We thought it would be an excellent time to talk about substance use in older adults as many of us gather around the Thanksgiving dinner table with our extended families. We invited Ben Han, a geriatrician and Assistant Professor of Medicine in Geriatrics at NYU, to talk about the research that he has done in this area.
In particular, we talked with Ben about the recent increase in substance use in older adults with the rising baby boomer generation, including use of alcohol, marijuana, heroin and prescription opiate misuse, and other drugs. To learn more about the studies he has done in this area, look at these great publications:
- Prevention and Screening of Unhealthy Substance Use by Older Adults
- Marijuana Use By Middle-Aged and Older Adults in the US
- Demographic Trends of Adults in NYC Opioid Treatment Programs
- Aging, Multimorbidity, and Substance Use Disorders: The Growing Case for Integrating the Principles of Geriatric Care and Harm Reduction
- Demographic Trends of Binge Alcohol Use and Alcohol Use Disorders among Older Adults in the US 2005-2014
Also, here is an excellent JAGS publication on medical marijuana in older adults:
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Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: Alex, there is somebody in the room with us.
Alex: We have, in studio, from New York City, Ben Han.
Eric: All the way from New York City.
Alex: All the way from New York City, we have Ben Hahn who is a geriatrician, Assistant Professor of Medicine in Geriatrics at NYU. He works quite a bit with Alison Moore, who's at UCSD, and he studies substance abuse in older adults.
Ben: Hello. Glad to be here.
Eric: Before we get into the topic of substance abuse in older adults, we always start off with a song. Do you have a song for Alex?
Ben: Yes, I do. I would love to hear Bob Dylan's Mr. Tambourine Man.
Eric: Bob Dylan, frequent request for you, Alex.
Alex: Frequent request. This is probably like, I don't know, the fourth, fifth song by Bob Dylan.
Eric: Do you like Bob Dylan, Alex?
Alex: I do. He's a tremendous lyricist. He doesn't sing, but he's a tremendous lyricist. This song in particular is just a wonderful vision fantastic song. We'll do a little bit of it then we can talk more about it.
Eric: Give us a little bit.
Alex: [Singing]. Mr. Tambourine Man.
Eric: What does that mean?
Alex: Right, I'm not sleepy. What do you think, Ben?
Eric: Is it about substance abuse?
Ben: It could be. There's a lot of different interpretations, like all Bob Dylan songs, so maybe he was high or under the influence and he saw someone like Mr. Tambourine Man, or maybe Mr. Tambourine Man is a drug dealer.
Alex: It has such great sort of visions, and dreamy lyrics. "Though I know that evening's empire has returned into sand, vanished from my hand, left me blindly here to stand but still not sleeping." This is poetry, you know, and it's psychedelic.
Ben: Right, right.
Alex: I've heard that he was also a member of, a person who played guitar in this track who used to wander around with a giant tambourine at night, and Bob Dylan claims that's who the song is about, but it's up to your own interpretation.
Eric: It is a good segue to the topic at hand, substance abuse in older adults. Is this an issue? Is this an issue that we have to worry about when we care for older adults?
Alex: Just to be clear, when you age, you stop using all drugs and drinking.
Alex: Because older adults are pure.
Eric: You turn 75, and you no longer-
Alex: Never, right?
Ben: Yes, it is. So, traditionally, older adults have not had very high rates of substance use, aside for alcohol and tobacco, but this is changing dramatically. A lot of it's the Baby Boomer generation, which has higher rates of substance use compared to any generation preceding them, and as we know, they're getting older and they've a big population size. We're definitely going to see a lot more older adults with substance use issues than we've ever seen before.
Alex: Can we just clarify what substance abuse means? When I hear that term, I generally think of nonalcoholic substances, but in our sort of conversation before this, you were intimating that it does include. So, what falls under that umbrella of the term substance?
Ben: Substance includes alcohol, tobacco, drug use. We're trying not to use the term abuse anymore, substance abuse, and more medical terms like substance use disorder, like DSM–5 criteria. You can say alcohol use disorder, which ...
Alex: So, why are we moving away from abuse and going to use?
Ben: Language matters, and so especially around drug use, it's been highly stigmatized so we try to avoid. We're really focused on trying to avoid terms like abuse, clean, dirty, addict, junky. These terms are very stigmatizing and they prevent people from getting care. I've seen that before. I've seen people who are in treatment programs who refuse to go to primary care because they feel like they're going to be judged.
