Season 1
February 7, 2019

Bonus Interview: The Bigger Picture

Bonus Interview: The Bigger Picture

Is the opioid crisis improving? What’s the real face of the epidemic? Find out in this week’s episodes of The Problem, featuring Joan Duwve of the Richard M. Fairbanks School of Public Health at IUPUI.


(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) Phil Lofton:
Hey, everybody. When we talked with Joan Duwve about the truths and misconceptions a lot of us have around the opioid crisis, It was a good fact check for a lot of the myths out there. You might remember that during that discussion, we briefly talked about some of the projects that she’s working on to help combat the opioid crisis. She’s been pretty prolific with a work combating addiction and she’s been the lead on two IU grand challenge projects. I wanted to make sure that we had an opportunity to dive into those a little bit more, so today’s bonus episode is entirely about her work with the grand challenges over the last few years. This is the problem. I’m your host Phil Loft. Project ECHO is a movement to connect local primary care teams with interdisciplinary specialist teams to spread knowledge and amplify local capacity to provide best practice care for complex chronic health conditions. ECHO’s goal is to enable rural and traditionally underserved populations to receive high quality care when they need it close to home

(02:11) Joan Duwve:
ECHO stands for the extension of community for community healthcare outcomes. You’re, you’re working with a group who’s helping you understand how to effectively treat patients.

(02:24) Phil Lofton:
ECHO sounds awesome. It sounds like it’s a really great resource to, to sort of spread that knowledge to areas that really, really need it and to reinforce folks that are really trying to be better doctors and better providers. What sorta adoption rates have you seen? What sort of utilization? How have you seen so far?

(02:39) Joan Duwve:
So currently, at the Fairbanks School of public health, we offer two ECHOs. We offer a hepatitis C ECHO, so training providers to treat patients with Hepatitis C. We know that Hepatitis C is spread very, very efficiently amongst people who inject drugs and we’re seeing skyrocketing rates of Hep c across the state of Indiana. Previously only gastroenterologists or infectious disease docs were permitted to prescribe drugs to treat hepatitis C. So we really limited access to treatment for Hep C. Now we know that Hepatitis C eradication is, is possible.

(03:18) Joan Duwve:
If we were to get rid of Hepatitis C, then we wouldn’t be spreading it in communities. But to get rid of it, you have to treat people who have it. Drugs were very, very expensive. I think that’s why the, the access to them was limited. We actually were able to work with FSA and Medicaid to engage them in discussions around training providers to treat patients with Hep C using ECHO and we said if we’re able to get providers to participate, will you allow them under Medicaid to prescribe treatment for hepatitis c? And they said yes. So we were at that point just thrilled that we were going to be able to expand access and there’s a little box now in the prior authorization form that asks, are you an ECHO? Are you participating in the ECHO program? And it doesn’t have to be our ECHO clinic.

(04:11) Joan Duwve:
It can be an ECHO clinic from, from anywhere, but you’re, you’re working with a group who’s helping you understand, um, how to effectively treat patients. What’s best practice for treating patients with Hep c? I think overall we’ve, we’ve touched about 30 providers with our Hep C ECHO and not all of them are currently prescribing. We’re actually going to work with Medicaid to get that data to see who’s prescribing, who’s treating, but we have, we have several providers that have presented to us multiple cases and we know they’re treating them. We had one advanced practice nurse who presented a really, really difficult patient, a patient coinfected with Hep b, who was also using alcohol and I’m on medication assisted treatment for an opioid use disorder, um, and worked with her to get the patient the appropriate treatment for the patients hepatitis B and Hepatitis C, and to get the patient into treatment for alcohol use disorder while maintaining her on medication assisted treatment for her opioid use disorder.

(05:17) Joan Duwve:
Really complicated, and an advanced practice nurse is totally able to treat a patient like this, although historically has not been permitted to do it. So we supported that provider while she was treating this complicated patient and um, we’re starting to see some great outcomes. So yeah, we’ve had 29 participants for our hepatitis C representing 13 counties. We actually have one provider who joined us from Illinois. There have been 31 case presentations, so these are 31 patients that we have learned about. It’s all de-identified, so nobody knows, but everybody learns from these case presentations and you know, it’s kind of like takes you back to medical school and this is how we learned and it’s kind of fun. I think that I learned so much. I know our providers learn a lot and our experts learn a lot too.

