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Martina Pesce Nov 06, 2020
How do we destigmatize drugs?
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Currently, the research world is investigating again as potential medical treatments all of the so-known "recreational drugs". Marijuana and have been seen improving post-traumatic stress disorder; MDMA is at the latest steps to also be proven helpful for that; Ayahuasca also seems to be helpful for post-traumatic stress disorder; LSD has been used to help psychotherapy since it was discovered.
On the Multidisciplinary Association for Psychedelics Studies site, it's possible to find a good window on the updated situation per every drug.
People with medical conditions that will require these kinds of medications are already part of a fragile portion of the population. The risk of these patients avoiding medicaments and feeling or being verbally judged is very high.
So, after decades in which every single state has been trying to demonize drugs, how are we gonna destigmatize them?
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Creative contributions
Spreading fact-based information
A lot of people demonize drugs without actually knowing much about them. Society's opinion is mostly formed by rumors and predispositions. And one factor that perpetuates this even more is that governments seem to be happy about this. Government function is to maintain a "healthy" society, therefore a little push towards rumors, in this case, works just fine and nobody hurries to supply people with factual information. What should be done instead is giving a clear and unbiased review on each drug :
- chemical and physical properties of the drug
- kinetics of the effect - how long does it take to start, when the effect peaks, how long it lasts
- description of the effect, what are you likely to experience
- side effects
- risk of dependency - physical, psychological
- potential health benefits and risks
- what has been proven by scientific research
- knowledge gaps - what still needs to be proven/investigated
This information could be kept in officially approved publicly available databases. In addition to that it could be promoted to be spread in various forms that are more acceptable to average citizens - social media, youtube videos, etc. (e.g. a post about new research on drug A, put in layman's terms). Such information concerning drugs should be regularly checked and assessed or only allowed if it's coming from trustworthy sources, efforts should be made to track and remove disinformation or information that lacks supporting evidence.
We need information like this to become common sense in society for stigma to go away.
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Stigmatization of drugs = vaccination against misdirection of values
People living in Australia would be wise to teach their children to categorically avoid ALL spiders and snakes. Not because all are dangerous but because the probability of running into dangerous species is high and the probability of children handling the dangerous species right is low. This cumulatively increases the chances of children dying or getting in serious trouble. Parents would be wise to err on the side of caution even if it means instilling fear (arachnophobia, ophidiophobia) that could last for a lifetime. Arguably the risk of phobia it's worth it to the person whose life it would save.
Similarly, it's wise to teach children to rigorously wash their hands and wear a mask even though they themselves are not in immediate danger of Covid19 complications. The habit of virus avoidance could directly save someone else and the child when they eventually reach old age.
Stigmatization of drugs is directed toward young people - those who are hopefully not yet in contact with them.
The development and maturation of the prefrontal cortex has not yet been complete in people under the age of about 25 years. The development of the prefrontal cortex is crucial for complex behavioral performance, as this region of the brain helps accomplish executive brain functions. People who don't yet have a fully developed prefrontal cortex are not well equipped to defend themselves against drug addictions. Stigmatization of drugs is society's way of looking out for them.
When it comes to the best feelings known to humans (happiness, high motivation, social acceptance, love), we will do anything that gets us those feelings and we will keep repeating what worked. All recreational drugs elicit one or more of these amazing feelings. That's why drugs are habit-forming. Some people will organize their entire lives around recreational drugs and give their "life calling" some good sounding names (shamanism, natural healing, etc) to give their life meaning and destigmatize their addiction.
Stigmatization of drugs might not be working all that well in preventing drugs from reaching the most vulnerable people, but it's one of the few tools in the small toolbox that humanity has against this threat.
Ask yourself - is the destigmatization mostly going to help heal, or is it to legitimize the love of my life? Some people might be oblivious to drug addictions solely because of the instilled fear. By removing the fear of drugs, are we going to liberate them or cut their brakes?
Sure, some people are terminally ill, in chronic pain, etc. Drugs would make them feel better temporarily. If they don't have long to live, they might not need to face the downsides of the ensuing addiction. There are situations where upsides outweigh the downsides.
