Learn how large-scale health systems are doing their part to combat the opioid crisis. This episode features Ashley Overley, M.D., chief executive officer of Eskenazi Health Midtown Community Mental Health and vice president of mental health operations at Eskenazi Health.
Phil Lofton: 00:00 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 industry’s 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 will 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.
Phil Lofton: 01:11 Tall buildings. Sprawl that seems to go on forever. Employees, not in the hundreds, but the thousands. Competing special interest groups. If it sounds like we’re talking about a city or a state, we’re not, but that’s no coincidence. Health systems are massive. They cover enormous regions of the country, crossing city and even state lines. When we talk about health systems, we’re talking about large nongovernmental organizations that span multiple facilities and settings. We’re talking about their employees, their infrastructure, their records, all of it. In fact, the World Health Organization expands the definition even further in their words. A health system consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health. This includes efforts to influence determinants of health as well as more direct health. Improving activities. Health system is there for more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home, private providers, behavior change programs, vector control campaigns, health insurance organizations, occupational health and safety legislation. In other words, if you’re hoping to make a society level change, health systems are a powerful engine to help make that happen.
Phil Lofton: 02:28 Welcome to the problem. I’m your host, Phil. Lofton. My friend Ashley Overley plays an important part in the Eskenazi health system here in Indianapolis.
Ashley Overley: 02:57 I am Ashley Overley. I am a psychiatrist. I am also the chief executive officer for Eskenazi health midtown community mental health. I am also a faculty member with the IU School of Medicine, Department of Psychiatry.
Phil Lofton: 03:10 When I told her about The Problem a while back, she was nice enough to agree to sit down and talk about the opiod crisis and how health systems can make an impact. This conversation has been edited just a little bit for length and clarity.
Ashley Overley: 03:23 Well, let me first talk about at the individual level. So how does a mental health professional think about addiction? And there really are two main tools. So one is medication and two his therapy. And so the longterm goals for addiction obviously are for someone to stop using the drug. It’s abstinence from, from the drug of abuse. That’s kind of the most concrete thing, but then more importantly, of course, it’s to return to normal functioning in all areas of life.
Ashley Overley 03:49 So restoring healthy relationships, meeting age appropriate developmental milestones in both vocational or educational goals. Really because addiction affects a person’s motivation and behavior is very complex in the kinds of outcomes and effects it can have in someone’s life. It really can affect every single area of life because if you think about affecting a person’s motivation and behavior, that really does literally affect everything. And so restoring someone to healthy functioning in all of those areas can be very complex. But those really are the ultimate longterm goals. Short term goals, really focus on reducing craving, increasing motivation for abstinence and helping someone sort of problem solve on a daily basis, uh, how to maintain abstinence from the drug. And so, just briefly, some of the medications that we use, there are a variety of ways that we can help people with medications to reduce their drug use.
Ashley Overley : 04:58 So one is by, actually in some ways replacing with a drug that can help reduce craving, so a very, a very common example is, nicotine replacement, so using nicotine patches or nicotine gum, that’s a form of the drug that can help reduce craving, but help avoid some of that compulsive use in situations that might be associated with other harmful health effects like smoking a cigarette. That also increases risk for cancer. In opioid use disorder, what we see is a use of either suboxone or methadone, which are two medications that can activate the same receptors in the brain that the opioid drug of abuse can, but it helps. It has a different pharmacology in such that it has a longer time period that is active in someone’s body and doesn’t produce the high highs that the drugs of abuse do, and so someone can take a dose or two a day and maintain functioning and not have the compulsion to seek other drugs of abuse during that time.
Ashley Overley : 06:13 There are also drugs that can help reduce cravings overall. So naltrexone is one of those that can help reduce the amount of craving that someone has. And then there also are a few drugs that we call them aversive medications, um, that changed the way a person metabolizes the drug so that when they take the drug then they actually have kind of a negative reaction to that. So, um, an example is acamprosate for alcohol, so it changes the way that your body metabolizes the alcohol so that if you use alcohol while you were taking acamprosate that you actually feel very uncomfortable, you get a sweating reaction and um, it feels, uh, just extremely uncomfortable. And so the idea is if you can at least be motivated enough to take the, acamprosate, um, then you will be less likely to use alcohol while you are taking acamprosate.
Phil Lofton: 07:09 So is there an intervention like that for opioid use disorder?
Ashley Overley: 07:14 Unfortunately, there’s not one exactly like that, but naltrexone, can also be used in opioid use disorder to help reduce the amount of craving that people have overall.
Phil Lofton: 07:24 So, wow, that is really interesting.
