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Episode 10: The Pills

Pharmacists will play a crucial part in the effort to end the opioid crisis. Learn about how they can be part of the solution.

Transcript

(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:
So far, in the episodes of this season, we’ve talked quite a bit about the way that opioids can impact all aspects of a person’s life. What’s more, we’ve talked about how experts in those disciplines have used their specific viewpoints of their disciplines to try and fight the opioid crisis. What we haven’t done though is look at it from one of the most important perspectives. The pharmacist’s.

(01:35) Noll Campbell:
Noll Campbell. I am an investigator with the Center for Aging Research Institute. I’m also an assistant professor with Purdue University College of Pharmacy,

(01:45) Phil Lofton:
And when you’re talking about a national level prices that centers around a class of controlled pharmaceutical substances that simply will not do.

(01:53) Noll Campbell:
Welcome to the problem. I’m your host Phil Lofton.

(02:07) Phil Lofton:
so first and foremost, it’s important to get on the same page as to what the duties and functions of a pharmacist actually are.

(02:15) Noll Campbell:
So pharmacists can be a great resource for education to the patient, but they also can be and I believe need to be supported in their role as identifiers of potential behaviors. Abusive behaviors. Pharmacists have the ability to communicate directly with physicians who might be multiple physicians who might be prescribing narcotics that to make sure they’re aware of what each is doing to recognize when risk is high and pharmacists are really at a nice intersection to be able and have a great opportunity to be able to influence the care of pain management in the state.

(02:50) Phil Lofton:
Pharmacists provide invaluable information to patients on how to properly take their medications and they advise doctors on medication therapies and they can play a pivotal role on the personal and systems level in fighting the crisis. We’ve talked a little bit in past episodes about how opioids impact the brain, but when we’re looking at the issue from a pharmacist perspective, it’s a good time to refresh your memories a little bit.

(03:13) Phil Lofton:
As a pharmacist, can you tell us how do opioids interact with the brain?

(03:18) Noll Campbell:
Opioids work at primarily immune receptors, although there’s some other subtypes of subtypes of mere receptive or other types of like kappa and Delta receptors that follows similar, a pharmacodynamic or pharmacologic interventions where they are intending to be used for analgesia. So they actually limit the activity of a pain signaling in the brain to limit pain.

(03:45) Phil Lofton:
Okay, now that is really, really clinical. So let’s unpack that for a moment. Basically, there are receptors in your brain that opioids latch onto now that triggers the pain relief function of opioids. That’s the analgesia that Noll’s talking about, but there are other receptors that the opioids latch onto as well. And when they do, it causes other effects like constipation and slowed breathing.

(04:08) Noll Campbell:
Those receptors also exist throughout the body and they can also have effects that can affect the gastrointestinal system, cardiac system, um, and produce some of the other symptoms that you could identify among users who are maybe using too much is typically when you might see some of those symptoms or they’re also known as common side effects.

(04:29) Noll Campbell:
So that’s typically how we, what we would call side effects. And that’s really just the drug working at other receptors throughout the body that the drug doesn’t know where to work. So it works everywhere. And uh, those, those are what often oftentimes what we call it side effects. So some most common side effects for opiates or opioids can include what we call respiratory depression, so it limits how quickly you’re breathing, can cause sedation, it can cause a low gut motility, which we oftentimes described as constipation, but it slows down how quickly kind of just slow down how quickly things work in your body. So the advantage of that from pain symptoms is that it limits how quickly the neurons are firing to indicate pain, but it can also slow down how other things are working, like your gut, like your brain from a perspective of consciousness.

(05:21) Noll Campbell:
And so sedation is also another symptom that we think of that comes along with Analgesia that, that this group of medicines provide. So interestingly though, one of the other mechanisms of, of the opioids that’s not particularly as well defined, so opioids have direct effects on cellular interactions or neuronal receptor interactions to know that. So we think that the drug itself works on how neurons talk to each other, but they can also affect how other neurons talk to each other. So other neurons being a adrenergic neurons, neurons with neurotransmitters, including Serotonin, norepinephrine, and they can affect how other neurons are talking to each other and that includes dopamine and so one of the things that becomes concerning about a pain medicine is how much dopamine it releases and that dopamine is kind of like a reward neurotransmitter, so opioids actually have a significant effect in releasing more dopamine into certain areas of the brain that make it feel like a reward that produces a euphoria and that produces an effected. A lot of people want to feel and leads to leads down the pathway of addiction and dependence and it’s to understand further the body’s ability to desire that activity or that feeling. I don’t know that as well, but we do see, and that’s part of the reason we’re talking about this. Part of the reason we have this problem is that there is a profound effect of dopamine on or the body’s desire to to pursue those activities that it finds rewarding.

(06:54) Phil Lofton:
So kind of going down this rabbit trail of just how the opioids actually affect your body. I want to loop back around to the chemical reactions and I want to just unpack for our listeners: how do you actually die when you overdose on opioids? What is the mechanical reaction that occurs in the body or the chemical reaction? I’m sorry, that occurs in the body?

(07:15) Noll Campbell:
Yeah, it’s a good question. So most often from an overdose of an opiate, most often the damning issue if you will, is respiratory depression. So the significant amount of narcotic and you’re in your body and your brain primarily in your brain is a depression of the body’s desire to seek, to breathe, the the intent of the body’s desire to bring in oxygen which the body needs, and so narcotics or opiates do suppress that body’s desire and so breathing tends to become shallow breathing tends to be become less frequent than what it needs to be. So we think about 12 breaths per minute is about the threshold through which less than 12 breaths per minute is oftentimes an opiate induced feature. And that can come as your breathing starts to slow in some people that comes with what’s called pulmonary edema or a buildup of fluid around the lungs. And sometimes, you know, the mortality is complicated by that. Sometimes it’s not. And that’s usually a result of the mechanics of air exchange. And in the lungs.

(08:28) Phil Lofton:
In Indiana we’ve had some big successes with the rollout of a program called inspect. Inspect is a prescription monitoring tool that helps flag behavior associated with opioid abuse, like doctor shopping where patients go from doctor to doctor to accrue more and more opioid prescriptions. It’s not perfect and historically it hasn’t been mandatory, but new legislation signed into law last year is gradually remedying that. What are some other interventions that we’ve used?

(08:54) Phil Lofton:
What interventions have proven effective so far in the pharmacist’s profession?

(09:02) Noll Campbell:
So when we use the language of proven effective, I think that the literature is still fairly young in my opinion. There, uh, there are a number of government mandated state mandated requirements that have been made about the way that opiates are prescribed and we’re just now beginning to learn about what the impact of those policy driven initiatives have on prescribing patterns for opiates. With that said, pharmacist involvement in the space of opiate prescribing is still fairly young too. And I use, I like to hold myself to a higher to a pretty objective evaluation metric. And so I don’t want to comment on something that sounds like it was a good intervention and it makes sense and makes logic, but it doesn’t end up resulting in a significant clinical benefit where we want that clinical benefit to occur. And I’ll give the example of a project in Washington that was recently published where the state medical society required as many states have done, Indiana included, required restrictions on prescribing and so limited in the number of prescriptions instituted restrictions on quantity. They restrict the institutional restrictions on how many providers could write for a particular patient. And what they found was they reduced the number of prescriptions written in the state of Washington and the patients in the population studied compared to those who, compared to those who were not seen by those providers who instituted those changes. So this was like it was actually a healthcare system specific intervention. And so what they found was they were successful in reducing the number of prescriptions and the dose of opioids prescribed overall. But their intention was to reduce the number of diagnoses or the evaluation included the number of diagnoses of opioid use disorders.

(11:12) Noll Campbell:
So that’s, that’s really a diagnosis of a continuing substance abuse problem and they found that among those who among those providers who instituted those change among patients, seen by those providers who instituted those changes versus providers who did not institute those changes. There really wasn’t a significant change in the diagnosis of opioid use disorders. Now, like any, any study that’s compromised by the limitations of the metrics and the and some of the limitations of the study and the way they conducted it. But it also tells us that although we might be limiting the number of many of the many of the activities that can be taken on by physicians, by pharmacists. Many of the policy or recommendations or guidelines, many of those restrictions may reduce process measures, but they may not reduce clinical outcome. And that’s why I want to hold myself to some of those outcomes.

(12:06) Noll Campbell:
So there are a number of pharmacists based initiatives that had been attempted. So pharmacists are actively becoming more actively engaged in emergency rooms where they have an initial influence on pain assessments, on looking at medication histories, narcotic or opioid histories particularly and using that information to inform what the next steps are in pain management. I’m a pharmacist, have for some time and continue to grow in their roles of managing postoperative pain and using a multimodal strategies to manage postoperative pain and not just relying on an opiate or a narcotic to manage post operative pain, but using multiple sources of pain management and really setting, using education to set expectations and set goals from a patient perspective of what do we hope that pain management does for you? What are the risks? What’s the time period through which we’re going to use these pain medicines and to tell people who are new starts, tell patients who are new, starts to opiate or narcotic use. How long do we think we’re going to need these? And setting the expectation upfront that we’re not going to use these for the rest of your life. We’re not going to achieve a zero pain scale for you. For a chronic pain measure or maybe we are going to for a short period of time, but we have to expect that if we have to have a reasonable expectation for these medicines, and in letting people know here are the potential side effects and especially if you’re using these above x doses or if you’re using these longer than this duration of that duration, then there are risks of dependence and abuse that become not uncommon and that’s where pharmacists can have an impact that seems logical. But the question that I still have and I think that I would like to see studied and published is what, what does that impact have on not just the number of prescriptions written, not just the total dose of prescriptions written, but the number of people who, who might be diagnosed with an opiate use disorder because that’s the real statistic that matters.