[1]Arain, Mariam et al. “Maturation of the adolescent brain.” Neuropsychiatric disease and treatment vol. 9 (2013): 449-61. doi:10.2147/NDT.S39776
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Povilas S2 years ago
Also, you are missing another important point here- not all drugs are equally addictive. Some have little to no addiction, this is the case with psychedelics. People don't take psychedelics for pleasure, they take it for experience. The effect a strong psychedelic will have on you is very unpredictable and depends on many factors - you might have a good "trip", in some cases you might have a bad "trip", but you are likely to have some of both. You are very unlikely to get addicted to strange experiences. So why are people doing psychedelics? Because they change the way you perceive and understand the world, some use the description consciousness-expanding. They affect your insights and emotional values and many people (and I'm not talking about hippyish junkies, but famous intellectual people like Steve Jobs, Sam Harris, Aldous Huxley, Ken Kesey, Jack Nicholson, I could go on) have called psychedelic experiences they had life-changing. So when you say that some people try to hide their addiction under the name of shamanism, natural healing, etc. you really miss this point.
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Povilas S2 years ago
Bans usually work in the opposite direction, especially for the youth - try to prevent something, they'll want it just because it's banned. And that's exactly the case with drugs - many teenagers want to try drugs, just because they are banned or if it's not the sole reason then it's a big part of the reason. Stigmatization doesn't help in any way, fear doesn't help. It only creates psychological tensions. If people will want to do it they'll find ways to do it and those ways will be more dangerous - bought from unsafe people, bad quality substances that are only more dangerous. Laws forbidding to sell drugs for underaged people is one thing, stigmatization is another. Stigmatization is mostly about providing false or inaccurate information and not explaining anything, just prohibiting. This is the worst way to bring up children. A child will instantly see that something is missing here, they are not telling me something, and no wonder they will want to find out by themselves.
As a kid when I asked adults why people smoke they'd give me those sorts of answers: "they don't know what they are doing", "they are stupid", etc. But not the truth. And the truth is - people smoke because they like it. Yes, it's harmful, it cause addiction, but it also gives pleasure, relaxation, whatever the reason for a certain person. And it's not because they can't quit, that's just an excuse, addiction is not so strong that it would take your will away, not in the case of cigarettes at least and I don't think it's the case even with opioids, it might be hard and very hard in the case of the latter, but it's still your decision, - they simply prefer smoking. And you can explain all this to the child and explain why it's banned for young people and what are the risks and why people use it, everything, no need for woo-woo.
The same with spiders and snakes - you can explain that it's easier to avoid all spiders than learn to differentiate poisonous ones. And it will work much better than imprinting blind fear, this kind of education will not only create phobias and psychological tensions in a young person, it will also worsen the relationships between parents and kids - a kid will feel that he/she is being treated badly, but won't understand why. This happens when things are not explained and only negative emotions are used in "education". Imprinting fear doesn't lead to anything good.
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Martina Pesce2 years ago
I believe this makes very much sense, and it is a good way to protect the under 25 population. Then a way to solve it so that this part of the population is safe and so that the stigma does not damage, it is indeed just to make clear how the dangers and risks change after that age. What do you think?
There are many many legal and dangerous accessible addictions (tobacco, alcohol, sugars, gambling, I could go on forever I think...). Why stigmatizing one that can even have at least one good side (=helping to treat some mental health disorder), while all the other addictions I just mentioned do not even have that? (apart from alcohol, partially, and tobacco for Parkinson's disease).
Also, I was not asking how to remove the fear of drugs, but the stigma. The knowledge and fear of the collateral effects of drugs it's of course very needed, but is the stigma also so needed?
It's true, drugs are also used to help terminally ill patients, but not only! As I write in the introduction to the brainstorming session drugs are used also to cure post-traumatic stress disorder and to help psychotherapy. I would say these are not terminal patients.
As I also write in another comment in this session, feeling temporarily better it's the actual key to treat not terminal diseases such as PTSD.
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Supporting drug-related scientific research
Governments should do more to support related scientific research both in terms of financial and other forms of support. Important changes should be made regarding laws that govern access for scientists to use those substances for investigative purposes. If that access was more freely available this would encourage more scientists to work on it. Scientific research is very important for changing the current dogmatized view towards drugs because it provides truthful, fact-based information and opens up possibilities of using drugs for beneficial causes such as treatment of physical and psychological disorders and also gives reliable insight to how these substances could contribute in creating a better quality life for any person in general.