So, a lot of that is surrounding stigma of drug use. But if we put in the context of this is a chronic disease. It's lifelong many times. It's relapsing. Just like I have a lot of patients who have diabetes who's all over the place and we don't punish them. We don't use negative terms. It's-
Eric: It also sounds like just because they've turned 65 or 75, this is still an issue.
Ben: Right, correct.
Eric: How big of an issue? Do you have data on like whether it be alcohol, marijuana? Is marijuana considered a substance?
Ben: Yes, it is.
Eric: Yeah, okay.
Ben: So yeah.
Eric: Hard to tell sometimes.
Ben: So, a recent paper we did, we looked at ... I've been using data from a national surveys called the National Survey on Drug Use and Health. It's really that's how we get prevalence estimates for drug use for the United States. I've been really focused on those 50 and over and looking at the patterns that have changed in this population.
Alex: How well does this survey capture older adults?
Ben: It's supposed to nationally representative, so the way percentage is supposed to be representative of the entire country, but it doesn't include people who are institutionalized. They don't do this in nursing homes, people who are incarcerated. They try to pick up people who are homeless, but that's obviously there's a lot of barriers to doing that. It's supposed to be nationally representative to a certain degree.
Alex: Maybe we'll take one substance to start with. What does it say about marijuana use among older adults?
Ben: Right. So, marijuana use is unique because laws are changing throughout the country and views on it are changing quite a bit. We did a study using the National Survey on Drug Use and Health in 2005 for people over 65, people who were 65 and over, the prevalence of past year use of marijuana was 0.4%.
Eric: Wow, that's super low.
Ben: So, not that many, right.
Alex: 0.4% of people over 65 had used marijuana in the past year.
Ben: Right. So, the most recent data from that paper, we combine 2015, 2016 data, it was I believe 2.9%. Yeah.
Eric: So, marijuana use is still pretty low. I was expecting a higher number than that.
Eric: Maybe because I live in northern San Francisco.
Alex: Maybe the Bay Area.
Ben: But we also saw huge jumps in people aged 50 to 64, so that prevalence for them is about 9% when before previously it was like 2%.
Eric: So it is a younger older age, probably like you said, will continue to increase.
Alex: The question is, how many people over their life course who have used marijuana at younger ages stop using it as they get to middle age or these people who are young old, how many of them will continue to use as they get into the older old categories?
Alex: Do you have any information about that sort of thing, or how many people start using it in old age?
Ben: Right. The data we looked at, it seems like the people 65 and over, they had first started using after ... I think we looked at it at ... They started using later in life, while the people who are age 50 to 64 almost an overwhelming majority of them used when they were teenagers. We don't have data ... Because this is cross-sectional, so we don't know exactly like did they start, did they use it at teenager, stopped and restart?
I suspect a lot of just clinically I have a lot older patients ask me about marijuana and they said they grew up in a time where attitudes were changing about marijuana. In the '60s, they tried it then and then haven't used it since, but now because it's getting all this press about, laws are changing, maybe could it be helpful for different symptoms. They're wondering about it now.
Alex: Right, right. Medical marijuana.
Ben: Medical, right.
Eric: So, what do you tell them? When they're in your office they're like, "I was thinking about trying it".
Alex: There was a New England Journal article about this just a couple of weeks ago, right? Medical marijuana for pain and one person argued for and one person argued against.
Eric: Journal of the American Geriatrics Society just had an article on marijuana in older adults.
Alex: JAGS, we’ve heard of that journal.
Eric: We'll have a link to that.
Alex: That's a good journal.
Ben: I cited that paper in my article.
Eric: What do you tell the older adult who is thinking about using marijuana again?
Ben: Right. Where I live, the laws are different than here, right? So, in New York State, there's medical marijuana but you have to meet qualifying conditions. So, recreational marijuana is not legal like it is here, right?
Alex: We've had medical marijuana legal for, I don't know, five years maybe longer and recreational marijuana as of last year. That was the ballot last year, one year ago.
Eric: But just because it was illegal before doesn't mean it wasn't happening. I’m not sure it changed that much.