(14:13) Noll Campbell:
And it’s really difficult I think, to tease out the appropriateness of opiate use. And I think that’s, that’s still a challenge. And we have that challenge in geriatrics. We have that challenge with a number of other fields that whether something is appropriate is oftentimes a matter of opinion and to one person it might be different or to one person who might be appropriate to another person that might be inappropriate and I think that’s one of the challenges that we face, but I think it gets around the point that we have a problem with an increasing number of complications from opiate use in our in our society and that needs to be addressed. The pharmacists are very accessible and they can be such a great resource and some of these interventions that have been required by the state, particularly in Indiana and the availability of the prescription monitoring programs offer tools for pharmacists to be more engaged in the opiate monitoring process.

(15:07) Phil Lofton:
So where do you think the profession is headed with regards to how they’re going to help combat the opioid epidemic? The opioid crisis?

(15:18) Noll Campbell:
Yeah, it’s really good question. I think obviously from multiple sources, the problem has been elevated and we appreciate that and I think one of the things that elevates it as is the support offered through the state, through the government to put dollars behind finding solutions. One of the things that frustrates me, and this is I’m saying a little bit more, this is what we shouldn’t do. One of the things that frustrates me is when we just, when we develop education and awareness campaigns to say, here’s a problem because we’ve seen time and again, how education alone doesn’t change behavior. And I, and I am hopeful that we just don’t rely on education campaigns and we aren’t seeing the number of different techniques being used from a policy perspective to try to influence behavior change. And I see this problem as requiring solutions from behavior change. And I hope that we pay more attention and invest more dollars in behavior change solutions than educational and awareness campaigns. Now, I think in the, in the eyes of mentors and colleagues, education and awareness is necessary but not sufficient for a problem like this. And I believe it’s important to explain to people why we need change, why we need to introduce elements that, that suggest behavior change or that support behavior change rather than just telling people we have a problem and expecting them to behave differently. But we’re learning significantly that if we modify, if we produce small changes in the way that we behave, that they can have significant impact on the outcomes that we’re trying to change. And we’re learning that as an example.

(17:10) Noll Campbell:
We’re learning that and some of our work in completely different drug targets, but we’re trying to compare what the influences of policy change versus behavior changed. Little nudges we call them from the field of behavioral economics and behavioral science and how, how those two different strategies might affect the way that we prescribe certain drugs. And they’re really interesting comparisons that will hopefully be able, to compare in the coming years in that we think of policy change, policy based change in some of the changes in requirements of, of how we prescribe opiates and some of the restrictions there. And some of the reporting metrics that we require. Those are a lot of those are driven by policy, by state medical societies, and even beyond that, we are interested in experimenting with smaller level change that that changed the waste of prescription order written that might change the number of drugs that are limited, that lean on some of the behavioral change techniques, including setting societal norms including setting defaults so some of those little level changes or minor changes and developing interventions based on those changes are a very interesting way and have been successful in other fields of changing the way we behave and so I’m really interested in comparing whether a policy changes required to change prescribing behavior or whether we can change prescribing behavior through nudges.

(18:45) Phil Lofton:
What do you think that might look like for doctors or for clinicians?

(18:50) Noll Campbell:
If we think about how we, how we, how we set our behaviors now, a lot of times it’s set about through the path of least resistance. Whatever’s easiest and quickest is how we do. We call that to some extent type one level thinking and type two requires a little bit more thought and our habits follow the type one, what’s easiest, where they don’t think about it. So we follow that pattern and behavior and so what we need to do is try to set out set about our behaviors instead about our routine and a lot of times we’re looking at the electronic medical record system through which we are as a potential source of intervention for these types of behavior. Let’s make it as easy as possible to do what we think is more of the right thing and make it as hard as possible to do more of the wrong things.

(19:38) Noll Campbell:
So let’s say I wanted to prescribe a really high dose of an opiate for somebody who I would do that if they’ve been on it for a long period of time. I’m going to try to make it as difficult as, as someone who might be using an electronic medical record to write that order. I’m going to interrupt them a fair amount, like six confirmation screens. I’m going to run some popups in there, and I’m going to make them cross reference and make them calculate maybe by hand what’s your total daily morphine equivalent level and did you know, check this box to make sure you knew that the intent is not to prevent people from doing what is appropriate for patient care, but the intent is to direct people more towards a safer practices of patient care.

(20:22) Phil Lofton:
It is undeniable how crucial the input of pharmacists will be in solving the opioid crisis, and again, this comes back to this key role the pharmacists play within our healthcare system, advising both the patient and the doctor of unintended outcomes of pharmaceutical interventions. If we’re going to make effective policies both legislatively and organizationally, that curb over prescription of opioids, the voices of pharmacists are going to be instrumental. Join us next time on the problem for an in depth discussion on Indiana state policies with some big shakers and movers, including Deputy Health Commissioner, Pam Pontones chief data officer, Darshan Shah and executive director for drug prevention treatment and enforcement. Jim mcclelland, you really, really, really won’t want to miss this episode. We’ll see you then on the problem.

(21:11) Phil Lofton:
Music this episode was from Everlone and Broke for Free. Our theme and additional musical cues in this episode were written and performed, as always, by Seven Frustrated Hoosiers. 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 Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at Regenstrief.org/theproblem . 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.

Bonus Content

How opioids work:

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.

Transcript

(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 Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at Regenstrief.org/theproblem . 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.

Bonus Content

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.

Transcript

(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 Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at theproblem.regenstrief.org. 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.

Episode 8: Robbie

What does it take to overcome opioid use disorder? In episode 8 of “The Problem”, follow the journey of Robbie as he recovers from addiction and finds a new passion.

Transcript

(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.

(01:12) Phil Lofton:
Hey guys, it’s me, Phil. Before we get into the episode, I want to give you all a heads up on some things. This week’s episode is so important. It’s the story of a man named Robbie about how he got into opioids, about how he recovered and about how he stays clean. It’s a story about the place he works, a really unique nonprofit that helps people learn valuable skills. It’s a story with a happy ending, but there are some serious dark spots on the way there. This episode features some candid discussions about depression, self harm, and suicide, so I want you all to be aware of that. Now, again, having said that, I think that it’s an absolutely vital episode because at the end of the day, everything that we talk about before and after this episode comes down to helping people avoid opioid use disorder. Welcome to The Problem. I’m your host, Phil Lofton.

(01:57) Phil Lofton:
Robbie’s story is about chance encounters about those moments where things line up perfectly and everything. Somehow, some way it goes right. The morning I met Robbie and Margaret, it felt like everything that could go wrong was going wrong. Seriously. My phone had broken the night before. I printed out directions to Purposeful Design, the nonprofit where I was supposed to meet both of them and I reserved a car from the Indianapolis Electric car share online at my computer. Of course, I discovered halfway through the ride that I had forgotten the printout of directions and with no phone and no clear map. I returned the car to a station about a mile away from the destination and began walking towards where I vaguely remembered Purposeful Design to be on my way. I was thinking of everything that could go wrong, tripping and injuring myself with hope of contacting help, getting hopelessly lost, having a missed cancellation email. Then I arrived. I met Margaret, Purposeful Design’s director of sales who explained the organization’s mission to me.

(03:11) Margaret:
So we started in a sweet little church right down the street here and building beautiful furniture like you see here in the showroom. We use solid wood and then also lots of metals for the basis of things. And we had five men working for us and now we’re up to 14. So God’s really blessed us. So, we hire our men mainly through Wheeler Mission and we have two craftsman that work for us who are their supervisors, who don’t have the same background as the other men. They train the men and mentor the men. And so several of our team members have been here from almost the beginning, about four of them, so they’re very skilled at their craft. And so our prayer is that the men want to stay and we just give them raises and promotions and that kind of thing because we want them to get better and better and better.

(04:09) Margaret: 
And you can see it, it reflects in the furniture. The furniture is really, really beautiful. Yeah. So, um, our main mission is to spread the Gospel and mentor these men. And um, we also started something called the school of woodworking and discipleship, which we’re really excited about. And so what we do is anybody that’s hit rock bottom or anybody from Goodwill, Salvation Army, any of the local outreach programs, they can send people to this school. It’s a 30 hour program where the attendees are, um, taught woodworking. Some of our craftsman teach them, also volunteers, discipleship. So we teach them about the Lord. And then we also have job readiness taught to them. So people volunteer from local businesses may come and teach them that. So it’s really exciting. We’ve had four classes and of those four classes I, I’m not sure the quantity of men I can get that information to you later.

(05:12) Margaret: 
I want to say it’s men. And we had our first woman, which was really exciting, but 90 percent of them graduate and then we have companies lined up to hire. I’m sure. So yeah. So we partner with salvation army, goodwill, um, and several other companies who, who will hire these people and then, you know, that’s one step. They’re just looking for a job, right? So it’s just, it’s really a great program and we believe that you have to change a person’s heart first before anything else. And the Lord saves, and that’s for sure. So let’s see if we can come over here.

(05:49) Phil Lofton:
After our tour, she walked me into a conference room, let me set up my gear and then sent in Robbie. Robbie’s a thin man with big eyes and a beard to match. He’s friendly and he was immediately ready to talk about anything from the shop to his past. This is his story.

(06:08) Robbie:
It makes me happy. I don’t mind coming into work everyday. I wake up in the morning and I feel good about what I’m doing. Feel good where I’m doing it. I mean I jumped off an overpass running from the police. That’s where I did that and I crushed my ankle and I never did get it fixed. Couldn’t go to the hospital because you know, I, I was running from the police and my ankles about that big around [gestures to ankle]. Gashed my eye. I had knee high socks on. I jumped off the overpass. When I did, this leg gave out, Bam. I hit the concrete divider there. I ran. After I did it, ran. I hit this bench and just fell over it. Took my shoes off. I took my socks off and I knew my head was cut, and my blood’s running into my eye and I was wringing blood out of these socks and after that I’ve had, I’ve had a lifetime of pain. I’ve been in pain every single day since I’ve done that, you know, and it was more of a pain thing. I had to climb ladders. I got to climb up and down ladders for living on roofs for a living, you know, with a broken ankle and being on a roof and hurts. No, I got on the opioids and uh, they did away with the opioids. So I got on. I wasn’t spending what they wanted for the pills no more. I got tired of so I went and got on the heroin.

