The ABC’s of Addiction: There are two distinctly different types of addiction and it matters
Thomas Kline MD, PhD,
Jed Graham, M.D.
Robert Parangi, M.D.
A JATH Educational Consortium, LLC Publication *
Prologue: Understanding addiction facts is to understand how millions of pain refugees were created in the last three years since the voluntary CDC “Guideline”. Pain patients have been taken off their pain medicines without consent something we have never done before as healers. Left in agony and disgrace millions of pain refugees have been banned from our health care system. Why?
The answer is Fear of Addiction Phobia. In order to rescue the estimated 5–7 million pain patients deprived of pain relief treatment without their permission we must first understand why we are so afraid of opiates to the point some terminal patients we hear from are denied end of life pain medicines to avoid “becoming addicted”.
Our paper focuses the idea that the word “addiction” is too broad of a concept to conduct studies or to development treatments or to understand why this country dehumanizes people who take opiates for their rare and uncommon long term painful diseases.
When we analyzed the literature and our clinical experiences and the experiences of others, there sorts out more than one type of addiction. This has help us to explain what had puzzled us: why has nothing worked to address addiction and attendant deaths on the streets. The “overdose deaths” we hear of every day are really 95% Heroin and fentanyl deaths on the streets not in communities as the CDC portrays.
We are proposing a division of the concept of “addiction” into two distinctly different sub-categories which we will call Type 1 and Type 2, similar but very different. A good parallel to understand this new concept is Diabetes. There are two distinctly different types, Type 1 occurring in children and type 2 occurring in adults. To understand diabetes you have to understand the distinctions. The same is true with Addiction. As you read this you will begin to see why mistakes have been made.
The biggest mistake we have made for over 100 years is failing to understand type 2 Addiction or the typical Heroin type addict cannot be controlled with substance restriction. This terrible error has lead to jailing of doctors, led to worse crime and murders, and worst of all the involuntary disenfranchisement of millions of people with uncommon painful diseases spreading like the plague to emergency rooms,post-operative recovery rooms, and inpatient services.
Which word grabs your attention in the title. You wouldn’t be reading this article if it didn’t. We were all taught the title of your paper is what will captivate your readers, grabbing their attention. The one word your mind focused on when you read the title, the one word an entire nation seems to fear: Addiction.
You hear it on the radio, see it on the television and parents everywhere grab their children in fear, as if they may catch it like the common cold. We have made an grave error. Ignorance is not having the facts. We will try to supply more facts to stop the lunacy promulgated by Physicians for Responsible Opioid Prescribing (PROP) and its allies at the CDC who are trying to delist 4000 years of successful use of opium products (opioids, opiates or narcotics). The have espoused a dangerous and harmful stance against opiate pain medicine based on the ignorance of the two separate types of addiction.
Thirty six state’s attorney generals recently wrote a plea to the federal government not to soften its stance on “drugs” since — “anyone can become addicted”. As we shall see, this is not true. To correct the misinformation that led us down a path of destruction of daily life and suicides in those having nothing to do with addiction we need to think and analyze what we have come up with for this paper. It is up to you. We at JATH present our research. What you do with it is up to you,
We were steering off the the tract of understanding at the turn of the century when opium opiates were deemed sinful and morally dangerous and worse brought to us by immigrants, the Chinese and the Mexicans. It began as combating immorality with Randolph Hearst leading the charge against “the Yellow Peril. They ran opium dens. White woman were seen there. It must be they are being seduced by Chinese men and ruining their virtue. Morality we see today even mentioned in DEA papers as one of their goals. Moralists making horrible medical decisions like Opiate Pain Medicine (OPM) is too dangerous to use, which of course it is not true. FDA considers it safe enough to not put maximum dose limits for the primary pain medicines.
Much of what we read, over and over, and throughout the years by scanning the New York Times articles on narcotics in the 1950’s looks like news stories today. Why has nothing change, why are we always in a “crisis”, “scourge” “epidemic”. Much of what we read and believe is factually correct but it is in the wrong context. Type one diabetes requires continuous insulin, therefore adult onset type 2 diabetes should require insulin also. Bad logic. Controlling substance can control cocaine and methamphetamine type 1 addictions but will not work for type 2 Heroin addictions.