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Stigmatization is a form of protection from the hack we are not designed to defend against
People form habbits based on feel-good neurotransmitters (rewards) for desirable actions. These desirable actions could be: finding food, finding a mate, making a friend, acquiring knowledge, perfecting a skill, creating something, etc. Drugs (including alcohol, cigarettes, chocolate, coffee, masturbation, gambling, etc) that "hack" those reward circuits are the problem. They directly activate or mimic the rewards even though the person has done nothing to deserve the reward. It's theft where you steal from your own shop.
The good feelings/benefits of drugs are a hologram - change of perception that is not based on real world action. It's a mind trick. Having acces to this easy hack you can keep comming back and repeating it rather than working for the reward the way our species was designed to do. This hack efectively turns you into a "gamer" that keeps building a virtual life rather than going out into the real world and doing some action that causes the release of endogenous feel-good neurotransmitters.
Forming a habbit around your drug of choice is misappropriation of your time and resources.
Stigmatization of drugs in some way serves to make the intersting-looiking hack less appealing and hopefully prevent some people from giving it a try and falling into the downward spiral. It's easier never to get in contact with the feeling in the first place than to sever your bond with your drug of choice once you've fallen in love with it.
Our brains are not designed to fight this threat. It's literally a hack. Stigmatization is society's way of warning us of the threat ahead. Yes, it's biased and the presented data is cherry picked. Those who present it might not be good at marketing. The direction is well meaning though. It's like folk songs - they are primitive but get the message across.
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Povilas S2 years ago
There is truth in what you are saying, but the reality is much more complex than you've described here. And that is stigmatization vs destigmatization. If you want actual, truthful information you have to consider many factors, such as - not all drugs are equally addictive, not all people are equally prone to addiction, drugs are not the only thing that causes addiction, many human behaviors have addictive elements, so it's not so easy to avoid it as it may seem, every drug has risks and benefits, it's possible to use drugs responsibly, etc., etc. I don't think that lack of information has any benefits over well-informed opinion, in case of the former you simply throw the baby out with the bathwater:)
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Probably, just wait
Everything takes time to percolate. Maybe waiting around for "good" non-addictive drugs to get destigmatized is another option. And that will eventually happen as more and more people start indulging in healthy use. Forceful destigmatization might lead the population to the other extreme where there is a rebellious over- and mis-use of all drugs (including the addictive ones). As Povilas pointed out, proper (unbiased) education (without any kind of encouragement or discouragement) is the key till we attain a new steady state.
The slow percolation of destigmatization will also uncover its effects. These can be used to decide the further course of action.
Destigmatization and legalization are two different issues. Those who know they are responsible users of a beneficial drug can, indeed, indulge and reap the benefits.
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Povilas S2 years ago
But waiting doesn't contribute to change. Every significant change in society requires some efforts to be made:) We can't talk about forceful destigmatization here, because now the situation is of forceful stigmatization, so significant efforts are required to simply shatter the basis of the stigma and make enough people to seriously question it. It's good to have a positive vision, but actions are also required.
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Martina Pesce2 years ago
Povilas S
I agree with Povilas S. Waiting could be a good strategy if the destigmatization process would have already (maybe even slowly) started. But here the situation is instead of forceful stigmatization.
I still believe that waiting is going to be fundamental, once the destigmatization starts, exactly to avoid everything Shubhankar Kulkarni said.
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Shubhankar Kulkarni2 years ago
Povilas S If someone is knowledgeable regarding the use of specific non-addictive healthy drugs, they will take it irrespective of the stigma. Those that need it (medical use), are given it irrespective of the stigma. The remainder is those that want to take drugs for recreation or because they are addicted. Is it worth to engage in forceful destigmatization then?
Individual thought always triumphs law, at least in the execution part. I mentioned in my suggestion that proper education is the key. I still stick to it. "Just waiting" does not include the education part. Proper education is necessary, either way. The "just waiting" part was for constructing laws that allow proper use of drugs, that is, the legal side of it.
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religions and pleasure
Most of the world population believe in some form of God, more precisely, they were a good 84% in 2012 .
It's a common trait of many religions to see pleasures as a sin.
Stop seeing drugs as a pure source of pleasure may be a good way to lower the stigmatization coming from religious communities. This could be helped by what @Povila was suggesting: the government giving fact-based information on the consequences of every type of drug.