(07:47) Phil Lofton:
How did you, how did you come to Wheeler Mission?

(07:58) Robbie:
Back then, I was on my dad’s couch. I ended up quitting my job to get off the opiates to get off the heroin. So I quit my job. My Dad said, hey, you know, you can live here. Oh, you know, he’s buying me my pack of cigarettes in my every day, you know, and it just, it was just overwhelming. You know what I mean? There I was living for nothing and I wanted to die every day. First thought, the first thought that popped into my mind every day is how much I hate this life, how much I wanted to die. One day I just had enough and I packed my backpack. My Dad was taking my brother to the dentist on Washington Street, so I packed a backpack and told him to drop me off at the dentist’s office and he got to the dentist’s office.

(08:59) Robbie:
I got out of the truck and I just started walking, didn’t know what I was going to do, didn’t know where I was going, but something either something was gonna happen for me to live my life, or I was going to die. One of the two. I didn’t bring my wallet too. I didn’t want them to identify the body.

(09:23) Phil Lofton: 
So where’d you go?

(09:26) Robbie:
I got out of the truck and I just started walking. I seen Good News Mission. They turned me away. So I thought that was the end. You know, I was going through downtown thinking about what I was gonna do. Didn’t have no money, no place to stay, no phone. Even if I had phone and nobody really wanted to call and you know, I was just ready to lay down on the railroad tracks and then I saw Wheeler Mission and it’s like, why not just give it a shot?

(10:04) Robbie:
And they accepted me. They, they took me in and that next day I went and seen the counselor and the counselor heard my story, everything I was going through and he said, uh, well you’re a perfect candidate for this program that we have: the STEPS program.

(10:29) Phil Lofton: 
What is the STEPS program?

(10:31) Robbie:
The first three months you’re in there, you don’t work. You did learn. You learn life skills. Really, about Jesus, about God, about a deeper purpose in life. You had to have something with and you know, trying to put yourself back together so you don’t fall back into the same thing that you used to be in it. It’s just the program to, to make you better, you know? It’s amazing. Yeah.

(11:20) Phil Lofton: 
It sounds like you think the work that you do, they make you take off work so that you can work on yourself.

(11:26) Robbie: 
Yeah. Yeah. They didn’t want us to do work for the first 90 days. I thought it was kind of strange, you know, but they just have everything. Yeah. Clothes, food, everything. In my whole life I went through, I think it nobody cared. You know, what to do now. What are you out there? Who, who catered at all and then I, I get into this place and they’re just, you listened to us worth this program and we’ll take care of everything. We just want you to know about t plus we want you to know about that.

(12:15) Phil Lofton:
Who was kind of the, the main person there, during the steps program. Is there one person that was kinda like your, your, your main point of contact during STEPS?

(12:24) Robbie: 
Well, my counselor, but there was one guy and I was tore up the first day I got in there. I was just, I didn’t know if I wanted to be there. I, I knew I didn’t want to be there. Not at that time, I just wanted to die.

(12:48) Phil Lofton:
So why did you stay?

(12:51) Robbie:
This guy took me out in the hallway. I’m bawling. Crying is, I know what to do, man. I, and he told me, he said, man, just stay here today. Stay here tonight, just cool down. If you want to leave tomorrow, then leave tomorrow, so just don’t leave tonight. So I sat there overnight. I talked to him and I talked to some of the other guys and, and realized, you know, my dad always told me I was here for a purpose because I’ve been through five or six near death experiences I shouldn’t be living. Yeah. But for some reason I’m still here.

(13:37) Phil Lofton: 
What was the recovery process like for you?

(13:44) Robbie: 
No, it’s terrible. It really was. I went to Valle Vista. They, they helped me detox, you know. So the detox was bad, don’t get me wrong, but Valle Vista took the edge off of it. I was on suboxone for a week or so. They usually keep people three days, four days. They kept me for two weeks. No, but they knew that I was just, I was at the end of my road and I had been for a lot of years and you know, I, I just don’t think killing yourself as is the right thing to do. I mean, it’s why I always try to. No, not directly do it, but still get it done. Right.

(14:46) Phil Lofton:
Is that how some of those near death experiences happened?

(14:49) Robbie:
Yeah, because I never, I mean, you don’t fear death. What do you fear? Right. No, nothing. I’ve never feared anything. No. As you know, being a painter, I’m 40, 50 feet in the air, hanging off ladders and everything. I mean there’s just no fear.

(15:16) Phil Lofton: 
How did you come to be involved in Purposeful Design?

(15:20) Robbie:
It was through Wheeler Mission. I was in their first school. Wheeler, one it’s s homeless shelter, the homeless shelter. But I was on the market street. That’s where I first went into and I was not going to be able to handle it there. I just couldn’t do it. I mean, I, I needed out of there that next day I went and talked to the counselor. He said, you’re perfect for this program, this and that. He said, I want you to talk to this guy. They had me out of there in two days and it usually usually takes people four or five months to get from Wheeler One to Two. The programs building. There was always somebody there that knew what to say to talk me down.

(16:13) Robbie:
Yeah, and in my life that I started feeling real bad, you know, like I wanted to die. Then my brother has a son and that’s my nephew and he’s like a son to me and I adore this kid. He kept me alive for years and then he moves. I get down on myself again and my other brother has a daughter and she, she kept me alive, you know, all this stuff just kept happening to do keep me going, you know, and I don’t know how to explain it. It’s just, there’s no explaining it. I kept having stuff put in front of me that you know, you. There’s a reason.

(17:14) Phil Lofton:
How did the steps program lead to Purposeful design.

(17:17) Robbie:
The class.

(17:18) Phil Lofton:
Gotcha.

(17:20) Robbie:
Yeah. I was only in, I wasn’t signed up for the class, but this buddy of mine said that “you might be interested in this class that that’s going” on because I wanted to do everything.

(17:39) Robbie:
I wasn’t wasting no time. I mean they gave me this opportunity. I was going to do everything that I could to change my life around. You know, I, I was ready for change and he tells me about this woodwork in school, you know, and why not? What have I got to lose. Yeah. So I came in and I met everybody here and the shop manager, Justin and me just got along. I mean, just Bam and uh, went through the class, got outstanding marks through the whole class. I mean, I had a good attitude, did all the homework, participated in class. My cutting board was nice. I made a nice cutting board and uh, you know, the class was ending. The three guys that were with me found jobs and I was reaching the end of my, my 90 days I had like maybe two and a half weeks left at the end of the class and the goodwill lady came and was trying to find me a job and I went.

(18:50) Robbie:
Justin called me in his office one day and he says, don’t leave here thinking that you might get a job. He said, Oh, you got to do is call me. I’ll put you to work. So I went back. I talked to my counselor. I said, Purposeful Design wants to hire me. He said, oh, well you must have done a good job. He’s in, but he let me go two weeks early out of the steps program.

(19:14) Phil Lofton:
What’s the shop like here?

(19:16) Robbie:
Uh, it’s a great atmosphere. I make people care, you know, we get our work done and you know, if we have a problem, if there’s 10 people to go to, you know, everybody watches your back and you know, if they think something’s wrong and they’re going to tell you about it, you know.

(19:38) Phil Lofton:  
So was there a moment as a part of this process where you were like, okay, I, I can do this, I’m going to make this happen. God’s going to help me make this happen. Like what, what? Was there a moment like that for you where you were like, okay, this is gonna, this is gonna take, this is going to work. When, when was it?

(20:01) Robbie:
Probably three days into the program. Yeah, three or four days.

(20:04) Phil Lofton:
The STEPS program?

(20:05) Robbie:
Yeah man. Yeah. You know, Mike asked me, he said stay. So I stayed the next day. Wasn’t really, you know, into it, but I’m going to try this, you know, we woke up in the morning at 6:30 a breakfast, then we had quiet time 45 minutes in the morning where you just sat with your Bible, did your journal. How I felt. How I feel right now. Your put offs, your put ons, you know, stuff like that. And uh, we had class from 10 to 1145, so 10:30 to 1145 something and one of the counselors would teach a class and it was all a Bible based and it was funny that I ended up not knowing, not knowing where I was going to go, not knowing what I was going to do and stumble onto the exact thing that I needed. And I didn’t. I just ended up on your doorstep here. I ain’t got to climb ladders and there ain’t in a lot of pain. My life ain’t pain anymore. You know, I don’t wake up hating life anymore. I don’t need to escape anything anymore. You know, I want to wake up in the morning, I want to live my life, y’know?

(22:01) Phil Lofton:
After Robbie and I wrap up, he leaves and gets back to work. There’s always another table or bench to make and he’s excited to do his part and getting it out the door. I stick around for a minute, looping back with Margaret debriefing and grabbing another cup of coffee before I go on my way back to the electric car share station. I think about how crazy it is that everything perfectly lined up for Robbie to wind up where he has being at the right shelter at the right time, making the friend that kept him in the steps program. Justin overhearing him talk about needing a job then because how could you not? I think about the 757 people that died from opioids in Indiana in 2016. I wonder because how could you not about how close they might’ve gotten having things line up perfectly to get them out of addiction. Would they have met the right person if they had overdosed in the right place near someone with Naloxone, but then I think again about Robbie because for him it did line up and I think that even among the countless people who didn’t make it out of addiction or who are still struggling, this one person did and that needs to be celebrated because why would we keep doing anything that we’re doing? If at the end of the day we can’t help get that one person out of trouble or if our treatment centers and our nonprofits can help keep that one person out of trouble. So I celebrate it and I keep walking. Thinking of the man who recovered. The man who found his place.

(23:27) Phil Lofton: 
Music for this episode was from Everlone and Broke for Free. Our theme and additional musical cues in this episode were written and performed, as always, by Mrs. Elodie Hess. 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 Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at theproblem.regenstrief.org. 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.

Bonus Content

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Episode 7: The Man in the Ambulance

Learn about Shane Hardwick and the Shalom Project, a community-based initiative helping EMTs and police officers get help to those who need it most.

Transcript

(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.