Ben: Right. So, it's a little bit different because if someone meets medical criteria, then I can refer them to someone who can prescribe them medical marijuana and they can go to the dispensary. Whereas someone who, in most cases, the patients I see don't meet criteria for it.
So, that's kind of a different story because one thing I warn patients is that the THC concentration in marijuana today, studies has shown it to be a lot stronger than what it used to be 30 years ago. So, if they're used to certain type of strength of marijuana, it's probably very different now than it was before.
Eric: Yeah. I just went to a really great talk on use of marijuana both medically and not, and it is so complicated now because it's not just kind of what you're getting, it's how you ... Are you going to inhale it? Are you going to use it as a brownie? Thinking about time-to-onset, thinking about if you have an edible or you do it like an oil. Knowing that maybe in half an hour you won't feel anything, but that doesn't mean you just keep on eating it.
Ben: Exactly. Right.
Eric: Because in four hours, you're going to be knocked out.
Eric: Then also thinking about testing the marijuana that you're getting to see like the THC content, like all the other components of marijuana and actually tailoring the type of marijuana to the symptom and potentially the disease that you're trying to treat.
Eric: It sounded like you needed a whole another marijuana fellowship to figure this out.
Ben: Right. I think a lot of this we don't know, because there are federal restrictions to really studying it and so a lot of studies come from other countries. But you're right. I think a lot of dispensaries have to tinker with this. The THC, which is psychoactive component, to like CBD, and really what ratio works well for what symptom, what ratio minimizes side effect. As we know, older adults are more susceptible to side effects, and so these are questions that we really don't know the answers to.
Eric: Do you tell them to watch out for any particulars? What side effects are you worried about in the older adult with marijuana?
Ben: I worry about dizziness, somnolence, I worry about falls. That's something I'd love to study because we know for alcohol, we've studied a lot about alcohol. Alcohol increases risk for falls. There's data on that, but for other psychoactive drugs, such as marijuana, there's a lot we don't know.
Alex: Right. Does it increase risk for falls? There was a recent study about cognitive impairment in people who are using marijuana. I think they took people who use marijuana heavily and I believe they had one group abstain and the other group continue using, and the memory scores improved among the abstainers.
Ben: Right, right, I saw that too. Right.
Alex: Yeah, and you worry about cognitive decline in the elderly. Is this enough? Is it going to tip you over into dementia?
Alex: Is it going to make you have difficulty tracking your medications, taking them correctly?
Alex: Adherence rates, et cetera.
Alex: Are you going to get financially incapacity as a result?
Alex: For many frail older adults who’s system is vulnerable to stressors and this may be a stressor.
Alex: On the other hand, maybe it's better than the opioids for pain.
Ben: Right, exactly. Right.
Ben: Mm-hmm (affirmative).
Alex: There are these trade-offs here of there's no best answer.
Alex: What has the least harms and the most benefits for the individual patient in front of you?
Alex: Marijuana potentially should be in that conversation.
Ben: Right. The problem is we don't know yet really.
Alex: We don't know.
Ben: Do the benefits outweigh the potential harms?
Ben: And for what patients is it most appropriate for?
Alex: Will NIH fund studies in this area?
Ben: I think it's complicated.
Alex: It's complicated?
Ben: I think there are some ... If you want to do an NIH study with marijuana, I think you have to get the marijuana from certain sites that are federally approved.
Ben: I don't know that much about it.
Alex: Yeah, yeah, yeah.
Eric: Any other advice for clinicians thinking about marijuana, older adults, things that we should be talking to our older adults about?
Ben: I always start off by telling patients, I say I don't know. They think that's funny because they don't like to hear that from their doctor that I have no idea. I don't know what the potential benefits. Usually people come to me as they want to try it for pain or for sleep, something that as geriatricians we see all the time and it's very difficult, right? Because we try not to use benzos and we try not to use opiates.
So, I start off by saying I don't know. It potentially could be beneficial, but I worry about the harms which are not well ... We don't know about the harms really at this point. So, I can't really give a straight answer. I think it's probably safer than opiates for certain patients, but there's no way I can really say that strong of a statement confidently.
Alex: Okay, related question here. Let's say you have an older adult who is in there for a standard office visit. This is not about asking about medical marijuana for pain.
Alex: Should you screen them for marijuana use? Should you ask about it?
Ben: Right. Absolutely.
