Season 1
February 7, 2019

Episode 9: The Big 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:
When I was younger, I used to think of health like I used to think of car maintenance. You drive around, completely fine, and eventually something breaks, makes a noise or falls off, so you go to see a mechanic. Or a doctor, in the case of health. As I grew older, I learned that health is something that’s always being affected by the choices we make, and by the environments we live in. The personal health of me, Phil, was affected by things like the tap water I drank or the food I ate, of course, but the health of Phil as a member of a community was affected by so much more than that. Our community, and by extension, me, could have its health affected by the absence or presence of sidewalks, our proximity to grocery stores that sold fresh produce, the brightness of street lights, and a seemingly endless cavalcade of other factors. Those factors, as well as the clinical information of my community, kept in our doctor’s records, make up a more accurate picture of the community’s real health, and they help scientists, health workers, and policy makers figure out what interventions and programs should be rolled out in a given community.

(02:14) Phil Lofton:
All of that and way more is what makes up public health. This is the problem. I’m your host, Phil Lofton. Public health is a massive discipline that cuts across so many industrial and conceptual lines that it almost seems endless. As usual though the world health organization has a helpful model for trying to sum up the functions that public health executes. They say that the key functions of public health are providing leadership on matters critical to health and engaging in partnerships were joined, is needed, shaping the research agenda and stimulating the generation translation and dissemination of valuable knowledge, setting norms and standards and promoting monitoring and their implementation, articulating ethical and evidenced based policy options and monitoring the health situation and assessing health trends. In many ways, public health is interested in making sure that everyone involved, doctors, patients, policymakers, everyone has the best information and the clearest picture of the community’s health.

(03:27) Phil Lofton:
A couple of years ago, I graduated from the Fairbanks School of public health at IUPUI. During my time there, I was lucky enough to learn from Joan Duwve who taught a course on public health policy.

(03:36) Joan Duwve:
My name is Joanne Duwve, and I’m the associate dean for public health practice at the Richard M Fairbanks school of public health here at iupui.

(03:43) Joan Duwve:
In her career, Dr Duwve has worked as the chief medical officer and medical director for Public Health and preparedness for the Indiana State Department of Health. She’s had experiences in the clinical political, and academic arms of medicine, which gives her a really unique and extremely valuable voice in the public health arena.

(04:02) Phil Lofton:
This year, she’s been working on a few projects for the Indiana University Grand Challenge and addiction. She’s the director of the Echo Center, an educational outreach program to practitioners that aims to increase knowledge and improve outcomes and patient. She also wrapped up the 2018 Indiana public health conference in October, which brought together professionals from a variety of backgrounds to talk about strategies for reducing the harms of opioid use on individuals suffering from substance use disorder. When we met up, we talked about her work on the grand challenges but also about the reality of the crisis. It was an opportunity to look into some of the presuppositions some of us might have, do some fact checking.

(04:39) Phil Lofton:
One of the things that I’ve really been looking forward to kind of enlightening our listeners about or are looping back around with our listeners about is just the face of this epidemic. I think a lot of us probably have a deeply ingrained perception of what this epidemic looks like, right? It’s, it’s rural. These people are white, they’re poor. How does that square up with reality? What does the opioid epidemic actually look like?

(05:05) Joan Duwve:
I think some of your observations are correct. You know, in 2017 there were over 1800 hoosiers who lost their lives to this epidemic. And the counties with the highest overdose mortality rates are rural. Like Wayne County, Stark County Fayette County, Randolph, though they have the highest overdose death rates in the state, but urban and suburban communities in Indiana have also been deeply impacted. Marion County, for example, lost more people to overdose deaths than any other county in 2017, so that over 360 residents of Marion county died in 2017 as a result of this epidemic. Lake County. Lost about half as many as 150 residents. And so what starting to see is, um, the sort of changing face of the opioid epidemic. Originally, many people were prescribed opioids by their physicians and that was happening a lot in, in rural counties that were economically depressed. Folks who, who were unemployed, and really, you know, suffering from job loss and loss of community, if you will.

(06:29) Joan Duwve:
Now what we’re seeing is a bit of a transition. I think Indiana has done really well at regulating or educating providers about opioid prescribing. And now what we’re seeing is more a shift to drugs on the streets. Including what we would consider prescription opioids, but more in Indiana we’re starting to see the transition to heroin. And then fentanyl laced drugs. So fentanyl, heroin is cut with fentanyl, but also drugs that are not opioids being cut with fentanyl like cocaine and Benzos, xanax. And so we’re also starting to see an increasing proportion of people who are African American affected by this epidemic. And that’s the transition, if you will. I think the phase, the phasing of this epidemic, as we’re starting to see it,

(07:28) Phil Lofton:
We talk about that first phase of the opioid crisis kind of being this symptom of an economic collapse, right? There’s a loss of community, loss of job, loss of purpose. So what do you think has kind of led to this epidemic moving into urban areas?

