Season 1
February 28, 2019

Episode 11: The State

Image of statehouse

Learn what policies are changing the course of the opioid crisis in Indiana, featuring interviews from Jim McClelland and Pam Pontones.


(00:00) Phil Lofton:
From the Regenstrief Institute, this is The Problem. The Problem is an anthological podcast dedicated to fighting the hydras of healthcare, those complicated big, hairy issues that impact healthcare on the societal level. Every season you’ll hear about a different big, massive problem and each episode within that season will feature a different discipline or industries take on that problem, how it’s being addressed, how it’s being talked about, and the trials and triumphs of those involved clinically and personally. This season is all about opioids. Over the next few episodes, the problem, we’ll talk about how we local communities, Indiana and the United States got into this crisis, how people suffering from addiction are treated and how the needle can be moved on addiction. This is a podcast for anyone who might be interested in how these problems have developed and are approached. You don’t need a PhD to be affected by them, so you shouldn’t need a PhD to learn more about them. Regenstrief institute is a global leader dedicated to improving health and healthcare through innovations and research and Biomedical Informatics, Health Services, and Aging. Welcome to The Problem.

(01:11) Jim McClelland:
A Friend of mine a few months ago had shoulder surgery and he knows a lot about this issue. So I said, okay, so, um, what did they give you? And he said, well, the surgeon wrote out a prescription for 55 pills. I gave it to my wife, he said, and I told her to have the pharmacist give me 10 pills. And the pharmacist did that. And he said, I took two of them. I didn’t need anymore. So then we have the problem. When you have situations like that, of all these excess pills. The DEA, the Federal Drug Enforcement Agency does have a take back day. So a couple of times a year. And during the most recent, which was a two day event in October, the state police, the pharmacy board through the Indiana professional licensing agency collected over 10 tons of pills. And since January, 2017, those efforts on those drug take back days have produced over 27 tons of pills. I have a hard time even imagining what 10 much less 27 tons of pills look like.

(02:32) Phil Lofton:
The opioid crisis as we’ve seen is something that’s personal. It’s stories of individual struggles and recoveries that play across the landscapes of homes and clinics. It’s systemic too, consisting of systems learning to push back against the waves of overprescription, but it’s also larger than that. It’s an epidemic that affects large swaths of the population across city, county and state lines. To fight the epidemic on this largest scale, the population scale, we depend elected and appointed officials in our governments to build coalitions and develop policies that will lead to prevention of addiction where possible and fast effective recovery for those already addicted to opioids. Today we’re going to be talking to several people leading efforts within Indiana state government. This episode is going to be split at the midpoint, so be sure not to miss the second part. First we’ll feature a conversation between Regenstrief President and CEO, Peter Embí and the executive director for drug prevention treatment and enforcement, Jim McClelland, as well as some excerpts from a conversation between Dr. Embí and Deputy State Health Commissioner Pam Pontones.

(03:35) Phil Lofton:
We’ll also talk to Josie Fasoldt and Darshan Shah from the State’s Management Performance Hub and organization within the state government that aims to connect and empower groups through data accessibility. What’s more, they use data visualizations to directly impact the day to day efforts of first responders. Welcome to the problem. I’m your host, Phil. Lofton.

(03:55) Phil Lofton:
Jim McClelland has a history of tackling big problems. Before he was appointed executive director for drug prevention treatment and enforcement position — oftentimes referred to as Indiana’s drugs czar — McClelland was the CEO for Goodwill Industries where he oversaw efforts to try and fight intergenerational poverty. In that effort, his team found that trying to address poverty meant trying to address a host of interconnected issues. A few months ago he sat down for a conversation with our president and CEO, Peter Embí, to talk about the opioid crisis and the lessons he’s learned along the way.

(04:28) Peter Embí:
First question really is from your perspective, what does the opioid crisis costs Indiana?

