The Epidemic of Epidemics: Opioids, Part I

JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On our inaugural episode—the first of two on the topic—we're discussing opioids and growing concern over a number of related health epidemics facing Americans.

DR. CONNIE WHITE:
If we just had an NAS epidemic, that would be one thing; if we just had an HIV, hep C epidemic, that would be one thing; if we just had a drug use epidemic, that would be another thing.

We have just a host, a cluster, of epidemics going on.

JOHNSON:
We'll focus on Kentucky and West Virginia.

DR. RAHUL GUPTA:
This is like no other in the 241-year history of this nation that we have faced, and we must have a response that is like no other in order to be able to beat this.

JOHNSON:
And the president's emergency declaration.

DR. JAY BUTLER:
This crisis touches people all across the country regardless of political persuasion, whether it's a red state or a blue state; and that actually creates a wonderful opportunity to come together.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

This inaugural episode is produced with support from the Health Resources and Services Administration, which oversees programs to improve health for those most in need, including pregnant women and people living with HIV.

AUDIO CLIP SPEAKER 1:
Drug overdoses now kill more people than guns or car accidents.

AUDIO CLIP SPEAKER 2:
The opioid crisis is an emergency.

AUDIO CLIP SPEAKER 3:
The opioid addiction is reaching epidemic levels.

JOHNSON:
It's estimated that almost 1000 Americans die each week from drug overdoses. Two-thirds of those are blamed on opioids, with more and more deaths also linked to heroin and fentanyl.

Kentucky and West Virginia find themselves at ground zero in this fight—unfortunately, they rank among states with the highest death rates.

Our guests know all too well the pain their states are feeling today.

Dr. Connie White is the deputy commissioner of the Kentucky Department for Public Health. Dr. Rahul Gupta is West Virginia’s state health officer.

First up, the relationship between opioids, hepatitis C, and HIV.

GUPTA:
I think you are so correct, Robert, in the sense that, for all of us, this really started out as a really a drug epidemic related to prescriptions. And since then, it has evolved in some of our states to impact just about each and every fabric of our society.

So, there's hardly any aspect of life that is untouched by this epidemic; and certainly infectious disease is something has become a significant and serious concern ever since the evolution of this particular epidemic from one being exclusively of pills to transforming itself as an injection drug use with street drugs.

JOHNSON:
Dr. White, how about the view from Kentucky?

WHITE:
Well, I'm going to, as we do in public health, shamelessly rephrase that I read in an article from someone from West Virginia School of Public Health where they were saying, “We don't have an epidemic. We have an epidemic of epidemics.”

JOHNSON:
Now, most people in our audience will be familiar with the connection between all of these various issues, but there might be some listening publicly who didn't realize that hepatitis C and HIV are connected to opioids.

The media talks about opioids all the time, and I don't think that in a lot of those reports we hear about how one thing leads to another. Can you just educate us on that topic?

Dr. White, maybe you go first; and then, Dr. Gupta, if you could follow up.

WHITE:
Well, we know that HIV is spread by contaminated needles and other instruments that are used with injection drug use.

Hepatitis C can live on inanimate objects for up to three weeks—it can live in a syringe for weeks, it can live on the tourniquet that people use.

So, I don't think that they are as aware of how vulnerable they are when they do inject something into their bloodstream. And I don't think they realize—

We had a positive hepatitis C here in my home community of Franklin County, and the woman said, “Well, how can that be? I only share my needles with my son.” So, that was a very painful message that people do not realize the importance of a clean needle to keep that spread from happening.

There are certain people in the community that are the main connectors, just like any social network. If we can find those people and get them to keep from sharing, that's going to be, I think, one of our ways that we're going to be able to lower this risk.

GUPTA:
I would second just about everything Dr. White mentioned, so eloquently mentioned, the risks from infectious diseases standpoint of this particular epidemic.

And then, if you look at the larger picture—I'll add to this—you know, this is an epidemic that really demands taking health in all policies approach.