Ashley Overley : 07:26 Yeah, so, so none of those methods is perfect, but they are associated with improvement in people’s abstinence rates, so, so it’s important though that medication really is only one component of treatment and so ideally we see people combine a medication with a psychotherapy approach as well and so psychotherapy is really designed to help people build skills to cope with the stress of abstinence, um, and to really build other habits and education around how can they, how can they problem solve their situation and their daily habits and life circumstances so they’re not putting themselves in situations that are attempting to use, um, and so that they can replace those use habits with other healthier habits.
Phil Lofton: 08:18 It sounds like, to go back to something you were saying earlier, it sounds like rebuilding that capacity of the brain to feel excitement in those small daily victories.
Ashley Overley: 08:28 Right, exactly.
Phil Lofton: 08:29 That’s awesome. That’s really, really cool. And it sounds very strengths based.
Ashley Overley: 08:32 It is, it is very strengths based. Yes. Awesome. Yes. I’m glad you mentioned that. In fact, that’s a very important part of definitely at midtown, but I think generally within the field of mental health, we recognize that a strengths based approach to recovery ultimately is a lot more successful. So building on people’s strengths and maintaining a nonjudgmental stance towards people and maintaining sort of optimism for their recovery is the attitude that’s most likely to actually help people be successful in the long-term.
Ashley Overley: 09:08 Speaking of Eskenazi and speaking of midtown, you guys have gotten quite a bit of attention for your interventions and how good and effective they’ve been at reducing addiction rates.
Ashley Overley : 09:18 Thank you. We worked very hard.
Phil Lofton: 09:21 So tell me a little bit about that. Tell me a little bit specifically about how Eskenazi has combatted the opioid crisis.
Ashley Overley: 09:27 Uh, yeah. So actually it’s talking about general systems approach is a nice way to frame what we are doing at Eskenazi. Yeah. Major professional organizations, including the CDC, the Center for Disease Control really recognized sort of three systems level best practices for addressing the opioid use epidemic. Uh, so the first level is prevention. So preventing people from becoming addicted to opioids in the first place is goal number one. So goal number two is providing adequate treatment for addictions at the individual patient level. And then goal number three is harm reduction efforts and that’s for people who are addicted, helping mitigate the harms that go along with opioid addiction. Um, and so I can talk about each of those levels and how we’ve approached them at Eskenazi, right? Um, so at the prevention level, the goal really is to reduce people’s overall exposure to opioids.
Ashley Overley : 10:38 And one of the things that we know is that unfortunately there are definitely is what we’d call an iatrogenic component to the opioid epidemic. And so yeah, so let me define the word iatrogenic it means basically induced by the healthcare system. So we know that prescribing habits of physicians have contributed to the opioid epidemic because we know that people’s exposure to opioids for pain control contributes to later abuse of opioid medications or opioids. And so as a system we have worked very hard to reduce the number of opioids that we are prescribing. Actually, since the year 2010, we’ve been able to reduce the number of opioid prescriptions by about 80 percent. So, and that’s been really significant efforts on the part of Dr Palmer McKie and others in really changing the way that we approach pain management, so finding more appropriate alternatives to pain management than merely prescribing opioids and that’s been a significant part that effort, but also making sure that we’re not prescribing unneeded opioids as well.
Ashley Overley : 12:00 So not writing a 90 day prescription for a visit to the ER or you know, for a follow-up of a, of a surgery. And so there have also been significant legislative changes that are focusing on this across the state. And so there are now requirements that physicians check INSPECT, which is our state prescription drug monitoring programs. So that’s something that allows a prescriber to see if patients are filling prescriptions of controlled substances from other prescribers. So they can see, for example, if someone is doctor shopping or something like that. There’s also legislation limiting the quantity of opioids that be can be prescribed in an initial prescription. Um, and so that’s something that we’re working hard to educate our providers about and using our electronic medical record system to put in alerts and a resetting the default settings and different things like that, that sort of facilitate clinical decision making in the moment, making sure that that information is available and accurate.
Ashley Overley: 13:04 We’re also working to put the inspect prescription drug monitoring information within our EMR as well that’s also in response to legislation, but it’s another step that will help prescribers have immediate access to information that will help them know if there are patterns of prescription fills that are concerning for a specific patient. So those are a lot of the system level initiatives that are really, again, focused on reducing exposure to opioids, reducing the quantity of opioids that are available out in the community, and hopefully reducing some of the risk for later a opioid abuse. So that’s one level. So that’s a system, a prevention level. At the individual level, at the treatment level, um, that’s a lot of what I talked about before actually.