[1]Pew Forum on Religion & Public Life (18 December 2012). "The Global Religious Landscape". Retrieved December 18, 2012.
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Changing the laws
One of the best ways to loosen the stigma is to change the laws directly. Often the main reason for people to have negative notions about drugs is the fact that they are illegal. This affects opinions and decision making whether consciously or unconsciously. Loosening drug-related laws will gradually change those rigid notions and make people reconsider the topic.
Many drug laws are exceptionally stupid and not based on anything rational. In some countries, you can get more time in prison for carrying small amounts of marihuana than for committing a robbery. Psychedelics are classified as schedule 1 substances almost all around the world regardless of the fact that they are pretty much the most harmless class of drugs. In comparison, alcohol and tobacco, which are legal, do much more harm both to the users and to people around them.
Rigid drug laws is also one of the main reasons holding back scientific research and lack of scientific research only strengthens biases and misconceptions and prevents exploration of potential benefits.
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Build up a platform for drug-sharing
This might sound a little bit too radical, but given that a lot of (especially European) countries are opting towards decriminalization and even legalization of some of the drugs like cannabis, it would be a nice thing to have a platform where you could share and exchange drugs.
However, strong regulatory frameworks have to be maintained to do so. So, I would propose a third party (usually the state/government) overseer who would monitor what gets exchanged and shared via the platform. Only the drugs/substances that are already decriminalised and legally accepted can be shared. There should be a cap to how much can an individual share and exchange. For conventional reasons, the threshold could be set up as much as the amount legally allowed to keep for personal usage.
Such a platform would indeed help solve some of the tangential problems associated with drug use. Firstly, like intended in the session, it would help destigmatize the notion of drug usage, even more so on the face of evidence that psychoactive drugs like cannabis are actually much safer and risk-free than previously thought. Secondly, such sharing platform would help curb at least some of the social problems like theft, robbery and similar minor/major crimes that would be committed by people in desperate need for the drugs (for example someone who is pathologically addicted to any drug might be motivated to rob another person just to be able to buy the drug s/he needs.) If one is guaranteed that he would acquire the drug from a public, open platform that is accepted by everyone, there would be much less stigma on the one hand and on the other, the user will not have to succumb to the darker acts of robbing or stealing.
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Martina Pesce2 years ago
I like it! Maybe a "weedswap" instead of "ticketswap"!
It would take the stigma away but with all the regulations (if well implemented) it would not help the perception that drug consumption is not a big deal.
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Povilas S2 years ago
Martina Pesce It's a pity that "instagram" is already taken:D
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documentary, movies, tv series
Netflix did amazingly with "Have a good trip" where famous movie stars and VIP tells their psychedelics good and bad trip stories. VIPs are often taken as models and their influence can be enormous.
This is only one documentary though and is just on LSD. I think it would be of great use to do something similar with other drugs too.
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Povilas S2 years ago
There is also a documentary about MDMA under production, but it's been a while already and it's not clear when or if they'll finish it, I hope they will though. You can watch a big chunk of the movie already on their website, they also have a crowdfunding campaign: https://mdmathemovie.com/.
Would be nice to see it done finally:)
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Creating safer, less addictive drugs
I like the attitude expressed here. Instead of banning and stigmatizing drugs, time and energy could be invested in trying to find better alternatives. This has already been done with smoking - e-cigarettes are a safer alternative. In this particular case, it's a novel consumption method, but the chemicals themselves could be replaced by different ones. The main problem with drugs is not really the addiction, but rather harmful side effects. Those could be diminished by design. Just like pharmaceuticals are engineered, psychoactive drugs can also be engineered.
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Help stations for drug users in public places
Those are becoming more frequent in festivals and other social gatherings. These days they are accepted more as a normal phenomenon when a few decades ago would be regarded as an indication of "junky gatherings". To help those get accepted even more as not only normal, but a beneficial and necessary thing is a good way of reducing social tension when it comes to drugs.
People would take drugs whether those help stations existed or not so to be able to provide psychological as well as physical help for people in need during the "trip" is a very beneficial thing. One of the most frequent problems that a person under effect of a drug faces is psychological anxiety and more serious problems usually come as a byproduct of this, so to be able to talk to someone trained for this is all they might need. In case there is a more serious health risk people working there could assess the situation with a clear mind and decide whether to call professional medics. People can also be given water or some light medications in case they are nauseous, etc. There is usually some useful information in a form of posters or flyers also, like which drugs are dangerous, neutral, or ok to mix together so that people could assess the risk and decide before doing it.