(07:48) Joan Duwve:
I think it was always in urban areas, but not to the extent that we saw it in rural communities in a rural community, if you have a high rate of opioid prescribing and high rate of opioid overdose death, that pretty severely impacts the entire community because those communities are so small. And I think the epidemic it existed in absolutely existed in suburban and urban communities. But it was easier to not notice if you will, because the numbers of people who live in those communities are so large. But now I think what we’re starting to see is the epidemic has continued to grow in Indiana. Our numbers have increased every year, and you know, in fact, had a significant increase between 2016 and 2017 in terms of the number of fatalities.

(08:48) Joan Duwve:
And that’s not true in every state. There are states that are leveling off or even decreasing. But we haven’t seen that yet in Indiana. So I think that we’re starting to see the expansion of the epidemic and it’s becoming more visible in our urban communities.

(09:07) Phil Lofton:
Can I ask you why you think that while other states are starting to level off a little bit, do you have any thoughts on why Indiana, we’re just not being able to curb this or are you comfortable sharing your thoughts on that?

(09:19) Joan Duwve:
Yeah, yeah, absolutely. Um, there are, I think, different ways to address the epidemic, but when we’re talking about overdose deaths, what we really need to do is to keep people alive. Indiana has been very proactive in terms of naloxone regulation, allowing first responders to carry and to use naloxone, but also the lay public and you know, really happy that more and more people are walking around with the dose of Naloxone.

(09:49) Joan Duwve:
So if they see someone who has overdosed, they can respond and hopefully save a life. But one of the things that we know absolutely impacts mortality is access to effective evidence based treatment, medication assisted treatment, um, and those treatments include Methadone, suboxone or Buprenorphine is the generic of suboxone is the name brand, and now naltrexone which namebrand is vivitrol and Indiana has really legged behind other states in terms of access points for those medications. And that has happened for a lot of reasons. For example, access to Methadone is limited federally, so you have to be working in federally regulated Opioid Treatment program to prescribe Methadone, to treat addiction. And that’s really interesting because Methadone itself was the preferred drug on Medicaid’s formulary for the management of pain, so anyone who could prescribe opioids to treat patients with pain could prescribe methadone but not to treat patients for addiction.

(11:02) Joan Duwve:
So we set up this disparity and how we’re using the drug even though there’s, you know, decades worth of evidence about Methadone’s effectiveness and it’s been used, you know, across the country to treat people with addiction. So I think that the, the federal restrictions on who can prescribe and how, how drugs can be prescribed is one barrier. Um, then with suboxone or Buprenorphine, um, providers can, primary care providers can prescribe that medication in, in an outpatient treatment setting. Um, there were federal restrictions on prescribing buprenorphine or suboxone as well, and the, those exist continue to exist, but they have been liberalized a little bit. So it’s easier now to, to become, um, waived or to be a physician or a nurse practitioner who can prescribe those medications. But there are still limits in terms of how many patients you can treat. Um, so, uh, you know, that there are barriers to providing treatment for people who have substance use disorder in the medical setting, in the correctional setting.

(12:22) Joan Duwve:
It’s just a practice that’s not done in Indiana. There is so much stigma about using evidence based treatment, um, methadone or buprenorphine to treat patients and to treat people with substance use disorder, um, that it’s, it’s really not done in correctional settings at all in the state of Indiana and other states are starting to do this. So there’s more access to treatment in the medical setting, more access to treatment in correctional settings, and they are seeing decreases in mortality.

(12:58) Phil Lofton:
What do you think needs to happen in order to start bringing Indiana up to the level of those states to, to start bringing us to the place where we can see more evidence based practices within the correctional system, uh, where we can see a better use of Medicaid medication, assisted therapies and treatments for folks with addiction. Do you think it’s an issue of education or communication? Do you think it’s a policy issue? What do you think?

(13:26) Joan Duwve:
I think all of the above. You know, I would love to think that there were a simple solution to doing this. Perhaps the most pervasive problem we have in the state of Indiana continues to be stigma stigma against people who use drugs. We as a state t, we’re having a hard time coming to terms with the fact that a substance use disorder or addiction is a chronic relapsing brain disease. Now people understand that about, for example, smoking tobacco or about weight loss that you can struggle for many years before you get into treatment that you can be successful in treatment, but then you can relapse and this can happen over and over again before you finally get to the point where you’re able to not smoke ever again in your life, not use alcohol ever again in your life or to keep off the weight that you’ve gained. But this is harder for people to understand when it comes to addiction.