I say that because—whether it's the baby that's being born from a mother who has a drug dependency and addiction issues and starts life with having this extraordinary dependency on drugs, in terms of neonatal abstinence syndrome; to the enormous amount of strain being placed on social services, like birth to three and other services from the Department of Education, having challenges in learning and impulse control; to home visitation services; the child protective services that are being burdened—there’s just an enormous amount of strain that has been placed with the programming, as well as the human aspect.

And one of the things we're trying to do in West Virginia is through the health-in-all-policies approach, looking at this as a larger issue. And I think in many of our states—certainly we work very closely in a lot of programming with our partners in Kentucky is looking at learning from each other to see what does that look like.

Earlier this year, we were able to put together some legislation creating the State Office of Drug Control Policy. Kentucky had a version of that already, and we wanted to make sure that we also start to put a focus and coordinate efforts across sectors of, whether it's labor education, transportation, certainly corrections and military affairs, and those kinds of areas, into health and ensure that, at the end of the day, we're taking a coordinated approach because this is a problem far and wide beyond just one particular area, especially including health.

So, that is the challenge we're dealing with when Dr. White mentions the epidemic of the epidemics. That's so true, and so correct, because this is like no other in the 241-year history of this nation that we have faced. And we must have a response that is like no other in order to be able to beat this.

JOHNSON:
Is this all happening or growing to a point of epidemic proportions because we've dropped the ball on other issues? Can you talk about that and how we got here?

WHITE:
Well, I think that in our two states we are dealing with poverty—and I think Dr. Gupta would agree—we're talking grinding poverty. We're talking an area that has had a perfect storm of issues.

We've had job losses in the coal industry—these were the prime jobs that people had in those areas, and those jobs have dwindled. So, people don't have other opportunities despite efforts to try to increase different education, employment opportunities in those communities.

And then, I think it's very clear that our areas were targeted by companies that found the Eastern Kentucky and West Virginia clients were particularly vulnerable to the new drugs on the market for the new opioids.

And I think those things together with the sense of hopelessness, this is where people went. I think we are—one thing we haven't discussed, and Dr. Gupta and I have talked about before, is adverse childhood experiences.

I think we need to go way back now that we know what we know about adverse childhood experiences and, being an OB-GYN physician, neonatal abstinence syndrome is a particular passion of mine. I think we need to start with these younger babies as we make sure that they are in a safe place, and that they are in a place where they cannot just survive, but also thrive.

So, I think we are turning our thoughts around now. Yes, we need to take care of chronic diseases, obviously we do—we have lots of things on our plate in public health—but I think paying attention to those early years of the hard wiring of the brain and making sure that we provide opportunities for these children to survive and thrive is going to be critical if we're going to work our way out of this situation.

GUPTA:
I think it's been said before that we are not going to be able to jail our way out of this problem. We’re also not going to be able to exclusively treat our way out of this problem.

We need to have a comprehensive approach. In so many ways, I think our two states are moving along, with several others as well, in this arena.

But the economic aspect of this is something that is often downplayed, if not downright not looked at. We know that the total societal cost of the losses that are happening right now today is huge. I mean, we literally have had over 64,000 Americans die last year at the rate of about 160, 170 a day, every single day—and that has not yet peaked.

Because of that economic downturn and the lack of the ability of having workforce retraining, part of the focus has to be in getting not just the ability to primary prevent, treat, recover, but also get people back into workforce retraining, and then have the ability to have available those economic opportunities that people can go back to.

It makes no sense for us to help the individual only to go back into the circumstances due to which they became addicted in the first place.

JOHNSON:
I remember, Dr. White, during a previous phone call on this topic to get ready for this podcast, you mentioned specifically, I think, about how the communities have come together and maybe you were a little surprised by that.

WHITE:
Well, when the legislature passed the ability for Kentucky to have a syringe exchange program, as I said, being a lifelong Kentuckian, I was shocked that this actually happened; because the way I looked at Kentucky, I just didn't think that this would be an acceptable approach.

Even though it's evidence-based and been around for decades, I just didn't think it would be embraced by Kentuckians.But I think at this point, every Kentuckian knows someone in their family who has been touched by this epidemic, and people have gotten on board.

In order for you to have a syringe exchange program in your community, your local board of health has to approve that. Then, the health department goes to the local community municipality, whether that's your city council or county government. And if you have both, both of those bodies have to approve the syringe exchange program.