(01:05) Phil Lofton: 
Hey guys, it’s me, Phil. Today’s episode is about the EMT perspective on the opioid crisis, and it’s largely going to be a conversation between myself and Shane Hardwick, an EMT with Indianapolis EMS and Shepherd Community Center. He’s in a unique position from most EMTs, and you’ll hear why in just a bit. But first things first: Welcome to The Problem.

(01:44) Shane Hardwick:
My name is Shane Hardwick. I’m a community paramedic with Indianapolis EMS.

(01:48) Phil Lofton: 
I met Shane a few weeks ago at the studio for our interview after my boss, John, was gracious enough to connect us. I got the impression at once that he was good with people — great with people, in fact — and he had a confidence that made me think he was exactly the sort of person I’d want taking care of me if I was hurt. It was clear that he loved his job.

(02:07) Shane Hardwick: 
I think being a paramedic is rewarding. No day is the same. I’m not stuck behind a desk. It’s a phenomenal job. You get to do and see some really incredible things.

(02:20) Phil Lofton:
How did you get involved with EMS?

(02:23) Shane Hardwick: 
Oh, well, going back a couple decades, ever since I was a kid I wanted to be a paramedic, and I can actually take it back to when I was leaving detention in fourth grade. I saw a crash happen right in front of me and, and, you know, just seeing the fire trucks and the police cars and the ambulances roll up. It went from chaos to calm just when the people started showing up. So that was something that was always kind of … I just always liked it. So at age 14 I enrolled in an EMT class and by age 16 I was the youngest certified EMT in the nation. Yeah. I had to go before the state commission, and they waived my age because you’re supposed to be 18 and kind of off to the races.

(03:18) Shane Hardwick: 
So I started hanging out in the Wishard ER on the weekends. What teenage kid doesn’t hang out in a level one trauma center on the weekends? But yeah, I’ve always done it. I’ve always loved it. I’ve actually officially been hired and employed for the last 25 years as an EMS professional.

(03:41) Phil Lofton: 
What does a day in the life look like for you?

(03:43) Shane Hardwick:   
Um, I think my day looks a little unique compared to most, EMT/paramedics and the fact that, my deployment is a little different. I’m not on an ambulance. I’m actually assigned to a police officer, so I work in a very, um, high violence, high over-utilization of 911, a lot of need neighborhood on the Indianapolis Near East side and I’m partnered with a police officer and we don’t just attack community paramedic-type stuff, of which the bread and butter is your repeat congestive heart failure patients, your repeat COPD-ers, diabetics, etc. We deal with that. But we also try to just kind of tackle quality of life in the neighborhoods. So we’re just as concerned with the diabetic that keeps calling an ambulance because they can’t get their insulin. We’re just as concerned about that as we are prostitution or illegal dumping and alleys. You know, we try to tackle the whole problem and it’s a… it’s a unique program. It’s actually Shepherd Community Center who spearheads that program. It’s at three years now, and it’s a very rewarding position.

(05:01) Phil Lofton:
I want to talk to you more about this. So it seems like you have a big heart for caring for the whole person. Talk to me more about how the program you’re involved with does that.

(05:13) Shane Hardwick:
So with our program, we use over-utilization of 911 as a symptom of an otherwise larger problem. So if you get the same person going to the hospital over and over and over again, obviously there’s something in the bigger picture that’s being missed. There is some need that’s not being addressed. And we’re kind of the last rung on the ladder, the last layer of the social safety net. So the same thing happens with the stories that you hear about the same person getting Narcan eight, nine, 10 times. And I think what’s different about us is not only do you have a paramedic and a police officer partnered in this area proactively identifying these people, but the back end resources that we have, we, we employ a Shepherd employee, a certified drug counselor, and we’re able to refer back to that counselor and kind of close the loop a little bit.

(06:16) Shane Hardwick: 
There’s more resources. And what we found are people that actually… they have that moment of clarity or “Today’s the day that I need to get clean.” What we don’t want to do is say, well, here’s a pamphlet, go call these people, we’ll have a bed for you in six weeks. So to have this clinical addictions counselor on the back end, he’s able to start working the phones and he’s able to start getting them into different hospitals, different treatment centers. But at the end of the day, we’re building a relationship with these folks, and we’re kind of showing them that someone does actually care about their wellbeing.

(06:59) Phil Lofton: 
What sort of an impact do you think that makes? Do you think that that’s a thing that people get all the time?

(07:04) Shane Hardwick: 
No, I don’t. I don’t think that’s something that people get all the time, and one of the things that I think we’ve become keenly aware of on the job that we have is that loneliness is part of that epidemic. It’s not just the addiction, but you know, what’s the root cause… and to have people that are otherwise strangers that are pouring into these folks’ lives, I think it does have a profound impact. And to know that there’s someone out there that truly cares about you and your wellbeing is, um, that’s a pretty darn empowering thing.

(07:40) Phil Lofton:
You’ve been involved with Shalom for three years now. How did that start? How did you become involved with it? Were you involved from the outset?

Shane Hardwick: 
No, actually it was the most amazing timing ever. I had my former career. I had been an administrator and had taken the last six months off and was a stay at home dad. I worked part time as a paramedic and kinda wanted to get back in because of the tuition reimbursement.

(08:12) Shane Hardwick: 
I kind of wanted to get back into full-time employment through IMS, and so I called called Dr. Miramonti and said, you know, you probably don’t have anything that resembles this but I need 9-5 Monday through Friday, and I’d really like to do outreach and um, “hat in hand,” you know. … And ironically enough, within a week of me darkening his doorstep, he had this meeting with Shepherd and the theory had been born of the Shalom Project and bringing a paramedic on board. So it was amazing timing. Um, and you know, Dr. Miramonti being the cool guy that he is was just like, “You know, I think I got something for you.” I left it at that. So I was kind of in limbo for about a week. And I met with the director of Shepherd, Jay Height, and it was a very eye opening interview with this gentleman where I used to work — the Near East side, years ago — and you know, you have a front row seat to what poverty does to families and the things that human beings are capable of, and after a while you become a little jaded, and you start questioning a lot of things.

(09:32) Shane Hardwick: 
And so I had promised myself pretty early on in my career that I wasn’t going back to this neighborhood. This came up and my curiosity was sparked. So I took the job, and I’m talking with Jay Height on the first day, and he’s painting a very bleak picture that the homicide rate is 200% greater than the average neighborhood, or the average zip code in Indianapolis. Overdoses are over 340% greater in the zip code, nonfatal shootings are 400% greater. The largest demographic we have is single mothers. Thirty-five percent of all houses are abandoned. And you know, I’m just getting peppered with these statistics, and I’ll never forget, he looks out the window and there were some kids playing outside. He just goes, “You see that young man out there?” And I said, “Yeah.” And he says, “His parents tried to sell him for drugs three years ago.” And you know… you hear that and… you’ve maybe heard stories like that before, but to actually see this young man out there playing, I mean, it just works on your heart. And not that one program or one person is going to, you know, knock the dust off the problem as much as it is people coming together in a collaborative effort. And I was hooked. I said this neighborhood needs some help. Somehow.

(10:58) Phil Lofton:
The part of Indianapolis where Shepherd Community is based did need some help. In 2014, the city looked at the neighborhood and found that it had 400% more shootings, 400% more mental health issues, and 300% more overdoses than the rest of the city. In response, Shepherd started the Shalom project, a project centered on three ideas: feeding the hungry, improving housing and Shane’s part, promoting health.

(11:25) Shane Hardwick:
And so it was off to the races after that first day in the car together with my officer partner. I very clearly remember we both agreed on it and said, look, we can’t overpromise and underproduce with this neighborhood. And so that was day one, hour one. We made a promise to each other not to do that. So I think we’ve kept to that. I think we’ve done a pretty solid job of gaining the trust of the residents in the neighborhood.

(11:56) Phil Lofton: 
Can you share with me maybe a story about a time where you felt like you were really, really making a difference with this program?

(12:07) Shane Hardwick: 
We brought our addictions counselor to the emergency room with this girl said enough, 30 years old, raging alcoholic shakes the whole, the whole shooting match and you know, we’re, we’re able to say, hey, you know, and the doctors are like, this is amazing. You did. You do what? I remember one guy that they called 911 and he just, he literally said enough’s enough. And we, we, we backed onto the run and we get there. And the ambulance crews like, well, okay. And he’d called the ambulance to say today’s the day that I want to get clean and we know that he goes to the emergency room, they’re going to sober him up and they’re going to give him a pamphlet and send him on his way. So we get there and we were able to bring our addictions addictions counselor to the scene. Numbers were exchanged the next day. Our addictions guy actually had made phone calls, work the phone that afternoon, was able to get him into rehab the next day, sober him up. He’s able to dig up funding for like a 30 or 60 days sober living.

(13:19) Shane Hardwick: 
So he’s in sober living for 60 days. He comes out, he’s like a totally different human being. Problem is he still lives in the same house, in the same neighborhood that has been a flop house. And so now you’ve got this guy who’s clinging on to sobriety and he’s terrified because people are just showing up at his house at 3:00, 4:00 in the morning.And he can’t seem to get out of that cycle of people just assuming that it’s okay. So we ended up having former addicts that wanted to volunteer their time, actually come to the house. They’d kicked in his door so they were able to put in a new door, a new deadbolt, new frame. And we ended up at the end of the day, Shepherd and their staff ended up helping this guy sell his home. We moved him into another apartment and to this day we’re still engaged with this guy and from start to finish from the day I met him to today, is a totally, totally different human being.

(14:22) Shane Hardwick:
But we were able to come alongside him and we were the only people that were positive influences in his life in years. So, I mean, it’s, it’s, it’s hard and it’s kind of like pick your favorite kid, you know, it’s hard to think of like the, the, the best story to, to, to put a bow on it and say, this is what we do. Addiction. Addiction seems to have no boundaries. It’s not, it’s not, um, socioeconomic. It’s not gender, it’s not race. It seems to be pretty equal opportunity. And so, um, you know, we have just as much. It’s just as impactful when it’s a 22 year old female as opposed to a 65 year old male. It just feels good to be able to kind of come alongside folks in and help them out and say there is a better life out there for you.