Ben: I screen for ... I ask all my patients about everything, in terms of substance-
Alex: Once a year or every visit, and how do you do it, and why?
Ben: It depends on the patient. The patients I know very well and I kind of have a sense of what their home situation is like and what they're like, I might not screen them that often. But every new patient, I ask about alcohol, tobacco, drug use including marijuana, I ask about cocaine, because at least in New York City some older people still use cocaine and potentially dangerous especially if you have underlying cardiovascular disease. So, I think it's important.
Eric: Let's talk about that. Let's move up this food chain. What about alcohol use? I think that one probably more people think about when they think about like substance use, well they probably don't think alcohol often as a substance, but it sounds like we should be thinking about that.
Ben: Right, definitely. The thing that we've been seeing from using the national data is that for older adults, it's really a large percentage have problems with binge drinking. I think a lot of older adults don't realize that the guidelines recommend lower drinking limits as you age, because there are physiological changes of aging that can make you more susceptible to problems with alcohol.
Eric: Wait, did you say binge drinking?
Eric: Like the stuff that we are about like college parties. Usually when we hear binge drinking, I think the usual thought is ah, that's something that people do in college.
Ben: Right. So, older adults, so the recommendation for older adults from the NIAAA is men and women over the age of 65 shouldn't drink more than three drinks in one day. If you have certain comorbidities, it should probably be less. So, a lot of people they don't consider drinking three drinks as binge drinking, especially when they were younger.
Ben: So, I have a lot of patients when they get older, they're like, "Oh, I've been drinking a six-pack when I see my friends occasionally. I've been doing that forever." They don't consider that really binge drinking, but because the definition changes as you get older, you are now binge drinking.
Alex: Do you know what the definition is for younger folks?
Ben: I believe for men it's five or more, and women it's four or more.
Alex: So, it's a pretty big change to go from that to three.
Eric: Two beers knock me out.
Alex: One for me. What comorbidities in particular are you worried about with alcohol use?
Ben: Obviously liver disease we worry about, but also hypertension, cardiovascular disease, people with heart failure. Yeah. I also worry, so I got really interested in this topic of like the intersection of chronic disease and substance use really from my home care panel when I was in fellowship. I remember Cynthia Boyd does multimorbidity and she had that paper on like a schedule for someone with several chronic conditions and what their daily life is like, all the things they need to do per their guidelines.
It's difficult to do that in general, but then I was seeing patients who were drunk all the time at home and so imagine doing that if you have multiple chronic conditions and then binge drinking, how are you going to do all the things you're supposed to do for your different diseases?
Eric: How common is binge drinking in older adults?
Ben: The last data we looked at, we looked at 2013/2014, so among people 65 and older, the prevalence estimate of people reporting past month binge drinking was 9% and those between age 50 to 64 was 19%.
Ben: That's actually using not the lower cutoffs for binge drinking for older adults.
Eric: What cutoff are we talking about here?
Ben: We used the standard one just-
Eric: Which is how much, again?
Alex: You mean like five and four.
Ben: Five and four, right.
Alex: Yeah, five for men, four for women.
Ben: It's actually going to be higher if we ... The problem with the survey, they don't use the lower cutoff for older adults.
Eric: It was 19% had five drinks or more over ...
Alex: Yeah, one day in the last month if they were men.
Ben: Or four or more in one day if they were a woman.
Eric: One out of five.
Ben: Yeah. The new survey for 2017 is going to come up soon, and so we're going to take a look and see if that's changed at all since 2014.
Alex: Right, and you expect it may be going up.
Alex: Looking at time trends.
Ben: Right. So, we're going to try to use the lower cutoff because I think now they have that available.
Alex: This is common enough that I agree with you, we should be asking about it.
Alex: With our patients.
Eric: Is CAGE question still a thing or should like ... What's new?
Ben: The problem with CAGE is that it doesn't really ... It won't pick up binge drinking, which you know-
Alex: Oh, right.
Ben: So, that's a problem.
Alex: I'm learning.
Ben: Because I've a lot of patients who will they won't drink. They'll drink maybe once a month like socially. They only drink one time a month, but that one time, they'll drink like six or seven drinks. So, they don't think that's a problem. I think have a patient who has heart failure he's like, "That's not a big deal. Just once a month just with my friends," but the fact that he's drinking so much in one day, that's potentially problematic.