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Martina Pesce2 years ago
I think this is a good idea, but not as long as drugs are illegal. I would be a bit of a contradiction, wouldn't it?
Also, I do not believe that it would help to destigmatize drugs because the festival environment is very limited and the category of people there very specific. The destigmatization generated by these stations is then gonna be directed towards a pool population which would already not stigmatize it that much.
Do not misunderstand me, I believe this would be a very useful tool for festival security, but maybe not for drugs destigmatization. Or have I completely missed what you were trying to say?
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Povilas S2 years ago
Martina Pesce It's not an idea, it's already a reality. I've personally seen them both in Lithuania and in France and heard about them existing in other countries, so I think it's pretty common these days, although I'm not sure how common. But obviously, at least in France, it was supported by the government and this is a very very wise thing to do in my opinion. The fact that they exist when drugs are still illegal contributes even more to destigmatization. They are not only in festivals, in France I saw it simply in a public square, I don't remember if it was an event going on or not, but it was probably the place where people often do drugs, a lot of bars around, etc.
But even at festivals there are all sorts of people, not all do drugs, some might even be against them and they would happen to see those stations and it might influence their opinion one way or another. But I think it's destigmatization from the point of the users also - they feel safer and accepted so there is less of this separation in the mind - "me the user and the rest of the world who will punish me" and this more relaxed state of mind then can be passed to others whether users or non-users. If you go sober and see this sort of station you then think (as I did) - "oh, this is nice, so maybe the situation with drug stigma in society is not so bad as I thought". And if you are on something you'd think - "totally sober strangers that are working in the festival (aka "officials") are here to help me instead of calling the police? Then maybe there's no reason to be afraid". You see the point here?:)
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J. Nikola2 years ago
Having a help station or train people to help you with something:
- that is not legal,
- has no proven generally beneficial effect on your health and
- could put you in a situation that you need psychological as well as physical help during the "trip",
seems irrational.
Maybe it could also make more people decide to enter that state where, if not anything more serious, then just acute anxiety could make you feel discomfort. I think it would require a lot more strong arguments.
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Safe drug use frequency and dosage standards
Up to 400 mg of caffeine per day is considered to be safe for healthy adults. Those kind of standards could be determined for each drug. This would be especially useful if more drugs got legalized or decriminalized, but even now it would be helpful for people who are using illicit drugs anyway to have some reference point, just like it's helpful for people who consume caffeine every day to know the "official" safe limit. With some more addictive or/and harmful drugs safe use frequency would be low, e.g. once in a few months or once a year, with less harmful/addictive ones it would be higher. Now this kind of information is not available even for legal drugs like alcohol, people just use their common sense to determine what's still ok.
A "safe" limit meaning you are unlikely to cause serious health problems if you stick to it is one thing, but it would be very useful to have another criterion - addiction limit, - a determined use frequency and dosage which prevents you from developing addiction to that drug if you don't exceed it.
Those standards could also be used for developing a smarter system to regulate legal drug availability to people. Each person could have a record of whatever drugs he/she buys and when purchases of a certain drug would exceed safe or addictive frequency/dosage limits that person would not be allowed to buy that drug until a certain amount of time passed. This record could be stored on an electronic card which a person would be obliged to present if he/she wanted to buy any drug legally.
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Shubhankar Kulkarni2 years ago
There is a simple way around this. I can ask you to buy drugs for me, probably pay you a bit more than the retail price. If I am an addict, I can have multiple people buy drugs for me.
Also, I am sure there will be safety drug use limits already reported (for every substance). This is because most of the drugs are part of some medications. For example, this article (https://www.ncbi.nlm.nih.gov/books/NBK430769/) reports the concentration of cocaine in one of the medicinal preparations. Drug users simply need to search the internet (science publications) before they indulge. How many of them do that? :)
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Povilas S2 years ago
Shubhankar Kulkarni
Sure, but it would still regulate much more than "you can buy as much as you want" system. Even for already legal drugs like alcohol and tobacco if you'd introduce it, then people who'd like to buy more than the standards they'd have to ask other people, probably those who don't drink or smoke at all, that would be the first complication for them - requires more effort, you'd probably need to pay them and also those people who'd buy for others would consider that they are buying it "from their own account", so if they'll want to buy for themselves they will have less left, etc. But you'd have to be a chronic user to buy much more than the standards and those cases wouldn't be that frequent.