(14:34) Joan Duwve:
We like to describe people who use drugs as sort of weak or individuals who just make bad choices. It’s a moral failure if you will, and what this does is it effectively creates a barrier. If I’m a person who has a substance use disorder and I know that you think it’s my fault, um, and that you think I’m a bad person, I’m less likely to come to you when I’m ready to seek treatment, humanizing substance use disorder and people who use drugs is one of the most important things we as a state can do. And the Indiana Department of Mental Health and addiction has really made this a focus of their work to try to put a face with substance use disorder with addiction to describe how there is treatment.

(15:35) Joan Duwve:
It’s a disease, there is treatment and people can and do get into recovery and lead very happy, useful, productive lives. And I really think that we need to continue to spread the word and continue to talk about addiction as a medical problem with hope for recovery. And that’s probably the most important thing. Once we get there, then we can have all the discussions about if this is a medical problem, how do we treat it as a medical problem, how do we get patients into treatment, how do we prevent patients from dying or from getting infectious diseases while we’re working with them to get them into treatment and that opens the conversation up to all sorts of things related to harm reduction and saving lives.

(16:28) Phil Lofton:
It seems like almost the right way to handle substance abuse disorder and how to, how to treat that is kind of like you treat people like human beings. You listen to people’s stories, you, you be a face that they can empathize with and that they can feel safe with. Right, and that reminds me from, from the public health courses, just one of the reasons why needle exchange programs are so effective. Right? And why they can actually lead to treatment and healing for folks.

(16:57) Joan Duwve:
Right, exactly. And I’ll just say a word about that if I can. So syringe services programs. Really it’s how we like to describe them because they do so much more than give people needles and I think when we call them needle exchange programs, we really start focusing on the needle and on the one to one, so we do have laws that, that sort of prevent that one to one exchange. But if we focus on the syringe services program, all the services that are provided by these harm reduction programs, I think we start to see the benefits in terms of humanizing individuals, providing them access to care, meeting them where they are, and walking with them through their journey until they’re ready to get into recovery.

(17:43) Joan Duwve:
Keeping them alive, keeping them well, not only is beneficial to the individual, but it’s beneficial to the society as a whole. And that happens in so many ways, right? So even the simple fact of giving, giving people clean needles, we all understand that that prevents ongoing transmission of HIV and Hepatitis C. It also prevents infectious diseases, abscesses or endocarditis or heart valve infections. And what that does is it keeps levels of those infections, lower in communities. And it’s going to protect other people in the community, but there’s also a huge economic benefit to a community to keep people healthy every time you have somebody with HIV in a community that means that there’s a lifetime of treatment costs that go along with that. And the same thing with Hepatitis C, it’s an expensive disease to treat. Hospitalization for heart valve infections is really costly.

(18:47) Joan Duwve:
So we provide social benefit to the community. We provide benefit to the individual and we provide this huge economic benefit as well. But certain services programs do much more than that. So we’re already at a, at a positive, um, balanced socially and economically and in certain services programs. Actually the immunized individuals. So for example, we have a hepatitis a outbreak now in Indiana, in that hepatitis a outbreak has particularly impacted individuals who use drugs and individuals who are homeless. In communities with syringe services programs, the majority of individuals who meet those definitions are already immunized against hepatitis A. So in communities surrounding Scott County, for example, that don’t have harm reduction programs, there are hundreds of individuals who’ve been infected with hepatitis a and that can spread really, really quickly throughout a community. In Scott County, there have been five. That’s because the syringe services program meets people where they are, provides them with services in a safe space for those individuals, individuals don’t feel judged, so they’re ready to walk through the door, they’re ready to accept help.

(20:09) Joan Duwve:
The other thing I’ll say about Scott County is that we know now that over 200 individuals have access to effective treatment in Scott County for their substance use disorder. The treatment providers coexist. They are in the same facility with the syringe services program. So you walk through a door when you’re ready for treatment and somebody can take care of you, somebody can see you. That model has, is brilliant, right? Because if, if you’d walked into an emergency department with a heart attack and I said to you, come back in six weeks and then I’ll have somebody here who can treat you. You’d be dead before then in this same thing happens with addiction when people are ready for treatment, you know, offering them a service, then and there walking with them, getting them directly connected to that service can be lifesaving

(21:07) Phil Lofton:
Other than syringe services programs, which I’m so glad I know that, that, that new word for it now, that new title for it now because that is so much better, and that’s so much more inclusive. What are some other unique ways that we as a state have been combating the opioid crisis?