Government estimates of Heroin addiction settle in around 500,000 to 750,000 with a high number of one million. We will stipulate the highest estimate of one million. This seemed like a lot to us until we divided the one million by the U.S. population of 320 million corrected to over age 12 (when Heroin addiction begins) of 256 million. The calculator said 0.4% or less than 1%.
We were curious about Heroin addiction rates in other years. We were surprised . The prevalence of Heroin addicts in 1925 was less than 1%. Why has not the number of “junkies” (as they call themselves) increased. With what we read every day you would think half the American population would be in the streets shooting up.
The rarity of type two opiate or Heroin addiction kept popping up with the same numbers, and nearly always the same percentages in the population with Heroin addiction looking over the years (see Medium paper by this group “Is addiction rare?” As we kept looking we began to realized that this type of addiction had to be genetic, an new realization that explains a lot. JATH will address the genetic argument in a separate paper soon to be released: “Is Heroin addiction genetic?”
Type I “addiction” but not correct for the genetically determined type 2 or Heroin type addiction, as we shall see .
What type of “addiction” are we talking about? It matters. There are two major sub-types of addiction quite different from one another: Type 1 and Type 2. It is possible “anyone” can become addicted but only to to Type 1 substances like methamphetamine, cocaine, marijuana, and most alcoholics. Many exhibit poor choice. Many have psycho-social problems and wish to feel better. Kelsey Grammer when asked “why to you take drugs” he replied “Because they make me feel good”
Opiate addiction to Heroin and other opiate pain medicine (opioids, narcotics) is impossible to addict 99% of the population. IV Heroin users returning from Vietnam had only a 2% addiction rate two years after begin tapered off by the VA.
How do we know Heroin Addiction is genetic? The details are in a companion JATH paper here in Medium entitled “ Opioid Addiction, is it rare?” Basically there is a large body of scientific papers that say it is. If you wish to read them google the “A118G Addiction” (the abnormal gene in Heroin addiction) and you will find the biochemical proof.
The epidemiological proof is the fact that the prevalence or percentage of people in the US, and in other countries, with Heroin addiction is less than 1%. It has been this way since statistics were available in 1920 and sampling over the years from 1950 on show the same exact prevalence rate of less than 1% (actually consistently 0.5%) Today the high estimate for Heroin Addiction is 1 million divided by our population of 320 million — about 1/2 of 1 percent. Should be much higher is what Thomas Frieden and PROP say that doctors prescribing too much have caused the “opioid” epidemic. Where are the numbers? No numbers, no truth.
A disease process that never changes in its occurrence, by our medical standards, has to be genetic. With all the wild accusations that doctors prescribe too much where are the additional heroin addicts? They are not increasing, a fact left out of reports of increasing overdose deaths. The overdose deaths are in the addiction population of Heroin addicts and have increased yearly since 1970. The only thing increasing is the fabricated new definition of Opioid Use Disorder (OUD) by the SAMHSA** federal agency. This is not heroin addiction . SAMHSA presents two statistics, heroin addiction and their new definition OUD, backhandedly proving Heroin addiction and OUD are different or there would not be two categories of “abuse”, a word found in the agencies name not found else where in the world. This is Government misinformation. SAMHSA, the “abuse” agency, has had its budget substantially increased over the years and is abusing definitions.
The only way to become addicted to opiates (Heroin, and all med-opiates pain medicine like morphine, Percocet, methadone, Vicodin) is to be in the type 2 addiction category. Since this type of addiction is genetically controlled, you either have the gene or you don’t. Less than 1% carry the gene, 99% don’t. The 99% percent will never become addicted to opiates. The 99% will never get “high” from any opiate, including Heroin (diamorphine). This is why the ten million people in the United States with the “monster” diseases of systemic inflammatory diseases such as Complex Regional Pain Disease, Trigeminal Neuralgia, Adhesive Arachnoiditis and Interstitial Cystitis, the big four suicide diseases due to pain that is so severe and intractable people cannot survive without pain medications for their painful diseases. “Chronic pain” is a misnomer sounding like something made up. I can tell you that the four diseases above plus another 25 or so, are not made up. Survival without high dose pain medications is impossible. It is no wonder the decision to escape life without life is commonplace in those tapered from their medications for no reason following the latest trend that opiate pain medicines don’t work for long term and cause overdoses deaths — no, false, they do work and those dying in the CDC report are all addicts, save 500 a year that die under a doctors care.
