risk factors because we know that putting in place socio emotional you know strategies strategies for managing depression anxiety impulsivity the earlier we can get that in the better you know we think about it then of course when we are at a point we're working with families in our practices etc and as you were right one of the the challenging things with families is that often there's both genetic and environmental risk and so kids who have parents who have substance use disorders are really getting a double whammy they're more likely to carry genetic risk so you know in this context they're more likely to be more disinhibited and they're more likely to be in a chaotic environment where they have fewer resources more opportunities to use etc and so so I do think that educating people and whether that is a family of course we know working with families is you know even better than working with individuals but not always possible but also working with individuals a simple place that I have talked with other I'm not a practicing psychiatrist but with my colleagues who do practice is that you know one of my favorite things that I was doing a panel with individuals with lived experience and a gentleman who had you know his life he'd been on the streets and other kinds of things and he said after I was giving my part he said you know that really resonates with me because my problem was always everywhere I went there I was meaning he'd stopped using substances but it was still this kind of disinhibited nature that next thing he was into he tried gambling and then he was you know of course having all these gambling problems and then he met somebody and next thing that led to a variety of risky sex and other sorts of you know things would led to other health problems and so I think that understanding something about these are genetically influenced characteristics and so it's not just addressing for example the substance but also thinking about the other ways that might lead to poor health and life outcomes can be another way that you can use this but thank you for those comments yes thank you so much for that profound talk I find it hard to imagine a world not in the not-so-distant future where a genetic panel is something like a vital that everyone has in interacting with their health care providers so I guess my question pertains to sort of bench to bedside so speaking from the perspective of the bedside you can have the best plan or the best medication or the best treatment ever for any given disease. I find that curating that plan or that medication or whatever that intervention to the specific person makes all the difference. I just wonder how information like this will affect you know the patient but also the clinician. Is there any work being done to explore how do we optimally curate and contextualize genetic information to reach desired outcomes and and prevent the inverse of that? It is a great point because of course we know that how we talk to patients has a profound influence on how they receive our advice, our treatment recommendations, whether they follow it I mean across all areas of medicine but also particularly in psychiatry and so the short answer to your question is yes there is work being done around that and so some of the biggest questions that I often will get are you know will will people adopt a deterministic mindset? How do you ensure that doesn't happen? Because obviously that is exactly what we don't want and there is some research showing that if you just give somebody genetic information you're carrying elevated genetic risk for depression or substance use disorder without any context that in fact it leads them to feel more hopeless helpless like they can't do anything about it which is of course the exact opposite of what we want to achieve with this information but the good news is there is also compelling evidence that from our work and multiple others that if you just give brief contextualization of that information so if one presenting it you talk about so genes play a role but they're only part of the role and the environment still plays a really important role and in fact the environment can trump genetics and so the way genetics can be useful is if you know if you're more at risk then you know you have to be more careful about your environment and your choices in the same way that if you have a family history of elevated cardiovascular disease then unfortunately you might not be able to eat the same foods or you might have to work out more and or you might have to be on a particular medication so the idea that and that resonates with people they get oh yeah I might be an elevated risk I can change my outcome by changing my environment and so even that sort of very brief contextualization appears to really reduce those deterministic mindsets the other thing you worry about is when you tell people they're low risk particularly for something like substance use disorders then you know you worry that they're going to be like well I can use drugs with reckless abandon because I'm not going to develop problems and in fact again we provide information in this sort of contextualized you know form about its genes but it's also environment so and what we find is no evidence that that is the case meaning that people that are getting low risk feedback are essentially more likely to increase their use in fact in a study that we ran it was not giving specific genetic feedback but we were essentially saying you know here's imagine this is your genetic risk profile how do you think you'd respond to it would you change your behavior people who got high risk genetic feedback or higher risk essentially 85% of them said I'd reduce my drinking people who got low risk lower