(06:14) Joan Duwve:
And I, I’ll never forget, our hepatologists who’s really amazing, um, who, you know initially said, well, if somebody is using drugs, you can’t treat them for hepatitis C. it’s sort of the way things used to be done. And we were able to provide education for the hepatologist about why it’s important to treat people even if they are still using drugs to prevent ongoing transmissions to work towards hepatitis C eradication. So if you will, it’s like the perfect marriage of medicine and public health, Hepatitis C’s and infectious disease. And we have an epidemic and there are public health approaches to um, you know, eliminating hepatitis C. and so the only way we can do that as to work with medicine and it works best if we work together.

(07:01) Phil Lofton:
So tell me about the LGBT ECHO because that sounds super fascinating.

(07:05) Joan Duwve:
Yeah, yeah. We’re doing LGBTQ+ care ECHO and we’re partnering with the Department of Adolescent Medicine and the transgender health clinic at Eskenazi.

(07:15) Joan Duwve:
We know that people who identify as LGBTQ have higher rates of addiction. And so that’s how this all fits in with the addictions grand challenge. We’re really working on preventing people from who are at risk of developing addiction from developing addiction. And we know that if people get appropriate care, if they’re able to connect, if they’re humanized and they feel like they are valued members of society, they are less likely to engage in substance use. So we are really working to help train providers around the state. And it’s really cool. We have a pastoral care person who really is interested in learning more about how best to minister to these patients. So it’s a very, very interesting and diverse group of individuals. We have people who represent campus health from campuses around the state, we have primary care providers, we have behavioral health experts, psychologists, all who are caring for people who identify as LGBTQ.

(08:24) Phil Lofton:
So what are some of the ways that ECHO, provides information to providers in that specific way? Is it just educating providers on the specific health needs of Lgbtq plus individuals and that, or tell me more about this program.

(08:39) Joan Duwve:
Yeah, it’s, it’s that, um, you know, so what are the specific health needs, um, for this, this population, also how do we provide culturally appropriate and sensitive care , to any group of individuals who, who may feel a little bit sort of on the margins of society, how do we embrace communities, um, to, to make them feel like they’re valued and welcome. And a lot of that really is based on how we meet them, where they are and how we don’t have any preconceived notions. We ask questions and we are very open in hearing and learning from our patients, and then providing the care that they need.

(09:34) Joan Duwve:
And I think that just being welcoming, being kind is really, really critical to helping people feel comfortable accessing care and services that they need to stay healthy. We are going to be launching a pain management ECHO and pain management is again, one of those prevention ECHOes related to addictions. And then we’re going to be working with folks from the Department of corrections inside three prisons in the state of Indiana training peer educators.

(10:41) Joan Duwve:
And the beauty of this is that you are training folks inside the prison. Folks who you know, have done well during incarceration. And these are the individuals that get recommended by the people who work in corrections and then we’re going to train them to be peer educators inside the correctional facility so they can help educate their peers inside the facility about healthy behaviors and how to prevent transmission of things like hepatitis B, Hepatitis C, HIV. They’ll talk about substance use disorder, they’ll talk about healthy eating, they’ll talk about tuberculosis, they’ll talk about, you know, why it’s important to get a flu vaccine. Not only do we have this going on inside a correctional facility, peer to peer, but once people do get released back into the community, they’re trained, they have, you know, a skillset that they can use to get a job which hopefully will support them

(11:41) Phil Lofton:
But her work developing the ECHO’s isn’t her only effort with the IU grand challenges. She’s also recently wrapped up the 2018 Indiana public health conference, which provided educational and networking opportunities to public professionals from all around the state.

(11:54) Joan Duwve:
That was amazing. It was so much fun to plan. So this conference, we did a conference two years ago and uh, the theme of the conference was health equity and this year we decided that because we’re in the midst of the addictions grand challenge, we would do a conference that focused on harm reduction and this just became so much fun because we were able to present harm reduction from sort of multiple learning perspectives. So we were able to engage people who participated in the conference. We provided naloxone training. We had a syringe services mobile van that the Tippecanoe county brought to us.

(12:42) Joan Duwve:
We had a model safe injection site, just to kind of start the conversation, what does this look like? What does it feel like to dispel some of the rumors what happens in this space? What else did we do? I think those were the main interactive. I’m sure there was one other that I can’t remember. One of our keynote speakers came from the Boston healthcare for the homeless initiative and talked about some really innovative harm reduction services that they offer. And so we were able to learn a lot from him about their mobile homeless health initiative where they’re actually starting people on medication assisted treatment. Using this mobile unit, so the find them on the streets and they’ll engage in a conversation if people are ready. They start then. And then also they talked about a bathroom initiative that they have, knowing that if people use drugs in public, they’re often going to use them in a bathroom isolated.