Alex: Can you say more about why binge drinking is potentially problematic? Because I think we've all heard about people who have chronically used alcohol and drink and have cirrhosis, et cetera. What are the issues with binge drinking? Are they the same, or are they different?
Ben: I don't think that's as bad as someone who has like alcohol use disorder who has liver cirrhosis, but that episodic binge drinking can suddenly increase your blood pressure. If you have chronic diseases, you might not take your medications. Yeah, it can exacerbate heart failures, something to worry about.
Eric: Falls and all the other consequences of intoxication.
Eric: Right. Okay, how about should we move on to, what are other substances of use or unhealthy substance ... What word should I be calling this?
Ben: I use unhealthy substance use.
Eric: What other unhealthy substance use is common in older adults?
Ben: So, tobacco is also one, but that's not really my ...
Eric: That's not your area.
Eric: How about other things? How about like cocaine?
Eric: Heroin, LSD, I don't know, all of those.
Ben: That's actually interesting. The prevalence rates for those are still pretty low for older adults. I'm talking like less than 1%.
Alex: Less than 1%.
Ben: But we're likely going to see a change in this as the Baby Boomer generation gets older. So, I work in New York City and I specifically work in my research is focused on older adults who are in opiate treatment programs for heroin and prescription opiate misuse, but that's a very different population than the general population, so I don't know if that's ...
Alex: Yeah, prescription opioid misuse is another.
Ben: Right. So that's what I'm in town to present. So using that same data, so I looked at prescription opioid misuse among older adults. It looked like the prevalence for people of 65 and over was I think 1.2%, which is much lower than other age groups, but older adults are prescribed opiates at much higher rates than any other age group.
Eric: So, what do we mean, when we say prescription opioid misuse, are you saying misusing opioids that somebody prescribed you, or misusing pills that you can also get on the street or elsewhere?
Ben: It includes both.
Eric: Any type of like misusing oxycodone no matter where you get it or other opioids.
Eric: What was the prevalence again?
Ben: I have it in my bag, the exact one.
Alex: But it's about 1%.
Ben: Well, about 1.2%.
Ben: The problem with this survey, it lumps people 50 and over together, and so as a geriatrician I find that problematic. That's why these papers that I'm trying to break it down 50 to 64, and then 65 and over. In 2005, the prevalence of opioid misuse among those 65 and over was like 0.5, so now it's ...
Alex: So, it may have doubled in that period of time.
Alex: We may expect it to continue to rise given the opioid epidemic and the aging demographic, Baby Boomers aging, higher rates among Baby Boomers.
Eric: Well, it's interesting. I remember in med school, way back when, we were taught things like CAGE questions and also ask about substance use and illicit drug use, nonspecific questions. How should we ask questions that can bring up issues like unhealthy or prescription opioid use? Wait, what's the term, again?
Ben: Right. When you're talking about ... So, stigmatization of drug use is still a big problem, especially for our older adults who really live through the negative language, punitive language the war on drugs, right? Hopefully as a society, we're thinking it more of as a chronic disease. But previously, the language wasn't about that. For older adults, they lived through this punitive language and so that's why when I screen patients, like to make sure not to use those kind of language. I start with alcohol and I usually use a one question-
Eric: Okay. We're going to role-play.
Alex: All right, role play! First time GeriPal.
Eric: I’m your patient
Eric: Ask me the questions that you would ask, because I want to do this now.
Ben: Okay. In the past year, how many times have you drank three or more alcoholic beverages, which I count as one drink is 12 ounces of beer or one and a half ounces of shot or six ounces of wine, how many times have you drank three or more on one occasion, one day, in the past year?
Eric: I never drink.
Ben: Okay. So, you would likely screen negative.
Eric: Alcohol out.
Alex: Right. Next.
Ben: So, I ask about smoking. I say, do you smoke currently or use any tobacco products?
Eric: I do not use any tobacco products.
Ben: Have you ever used in the past?
Ben: Okay. Good. Then I move on and say, so I'm going to ask you about other drugs that some people continue to use on their orders. Have you used cocaine at all in the past year?
Ben: Okay. How about have you used any injection drug use in the past year?
Ben: Have you used any prescription drugs that were not prescribed to you? I would know if you're on ... Have you used any prescription drugs that were not prescribed to you like pain medicine or medicines for anxiety?