So “she takes drugs” is not a proper statement. We need to ask which type of drugs are taken and which type of addiction is occurring. The failure to understand there are medically defined sub groups of addiction has caused one hundred years of misunderstanding, fear, and 5 drug wars. The control of the practice of medicine has left both groups of opiate disease left out in the cold —Type two addiction disease and ten times as many people with long term painful disease we just alluded to. If we are reading the newspapers correctly we fail to see a successful outcome of any of the drug wars, only billions spent assuaging irrational phobic fears and getting no where with the various “crises” and “epidemics” since Eisenhower. The crisis today the epidemic today is indeed correct, but it is no different since data began to be collected in 1970 by the Bureau of Vital Statistics.
Disease is morally neutral. We blame people for their diseases. This helps no one and makes things worse, adding stress and grief to the medical treatment equation. “Poor choice” has nothing to do with the pathology of the disease process in Type 2 opiate addictions, but yes is a factor in type 1 addiction disease.
In three years since the biased CDC “Guideline” was published we have seen wholesale abandonment of traditional medical practice treating all the sick. This will go down in history as the worst medical tragedy in our history, because it involves millions of people and it was done on purpose fearing more dope fiends or opiate receptor disease type 2 addiction, the reason we are presenting our findings to you. To understand the cruelty of trying to prevent more addiction by removing vital medications is not only showing ignorance of the medical facts, it is cruelty beyond what is expected given the morals and ethics of our american culture.
This paper hopes to begin a new thought about these different diseases.
Understanding there are two types of drug addiction explains a lot. It explains the failure of the one trillion dollar, hundred year War on Drugs — five of them. The War has been conducted on the wrong drugs, for the wrong reasons, on the wrong people. We are afraid of the wrong drugs. Had we realized the obvious differences between the two addictions we could have spend the money building 75 more aircraft carriers or 20,000 new high schools. We could have directed the funds to the type one addictions where serious non theft crime is prevalent, where people can become “crazy” through toxic psychoses, not found in opiate or Heroin type 2 addiction.
The two types or subgroups of addiction are:
Type 1 Addiction. JATH defines this addiction sub-type as “Substance use negatively affecting daily life”. If daily life is not effected then there is no addiction disease. This is a medical issue not a moral issue. Medically to have a “disease” one must have interference with homeostasis or life equilibrium If you use too much of substance that interferes with your life — you have a disease
Type 1 addiction frequently starts with maladjustment to the psycho-social equilibrium — feeling bad but not to the point of clinical depression, just feeling lousy. It is a medical/behavioral/psychological illness. It is not “abuse” or “misuse”. These are politically inflammatory words, not medical words.
It is, indeed, making choices along the lines of eating too much, or the choice to drive without a seat belt. “Poor choice” is another political, moralistic adjective, not a proper medical term. It does not help to label people with distressing diseases. He is fat, because he makes poor eating choices. So what? Does this guide treatment or does it discourage treatment? The holier than thou principle of medical treatment is no longer appropriate. We are going to substitute “love the neighbor” as the guiding treatment principle for addictions, both of them. Shaming and blaming is not acceptable medical or psychological treatment. Nor is it acceptable for $1000 a day “drug rehab”.
Type 1 Addiction is soft-wired in the brain, but wired just the same. It is identified with operant conditioning or behaviorally acquired addiction pathways or as some would say “learned” pathways. This is not the case in Type 2 or Heroin addiction as we shall.
Type 1 addiction can be stopped by stopping the substance. Type 2 where it is biochemically impossible. Type 1 can more easily stop but do not wish to so. Type 1 addiction goes away when the substance is no longer involved to the point of ruining daily life.
Rehabilitation talk therapy usually helps in Type 1 addiction. Lives can return to what they were before the substance involvement. This is not true for Type 2 or “Heroin type” addiction, a lifelong biochemical disease.
Type 2 Addiction, is defined here as “Intense seeking of substance without regard to consequence”, the definition developed with the help of those with type 2 addiction , or “junkies” as they tongue in cheek call themselves. This is a group rarely consulted. Why not? They are what this is all about. Aren’t they the stakeholders? Are they all untouchable? Are the god fearing? Are they mothers and husbands? Are they in the work force? Or are they no longer humans just sub human dope fiends terrorizing our neighborhoods and our children like some proverbial boogeyman?