(21:25) Joan Duwve:
There are, there are initiatives that are being offered by our state partners at the State Department of Health and the Department of Mental Health and addiction. Our state medicaid providers also, there are lots of them, but they include making sure that that first responders and that individuals have access to Naloxone, working with people at the community level to help them collect their thoughts about what they need to do to move forward in their communities and providing them with data and with best practices to choose from. So that communities can truly have a community oriented approach and there has been a huge initiative to increase access to medication assisted treatment. Working with providers and communities to expand opioid treatment programs, so access to methadone, and that continues to happen. And then working with providers to get them trained and supported if they should decide to, to provide buprenorphine in their clinical practices.

(22:44) Joan Duwve:
The whole humanizing campaign has been ongoing that has occurred at the state level, but anyone at the community level can actually get a readymade presentation online and can take that and share that with members of their community. I know the state has been working with faith based partners to help them understand the impacts of the addiction crisis in their community, but also to help lead them to how they can participate to become part of the solution. And I’ll go back to Scott County and we saw a tremendous response by the faith based community in terms of providing transportation for folks who needed medical care or treatment. Providing food, there has been a huge outpouring of support working with first responders and law enforcement I think is a critical area of need. We ask a lot of our first responders, we ask them to administer naloxone every time they’re called for an overdose.

(23:57) Joan Duwve:
They walk into situations that over and over again, you know, really have a tremendous impact and it’s time to really get with first responders and to have a conversation and to understand how this epidemic has impacted them professionally and also personally, and to provide them some support. And I don’t know what that looks like. It’s going to be part of the conversation and it may be a little bit tricky, um, understanding how much we need them and how important they are in terms of saving lives. But also I’m coming to grips with their realities on the ground day after day.

(24:42) Phil Lofton:
So kind of in that same vein, one of the really hazardous things that has been a development in the, in the last couple of years with the opioid crisis, we touched on a little while back, the emergence of drugs laced with fentanyl. And that poses a serious, serious risk to anyone trying to administer care when that, that fentanyl is present, correct?

(25:03) Joan Duwve:
No, I think that’s an overstatement actually. Glad you asked that question because I’d really like to dispel that myth. Um, fentanyl, you know, fentanyl is a prescription opioid as well. And there it’s very difficult to get fentanyl to absorb phentenol, transcutaneously. In fact, there are preparations that, you know, patches, that people use when they’re having hospice care or care for their cancer pain. And those patches you put them on, but you don’t get the effects of the drug for days, or, you know, maybe maybe a day, 24 hours, nonetheless, it’s not immediate. Um, so, absorbing fentanyl through your skin is a fallacy. A powdered fentanyl is not easily absorbed through your skin. Now, would I want to play in powdered fentanyl without gloves on, absolutely not, but it doesn’t pose a risk during a resuscitation.

(26:08) Joan Duwve:
You just, if you don’t have gloves on you, first of all, I would suggest that you have gloves on but if you don’t have gloves on. You just wash your hands.

(26:17) Joan Duwve:
Over the last few years. Are there any interventions that you’ve seen us rollout that maybe when we were rolling out we thought, yeah, this is going to be great. This is really gonna make a dent in it and they just haven’t really had the efficacy that we thought they would?

(26:30) Joan Duwve:
Well, I think that, um, and I’m not sure these are, these are sort of new interventions, but let me just take a step back to interventions that have been used to treat other types of addiction. So 12 step programs and recovery housing for example, which have existed for a long time, 12 step programs were developed to treat patients with alcohol use disorder. And I think they have had some success in that realm.

(27:03) Joan Duwve:
What we know with opioid use disorder is that it’s a really difficult disease to treat and the best way to treat opioid use disorder is using medication assisted treatment. And unfortunately, historically, 12 step programs, really would not allow people who are using medication to participate. This is starting to change, which is a really good thing, but the system that the program is really centered around abstinence and can be very, very difficult for people who are on medication assisted treatment, which, which is unfortunate because medication assisted treatment is just that. It’s medication, but assisted by recovery supports by behavioral health interventions, and that makes it work better. It makes it stronger.

(28:00) Phil Lofton:
The crisis is still ongoing in some ways. It’s getting better in others worse, but to effectively fight the crisis, we always have to be looking at the facts, the reality of what’s working and what isn’t. And we have to share that information with others.

(28:16) Phil Lofton:
Join us for a special bonus episode next week as we look at Dr Duwve’s projects for the grand challenges, which are all focused on spreading information about the opioid crisis to the people who need it most. Hear it here on the problem. Music this episode was from Broke for Free. Our theme and additional musical cues in this episode were written and performed, as always, by Lil’ Newt. 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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