(13:53) Joan Duwve:
And that’s where a lot of people are found, overdosed and dead. And so they created a bathroom initiative where an alarm sounded if somebody hadn’t moved in a bathroom for, for awhile, which was really fascinating. And obviously it’s, it’s something that they’ve just started and it’s not widespread yet, but I think it made a lot of people think about what were people are overdosing if they are, you know, part of the homeless community and how we might be able to, to identify and respond to those overdoses.

(14:27) Phil Lofton:
I love that, that train of thought too, because it expands this definition of WHO’s responsible for helping people. Right?

(14:34) Joan Duwve:
Right. Yeah.

(14:35) Phil Lofton:
Not just the doctor’s responsibility. It’s not just the community health workers responsibility. It becomes this thing that’s shared amongst the community. We all have to keep an eye out for each other.

(14:44) Joan Duwve:
Exactly. Yeah. It is cool. And I think that’s, I think that’s so true.

(14:48) Phil Lofton:
Towards the end of our talk, I asked Dr Duwve, just out of curiosity, why she’s chosen to dedicate such a big chunk of her career to fighting addiction.

(14:56) Joan Duwve:
You know, I, I grew up in the seventies and I remember there was a lot of drug use. I remember at my middle school kids being taken away by ambulance, right at the front door and I think I was deeply impacted by the effects of drug use.Even at that early age, I remember the stories about heroin, and just really had this feeling that, it must be an incredibly difficult addiction to overcome based on what I had heard and read. And then we didn’t see heroin for a very long time. I think the next thing I remember about heroin is being in medical school in East Baltimore, and watching drug deals on the corner right outside our medical school, one of the lab windows.

(15:59) Joan Duwve:
And then watching the levels of crime increase, and hearing about people overdosing on doorsteps. It just felt so out of control and unsafe to me at that point. And then fast forward to the early two thousands and two small kids and family here in Indiana. I’m in a suburb and I turned on the news one night and I saw a mom talking about her child who had died of a heroin overdose. And I can’t even describe to you the gripping fear that came over me when I heard that story because I just really hadn’t heard or thought that we would be facing a heroin epidemic again. Or that I would be the mother of two small kids trying to raise them in a world where this will continue to be a risk. And thinking a lot about how that was going to change the conversations I had with my kids.

(17:09) Joan Duwve:
And then a few years later practicing in practicing medicine in that small, in that community, I learned that one of my patients had died of an overdose. And this was a kid, a young man. He was probably in his early twenties at the time, who came in to see me periodically. He would talk to me, would bring me chocolate bars. I knew his family and the most loving family. And I had no idea that this was going on in the background and I to this day wonder what, how I could have known, what questions I could have asked where he got the drugs because it wasn’t from me. He didn’t get opioids from my practice. Other patients were. I don’t mean to suggest that I, I was not at all complicit in this whole epidemic. We as providers were, but not this guy. And when he died and when I learned how and why I, I grieved and became resolved that I needed to really be part of the solution.

(18:31) Joan Duwve:
And to understand what was going on. And then I joined the State Department of Health. It wasn’t a priority problem when I joined for the state in 2008 and it wasn’t until 2011, 2012 that I started to really pay attention from the state perspective. And at that point, I think I saw a statistic that showed a 500 percent increase in drug overdose deaths between 1999 and 2008. And I just said, it’s time to spring into action. Here we have a problem and states around us have a problem and we’ve got to do something. I was fortunate enough to have met some amazing people from the office of the Attorney General, um, so Greg Zeller at the time, and Natalie Robinson was the person who, who I originally had contact with and she herself was very, very interested in doing something together. The two of us with some other staff from the office of the Attorney General put together a task force and that task force, actually, we spread our wings really, really widely, to include as many people as we could.

(19:54) Joan Duwve:
So law enforcement and healthcare professionals, people with a history of substance use disorder, people who had lost family members, pharmacists, behavioral health care, many state agencies, and we actually really started pressing the conversation at the state level. So I think that once we started doing that, more people became interested, began to identify this as a problem, a serious problem that really needed some significant interventions. And we started asking the hard questions. What about Naloxone? You know, and I remember conversations when we first introduced the idea of expanding access to naloxone. The conversations when something like this, Oh, you’re just gonna encourage people to use drugs or why would we want to do that? And those were difficult comments to hear, but I understand, right? There was just not a whole lot of knowledge about addiction as a disease. And about the, the opportunity for people to get into longterm recovery, into really be positive influencers in this space in the state of Indiana. So we have come a long way

(21:25) Phil Lofton:
Music this episode was by Everlone. Our theme, and additional musical cues, were written by Monopod Infinity. 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.

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