You cannot stop the substance in Type 2 addiction (Chemical Receptor Disease is a more medically correct term -CRD). Many Heroin type addicted people wish to stop but the biochemistry makes it a herculean task.
“Why don’t you just stop?” is a fundamental misunderstanding about this type of lifelong addiction. It is same biochemistry that will not allow thirst or intense hunger to go without “seeking substance”.
Type 2 opiate addiction is due to at least 18 genetic errors (polymorphisms) in the brain in charge of building the mu opioid receptors found in the brain, peripheral nerves, GI tract, and inflammatory tissue. These receptors are the new biology of all the humors of the human body, it is how estrogen, and insulin act on the cell. They sit on the surface and cause the activity in the cell to change, like poking a air needle in a basketball.
The receptors have to be just right. In Heroin type addiction something goes wrong with the genes that build the mu opioid receptors. It is inherited. It runs in families and soon the genes could be detected with just a mouth swab.
As a result of these genetic changes opiates cause a rare and unusual side effect — extreme, uncontrollable euphoria, almost an ADR or adverse drug response. This side effect only occurs in those with the genetically altered mu receptors, about 1 in 250 people.
How do we know there are changes in the mu receptors? Science. Cell biology, genetics, and biochemistry. The gene involved with the Chemical Receptor Disease or CRD is A118G.
According to an ex-opiate addict who now serves as a Judge in a New York drug court, the euphoria is of the same nature as the euphoria of child birth for woman, of eating a good meal, sex, finishing a workout routine — but, a 1000 times higher.
For people with the genetic type 2 disease when the very first opiate is taken into the body, the adverse drug response takes place instantly. The normal response to an opiate for 99.6% of the population without the abnormality of the A118G gene is sedation, not euphoria. Only the 0.4% of the population will experience this intense side effect governed by the A118G gene.
Soon a genetic test for opiate or Heroin type addiction will be available. The FDA has fast tracked the application process. The test will tell us who will not addict and who will.
“High” is a word which has enslaved us fearing this feeling leads to unpredictable behavior and crime. We never use the word “high” for the disease actually associated with serious crime and the highest overdose death rate of all addiction diseases — alcohol. The lowest rates of serious state penitentiary type crime occur with Heroin, the highest alcohol followed by meth-amphetamines and cocaine.
Because Type 2 opiate addiction is really genetic, those with triggered opiate addiction represent a random cross section of society, not a limited psycho-social/environmental sociological status incorrectly assumed for all “addicts”. A history of psycho-social problems is frequently observed for “addiction” disease but these Studies are conducted without separating the two types. The averaged results hid the difference of type 2 addiction disease the smaller of the two types. It is a critical difference.
Type 1 disease responds to “talk therapy” and traditional “rehab”. Type 2 disease does not respond to residential treatment and lead to overdose deaths due to forced abstinence and the changed tolerance to opiates. Type 2 disease requires Medication Assisted Treatment or MAT. There are no other effective options for this type of addiction in spite of moralistic protestations: “What? Treat junkies with more dope?” But then those protesting are moralists not doctors.
Medical treatment is provided in the U.S. only under FDA supervision and DEA (federal drug police) licensing. In Canada, for example, it is legal and proper for any physician to treat any addiction. Canada has no federal drug police, as is the case with other countries around the world.
This negative, criminal model for real medical disease in Heroin type 2 addiction seems to be the reason. “Oh yes, heroin addiction is a disease, I am sure”, but then funding goes wanting, fear and prejudice intervene.
Currently in a hot spot for opiate addiction north of Raleigh N.C. only about 20% of Type 2 Receptor Disease addiction is being medically treated with substitution protocols. National figures are about the same. It was this way with methadone and residential treatment in the 1950’s. Articles retrieved from the New York Times in the 1950's could be pasted into today’s newspapers without a noticeable difference.
There is no question substitution treatment (MAT) stops crime, stops overdose deaths, stops expensive incarceration, and restores the lives of those with type 2 opiate disease.
The answer to why should we use opiates to treat opiate addiction is first an understanding that we have a difference disease here. In substitution treatment we doctors will use much less opiate medicine, given under our strict medical direction, and using medicines not made and sold by criminals. MAT works, and works so well that more enlightened countries in Europe have had crime evaporate. A prescription pad is a great competitor for the 1000% profit margin street drug enterprises.