(15:25) Shane Hardwick:
I’ll tell you a story. This is kinda just the way our program works because we’re out in the neighborhood. We pulled up on a man that had been stabbed to death in an alley back in July, June or July. And we were the first people there and so we pull up and there’s a man doing CPR on this guy and, you know, hey, thanks, we got it from here. So we started working this guy and, and ultimately he passes away. Fast forward the next day and one of the fire crews in the area calls and says, Hey, we’ve got these people, we’d like you to come help out. They’re, they’re living in the parking lot of a grocery store. So we get over there. We’ve got four adults living in a Ford focus. Yeah. So we got four adults living in a Ford focus. Turns out the guy who lived in the driver seat quite literally was the same guy who was doing CPR on the gentleman the day before. So they had a flat tire. Um, they were trying to make ends meet. They were obviously, they were addicts. And so through some of the connections we made, we were able to make phone calls and say, Hey, this guy’s got a flat tire.

(16:44) Shane Hardwick: 
They’re trying to get wherever we know a tire shop in the neighborhood and you know, it literally was like, Hey, this guy, this guy was a good Samaritan yesterday and helped us out. Is there any way you can help him out? So we were able to get the tire to the tire shop. They replaced it free of charge just because they had done what they did the day before. And so while we’re talking to him, we had a very frank conversation and um, I was um, kind of collectively giving public safety and public of Indianapolis a pat on the back that last year. It seemed like we were giving out Narcan by the gallon and this year we’re just not really seeing it that much and what a great job we’ve done. And obviously someone has stemmed the tide. And um, it was a very sobering comment that the girl I was talking to, she goes, oh, make no mistake about it. It’s not what you’re doing. It’s the fact that the drugs in this town are not good anymore. And it was kind of frightening that basically the potency of the drug wasn’t fatal anymore. It wasn’t killing them. So it’s, it’s, I don’t know, it was, it was a very, it was a very sobering thing to hear from somebody who was like, make no mistake about it. It’s not what you guys are doing. We just can’t find any good drugs. So you hear that and that’s a little disheartening. And I think what you’re going to see is a pretty big uptick in methamphetamines.

(18:16) Phil Lofton:
Why do you say that?

(18:19) Shane Hardwick: 
Without sounding incredibly callous? I think that, and this is just my humble opinion, I think that the cartels realized that they were killing off their loyal customers and I think they switched to something that’s equally as addictive, but the people are still going to be around to throw more money at it.

(18:43) Phil Lofton: 
Can I ask you, this is another one that wasn’t really on our list, but I think it’s relevant given the conversational arc. How do you think we got here?

(18:53) Shane Hardwick:     
Oh man, that’s a good question. I don’t know. I know back in the seventies, from what I’ve heard, it came back from Southeast Asia. Yeah. This go around. I have no idea. I don’t know. There’s a million things you can pin it on, but I really, I’m not going to say it’s because we’re over prescribed. I’m not going to say that. I don’t know. I mean, is it, is it culture? Is it the en vogue thing to do that? I don’t know.

(19:29) Phil Lofton:
It seems like that a lot of the work that you do, it’s about fixing a brokenness in a community that is associated with the overuse of addicting substances. How do you think that we got to the point where that is what our communities are turning to?

(19:49) Shane Hardwick:
It’s a good question and I don’t know, is it hopelessness? Is it that, you know, is it the loneliness component to it? I don’t know. Is it chicken or the egg theory? We have our, our area, we see a lot of folks that were once housewives on the north side that kind of leave everything. We’ve got a couple of those, they leave everything and then they go where the drugs are at. So, you know, we have people that five, 10 years ago were living it up on the north side and living normal lives and now they’re, you know, they’re, they’re out walking the streets and we had a woman that actually flagged us down, showed us the mugshot photo and said she’s wanted, please find her because we know she’ll be safe in jail.

(20:57) Phil Lofton:
So what’s next? If we’re basically out of the worst of it, the absolutely threatening part of it. What’s next? What do we need on the EMT perspective?

(20:59) Shane Hardwick:
I don’t know, because, because I, I think what we see a lot of is you’re exchanging or you’re trading one addiction for the next. And I’ll give you a perfect example. Spice. Synthetic marijuana that in our neighborhood, they’re spraying oven cleaner and bug killer. And it enhances the effects of this synthetic marijuana. We encountered a gentleman one day who was schizophrenic, unmedicated, and he was self medicating with synthetic bug sprayed marijuana. And it was, it was frightening because I said, man, why do you smoke this stuff? And he said, well, because I hear voices all the time and they’re usually telling him pretty unpleasant things. But when he smokes spice, it changes the sound. It’s a more pleasant sound in his head when the voice is talking to him. So I don’t know, I think it’s, they’re usually just trading one addiction for the other. It goes, it goes deeper than just what drug it is, you know, how do we fix that, you know, how do we keep people from not hurting themselves? I don’t know the answer to that.

(22:16) Phil Lofton: 
You are so involved on the front line of this crisis. You are so involved on the rebuilding of communities. What is one or two things that you would want everyone to know about the communities that you’re involved in, about the work that you’re doing about what this crisis is like, that you don’t think that people know or if you think people know, you think maybe they forget.

(22:38) Shane Hardwick: 
Sometimes I’ll tell you what, the neighborhood that we work, there’s a lot of good people, there’s a lot of good people in this neighborhood and it’s very easy to rope and entire community into very few people that are committing x, y, and z crimes. We’re doing x, Y, and z things. Like I said, the number one demographic in our neighborhood are single mothers followed quickly behind senior citizens. Um, but yet we still have, you know, this, this lagging problem with, with crime and crime goes where it’s appropriate. And I can tell you that a fast majority of the people that, that we, that we interact with in the neighborhood are just good people and they’re not drug addicts and they’re not violent criminals.

(23:32) Shane Hardwick:
That’s the one thing that I would say if you’re, if you’re talking about the 10,000 foot view of the neighborhood, is that there’s a lot of good stuff going on in this neighborhood and there’s a lot of people that care. We recently partnered with, Partners In Housing. We recently partnered with a charity that came in and built some new homes in the neighborhood and they couldn’t figure out how to zone it properly because it had been since the 1960’s that anyone had built a residential home in this neighborhood. So, you know, you talk about stemming the tide and changing things in the neighborhood. We’re building new houses and we’re trying to educate children. Shepherd community center has a community center and also has an elementary school and they have kids now from this neighborhood that are in, IU, they’re in Purdue, Notre Dame, Harvard. It’s the empowerment. It’s having people coming into their lives and saying, you know what, you can do anything you want to do. Your life is not defined by just this block.

(24:40) Phil Lofton:
Before we wrap things up, Shane shared something with me.

(24:44) Shane Hardwick:
I’m the luckiest guy I could possibly be. I’ve got a job that I cannot wait to get, to get to work in the morning and do some of the stuff that we do. And it’s always fun to get out first thing in the morning before the school bus runs and see the kids on the sidewalk and, and, um, it kinda reminds you like what we’re here to do. And we delve in some pretty dark places sometimes, but at the end of the day, I think we’re kind of doing the greater good when it comes to just bringing something to the neighborhood that says, we care about you.

(25:22) Phil Lofton:
We know that our social factors can impact our health. We heard that last episode with Shaun. We know that health systems aren’t always designed to treat people’s total needs. We heard that with Andy Chambers and with Ashley Overley and we know from our talk with Carolina and Deb Litzelman that the best possible way to help people effectively is to give them care in a way that makes them feel safe and comfortable. I think about all of that is Shane and I wrap up and I think about the statistics that led Shepherd Community to start the Shalom project. Then I think about the man in the ambulance and I think that if we’ve got people like Shane looking out for our communities, we might be okay in the end.

(26:02) Phil Lofton: 
Music this episode was from Everlone and Broke for Free. Our theme and additional musical cues in this episode were written and performed, as always, by the Apophatic Five.

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 Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at theproblem.regenstrief.org.

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.

Episode 6: The Information

Data science and informatics are a massively powerful tool in the fight against the opioid crisis. Sometimes we have too much information, sometimes too little. Learn how informaticists are working to make sure we get the right information in the right hands!

Transcript

(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.

(01:13) Phil Lofton:
You start as a name. Syllables strung together with love and care by your parents to give you an identity, to give them a way to talk about you, but you were so much more than that. Every person is. You grow up, you develop likes and dislikes. You run around in a neighborhood goofing around after you get out of school with people who come to think of you as a friend. Hopefully staying away from anyone who’s come to think of you as an enemy. You get vaccinated or you don’t. Your parents take you to a doctor who examines you, treats you, and does their best to care for you. They give you diagnoses or they don’t. You grow older still and the points of information that orbit around that first crucial data point given to you by your parents begin to connect to each other like constellations, across geographies and industries.

(01:59) Phil Lofton:
Your name may be joined by your driver’s license number, your passport number, your social security number, and other digits and factoids that you accrue as you go. This first likes and dislikes become spending habits, browsing trends, social media posts, college majors, and careers. Those friends that you made, those schools you attended evolve into relationships that you joined, the neighborhoods where you live, and the society, that you’re a part of. What started as just a name becomes so much more. It becomes a mass of interconnections and interactions. Maybe even more names if you choose to add children to your life. Today, we’ll be exploring how data scientists can use these interconnections and data points to help fight the opioid crisis. Welcome to the problem. I’m your host, Phil Lofton

(02:54) Phil Lofton:
We live in the age of big data. You don’t have to look far to see the impact of data science in the news, but did you know that some of the most important data to your health might not make it onto your medical record? To learn more about these data and how they might have an impact on the opioid crisis, I sat down with Shaun Grannis, a world class informaticist. Informaticists are data scientists who use information to draw findings about the way the world works.