So, that has involved some tremendous work on the local communities’ part to get that buy-in and to educate people about communicable diseases and about are there they're vulnerability for HIV and hepatitis C. And it's just been a wonderful thing to watch these communities blossom as they form new partnerships with the police, with the school systems, and with everyone coming together saying, “We don't want this in our community.” So, that has been a huge community growth that we've seen.

The other thing that we've offered to communities is our mobile harm reduction unit, which our preparedness branch has a mobile pharmacy—it's a 60-foot-long trailer that is a working pharmacy—and we have been invited by communities to come to their community, set this a van, this trailer up, and we have been providing free naloxone training and free naloxone kits in local communities.

Some communities ask us to come because they want a syringe exchange program, and this will bring visibility. Some of them ask us has to come because they have a syringe exchange program, but they, again, want that picture in the local newspaper of this huge 60-foot truck coming from Frankfurt with the Kentucky Pharmacists Association and local pharmacist joining in to educate people about naloxone use and to be sure it’s in the hands of everyone. We also provide hepatitis C and HIV testing when our local unit comes around.

In less than one year, we've been to 30 different communities, and we have trained and passed out 1,373 naloxone kits. So, if you double that—’cause there's two doses in each kit—that's 2,700+ doses of naloxone. It's a start.

We also ask the local health department, when we come, to put together a handout we can give people of what facilities the local health department has for other needs that these folks might need that have a substance use disorder, such as other STD testing, contraception, and then we've asked them to pull together what local treatment availability there is in the local community.

So, this has been communities asking each other for help. And I think this has really brought this out of the shadows in this is a front and center issue for local communities.

JOHNSON:
So, Dr. Gupta, is coordination the number one factor required for success, or would it be something else? What is it?

What is the main ingredient to making headway on these issues in your state?

GUPTA:
I think the most important ingredient is to be data-driven, evidence-based, but also ensuring that there is a local buy-in and community buy-in and people understand the importance of those programming that has the ability to get a response immediately, as well as long-term response.

So, I think the number one factor is to ensure that there are good relationships, good partnerships; have conversations that are aimed at reducing stigma when we talk about this particular epidemic.

Stigma and a reduction of such across communities has been the most critical aspect of making progress from town to town, neighborhood to neighborhood, across communities in the state.

JOHNSON:
Shortly, Drs. White and Gupta are back with some closing thoughts.

Dr. Jay Butler is the chief medical officer and director of the Alaska Division of Public Health. He also was ASTHO’s last president, which gives him a national perspective on the President's public health emergency declaration issued last fall, and the work going on in the states.

BUTLER:
Well, the states are all responding.

The opioid crisis has really raised the level of awareness of the broader challenges of substance misuse and addiction as public health issues and not just issues that are addressed by behavioral health issues; but really, issues that are going to require a multi-sectoral approach with multiple state departments, as well as non-governmental partners around the table.

Our approach to the opioid crisis, in many ways, provides opportunity to address other public health challenges as well. Hepatitis C and some of the current drivers behind the HIV epidemic are linked to self-injection drug use. So, as we begin to reduce the impact of the opioid epidemic and, ideally, reduce self-injection drug use, or at least implement harm reduction measures, we should begin to see some impact on reducing the risk of hepatitis C and HIV.

Most of the states are seeing increases in the rates of hepatitis C among young adults, especially under age 30. So, these are people who do not have the traditional risk factors. They're not even, apart of a history of self-injection drug use, going to be recognized as people in need of screening.

But if we look even more broadly at some of the health challenges for the 21st century, we begin to look at things like interpersonal violence, the ongoing challenges with the lack of health equity, human trafficking, homelessness, many of the social determinants of health. We find that all of these issues are oftentimes interrelated with the challenge of substance misuse and addiction.

And it's a different model of approaching a public health problem than in the past, in what’s sometimes called the public health 1.0. The 19th and 20th-century public health, which was so successful in addressing the challenges of infectious diseases, we thought in terms of the cycle of transmission and how to interrupt that cycle. Looking at the challenges that we have today, really a public health 3.0—with public health 2.0 being the chronic diseases—it's a different model. It's an interrelated web of effect, cause, and effect.