To review the important differences between Type 1 and Type 2 addictions the table that follows illustrates the critical differences
Nearly everyone can get “high” or “buzz” from Type 1 substances, marijuana, amphetamines, cocaine and alcohol but only 1% of the population can get the intense “high” response from opiates, orally or IV, it does not matter. This surprising fact makes biological sense because in Type 2 “Opiate” addiction, you must first have the genetic foundation to experience the “magic carpet ride” or “going to the moon” noticed when taking the first opiate pills. This is why prescription limitations 3 or 7 days, or whatever, will not stop Heroin addiction since it starts with one or two pills.
We need to stop limiting substance since it will not prevent type 2 opiate addiction unless every single pill is removed from the planet. It is cheaper and more humane just to ask the critical question “have you ever had an opiate”.
So yes addiction can start with the first doctor’s prescription, but the doctor is not causing the addiction but unwittingly triggering it. Is the doctor at fault. Yes. The doctor, who understanding the genetics of the disease, should have asked, have you ever taken an opiate before? Do you know the euphoric danger symptoms?
If you prescribe “heroin pills”, a pejorative term, for pain medicine, to 1000 people only 3 or 4 will get “opiate high” and if left untreated then our definition of type 2 addiction prevails: “intense seeking without regard for consequence” sets in, street addiction starts, that carries a 2% per year mortality (this mortality is the actual CDC overdose death data, not due to prescription drugs but due to street drugs— a fact not revealed by CDC).
Okay, what if you are in the 99.5% population group that does not have the genetic abnormality? Is opiate use still a problem? No, it is not. Talk to Type 1 addiction people. Almost none use Heroin, no genes- no high. The failed efforts over the last one hundred years, the terrible waste of 1000 billions (1 trillion) of dollars, and the terrible and widespread damage done to non-addicted medical pain patients stems from lack of basic medical information about mu receptor addiction or Chemical Receptor Disease (CRD) — the “junkies”. The true addiction is controlled by genetic not by the abundance of opiates. Substance exposure philosophy sounds logical but it is not medically valid.
The Type 2 Addiction is reported to be between 500,000 and one million people in the United States. It is not the two million reported as Opioid Use Disorder (OUD). OUD is a new governmental disease created by SAMHSA by changing the real medical definition into a governmental funding definition.
The previous medical definition of OUD was a person who takes their medicine in a way not prescribed by their doctor. This is a fairly accurate portrayal of type 2 addiction at least as a place to start. SAMHSA , our federal 4 billion dollar a year federal “abuse” agency changed the definition a couple of years ago to “any one who takes an opiate other than what the doctor prescribed”. This is flim-flam. Government agencies do not have medical prerogatives to change the original American Psychiatric Society’s definition of OUD (opiate use disorder) or any medical practice interference for that matter (see federal law 42 USC 1395, section 1801)
If a person with painful medical disease has a flare of their pain and takes two percocet instead of one they now have SAMHSA “OUD” or “opioid use disorder”. Wrong. They are taking what is needed because the doctor had no idea of the character or intensity of their pain, did not and could not, accurately prescribe the proper range of doses. The newest “abuse crime” gets funding and gets attention. Look for OUD in your next newspaper article.
To show the fallacy of the federal government interfering with medical practice notice the federal agencies report two different statistics: 500,000 Heroin addicts and 1.5 million OUD proving the new government disease which of course needs corrective action and more funding the new OUD.
Changing the definition from the original medical definition would seem to increase the numbers of “abusers, misusers, and drug miscreants”, a surefire way for congressional funding requests to be filled, since drug abusers are classified on the “horrible scale” right next to espionage agents and human sex slave traffickers the self righteous set prison sentences for this medical disease are frequently longer than for spies and human traffickers.
In 1925, after first federal ban of Opium, there were 200,000 heroin addicts within the United States’ population of 114.3 million citizens, for a rate of 0.2% Type 2 Heroin addiction the same number percentage wise as today!
Why is this? Why has this not changed? Are we not awash in opioids “given out like candy”? One would surmise this figure should be much higher, substantially higher — not essentially the same.