(03:19) Shaun Grannis:
Sure. My name is Shaun Grannis, I am the director of the Center for Biomedical Informatics here at the Regenstrief Institute. I’m also an associate professor of family medicine at the IU school of medicine.

(03:31) Phil Lofton: 
So Shaun, we, we talk about the richness of data that surrounds a person and one of the big words that, uh, you know, our listeners have heard kind of popping up around that is social determinants of health. We’ve heard it already in a few different episodes, but what are social determinants of health?

(03:48) Shaun Grannis:
Sure. So it’s common sense, but we know that health starts in our homes and our schools and our neighborhoods and our communities. We’ve known for a long time that we can take better care of ourselves by eating and exercising, staying active, not smoking, getting the right immunizations and the right screening. All of these things and seeing a doctor when we’re sick, I’m all influence our health, right?

(04:12) Shaun Grannis:
So there’s a lot of factors. Um, our health is determined in part by access to social and economic opportunities. The resources and supports available in our homes, our communities, our schools, the quality of our workplace, the safety of our neighborhoods, um, and how clean our water is. All of these things influence our health. So what are social determinants? Well, the definition of social determinants of health would be those are the conditions and the conditions in our social environment and our physical environment where people are born, they live, they work, they play, they worship and um, that affect a wide range of functioning and quality of life outcomes and risks. So that’s the formal definition. And really the way I explain it simply is, it’s sort of those nonclinical factors, those factors outside of the healthcare system that influence our health.

(05:06) Phil Lofton: 
Gotcha. Anything that wouldn’t normally be contained on an electronic medical record, but that is important to your medical outcomes.

(05:12) Shaun Grannis:
That’s a social determinant of health. Yes. And that, that, that definition still works, but increasingly we are beginning to capture those in our electronic medical record. So that definition is that going to work forever. So why are we stepping up the, uh, the attention to these? Why are they important? Sure. Well, they’re important because we’re beginning to realize how much they do impact our wellbeing, our health. You know, historically we’ve sort of thought of health through the lens of the healthcare system, but now we know things like, if you don’t have appropriate nutrition, you’re going to be ill, you’re not going to be as healthy as you can. You’re more likely more susceptible to diseases. Your immune system isn’t as strong if you don’t have appropriate housing, you’re at much higher stress levels. You’re subject to the environment. With all of those challenges with overheating and being cold. Lack of transportation, you know, people who don’t have good transportation, they’re less likely to be able to get to those resources that they need to be healthy. Right? So there’s just some very obvious thing and this is why they’re important. And um, understanding and beginning to recognize their importance is really, you know, there’s been a revolution over the last couple of years in recognizing this and starting to think about how to incorporate them into the overall health of a person.

(06:38) Phil Lofton:
So it almost makes me think of like Maslow’s Hierarchy of Needs, right? And it’s not as simple as just like we’ve only been addressing the middle stage if only it was that simple, but it does seem like we’re missing some bricks on the bottom level. We’re missing some bricks on the middle level. Right. And if we can’t get those bricks taken care of, then we can never address the whole person’s health rights.

(07:00) Shaun Grannis:
Right? Correct.

(07:01) Phil Lofton:
Man, that is so fascinating. So talk a little bit more about how these things impact health.

(07:06) Shaun Grannis:
Sure. You know, I think one of my favorite examples is we, you know, we think about, I’ll use an example, lung cancer and you know, there’s a lot of great, awesome NIH funded genetic research into lung cancer, but we know the number one cause of lung cancer doesn’t have to do with our genes. It has to do with our behavior and that’s smoking. Right? And so that’s a great example of a, an environmental community as social behavior that directly impacts health, right? We know that obesity is associated with a number of diseases from osteoarthritis to other forms of cancer to high blood pressure and heart disease, right, so so our eating habits, our food habits directly impact our health as well, and so we’re starting to think more directly about these and these are factors that often the healthcare provider doesn’t directly deal with.

(08:02) Shaun Grannis:
If you want to be successful with moving the needle on these factors, you actually need to be able to get out into the community. You need to be able to work with these people in the lives that they live day to day, not the point one percent of the time that they’re in the clinic.

(08:18) Phil Lofton:
To to dive into that a little bit deeper, I think that’s really interesting that you bring up those two examples because both of those things could be things that could be immediately addressed on the EMR. Right? Do you smoke? Yes or no, but it’s more. It’s more interesting than that, right? Because the EMR doesn’t ask, does your mom smoke if you’re a kid? That’s right, right. That’s right. Does your grandpa smoke? Does. Does your spouse smoke know there’s so much more richness there than just the simple answers on the EMR that exist right now. That’s so fascinating. And same with obesity too, right? Because like our, our, our cuisine is so tied to our social status, our cuisine is so tied to our economic status. It’s fascinating. That’s so cool. Yeah. But what does this all have to do with the opioid crisis?

(09:03) Shaun Grannis:
Sure. So, we’ve already talked about the fact that social and economic factors influence behavior, access to resources, um, so therefore it impacts the health of drug users as well. Right? So this is a, a layering factor on top of that. Um, we know that these factors are strongly correlated with drug seeking behavior and the person who’s suffering from opioid use disorder, their ability to recover their health, right? So these are, these are additional risk factors that we know are associated. We know that social factors influence whether you can get to a support system at all.

(09:49) Shaun Grannis:
So, the leading social scientists today know that social factors play a key role, a directly and indirectly and determining the incidence and prevalence of opioid use disorder. Now we don’t know when part of the research that’s going on right now, we don’t know whether those social factors are the result or the cause of the opioid use disorder. So we need to better understand. So do you wind up in a different social environment as a result of your opioid use disorder or does your or do your social environment lead you to your opioid use disorder? Right. And so the answer may be both, but we need to understand the degree to which those influence one another and context is important. Indianapolis is not the same as Los Angeles is not the same as you know, Miami, Florida. And so we need to better understand the actual context in which people live. Because the answer to that question is it the result of the cause may vary depending on your context.

(10:51) Phil Lofton:
So really this is nature versus nurture in a really, in a very real way.

(10:55) Shaun Grannis:
Yeah, I think that’s, that’s, that’s one of the good ways to think about that. I think it’s a good framework for thinking about it.

(11:02) Phil Lofton:
Thank you so much.

(11:03) Shaun Grannis:
Oh, you’re welcome. My pleasure.

(11:13) Phil Lofton:
So the answer is more information in the EMR, right? The more information that we have about a patient’s context, the better we can understand their holistic health, but it’s not that simple. In fact, in many cases doctors and other clinicians have too much information at their fingertips.

(11:29) Chris Harle:
Hello, this is Chris Harle. I’m an associate professor of health policy and management at the Fairbanks School of public health. I’m also a research scientist at the Regenstrief Institute Center for Biomedical Informatics.

(11:40) Phil Lofton:
He’s a researcher focused on empowering clinicians by putting all of the most relevant data in. One quick easy to find the spot. It’s called the one sheet.

(11:50) Chris Harle:
Information chaos as we talked, is described as several different things, so on one hand EHR as they talk about overloading the clinician. So there’s tons of information in there, but at the same time sort of paradoxically, they underload the clinician. So I’m the doctor, I’m the nurse. There’s something specific I’m looking for. It’s there, it’s a needle in a haystack buried somewhere, but it’s not exactly what I need when I need it. In addition, we ended up with erroneous information in the EHR, so information that’s. Maybe it’s just not current. Maybe it was recorded inaccurately, maybe? No, maybe it’s not been updated based on that new emergency department visit or that other doctor that I just saw.

(12:31) Chris Harle: 
How does your work suggests that we can kind of calm the information chaos?

(12:38) Chris Harle: 
So I think the first thing that we focused on in on in our work is really about understanding at a low level what a physician, what a nurse practitioner or what a nurse or another member of the care team, what does their day look like, what does their work look like?

(12:56) Chris Harle: 
We have to really understand how they go about the business of healthcare or the operations of healthcare that the constraints that they live under, like really short time period. Right? We know from any, any of us can imagine what we do on a day to day basis in our work and we can imagine how it feels when we don’t have enough time, when we’re overloaded with information or when we need key information that we just don’t have. It’s stressful. It’s anxiety provoking. It prevents us from doing our job as best as we can and so we see that in healthcare. If we think about primary care practices where we spend a lot of our time doing our work, there’s huge time constraints. There’s lots of patients coming through. We had a clinician once tell us, you know, I would love to be able to treat chronic pain by really sitting down with the patient and having this long, involved discussion and doing lots of formalized assessments and tracking those assessments over time, but that’s not what our practice is set up to do.

(13:54) Chris Harle:
It’s set up to push 35,000 patients a year through those doors. And so under those constraints, we need to sort of be really thoughtful about how we set up our information systems, how we set up our EHR is how we design communications, the information that we put in front of a clinician, so we need to think about not just giving lots of assessments or lots of background and lots of context, but in so far as we can make a recommendation to a clinician, let’s do that. Let’s not provide information at a point in time when they can’t make a decision. They’re not ready to make a decision. Let’s try to provide the right information at the right time, through the right channel for the right person, and in many cases, that’s not the doctor, right? We have to do better in our health system of using our care team to its fullest.

(14:46) Chris Harle: 
The nurses, the medical assistants, the community health workers, the others who are vital to interactions with the patients and care for the patient. We can’t always say we’re going to give another alert to the clinician or we’re going to give them another assessment that they have to try to think through. How can we put that in the hands of the other members of the care team, let them filter through it, understand it and boil it down so that they can all work as a team as opposed to the buck always stopping with the clinician or the provider.

(15:16) Phil Lofton:
That’s really interesting. So like how, how would your work suggest that? Would it be like sending an alert to the community health worker to prompt for wraparound services or would it be sending. I don’t. I don’t know. I’m hung up on the sending an alert thing, but can you give me some examples of what that would look like within those specific care team roles?