(04:35) Jim McClelland:
Well, in monetary terms. So, IU’s Kelly School of Business has done some work that calculated the annual cost in the state at about $4.3 billion. Now that’s direct and indirect costs. The, the direct costs of that are probably around $1.3 billion. That’s health care and treatment costs, criminal justice costs, deaths, disability, foster care, cost to employers. Who also by the way are having in many cases, a very hard time filling all their vacancies because they’re having so many people who can’t pass an initial drug screen. So using the four point $3 billion figure, that comes out to be about $11 million a day, and that of course said pales in comparison to the toll on human lives, the devastation to families, just the overall damage to communities.

(05:38) Peter Embí:
Sure, sure. That’s the, that’s really the cost. In your interview with No Limits, you talked about the crisis as something that had to be attacked on multiple fronts at the same time. Could you say a bit more about that?

(05:49) Jim McClelland:
Well, first and foremost, we want everybody to understand that, that this, this is really a public health crisis, but every public health crisis is both a medical issue and a social issue. Now we took a look at this. So when we, when we first started working on it early in 2017 and we thought, my, gosh, you know, we, we better have a strategic approach to this so we don’t just end up playing whack a mole. And so we developed that and we have two overarching goals that have been the same since we began our work.

(06:20) Jim McClelland:
First of course, is to help as many people as possible who have a substance use disorder achieve and maintain recovery so they can become or return to being productive, contributing members of their community. And at the same time, we want to take steps to help substantially reduce the likelihood that we will ever again be affected by a crisis of this magnitude arising from the use of any addictive substance. So, so we developed the strategic approach and understanding that, that people who have an addiction to opioids have a chronic disease, they have an opioid use disorder that requires treatment. Now, we set particularly high priorities, broad priorities. One is to do everything that we can to help keep people alive. A second is to greatly expand access to treatment, particularly medication assisted treatment, which is the gold standard for treatment of an opioid use disorder.

(07:18) Jim McClelland:
Third, to do as much as we could to help prevent other people from developing an opioid use disorder and fourth, to do a lot more to educate and inform people and reduce the stigma that is so often a huge barrier to effective harm reduction and treatment efforts.

(07:38) Peter Embí:
What impact has your work had on that?

(07:40) Jim McClelland:
FSSSA last year launched what they refer to as a humanizing campaign, which is basically an anti stigma effort, called Know the O facts, to try to educate people that, number one, an opioid use disorder is a chronic disease. It has affected the structure of the brain. It has affected your ability to make what the rest of us would consider a rational decisions. And the longer you’re on it, the more difficult it can become to get off.

(08:17) Jim McClelland:
But the good news is it is treatable and recovery is possible. So this is the basic message that FSSA launched, last year. there’s a link to it on the next level recovery website, It’s also on FSSA’s website. And we know that several thousands of people have access to that. We know there is some improvement in the way people are viewing this as a chronic disease rather than simply a moral failure. And trying to educate people that it’s almost impossible for someone to just stop. A lot of people think, well, why can’t you just say no? Well, it just, it’s affected your brain, right? And it’s the strength off opioids, the effect that they have on the brain is so powerful, but it’s almost impossible to it to just stop without treatment.

(09:23) Jim McClelland:
And, you know, abstinence only treatment, it can work, but the success rate is single digits, right? Some studies have shown 5-6% success rate. You have a much better chance with a medication assisted treatment, which is the use of one of three drugs approved by the FDA for treatment of an opioid use disorder, combined with counseling and behavioral therapy. So we’re making some headway, but we still have a long way to go to eliminate the stigma surrounding this disease.

(09:58) Peter Embí:
Yeah. So important and it is a disease and that’s exactly right.

(08:28) Jim McClelland:
The other thing that I think is particularly important here is to understand that the younger a person starts using any addictive substance, the greater the risk of a serious addiction problem at adulthood simply because the impact that these substances have on the developing brain of an adolescent is much more potent.