than average genetic feedback though 25% of them said they would reduce their drinking so I think that's really interesting it's as if just giving information reminding people these are genetically influenced outcomes actually prompted them to think about whether they might moderate their drinking now across the board three percent of people said they would increase their drinking in response to their genetic feedback and that was true in every single genetic feedback condition so whether they were getting high average or low so I think that's probably more indicative of you know a certain personality trait than a response to the genetic feedback so those things are look promising and and essentially we are we're working with genetic counselors as well about the language and candidly one of the reasons that I've become interested in building this in a kind of online platform way is to provide clinicians who you know might not have studied all I mean clearly things have changed drastically people can't be expected to fully understand all these advances and what they mean and how to talk about them to provide language for clinicians for patients etc to make it easier because I agree that we need to be thinking about that piece I guess a follow up question how do we give chocolate covered broccoli to clinicians that they can learn to curate in a way that's helpful for for everyone I would need that I hate modules so so hurting hurting fellow clinicians physicians academics that's a nut I'm still trying to crack you know I'd rather work with patients and clients and parents and kids any day I say that half kiddingly I'll give you an example of something that we're doing at Robert Wood Johnson Barnabas health care system so in the Rutgers health care system is that essentially we've hired in an addiction medicine specialist and so we have brought together a task force with the heads of emergency medicine of women's health of essentially all the different areas of pediatrics etc to talk about how are we going to address think about substance use disorders and think about getting new best practices into our clinical areas so when it came to our emergency departments are prescribing of buprenorphine was very low as it is most places and we realized we needed to do better we wouldn't send someone out you know who had any other medical condition was such a high likelihood of death or of coming back in within a few days as we do for substance use disorders that was not OK and so we actually worked with the head of emergency medicine across all of our hospitals and tied that to our physician metrics for the year we did extensive training with the physicians we work with them we are addiction medicine specialist meets with them all weekly or monthly she's available to help support the implementation of this but now their performance metrics are tied and the hospital systems all have to hit certain targets for of the people who come in who should be leaving with a buprenorphine script how many of them actually do so that is you know is it chocolate covered broccoli I don't know maybe it's sugar or salt on the broccoli yeah we're trying to sweeten it a little bit for them while also having a bit of a stick it's do this or you'll have to eat this broccoli a little bit of both we're also providing user-friendly training where they can essentially check off certain CME credits with what we think of as more fun engaging cutting-edge kinds of videos and things as well as part of this so it's a little bit of carrots and sticks thanks for a fabulous talk as far as environmental influences in mental health one of the areas where there's a lot known and still a lot unknown is if a mom is exposed to inflammation during pregnancy it's called maternal immune activation and there's really strong evidence that this can activate the dopamine system strongly the strongest epidemiological evidence is that this increases risk for schizophrenia in the offspring it also increases the risk for psychosis and bipolar disorder so if you have the genetics for bipolar disorder you're more likely to become psychotic and there's there's some evidence from animal models suggesting that it can influence the risk for addictions and so I'm curious kind of two parts if you're able to include questions about this for for moms and if you were and they were able to tell which trimester they were exposed that would there's an awful lot unknown about this so I'm interested in in your thoughts on that and and I have to you know I will say I don't know a ton about this and so please feel free to follow up with me because I'd like to learn more about that wonderful and we certainly know that there you know there are obvious environmental triggering events for individuals who are genetically at risk right this is the whole idea that you can carry genetic influences and still you know as someone I I happen to be giving a talk yesterday and somebody pointed out you know even in those higher risk families with the high-risk genotype only 50% of them went on to develop problems and I went absolutely right I mean so yes we that that and those individuals are far elevated risk but only half of them are developing problems half of them are not and so we know that you know risky environmental conditions or environmental triggers are are also really important so identifying what those are and what the protective and resilient factors are and we know some of them you know many of them when it comes to substance use disorders but there are these other things too that we're learning particularly I find that in utero the fact that there can be in utero factors a variety of which one might be substance use in the parent that can also create some of