(15:33) Chris Harle:
Yeah, so one of the concepts that we’ve been developing in our work is what we call the chronic pain one sheet, and this is a tool that could be used by a nurse, a medical assistant or the physician. And one of the things we talk about a lot is how do we put it into workflow so that the nurse or the MA is using it at the time they need it, the physician is using it at the time they need it and it fits into whatever they’re thinking about whatever they’re doing. But let me take a step back. So what is this chronic pain one sheet? So the chronic pain one sheet is really a reflection of all of the time we’ve spent observing how care happens, understanding how doctors think, how they prescribe, how they interact with the nurses and others in their care team with the information they have, the information they don’t have.

(16:20) Chris Harle:
And it’s really striking going back to kind of just the way an EHR – electronic health record – functions. It’s striking that oftentimes all the information they need is there, but it’s not easily accessible, right? Just imagine you and your job, whatever it is you do on a computer, whether you’re doing, sending a lot of email, whether you’re doing graphic design, you know, imagine if you’re kind of overloaded having to click an extra dozen times every time you want to take the next step, do the next task, right? I have to click more, search more filter and sift through information more. You’re not going to be very productive. What we noticed is there’s sort of a core set of information that a clinician needs to know about a patient with chronic pain. They need to have a sense of, okay, what is their condition? What is the type of pain they have as far as we know, what is their history of treatment?

(17:13) Chris Harle: 
What are all the things we’ve tried to treat them with, but having to work. What are the things we’ve tried that did work, what are they currently on and what are the risk factors and what are the doses of their medications? Are these moderate risk or high risk doses of opioids that we need to cut back on? We need all of that current and historical information in a single place and organized in a way that’s a cognitively pleasing. The way that they sort of fits with the way their brain works and it’s not how information is typically presented in the EHR. It’s all over the place and it makes it hard. And what does a person do when it’s too hard to get that information? They don’t. They again, they fall back on simpler decisions or they fall back on making decisions based on incomplete information.

(17:59) Chris Harle: 
So the opioid one sheet, I’m sorry, the chronic pain one sheet. It tries to bring all that information into a single place and then we’re trying to embed it to use at the right place. So when a patient who’s been prescribed opioids for their pain calls in for a refill, we want to put that one sheet in front of the nurse so they can grab that one sheet and say, okay, this patient is on this dose and they can quickly through that one sheet, pull up their prescription drugs, prescription drug monitoring report that shows all of the opioids and other controlled substances. They have been prescribed and have been dispensed to them. Pull that up right there and the one sheet and say, okay, their prescription drug monitoring report suggests some red flags or everything looks clear. They’re going to want to right there on the one sheet they’re going to be able to view their urine drug screen information, so has the patient had a urine drug screen in the last year as mandated by the state law or in the last six months because maybe that’s the policy at our practice. Have they had that and what were the results so you can imagine that patient called triggering a nurse or another member of the care team to pull that information up, review it, understand it, filter through and sift it and then make it that much easier for the provider or the prescriber to say, yes, we’re going to prescribe that next opioid or no, we’re not. We should probably bring that patient in and maybe we need to talk to them about tapering down or doing something different and then the provider, when they have that visit with the patient, they may also pull up this chronic pain one sheet and they may review that information with the patient.

(19:26) Chris Harle:
They may talk about the risk factors that show up on that, that one sheet, but they’re doing it all in a single place in the EHR. It’s all bringing all the information together and it’s helping them to make a decision. It’s also helping them to talk through with the patient, here’s why we might want to not prescribe opioids anymore. We have these factors that may be concerning and here’s what we can do instead. That’s another big important thing that we need in the electronic health record is not just, Oh, we can’t prescribe opioids anymore. What are we going to do? So this is another thing we’ve built in to our chronic pain one sheet which we call the treatment tracker. It’s a way of in one place telling the clinician, here are all the different things you can use for pain here, all the other medications here, the nonmedical reasons you can use and here are the things that you’ve tried in the past, but here are the things you haven’t. Why don’t you talk to the patient about those?

(20:18) Chris Harle:
Huh? That is so fascinating. So what does the future of the one sheet look like?

(20:20) Chris Harle: 
The future of the one sheet. So we are currently building a version of the one sheet here with one of our local partners in their health system and that one sheet is really highly customized to the electronic health record that they use the system that they use from their vendor. The future of the one sheet. So we hope to. We’re implementing it there and we’re gonna do some research studies to examine what happens if your doctor has the one sheet versus if your doctor doesn’t. You’re a patient with chronic pain. You may be getting opioids or not. Well, we’re going to run a study and see when our doctors and our nurses and our other members of the care team, when they have that available to them in the EHR, how does that affect the efficiency of their visits?

(21:01) Chris Harle:
How does that affect their likelihood to prescribe an opioid? How does that affect their likelihood to prescribe something else, a non opioid medication for pain or a nonpharmacologic pain treatment altogether, so we’re going to see, does bringing all this information together in a single place, does that make the care teams more efficient? Do they get more information in a shorter period of time, more relevant information in a shorter period of time? We’re also going to see if that changes the way that they prescribed the way that they treat pain. If they use more non opioid options, if they’re less likely to continue in opioids. And then another piece in terms of the future of our one sheet is we want to make it usable, accessible. In any electronic health record, there’s sort of a market of different EHR vendors and it’s not a huge number of vendors, not a huge number of companies that provide EHRs, but what we’d like to do is essentially make the one sheet, like an app that you’d have on your phone.

(21:59) Chris Harle:
Right, so you can, whether you have an Apple or an Android, a lot of apps are available across both, right. We want to make the one sheet available on the different vendors EHR platform, so you have major vendors like an EPIC or a Cerner or Allscripts. It would be nice for them and for the health systems that use their products. If you could plug the one sheet in like an app and it would be seamless for the doctor. That’s important. It shouldn’t be an app that you have to go look at on a different device. Right. You shouldn’t have to pull out another phone to get your one sheet or another tablet or another computer or go to a different website even. Yeah. But, uh, it would be nice if you could, if you could hop right, right there, your EHR, no matter who your, your EHR vendor is and you could pull that one sheet up for your patients.

(22:39) Phil Lofton:
We have talked a lot about your work and how it’s filling this specific hole within the health data landscape. Where are some of the other big gaps in health data for how we’re attacking the opioid crisis? Where do you see opportunities that aren’t necessarily being pursued right now?

(23:00) Chris Harle:
Sure. So several things I could think of. One, as I said, we still have relatively siloed data and information in healthcare and patients with chronic pain patients who have or are being prescribed opioids, in many cases they may bounce around from system to system, hospital, hospital, doctor to doctor. Not always because they’re sort of drug seeking as sort of I think we unfortunately labeled people with, but they’re seeking relief, right? And they are seeking better care for their pain and in some cases their substance use disorder. We need to be able to pull records and not just from within our health system, whatever health system that may be, we need to be able to pull records and information from across health systems. If you’ve seen many doctors or you’ve been to emergency departments, we need to know that. So that’s a huge challenge and you could see how that sort of interoperability, that sort of exchanging of information would be really useful and help fill out a chronic pain one sheet or any other EHR tool. It provides a more complete picture in this chaos.

(24:03) Phil Lofton:
But this issue of data chaos doesn’t just exist in the context of personal medical records. If you zoom out, there’s been a big disconnect for ages between several data sources that could be working together to accomplish more, to learn more. I talked to my boss about the Indiana addiction data competence of old new project that will help researchers find data across a large variety of sources.

(24:30) Peter Embi:
Peter Embi, president and CEO of the Regenstrief Institute. So the Indiana Addictions Data Commons is this concept we have and we’re now in the process of operationalizing which is to really bring together data from multiple different sources in order to address this addiction crisis that we’re facing not only in Indiana but nationally. The idea is that we have for a long time been trafficking, particularly at the Regenstrief Institute in healthcare data for the purposes of research and being able to use that to great benefit in terms of making new discoveries and being able to improve care, uh, and the like, and we’ve certainly been, um, working with our health system partners and others on this opioid crisis and the general addictions crisis.

(25:09) Peter Embi:
But what we recognized especially going into an initiative that was started by Indiana university around, what’s called the Grand Challenge Initiative to address the addiction crisis in the state of Indiana, is that there are a lot of data sources that we really need to have access to if we’re going to properly characterize, understand and be able to address this addiction crisis. And that includes not only the healthcare data we have about, you know, when people show up at emergency rooms and what kind of prescriptions that are being, uh, they’re, they’re getting in their doctor’s offices, et cetera, but also other information that probably is just as relevant, if not more relevant to the crisis around everything from information from the government. Regarding the people’s access to resources, justice information. So as we want to address this, this crisis from multiple different angles, we recognize there are things we’re going to need to tackle, for instance, in the justice system, with regard to informing policy and legislators, with regard to informing healthcare systems and healthcare providers and communities. And if we’re going to do that, we need to have access to data from a lot of different sources.

(26:28) Phil Lofton: 
So I think one of the big questions that I have is, is as important as this seems, how has this not been done already?

(26:37) Peter Embi:
That’s a really great question. The reality is that it probably should have been, if we think about our public health information systems, I’m not to go too far into the history of things, but they kind of go back to the pandemic flu of 1918 and the idea that we’ve set up our public health infrastructure really add a sort of county level or community level and we haven’t necessarily created an information network that brings all of these data together for the benefit of the population. That idea has been around for a while, but technically it wasn’t really possible for quite a long time.

(27:15) Peter Embi:
So now we have the technical capability to do it. And the idea of using these data for good, being able to, of course respect everybody’s privacy and make sure that we do everything from an ethical perspective is critical. But also that we actually address the other ethical need which is to make best use of these data so we can actually find solutions to public health crises. And the opioid crisis is certainly a big one of those. And, you know, we know that there are literally tens of thousands of people dying every year from this epidemic. So, it’s really our obligation to use this and to figure out the issues. Then another reason I think that we haven’t quite addressed it is there hasn’t really been the political demand and the sort of social demand to do it until recently.