(10:26) Phil Lofton:
From previous episodes. We know that the stigma, that sense of shame and dehumanization that sometimes hoisted onto people dealing with substance use disorder can be a barrier to recovery. And as you might remember from Robbie’s episode — that’s episode 8 — overcoming that stigma can be a key moment in journeys back to health. Here’s an excerpt from a talk that Peter and I had with Pam. Pontones, deputy health commissioner with some more thoughts on overcoming stigma at the local level.

(10:52) Pam Pontones:
It’s really getting folks to understand that addiction is a disease. Treatment is available and recovery is possible. And we do see that we see in folks who have traveled this journey, who have suffered from substance use disorder becoming peer recovery coaches, helping others find resources in the, in their community because they know that journey. Really engaging folks that it is a disease. It is not a moral failing. It is not a weakness. It’s not a lack of willpower.

(11:26) Phil Lofton:
And when you’re getting there, that’s, that’s really laudable and we completely agree of course. And that’s a, that’s a great message to be sending. As you’re, as you’re communicating that message through various means, how do you see that being communicated most effectively? And when you think about partners and others to help get that message across, what have you found to be most effective in that regard? Really it’s opening that conversation. So wherever

(11:54) Pam Pontones:
we are meeting with partners, whenever we are invited to give presentations, wherever we have a way to interact with the public, this is a message that we promote, whether it’s in person, whether it’s through billboards, whether it’s through websites or other presentations, training programs. Really taking that message wherever we go in whatever community, even if it’s at a booth, at an exhibit, there are a variety of means that we can do this as social media is another one. So we use every available tool that we have, wherever we are, and when we, we work with partners, we present that and in, in helping to spread that message. So really we’re starting from that same point.

(12:40) Phil Lofton:
Indiana is a pretty diverse state. Your situation in Scott County is different than your situation in Marion County, but at the same time, the factors that drive a person to substance use disorder are similar in different settings. They’ve got different upstreams factors. But I guess to get to a point, um, how does the approach look different in addressing those upstream factors in a place like Scott County as opposed to a place like Lake county or Marion county or Monroe County, where does, how do those efforts become distinct at those different regional levels?

(13:18) Pam Pontones:
That’s where a local communities and partnerships with those local communities become so important because, there may be common factors that lead to substance use disorder and the disorder itself has some commonalities, but it’s not a one size fits all approach to solutions because communities have different needs. They have different folks living in those communities. So it’s extremely important for us as a state agency to partner very closely with local health departments, with faith based organizations, with community groups and coalitions that are working very hard to combat substance use disorder in their communities.

(14:05) Phil Lofton:
And do you feel comfortable talking about any partnerships on that level that you feel like have worked particularly well?

(14:12) Pam Pontones:
Any good examples of that one certainly would be with the local health departments and rural first responders where, Indiana State Department of Health has granted resources for a naloxone procurement or actually distributed in the Blackstone kits so that we can get those to those areas that may need them and may not, it may not be as readily available.

(14:37) Pam Pontones:
We’re actively working with faith based organizations that have outreach in their communities. Um, across many different areas. That has been a strong partnership that we’ve been working to develop. We’ve continued to develop relationships with coroners so that we can get better data on fatal drug overdoses. Working with hospitals to be partners in their communities on substance use disorder education, working with other community groups, regarding stigma and how we can move folks toward treatment and recovery. And then encouraging and engaging folks who have traveled that journey of substance use disorder into becoming peer recovery coaches. How they can help others since they’ve had that experience is extremely powerful. But it’s really getting to know the local community, knowing what the community needs and then finding a way to connect communities to resources, um, to evidence based practices to toolkits that they can then use to, um, see what really works best for them.

(15:51) Pam Pontones:
One example again that we have of this is in our syndromic surveillance data. So people who present to the emergency department, with a suspect substance use disorder, those data are tabulated and collected. We look at the numbers of chief complaints and hospitals, and if those chief complaints of suspect drug overdoses exceed certain levels, the system generates a warning or an alert that is then transmitted to the local health department in that county where the hospital is located. We have a program now where individual counties in looking at this, formed a pilot to develop their community best practice solutions. You get this warning or an alert, what do you do with it? And they’ve literally developed toolkits and practices that are really ingrained in their community to see what works best for them. Because what works in Indianapolis may not be the same in Scott County and may not be the same in Monroe or, or another community.