these epigenetic changes and things that we don't know a ton about yet it's really fascinating yes thanks again for all the work you're doing and especially even doing the popular book to try to get the information out there I'm a psychiatrist who tests every patient that I see for their genetics so I've got a ton of data but what after doing all this testing I still have seen you know I'm doing it for 12 years I see very little movement in terms of widespread adoption right and you showed one of my favorite clips which is Gattaca I have another favorite clip which is there's like a back alley testing that happens at one point in the film and I I think that might be the future at one point but um but the they're doing the heel stick you know and their baby is getting a heel stick for PKU which is extraordinarily rare but they're not doing one for MTHFR for example which is one of the genes that has a lot of literature behind it and really changes outcomes you put the quote on the screen of I wish I had known and that's like the most impactful phrase that I hear all the time especially in older adults you know I've got 60 70 year old patient sitting in my office crying saying I can't believe I live my whole life not knowing this I had this genetic variation if I had just treated it back then my whole life would have been different right so how do we get the testing done well either universally or at least at a younger age yeah so I'm curious what kind of genetic testing you're currently doing the genes that I'm looking at are MTHFR CACNA1C, ANK3, ADRA2A, COMT okay those are the main ones there are other genes on the panel but those are the ones that I can use and do something with yeah you are right that there have been a variety of candidate genes and different kinds of things happening in smaller scale you know they haven't been as you mentioned they because these candidate genes on their own don't have large effects and there aren't necessarily clear implications with what to do with them you know they they haven't been widely adopted because they haven't been widely useful and so I think that as you know the genetics has really taken off in the last five years I would say maybe even in the last few you know couple years so I think that it is gonna become increasingly likely because as it becomes more useful it's sort of like how do you create spread what why did it uber become so popular well it solves a problem and it's easy to use and it works and so I do think that as the tests become better that they are more likely to become widely used this is also why I co-founded this company because I do think you know not because I'm hoping to like run off and make tons of money I'm an academic I just want to get the information out to people and I've realized that actually when you do partner with the private sector they're better at that than we are in academia and so so there are things if you are at all interested if you go to the Rutgers Addiction Research Center website we have a page where you can find out about the platform that we're building and we kind of have a you know if you're interested in staying in touch let us know I think it will become more widely available over the coming years I also think it is more likely to become available direct to consumer than it is widespread through our health systems and so you know obviously I'm a part of Rutgers health we're partnering with our health system to try it out in different places and I would say actually the ideal places might not be in psychiatry first it would be in primary care providers and pediatric offices etc because you ideally by the time folks are often in psychiatry practices they have developed problems and often more severe problems and that's how they've been able to get into psychiatric care so so we're working on it do I think that you know as I mentioned I have a 7 and a 17 year old I think that within my child's lifetimes they will have access to their whole genome sequences I think all you know I don't know depending on our age maybe some or some of us won't but I definitely think my children will will it happen at birth I don't know those are the really interesting ethical questions because I think we have a lot to do about with educating society and educating people about how complex genetics works before we wide scale just make this information available to all clinicians and to all individuals because now I'm gonna hop on my soapbox for one moment if we think back to you know if you're not an MD what kind of genetics do you get in high school biology you get Mendel and peapods and you know single genes and brown eyes and blue eyes you don't get polygenic you know thousands of genetic variants that increase or decrease your risk a little bit and they're not determinative and they interact with the environment and of course we know complex genetic traits are what are most of the major medical health outcomes that will impact so far more of us than rare genetic disorders so I think we need to do a lot more to educate the public before we can get to the point that you're talking about where you know we're not just testing for PKU but we've got the whole genome sequence I do think it's where we're going so it becomes critical to do these kinds of educational things and all of us can play a role in that because you don't have to be an expert in genetics to say there is no gene for depression or alcohol use disorder or substance use disorders there's thousands of genes and they all increase or decrease your risk a little bit and we can add them up now to get a risk score but it's not going to determine your outcome the environment still plays a role every one of us can and probably should have those conversations