There is only one scientific explanation for this inconsistency. Type 2 Addiction is not environmental, it is genetic. With enough opiate pain medicine “for every man woman and child”, where are the additional “addicts”? Government data does not show an increase addiction in spite of the assumptions by many claiming “increase in addiction”! “Run for cover dope fiends are on the loose and there are more, lots more”. This is not true. This is fear of addiction phobia, a disease highly prevalent in the U.S.
We have looked and looked. There is no CDC or other agency statistic showing more addiction just the phony OUD polemic.
Ninety percent of Type 2 opiate addiction occurs in teenage years due primarily to experimenting. Doctors providing the first opiate pills about 20% of Type 2 addictions. Why? Failure to ask the simple but critical question — is this your first opiate? If the answer is no, and the person is not an addict already, the person has passed the triggering threshold and will never addict lacking the gene running in families.
If the answer to the million dollar question is, “No, I have never had an opiate pain pill” then this person has a risk of 1 in 250 or so of having the sentinel symptom for Type 2 addiction of being energized or euphoric on the very first pill, not feeling drowsy like 99% of people.
If we asked this critically simple question deaths from street overdoses (the CDC data source) would begin to dwindle.
In addition to the simple, compelling observations opiate addiction must be genetic, the idea is bolstered by 600 papers in the cell and brain biology medical research field. This supports Type 2 opiate addiction as a tragic genetic mistake allowing opiate pain medicine to lead to an extreme over reaction of the pleasure and reward center. Sadly this leads to “intense seeking without regard to consequence”.
The biochemical drive compelling the organism to seek opiates is no less powerful than water seeking for someone with three days of water deprivation or from the disease of diabetes insipidus a disease of water balance where people would do anything to find water.
It’s not the amount of opiate that causes Type 2 addiction thus all attempts to control substance through harmful manufacturing reductions by the federal drug police, by limiting dose and amount, by arresting doctors, by pharmacists refusing to fill prescriptions has not and will not prevent one single case of Type 2 addiction nor one single overdose death. This is hard to believe but look at the perennial failures, look at the data going no where.
Jamie Lee Curtis’s recent disclosure of her Type 2 opiate addiction supports the model presented here. Curtis mentioned with the very first pill a 10-year addiction battle began. According to the article produced by People magazine about Curtis’s addiction, it also shows that Type 2 addiction was in her family. Her father Tony Curtis and half-brother Nicholas were among the family members who had Type 2 addiction a familial genetic disease. “Tony abused alcohol, heroin, and Nicholas died from a heroin overdose.”
These were real type 2 addictions. Positive family histories are frequent in type 2 addictions, but less in Type 1.
You can’t stop opiate addiction because it is genetic but we can certainly stop overdose deaths with early intervention. There needs not be a single new CDC street overdose statistic.
Ninety percent of opiate addiction is triggered in teen years. Why are we not warning teeenagers that any “wild, magic carpet ride” or
going to the moon” when taking the first opiate as one Heroin addict described the unusual phenomenon or symptom of the disease.
Education based on don’t take drugs has not worked, nor will it. Teenagers need information so they can spot the sentinel symptom of feeling too good taking an “oxy” or “percs” when it is supposed to make you drowsy. Danger! A serious life long disease is on the horizon.
Failing to understand the addiction disease types, spending time denying the medical facts, demonizing and shaming people with opiate addiction disease or the “junkies”— or any addiction, for that matter — along with refusing medical care show how little we care for addicted persons as real people is shameful.
Fear of Addiction Phobia is driving irrational solutions to problems we do not understand in the first place. Fear of addiction phobia has spilled over into the other diseases requiring opiate treatment — the 10 million people with rare painful diseases. None of these patients will addict but 2/3 have been forced off their pain medicines without consent, something we have never heard of.
Failing to understand the simple medical facts presented here has only harmed those with addiction disease and those with painful disease.
We need to look at who are and what we stand for — compassion is not just a word in Webster’s.
- * JATH Educational Consortium LLC, was formed in Raleigh in 2018 as a research group of professionals, patients, and interested parties with particular skills in research, editing, and writing focusing on discovering little known truths about a broad range of medical topics. Members do not receive fees, nor does the group as a whole receive any outside money nor affiliate with any organization or University department. All information can be freely used. See JATHeducational.com
- ** SAMHSA is the Substance Abuse and Mental Health Services Administration
Thomas F. Kline MD, PhD
Raleigh, North Carolina
see youtube videos: Thomas Kline MD