Ashley Overley : 14:04 So that’s a one on one, making sure that treatment is available to someone that they are getting treatment for both their addiction and for any other mental health comorbidity. So uh, depression and anxiety and bipolar disorder, schizophrenia, these are all conditions that are very highly associated with substance use disorders and we know that overall people do better when both of those are treated (NOTE: This is discussed at length in Episode 5, featuring Andy Chambers). And so making sure that someone has access to high quality treatment for, for all of those relevant conditions. And so we are working very hard as a system to make sure that we are training more providers to be able to prescribe suboxone, which is one of the main medications we use for opioid use disorder where even training primary care physicians right now, that’s actually an effort we’ve been really pleased with because we’ve been really encouraged to see how many primary care providers really see this as part of their job as well.
Ashley Overley : 15:03 So kind of to the point of your podcast, this is not only a mental health problem is we can’t say, oh, psychiatry needs to deal with that. Like, well, yeah, psychiatry should step up and do a lot, but I mean this is really something that everyone has a role in addressing. And so primary care providers, I’ve been really impressed with how much they’ve stepped up to say, well, I, I’m seeing this person, they have this problem. If I learned this skill of how to prescribe suboxone, I can help this person too. And we’ve seen some really great stories and examples of people who ended up patients who would not go to a substance abuse program. They say, I’ve already done that, I’m not going to do that, that’s not for me. I’m not, I, I don’t need that service. But they are willing to see their primary care doctor and so they are getting the care that they need within primary care and really doing much better.
Ashley Overley : 15:52 So that’s been very cool. So that, that whole, the treatment aspect, we’re really focusing on just making sure that as a system we are operations are as efficient as they can be so that we can offer as much access as we possibly can. Or recruiting addiction prescribers and really working hard to make sure that we are serving as many people as we can as a system. And then finally, harm reduction is the third method that a system should be using to approach the opioid epidemic and that really is mitigating some of the worst outcomes that we know can happen with opioid use disorder. And so, I think death from overdose is one of the most dramatic examples in one of the worst outcomes that we see. And so one of the tools that can help prevent that is use of Naloxone, so naloxone is, you may have heard it referred to as an overdose reversal drug.
Ashley Overley : 16:51 And so this is something that can help counteract the effects of an opioid overdose on help revive someone that has overdosed on an opioid. And so there’s been a big push to educate the public about the use of naloxone. Um, our EMS providers now carry naloxone with them, and we want to make sure that it’s available to people who are within the community to people who might have, have need of that, and people who are at risk for an overdose. And so we’re making sure that that information and education gets out there. The Marion County public health department has very recently pioneered the start of a needle exchange program for Marion County actually. Yes.
Phil Lofton: 17:40 So super interesting.
New Speaker: 17:42 it’s awesome news. It is great news. I’m actually really, really pleased with this. So the city county council actually voted unanimously to approve the needle exchange program for our county.
Speaker 4: 17:56 So needle exchange program is a program by which a person who is using IV needles to inject drugs can, instead of reusing needles, which increases rates of infection because they’re sharing sharing needles that have shared potentially infected blood, um, they’re able to go to the needle exchange program and receive clean needles that they can use to inject, um, they, the needles are closely accounted for. So, um, people have to return the needles that they receive in order to get more needles. They are also provided at the same time with education about where they can seek treatment for their, a drug use disorder. The great thing about this is that this will really be another step to provide information and education to individuals who are using needles to administer drugs. When individuals participate in this program, they will –
Ashley Overley : 19:04 It’s not just a matter of handing them clean needles, but it’s also handing them education and encouraging them to get linked with treatment. And what we know is that people are significantly more likely to engage in treatment if they are utilizing a needle exchange program than if they are not, um, it does not increase crime. It does not increase drug use. This has been well studied for decades and decades. People who utilize a needle exchange program really are, it’s one step closer towards less risky behaviors and more healthy behaviors versus using needles on their own. I think this is a great step for Marion County. This is one additional way that we can help mitigate the harms that we know happen. I think the other information that’s really compelling about this is that it’s just infinitely cheaper to provide clean needles than to treat HIV or hepatitis, for example.
Ashley Overley : 20:11 And so the math is really compelling to be able to say, well, if we’re, if we’re going to invest our resources, what’s the wisest way to do that? Should it be in treating hepatitis and HIV outbreaks or in providing clean needles and encouraging people into treatment? We know overall that a treatment is cost effective and that it’s worth the investment.
Phil Lofton: 20:38 Really. What does success in combating addiction look like from a psychiatrist’s point of view and for a system administrator’s point of view?
Ashley Overley : 20:48 Yeah. So I think from a psychiatrist point of view, you really are focused on helping an individual person reach their specific goals and that’s highly individualized and will look different for every person. For one person, it may be being able to be reunited with their family and live with their spouse and rekindle a relationship with their, with their siblings or their children who are, who are able to support them in a, in a healthier way.