And it—I sometimes use the very Alaskan analogy of a tangle in a casting reel. It can be very frustrating to untangle that, but it oftentimes starts with beginning to identify loops that can be pulled out and loosened.

And I think one that really is crying for us to address, and actually is presenting an opportunity for us to address these broader issues, is the opioid crisis and the public health response.

JOHNSON:
Well, and it is not getting any better. It sounds like it's getting worse by the day.

BUTLER:
Well, that raises a very good point about the importance of what I call situational awareness or access to timely data, accurate surveillance, whatever term you want to use. Because I think it's so important that we be able to know what are the epidemiological trends in the opioid crisis.

In many states, including my own, we actually are making some progress on preventing deaths due to prescription opioids. We're actually seeing some declines in heroin overdose deaths. But unfortunately, most of those gains are being offset by increases in fentanyl-related deaths.

And, of course, fentanyl is being trafficked in, in a different way. It's being used differently and, actually, oftentimes people who are using aren't even aware that they're using fentanyl. Because they're using what they think is heroin that they've bought illicitly, or perhaps they've purchased pills on the street that they think are, say, oxycodone, but are, in fact, counterfeit pills that contain fentanyl.

So, it requires a lot of agility to be able to continue to adjust our response. I think if we looked only at opioid overdose deaths as a whole, we could just sort of wring our hands and say, “Well, we're not making progress.”

Whereas, in fact, we are, but this is an evolving epidemic. And we have to be able to change our approaches to meet some of these new challenges as we move forward.

JOHNSON:
So, speaking of changing approaches, the president, in October, announced a public health emergency, a 90-day period in which the federal government would focus on this issue.

Can you talk about that and what that means to the states, how the states have reacted to it, and whether it's going to make much of a difference, in your opinion?

BUTLER:
Well, I think the president's declaration is a good thing in that it reinforces some of the work that's occurring in the states. Whether they're states that have declared a state of emergency or disaster, public health disaster—as we have in Alaska—or not, it elevates the discussion.

And in the speech that the president gave, as he announced the declaration of emergency, he highlighted some of the specific areas that are opportunities for the federal government to be able to partner with states and territories, as well as a tribal organization in cities and counties.

One of the downsides, though, is currently it's not translating into additional resources.

I do want to say that the federal resources that have become available over past couple years have been crucially important for us to be able to respond that the state level.

However, I hope that the declaration of the emergency will also then open the door to supplemental appropriation, whether it's through the public health emergency fund or however, to continue to support increasing agility and also changes in our response to this evolving epidemic as well as additional opportunities for multi-sectoral partnership.

JOHNSON:
How do you see Congress reacting these days to this challenge? The money comes from the Hill and so they've got to be involved. What do you think is coming, in that regard?

BUTLER:
Well, of course, Congress has a lot of things on their plate. I'm pleased to see the fact that the opioid crisis is among the priorities. And I see their response is one that really cuts across the spectrum of different political affiliations. I see different types of committees that are adding the opioid discussion to their agendas.

I actually provided a testimony to a Senate commerce committee that was focused on sport's safety, and while the discussion was fairly broad and included things like post-traumatic encephalopathy and a sexual assault among athletes, we also discussed the challenge of sports injury increasing the risk of starting down that path to opioid addiction.

JOHNSON:
In the meantime, the states are handling this issue with people on the ground, programs in play.

How would you grade the effort among the 50 states at this point?

BUTLER:
Well, the problem with grades is, too often, it translates into rank them and spank them, and the response oftentimes is unique to each state.

What I can say is that it's very impressive that every state is very active in this, both in terms of the implementation—that is, the, the tactical response, the strategic approaches to plan out what is going to be happening down the road, because this is not a salmonella outbreak that's going to be over in two weeks. It's going to require a prolonged response.

And also, in addressing policy. I think just about all of my colleagues have been very actively involved with their legislatures in terms of developing a new policy, to be able to address this crisis.

JOHNSON:
As you think about that and your experience and talking with your colleagues around the country, this audience is really that group of people. What would you say to them as we look toward the end of this year and into 2018?