(17:02) Pam Pontones:
So it’s really determining what works for them. And this has continued to grow. I believe we’re up to 13 counties now that are developing these toolkits and protocols for their own counties in responding because sometimes developing a blanket protocol may not work as effectively for everyone. But we can leverage a unique resources and talents within communities. And we can share best practices, um, when we come together and, and that’s what we’re all learning and everyone has stories and successes that they can share and we can all learn from one another.

(17:40) Phil Lofton:
Just as important though, is understanding what causes people to become addicted to opioids in the first place. Peter and I talked more about some of the complicated interconnected causes behind the crisis and how to address them with Jim McClelland.

(17:53) New Speaker:
It’s kind of interesting. There was a study done at Syracuse University that was published earlier this year, where they studied 500,000 overdose related deaths between 2005 and 2016 and they compared those county by county with various economic and social factors. And they found that the average mortality rates were significantly higher in areas with greater economic and family distress. Interestingly, they also found that average mortality rates were significantly lower in counties that had a greater number of religious organizations. Now their conclusion from that was that those organizations provide a community, a sense of community. And connectedness with people. And there’s so much of what we read these days that indicates there are a lot of people who really have become disconnected.

(18:59) Jim McClelland:
There was a lot of loneliness particularly in areas where perhaps there used to be one factory that provided the economic base for a community and it’s gone and it’s not coming back. And you’ve got a lot of people who have unfortunately lost hope. So, there were a couple of researchers who have done quite a lot of work on this, they call this and alcoholism and suicide diseases of despair. It’s something that I think it’s a whole society. We have a responsibility to see how can we reduce this? How can we replace despair with hope?I think we have our work cut out for us in a, a number of areas.

(19:50) Peter Embí:
That’s so important. You bring that up and it is such a complex issue for that reason. We often refer to it occasionally if not as a crisis as an epidemic. And yet it’s not an infectious disease. It’s in some ways more complex than that because of exactly what you say. These social factors make it much more complex than just a medical condition, even though it isn’t a medical condition.

(20:12) Jim McClelland:
And it is, it’s incredibly complex. There’s a lot of data showing how many of our social problems are interrelated. Sure. Poverty, low education levels, crime rates. So births to young, unwed mothers in low income households, a host of health issues, they are frequently interrelated. They frequently reinforcing compound each other. Our tendency as a society has been to try to treat each one of these in isolation from the others.

(20:41) Jim McClelland:
And we’ve not done very well. We have a lot of good pieces out there. We have a lot of good pieces in the, in the public sector in the, not for profit sector but, but typically each effort is focused on one piece of a much larger, more complex set of issues. And frankly, as a society, we haven’t done a very good job of connecting the pieces. And I think that perhaps is one of our biggest challenges where we can connect these pieces and some focused ways, and with existing resources at collective resources, really be able to see a lot more effective use of those resources. And it’s similar to, and just within the healthcare sector. For example, there’s strong comorbidity between mental illness and substance use disorders.

(21:36) Jim McClelland:
The surgeon general issued a report earlier this year that indicated that about 45% of people with a mental illness diagnosis also have a substance use disorder. Although only about 51% are getting treatment for either, and only a small minority are getting treatment for both and they’re connected with each other. Eskenazi has done some really interesting work that was published not too long ago where they, at their federally qualified health centers, they have integrated primary care and behavioral health, including a treatment for addiction and mental illnesses and augmented those services with nonmedical services, that help deal with some of the social and behavioral problems that individuals are facing. And they found that that combination significantly reduced future hospitalizations and visits to emergency departments. (NOTE: See Episode 5, featuring Andy Chambers.) So it’s a way to save money and also improve outcomes.