Ashley Overley : 21:21 It may be getting and keeping a job and not losing a job due to substance use. It may be being able to finish a degree. There are a lot of different things that would be success for a psychiatrist helping an individual patient. I think from a system level it is an aggregate of seeing those collective individual success stories, but additionally seeing reductions in ED visits for so quality of drug use, overall seeing reductions in diversion of drugs in an inappropriate way. Overall seeing people better able to utilize healthcare resources overall. It’s a also seeing really seeing kind of the emergent properties of people being able to work and be productive and not spend their time involved in activities surrounding seeking drugs or using drugs.
Phil Lofton: 22:36 From a discipline level perspective, what do you think is the next step for psychiatry in how it will evolve and how it will evolve with regards to treating the opioid crisis? And then on that other side, because you kind of carry both of these things in your hands at the same time, what do you think the future of health systems looks like with regards to combating the opioid crisis? What do you think is next for both of those disciplines?
Ashley Overley : 23:01 Okay. No, this is really good. Really deep, actually. No, no, no, that’s okay. I mean we like to think that we’re providing the cutting edge of what’s currently available. So, um, let’s see. So in terms of future for psychiatry as a discipline, I mean, unfortunately I wish that I could tell you that I knew about some like very cool drug that’s on the horizon that is going to be a game changer for addiction. There’s not any that I, that I know about. And in terms of behavioral health of the therapy interventions there, those things are so fundamental to it, to the kinds of experiences and skills that shape behavior that I don’t think that we anticipate any specific changes that I think, I guess I feel like in a way asking for something new or different in that way as sort of like asking for a different answer than wait, how do we keep our physical bodies healthy while you eat healthy food and you exercise like at the end of the day, that’s kind of it.
Phil Lofton: 24:12 Like, so like some crazy new cruncher equipment or something like that. But you’re really doing crunches, correct?
Ashley Overley : 24:18 Yes. But really you’re using your muscles and your keep, you know, you’re keeping yourself physically active and you’re maintaining your body. And so that, when I think about therapy like that, that is sort of that – you’re building skills, you are learning how to cope with stress of daily life. So there’s not some fancy other thing that’s going to circumvent the need for developing those skills. I think where the real innovation needs to happen is at sort of a system and a funding level. So like I said earlier, there are unfortunately a lot of silos with mental health that view mental health and addiction as separate things and they are not. And so I think there’s a huge need for greater collaboration and greater integration between funding streams and research streams that have historically approached these as separate things.
Ashley Overley : 25:22 So as a result, sometimes we have people who are, they’re able to get high quality addiction treatment services but not high quality mental health – traditionally viewed as mental health services. And so what we need is a system level approach that really does combine the tools necessary to treat both of those at the same time and not see them as separate issues. So that is the kind of innovation that I think would be a huge step forward really. And so it’s not, it’s not fancy, it’s not rocket science. Like that’s not something new in terms of the things that we can offer people.
Phil Lofton: 26:03 But it’s stopping thinking about improving your physical body as DIET and EXERCISE. It’s diet AND exercise.
Ashley Overley : 26:11 Exactly correct. And it’s bringing the two of those things together and saying the, the services that we offer should be available to people. And in any context really, so not saying, well you need to go to this clinic to get your addiction services and you need to go to this clinic to get your depression anxiety or schizophrenia or bipolar treated.
Ashley Overley : 26:29 It’s really saying that we should be able to provide all of those in the same context. So one thing that I continue to hear about in the community I guess is that there is a perception that I’m using medication to treat an addiction is quote unquote replacing one addiction with another. And there are unfortunately some programs that require that for, for people to participate. They say, well, you can’t be on any psychiatric medication. And so there continues to be just a real stigma within the community about not just mental health but particularly addiction in general. And so I think it’s important for people to realize that the treatments that we have to offer both medication and psychotherapy really do go hand in hand in, do help people reach long-term goals of recovery and healthy functioning in society. There’s no, there’s no need to be afraid of those kind of interventions and there’s no need to marginalize them. We really should be embracing both the medication assisted treatment and even harm reduction strategies like needle exchanges because these are tools that help move people toward a healthier lifestyle and a healthy recovery.
Phil Lofton: 27:56 Great. Ashley, thank you so much. It’s been a joy talking to you today.
Ashley Overley: 27:59 Yes, thank you.
Phil Lofton: 28:01 So health systems can make a big impact by playing to their unique strengths by preventing and treating addiction at a variety of different levels. Join us next time when we talked with addiction psychiatrist, Andrew Chambers about his discipline’s unique point of view and a new clinical model, but can make a serious dent in the opioid crisis. Join us then on the problem, our theme and additional musical cues. This episode were written and performed as always by Burt Sturlisson. That intro music is by Everlone. 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. To learn more about our work and how you can get involved at Regenstrief.org and see bonus content from this episode including sources, pictures and more at regenstrief.org/theproble