Reporting the concentration in a medicinal preparation is not the same as a safe dosage standard for recreational use. I mean for single ingestion - sure, you can find what is a low, medium, high dose and what is too much, but I meant it in a context of frequent use. For example, in the case of caffeine, you can ingest much more than 400 mg and still end up ok, but if you use higher doses frequently it will be a problem. It's a kind of ratio between dosage and use frequency. This kind of information is far from common.
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Shubhankar Kulkarni2 years ago
Povilas S I think it is more of a matter of willingness to look for the inflormation than the availability of the information. The safety dosage of a drug would not differ based on the type of use. If more than x amount is not acceptable as a medicine, it will not be acceptable for recreation.
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The trust is built on a solid scientific approach - the need for "opposition"
We already discussed the increasing need for new drugs for specific disease and disorder treatments, but it's important that things go gradually and thoughtfully - that's the key to winning the people's trust and destigmatizing still illegal drugs. People are still afraid of drugs and we need to work on the overall picture of drugs and bring them up as scientifically/medically processed products.
The story of AstraZeneca COVID 19 vaccine
A bit less than one year since the beginning of the "corona pandemics", AstraZeneca's vaccine came out. Since it had the efficacy of 63.09% against symptomatic SARS-CoV-2 infection, it was approved for emergency use by WHO and European Medicines Agency (EMA) . People were relieved to finally have one more solution to end the corona crysis and more than 17 million got vaccinated in the EU and UK, only. Although the concerns on safety and adverse effects were risen by the public and countries stopped using the mentioned vaccine, the company confidently defended its vaccine's efficacy and safety. The ongoing problem is that people still avoid it.
It seems that we need a million reasons to trust and only one reason to doubt.
The problem with psychedelic drugs is much bigger, but similar.
Disbalance in scientific approach to psychedelic drugs
In the last decade, more and more papers have been published showing the incredibly beneficial effects of cannabis, LSD, and other unusual and stigmatized drugs. As a consequence, medical marijuana is now at the everyday disposal of numerous veterans and others suffering from post-traumatic stress syndrome (PTSD). What scientists discover now is that the prescribing practice has maybe run ahead of the evidence supporting it and caused the scientific disbalance which reflects negatively (only supporting studies, no public preclinical and clinical assesments of safety and adverse effects).
Opposition kicking-in
The recent study published in PLOS One journal observed for the first time the short-term impact of smoked cannabis versus placebo on PTSD symptoms . The study was a randomized, double-blind, cross-over preclinical trial on 76 participants which reported that no active cannabis treatment statistically outperformed placebo in reducing the PTSD symptoms. Similar point of view can be seen in the video. Another example is the use of cannabis to treat migraines. Although people widely accepted cannabis use as a way to self-treat migranes, a study showed that there is a association between canabis use and medication-overuse or rebound headache in people with chronic migraine . If you are interested, there is also a video dealing with this problem.
Mentioned papers are important, not because I don?t like marijuana and I don't want it to become a legal cure for many things, but because they are highlighting the psychedelic drugs as a potential solutions which are throughtly analyzed from both, the supporting and non-supporting side.
These papers make stigmatized drugs look more Aspirin-like. Normal.
Also, on a way to destigmatize psychedelic drugs we have another big obstacle - their past and present of illegal abuse. As seen with AstraZeneca, it's hard to make people trust you even when you have no past. That surely makes the way up for many stigmatized drugs much harder, but as @Shubhankar said, if we give people time, they will forget and accept the new normal.
My point here is not to stop or slow down the future research and use of psychadelic drugs, but to point out the importance of ballanced gradual research and progress. Unless it a COVID 19 vaccine which we need fast to stop the tumbling of the world's economy, I think we should go step-by-step and do all the necessary toxicology and comparison studies on new drug's effect on our bodies. We should also invest money and time to give people a whole new picture of drugs, where they are not abused, but safe, over-the-counter solutions to medical issues.
[1]https://www.who.int/news-room/feature-stories/detail/the-oxford-astrazeneca-covid-19-vaccine-what-you-need-to-know
[2]https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246990
[3]https://www.medscape.com/viewarticle/947086
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