(22:39) Jim McClelland:
So we have a, I think this is one of our biggest challenges. We need to find ways to reduce the fragmentation, integrate services, deal with people holistically, often with the whole family. And we’ll find that we can get much better results with the same total resources that, that we’re applying to this, to a lot of these issues individually. Right now, given the, that need for a holistic view, how do you, begin to tackle this at a policy level? That’s, that’s a whole other level of complexity. So, well, I can tell you what we’re going to be doing in 2019, and the governor recently announced his 2019 agenda. There are several items there that apply to this issue, and by the way, this remains one of the governor’s top priorities, going into the third year of his administration.

(23:29) Jim McClelland:
But one of the parts of that agenda includes, reducing, taking additional steps to reduce a perinatal substance use disorder and neonatal abstinence syndrome. we, we’ve taken some steps, and supported some programs, several programs, along those lines. We’ve got to be doing more, this coming a year. We are going to also significantly expand, our support for additional recovery housing and Indiana. We need a lot more sober housing opportunities for individuals, some for men and for women, some for families with children, where, where people can support each other. They can be in an environment without the, the triggers that so often lead back to a more substance use disorder, substance abuse. And we’re going to be doing that. We also are going to fund some pilot programs using medication assisted treatment and some of our jails, this is, there’s a huge need for this.

(24:37) Jim McClelland:
Unfortunately, our jails in many cases have become defacto detox centers without treatment. Now there are a few jails that were where they are providing some treatment, but we need a lot more. What happens is if an individual, with an opioid use disorder is in jail, for a few months, let’s say, that individual is losing the tolerance, but the craving is still going to be there. And then when they’re released and they go back to using, they don’t have the tolerance for the same amount that they were using before and their risk of overdosing and dying during the first two weeks of release from incarceration, is extraordinarily high. And we’ve got, we just have to change that. Yeah. I have a young man, I have a friend who’s a, who’s 25 years old right now.

(25:37) Jim McClelland:
I was talking to him, not too long ago and by the way, his problems began when he was 15 and had an appendectomy and the surgeon prescribed an opioid. And as he said, that first pill that he took, he said, I fell in love. And that was the beginning. And so I asked him, he said, any history of alcoholism in your family? Oh yeah, it’s all over the place. He said, there’s also a history of depression in my family. You take those two, there was a genetic predisposition to this. At any rate, he’s doing really well now. But he said that, about a year ago he was arrested and he knew he was going to have to go to jail. And so he hid some stuff in his parents’ bedroom. they didn’t know anything about it.

(26:28) Jim McClelland:
And, he said, that was in jail for about three months. And when I got out, I went back and, and that night I went home that night, I used what, what I hid and he said I overdosed. Wow. And his mother found him now, he wasn’t breathing when she found him, but she, she knew CPR and they also had Narcan, the reversal agent for an opioid use disorder in the house. But because of his history, and they brought him back and he’s, he’s doing well now. He’s, so he’s on medication assisted treatment. They’ve got a good job. He’s doing well. But the point here is that this can happen and it happens way too frequently. There was one study that indicated that, a person, with opioid use disorder released from incarceration without treatment, has a 129 times greater risk of overdosing during the next two weeks than the general population.

(27:31) Jim McClelland:
I couldn’t. it’s just staggering. At any rate, we’re going to be increasing our support for, for, pilot programs in some of our jails. We’re also going to, provide some, support, to help, implement more a family recovery courts in the state. We only have seven of those. They’re there for families, involved in Chins proceedings involving substance use disorders, to improve treatment completion, a family reunification, and also reduce a, not a place out of home placement costs. The chief justice and and DCS are working together on some of these initiatives. we’re going to be providing some support, and they would like to see the number increased, to about 26 around the state.

(28:24) Jim McClelland:
We’re not going to be able to do that in the next year or two, but, but we can certainly, probably, substantially increase the, number that we do have.

(28:33) Peter Embí:
Yes. So, you know, you’re very well aware, I think he said, and in 2017, interview with Indianapolis monthly that you believe we still hadn’t seen the worst of the addictions crisis. Do you think the worst is behind us now or are we still seeing it worsen?