What's the outlook? What's your projection for how we'll do in the next 12 to 14 months as it relates to battling this epidemic, making a dent in it, staying up with it?

BUTLER:
So, what I’d want to say to my colleagues is, first and maybe foremost, is thank you. Everyone has focused on this issue.

It wasn't that long ago that I think those of us in public health who didn't have direct oversight of behavioral health agencies really didn't see this as part of our jobs. And I think because of the growing partnership with our behavioral health agencies, the relationship between ASTHO and NAS that we've recognized that there are really complementary roles and public health has an important population-based approach that is complementary to what is being done through behavioral health.

I think the second thing that I would want to pass along is hang in there because this is going to be a long-term response, in some ways will be our new normal. And it's important to recognize that while we may be making some gains in the opioid crisis, there are other substance misuse issues that will also need to be addressed using some of the same tools and the lessons learned from the opioid crisis.

For example, like many western states, here in Alaska, we're seeing an increase in methamphetamine deaths, and it's not because the community-based labs are coming back. It's because there are new ways of trafficking that are driving down the prices. Methamphetamine is now very cheap and available.

And it reminds me of the model of what's happened with the opioid crisis with cheap and available heroin coming in and entering into a population that had a much higher rate of dependency and addiction because of how prescription drugs were being used. And then, more recently, that being superseded by the much cheaper and also available illicit fentanyl.

The final thing is, as we look at projections, there's election days coming up. And, of course, the half-life of a state health official was relatively short. So, think in terms of the sustainability of the response, not just your leadership has been able to make possible, but how do you build up your staff that is going to survive through changes of administration, and also be able to set up away for your successor to be able to continue the good work that has been started.

JOHNSON:
The opioid epidemic has been called the worst public health crisis in America. These unintentional injury deaths are considered a major contributor to a drop in the U.S. life expectancy rate in 2015.

Just thinking about it can be overwhelming, but that's what Drs. Rahul Gupta and Connie White do every day. We ask them whether they were worried or hopeful.

GUPTA:
I can tell you with certainty there's not a single day that goes by that I don't worry about this crisis.

I am an optimistic person. I remain hopeful that we're going to be able to address this. I am, at the same time, concerned that the urgency with which this crisis needs to be dealt with and addressed is perhaps something that we can hope for, and we can attain.

Yet, what we're doing is having an all-hands-on-deck approach with a full commitment to do what we can.

If you ask, “Are there more resources needed?” Certainly.

I think this is the most significant domestic problem issue we have from a policy standpoint. Yet, there's probably not the level of resources in proportion to the level of destruction that this problem has and it continues to create. That's where my worry is, that's where my frustration may lie.

But we have a lot of committed people across sectors—it's not just public health for this particular epidemic—and all walks of life and all professions that are committed robustly to this, addressing this problem nationally.

WHITE:

Well, the question is, “Am I hopeful or worried?” And the answer to that is yes. I think I'm worried, but I'm also a very hopeful.

We have, as Dr. Gupta said, we've formed partnerships that I think are going to help us, not only in this epidemic but going forward. I look at the 2016 National Survey of Children's Health —getting back to ACEs—Kentucky scoring on that is higher than the national average. But I'm also encouraged because that same survey does resilience questions, and in Kentucky our resilience scores in almost every question are higher than the national average.

So, I think both Dr. Gupta and I have folks in, Eastern Kentucky and in West Virginia that are hard-working, resilient people that will rally around this and say, this is not going to happen to my community. And I think we're beginning to see the tip of that iceberg, the tip of that rage, outrage that he was mentioning.

So, I see us going nowhere but up. I see us leveling off those opioid deaths. And then, I see us eventually seeing a slow decline. It's taken 30 years for us to get where we are. We're not going get this better in the next month, in the next year—it's going to take time—but we will do this slowly and we will see this improved.

JOHNSON:
In our next episode of Public Health Review, we will continue this discussion, taking you to the front lines with the interviews featuring public health workers who are battling these epidemics.

We'll talk about West Virginia's crusade to help babies born exposed to addictive substances, and go deeper into the case for why current and reliable public health data matters. We'll also get the view from America's public health custodians within the federal government.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear you. Email us pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.