Ben: Okay, good. I talk about injection drug. Have you ever used any drug by injection?
Eric: Yeah, lots of heroin.
Ben: Okay. When was the last-
Alex: I knew there was going to be a positive in here.
Ben: Okay, that's okay. So, when is the last time you used?
Eric: Great. That was very nonjudgmental. Didn't even faze him.
Eric: So then you're trying to get more of the history kind of how often I'm using it.
Eric: My safety around using it, like where am I getting needles, things like that?
Ben: Right, right. I mean, I work with trainees, with fellows and they always ... Why am I asking a 95-year-old grandmother if she uses drugs or alcohol, and they find it uncomfortable, but you pick up things, right? I pick up things all the time.
Alex: Who knew that the GeriPal podcast co-host was using heroin regularly.
Alex: Lots of heroin.
Eric: Don't judge me.
Alex: We can't judge him based on his radio personality.
Eric: Why are you judging me?
Ben: We had to put in the context of your overall health, right?
Alex: That's right. That's great.
Eric: By the way, I do not use heroin every day, just for the record, every other day.
Alex: In case anybody at the VA is listening. Interesting. So here's a question. What's the most surprising? Talk about the 95-year-old grandmother.
Alex: Have you had clinical scenarios that are somewhat surprising? Well you know I ask, wow, who would have thought?
Ben: Right. I definitely do. There's a patient I thought I knew really well, 95 but fully functional, still working. She works at the ...
Alex: Still working at 95.
Ben: Right. She works at a restaurant. She also works at polling places. I asked her, I didn't ... I admit, I didn't really ask her about alcohol because I just assumed she didn't, but then one day I was like, I had this student with me I was like, oh, I should really be a good example.
Alex: I should model what I teach.
Ben: So I was like, "When is the last time you drank alcohol?" She said, "Oh, this morning. Since I was little, I always drank. I took my medicine with alcohol, just a shot of brandy." She said 30, 40 years ago, it used to be just once or twice a day, but as she's taking more medicines, like she has-
Alex: That's a lot of brandy now.
Ben: Right, exactly.
Alex: One for each pill.
Ben: Then she's wondering, sometimes I feel dizzy. She'll take her morning medicines with a shot of brandy and then go to work or go out because she's still fully functional.
Ben: She's like, "I started to feel dizzy and not so good." I had to put her on a TID medicine and she was like, "Yeah, I just ..."
Alex: That's three drinks of brandy a day.
Ben: Right, exactly. So, yeah I was kind of taken aback. I was like, oh, you know.
Alex: Yeah, it really brings it home, right?
Alex: You need to ask about this, because it's increasingly common. It's more common than we think. It may surprise you who's actually using.
Alex: Using is okay.
Eric: Is using-
Alex: I was trained in an era where we said abusing, so that language slips in every once in a while.
Ben: That's okay.
Alex: Drinking? drinking, drinking. That is fascinating.
Eric: Anything else that you teach trainees that you think me and Alex should know?
Ben: My career focus is really trying to bridge geriatric medicine with addiction medicine. That's kind of what my career path is. As I was entering more into the substance use world and looking like principles of treating substance use disorders, harm reduction, I realized a lot of these principles are very similar to geriatric medicine principles. Patient-centered, nonjudgmental, not so much a focus on I'm just going to cure you, fix you. It's working with patients, what their preferences are. So, I find that really fascinating and so that's what I hope to bring into both fields.
Eric: That was absolutely fabulous. I learned a ton.
Alex: Me too.
Eric: Including like I don't usually think about asking about binge drinking. I think about asking about alcohol use and I think for a lot of geriatricians they think about alcohol use but the idea of like the binge drinking, or just the idea of like the pills, because I think that that brandy with pills is probably a lot more common than we think. But I just want to thank you a lot for joining us today.
Alex: Thank you so much for coming out to our studio.
Eric: Yeah, to our lovely studio. Maybe we can end with a little bit more Mr. Tambourine Man, maybe we can get some more of those lyrics.
Alex: Thank you, Ben.
Eric: And figure out what's going on here.
Eric: With that, I'd like to thank all of our listeners for joining us this week. If you have a second, please rate us on your favorite podcasting software or iTunes, and we look forward to you joining us next week. Goodbye.
Alex: Thanks, bye.