(28:47) New Speaker:
Well in, in 2017 there’s no question the numbers were worse. In fact, a lot of what we, we’ve been, we’ve been working on this, at the state level, out of the governor’s Office for two years now. And, and a lot of the things that we started in 2017 didn’t start having an effect until toward the end of 2017 or into 2018. but so the numbers in 2017 were really bad. This year we are seeing some encouraging signs, and the CDC posts on their website some provisional data. Now it’s very preliminary numbers and we’re not drawing any conclusions from it yet. but, there’s some preliminary, numbers on overdose deaths that indicate during the early part of this year, there actually may have been a decline in deaths. it’s way too soon to celebrate. I try to remind people that it took this epidemic, 20 years to develop. And there are no quick or easy solutions to it. we can end it in a lot less time than it took to create it, but still it’s not overnight. And even if we could eliminate all overdose deaths, we still have in this state, literally tens of thousands of people who need treatment. They have an opioid use disorder, they need treatment in order to be able to recover.

(30:08) Jim McClelland:
So, this is going to go on for a while. And then in addition to that, we have an awful lot of kids who have been affected by parental substance use disorder. And that’s a, that’s a whole nother topic.

(30:19) New Speaker:
Yeah. Yeah. I wonder if I could follow up on that. I, I appreciate what you’re saying very much and one hopes that those numbers that are just an early indication hold and we do start to see some improvement. Um, are we also seeing some differences? Do you have any sense of whether the nature of who’s being affected is changing? Um, what’s happening on that front?

(31:12) Peter Embí:
As much as you’re doing, what is it that keeps you up at night? What are the things you really worry about with regard to the crisis?

(31:18) New Speaker:
There is nothing about this epidemic that troubles me more than the impact on children. we have learned a lot over the last 20 years about the longterm effects of what are termed adverse childhood experiences. Things like, physical, emotional or sexual abuse of a kid, a death of a parent, divorce, substance abuse by a parent, mental illness of a parent, incarceration of a parent. These are cumulative. There’s a lot of research on this. it really started back in 1995, in a project of some research done by the CDC and Kaiser Permanente and the impact is cumulative. So the more of these you have, the greater the likelihood, in other words, the higher your ace score.

(32:13) Jim McClelland:
That’s how they’re termed adverse childhood experiences. Aces, the higher your ace score, the greater the likelihood of a number of negative economic and social outcomes. A host of chronic diseases, including alcoholism and substance abuse, and early death. So high ace scores don’t have to be destiny. But if as a society, we don’t do enough to help mitigate that impact, we and those kids are going to pay a heavy price just a few years down the road. We’ve got to stay aware of this and we’ve got to do something about it. And this is a responsibility of our whole society. We cannot just let this happen to these kids and to our society as a whole.

(33:07) Peter Embí:
Well, Jim, thank you so much for sharing those thoughts and more importantly, for everything you’re doing on behalf of, of, all of us, to, help, address this crisis. I really appreciate it.

(33:20) Jim McClelland:
Thank you, Peter.

(33:20) Peter Embí:
Thank you.

(33:22) Phil Lofton:
Join us in Part 2 of the episode, available now, when we hear from Josie Fasoldt and Darshan Shah about Indiana’s Management Performance Hub, and how Data Visualizations are empowering first responders to save lives. Music this episode was from Everlone and aBroke for Free. Our theme and additional musical cues in this episode were written and performed, as always, by Luger and the Senators. The Problem is produced at studio 132 in the Regenstrief Institute in Indianapolis, Indiana, where we connect and innovate to provide better care and better health. Learn more about our work and how you can get involved at, and see bonus content from this episode, including sources, pictures and more, at The Problem is written, hosted, edited and produced by me, Phil Lofton with additional editing by Andi Anibal, John Erickson, and Jen Walker. Web design and graphics are by Andi Anibal, and Social Media Marketing is done by Jen Walker. Special thanks to Peter Embí, who slid behind the interviewer’s mic for this episode.Jim

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