with everyone we meet so yeah I was just gonna share for everyone in the room I met a gentleman who is developing a point of care test for primary care or specialty care where just like you can get you know a strep test at the doctor's office you'll be able to get a gene test right there and that should be rolling out probably in the next five years or so yes it's coming thank you thanks for a great talk one of the questions I have is you touched on it briefly but like what kind of environmental factors we are looking at because when I consider environment I also consider what medications are you taking and what air you're breathing what food you're eating so I feel like there's a big need of having multiple people from different fields kind of collect together and work on this you are a hundred percent correct and often we talk about you know the expose zone now and it does include all of those things you're talking about as well as several of the things that I was focused on today I'm a psychologist by training and so I naturally think of you know psychosocial kinds of environmental factors things found in parents families neighborhoods schools and we know those play a big role in substance use outcomes but I think you are absolutely right that there are these other kinds of you know teratogens in our environments and that are likely to be triggering etc and we haven't studied those as much and that will become critical to I'm glad that you're setting up a company around this because I feel like we also need to have some guidelines I don't know if you're doing this already but to control for bad players who just want to be out there get a quick test make money out of it and they're like quick to produce stuff so people gravitate towards it versus like doing an in-depth details while someone is doing a debt in-depth research on it sure it gets out at the right time well thank you I appreciate that and it turns out you know being constrained by the science is really you know hampering to a lot of the way in terms of the way a lot of entrepreneurs think and you know we can look at companies like Theranos and see what happens when you have a good idea that is not backed by anything that is actually going to work in science and I think that you know with the tragically with the opioid epidemic there's a variety of companies that have come online for you know treating opioid use disorder addressing it many of which are doing great things really interesting things but the other piece is that we we want to make sure that those products are in fact grounded in good science and and so yes that's why I you know ended up wading into this world that I never imagined and to your point about how do we also have some some bumpers around how are we going to address you know to your with the kind of bad players and I would actually say that one of the challenging things is that I don't think any players think they're bad I think all players kind of you know want to do something to help solve this problem maybe I'm being overly generous maybe they want to make they see dollar signs but I'm gonna say they but the problem is if you don't especially with genetics if you don't really understand the science it's extremely complicated and it's easy to find spurious things and so actually the International Society of Psychiatric Genetics which is the big professional organization in this area I was part of a meeting just last Wednesday about we need to have a more active voice in this you know thinking about putting out good guidelines not just kind of going after you know different players that pop up but also what are the what are the things that you should be looking for that represent best practice so we're certainly working on that and I am encouraging and trying to pull along more scientists to think about how we have an active role to play in speaking to the public and being a part of these conversations. Just one last question what I was going to ask was I my background is engineering so I think of things like programming and like a model so I feel like you build up a model around substance use disorders have you thought about taking that model as is and say let's see what happens with this model with depression what happens with bipolar? Yes is the short answer so obviously my primary area that I work in is substance use disorders but of course I collaborate closely with and of course substance use disorders are closely related with other kinds of psychiatric outcomes depression anxiety more severe mental illness etc and they vary in terms of where they where they fall on the genetics and I think one of the but we're in the same situation where we have genetic advances we know a lot about environmental factors it's a shift for scientists to think about you know we generate all this knowledge and we put it out there in our journals to okay but how are we actually now going to make this user friendly and get it to the public and get it to the public and practitioners and people who can use it that's not traditionally how we were trained but I am and we could you are absolutely right we can do it for other conditions I'm thinking about that and trying to bring in some of my colleagues who work in those areas it just requires a little bit of a shift in in that academic mentality as well to to want to do those things so we're working on it and I think it will it will come and it will come hopefully sooner rather than later. Thank you.

genetics

psychiatry

Rutgers Addiction Research Center

substance use disorders

Genome-Wide Association Studies

genetic predispositions

preventive care

personalized care

brain processes

early interventions

predictive healthcare

genetic testing

public education