(28:09) Peter Embi:
And a lot of these information sources get integrated because of drivers cost drivers or quality drivers or laws that could pass. That requires certain programs to be initiated. So if we know there’s a need to track information around certain infectious diseases, we put information systems to do that in place. If we know there’s a need to track information for cancers, we put information systems in place to do that. If we know there’s a need for tracking information around, let’s say, environmental issues around air quality or algal blooms or various other things, we do that, but we don’t necessarily think about tying all these things to each other in order to be able to discover what other issues are coming up or be able to respond to the next unforeseen thing. We tend to be somewhat reactive. So in this regard, what we’re saying as well, we have the technical capability today.

(29:03) Peter Embi:
We have the political will because obviously this is a major crisis and we’re able to address this in a way that respects everybody’s privacy and security and do this in a, in a way that we think is very sound. And so, um, it’s our obligation to do it. So we’re working very closely with partners not only across the universities and their systems, but also across communities, across our partners in state governments and others to be able to really be in a position to better inform how we can care for hoosiers.

(29:37) Phil Lofton:
That’s awesome. So I want to double back and drill down on exactly how you see the IADC being able to drive policy. What do you think that looks like?

(29:47) Peter Embi:
Yeah, that’s great. Great question. I think there’s a couple of different ways, at least one is that as policy makers are thinking about policy solutions that need to be put in place for this crisis, we want to make sure that they want to make sure that they’re basing their decisions on the best possible, uh, information and evidence that they can get their hands on.

(30:09) Peter Embi:
And to the extent that we haven’t engaged in a project like this to bring together this kind of information. Oftentimes we’re making policy decisions based on informed guesses or are the best evidence we have, which is sometimes anecdotal. Sometimes it’s related to what’s happening in the news or what we’re learning about from the different communities that we happen to interact with. But it’s not necessarily informed by all the different kinds of data sources that we could be bringing together. And so one of the reasons to do this is to inform policy makers and policy level decisions with the best evidence and information we have, and then I think once we’ve actually enacted policy or as we are enacting policy or putting initiatives in place or putting programs in place to address this, we want to know if they’re working and knowing whether they’re working.

(31:03) Peter Embi: 
Again, it needs to be measured using information from a variety of different sources. And by having a resource like this, we think we’re going to be in a much better place to know if the policies are working, if they’re having the intended impact, if they’re having unintended consequences, if they need to be adjusted or changed. And I think that kind of information can also feed back to help policymakers.

(31:24) Phil Lofton:
So the IADC works to inform policies at the creation stage, but then it also works to inform the modification of policies, the fact checking of policies, the quality checking of policies. Is that, is that basically a good way to…

(31:38) Peter Embi:
Yeah, that’s right. That’s right. And I think, and I think the ability to track whether a policy is actually having the intended effect is, is as, or more important frankly, than, um, than what policies we put in place in the first place because, you know, history is replete with a lot of very well intentioned policies that didn’t have the effect they were meaning to have.

(32:00) Peter Embi:
So I think to the degree that we can better inform our communities and our citizenry and our and our representatives in terms of what’s needed, what’s working, what’s not working, and do that in as close to real time as possible. Especially with a crisis like this that is affecting people every single day. That’s, you know, rapidly moving and unfortunately is still heading in the wrong direction. I think we need this kind of a resource more now than ever.

(32:29) Phil Lofton: 
You are so much more than just your name, you’re more than all the things that describe you. You’re the intersection of countless pieces of information. But on multiple levels those descriptors haven’t been connected or discussed collectively in healthcare. If we can change that, if we can start talking about people in ways that incorporate more of their context, empowering doctors by presenting them with the right information and enabling data sets to work together on the population level. Informatics might be one of the most powerful tools in the fight against the opioid crisis

(33:00) Phil Lofton:
Music This episode was from Everlone and Broke for Free. Our theme and additional musical cues in this episode were written and performed as always, by Nescience. The problem is produced at Studio 132 in the Regenstrief Institute in Indianapolis, Indiana, where we connect an innovate to provide better care and better health. 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/theproblem.

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.

Bonus Content

Shaun Grannis talks more about the social determinants of health, and a new tool to help doctors better understand how they affect health:

Chris Harle talks to Side Effects about data, and how it can impact the opioid crisis:

Episode 5: Rewired

Why are opioids such an addictive drug? How can we treat addiction AND mental health? Learn about the field of addiction psychiatry in this interview with Andy Chambers of IU Health.

Transcript

(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.

(01:14) Phil Lofton:
Hey, do you hear that? It’s kind of familiar. The baseline sure sounds like something I know, but it’s different. Today’s episode is going to be different too. Usually I’d have some parable about the discipline we’re discussing, but today I just want to get right to the meat of the topic. Do you ever have one of those conversations that just messes around with your understanding of time? I mean one of those conversations where you think it’s just been a few minutes and then you look at a clock and an hour somehow flown by. This is one of those conversations. Andy Chambers is an Addiction Psychiatrist with IU School of Medicine and Eskenazi Health’s Midtown Mental Health Center. For those of you taking notes at home, that’s the same organization as Ashley Overly from last episode. Doctor Chambers is a national leader in his field and he runs the addiction psychiatry fellowship at the school of Medicine. When we met up to talk, our conversation sped between topics touching on the past few decades and looking forward to what comes next. I want to hurry up and get right to it, but first things first. Welcome to The Problem. I’m your host, Phil Lofton.

(02:28) Andy Chambers:
How does addiction change the makeup of the brain?

(02:33) Andy Chambers:
Wow. So, we’ve learned a lot about this in the last 20 years. This is pretty recent science. What we’ve come to understand is that addictive drugs actually cause the disease through common pathways. What’s important to realize is that nicotine, alcohol, cocaine, opioids, amphetamine, these are all drugs that have different intoxicating profiles, right? They’re very different highs when you’re using them, but they’re all addictive and the way that they create the same illness of addiction is actually through more common pathways. The ways that the drugs overlap in their properties and one of the major neurotransmitters that is affected by all of these drugs is dopamine and that’s a neurotransmitter that regulates – this is really key – It regulates neuroplasticity and the part of the brain that controls motivation. So when I say neuroplasticity, I’m really talking about changes in wiring of neurons that governs learning and memory.

(03:52) Andy Chambers:
When you’re talking about motivation in a lot of people don’t realize at first until you really discuss this from a neuroscience level, but motivation is a, is a product of the brain, just like movement and emotion and sensation. Uh, so motivation is a product of the brain and it’s controlled or you know, involved with decision making. Um, it involves, you know, we call it freewill, sometimes willpower, all those terms apply to motivation and it’s a product of the brain. And as such, it’s capable of change when we grow up. I mean, we go from childhood to adulthood. Our motivation center of the brain evolves. It changes. We are motivated to do different things As we get older. Our behaviors are aligned differently as we get older and that’s natural and positive actually. So we know that system of the brain is capable of adaptation.

(04:52) Andy Chambers: 
One of, again, one of the major transmitters that governs that adaptation, that rewiring that changes our motivation is dopamine. And unfortunately, all of these addictive drugs stimulate the neurotransmitter dopamine. So these drugs evoke a neuroplastic response in the motivation system. And, uh, what’s particularly devastating about that particular change is that it, um, it instills a motivation to use the drug. So, uh, as a person continues to use a given addictive drug, it’s creating a neuroplastic change in the brain that causes the person to want to use that drug a little bit more. And after that there’s a slightly increased probability they will use it again. And if they do, they use the drug again, another incremental neuroplastic change. And before you know it, it’s like a train that begins to build momentum coming out of the station at a higher and higher speed, um, this kind of interactive effect between drug intake, neuroplasticity, behavior change, drug intake, plasticity, behavior change, and it just, it’s a cycle and it gains momentum. And after a while someone is compulsively using even as they’re destroying many other precious things in their lives.

(06:25) Phil Lofton: 
So to unpack that and to couch that an idea for an addictive context, because we’re going to be talking about it within the context of opioids, right? But some of the other contexts that people may be familiar about this with a would be like alcohol. That principle of tolerance, you have your first drink and your head spins, and then the next time to get that sort of reaction, you have to have two and four, and then the next thing you know, you’re downing the whole sixer during the night to get that same feeling. Yeah. With alcohol, there’s that sort of wall that you run into with the hangover. Sure. With opioids it’s a little bit more dangerous, right?

(07:02) Andy Chambers:
Well, alcohol is per dangerous too, you know, they’re there. It’s interesting you bring up alcohol, um, because they’re, they’re good to compare. It’s good that you brought those up. So where they’re similar is the alcohol and opiates, you know, people overdose and die on both drugs. It happens all the time. So they’re both lethal with a bigger overdose. Right? There are other addictive drugs are less lethal to overdose on. Um, both alcohol and opiates are sedatives, you know, they, they can knock you out if you do enough of them. So they’re both sedating and that’s different from say, nicotine or cocaine. Um, but in a head to head comparison, alcohol is a lot – It is addictive – but a lot less so than opiates, uh, and, and how do I, what’s my basis for saying that? Well, you know, about 80 percent of the US population are regular drinkers, um, but only about 15 percent have alcohol addiction, which is a high number, maybe 10 to 15 percent have some degree of alcohol addiction (NOTE: This survey is fascinating – lots of amazing data about drug/alcohol consumption!).

(08:08) Andy Chambers:
So only maybe one in eight regular drinkers have alcohol addiction (NOTE: See the survey linked above). That’s interesting, right? Because they’re irregular users of the drug, right? But only one in eight of that group actually has alcohol addiction. Whereas opiates is a different ballgame where once you become a regular user the likelihood that you also have addiction to that drug is much higher. What is it? Oh, it’s hard to say because the data is not very clear because it’s…that’s goes into another issue is that, you know, it’s prescribed for medical application, hence, you know, opiates for pain. And um, you know, the, the waters are very muddy there about how many people with pain on chronic opiates have opiod addiction. But let me, let me just hazard a guess that it’s probably, you know, the majority of people use opiates for whatever reason have addiction to those drugs too. The majority.

(09:09) Phil Lofton: 
Wow. Yeah. And that is really interesting. So can we talk about from the neurological perspective why that is? Why are opioids so much more addicting than alcohol or then nicotine or anything like that?

(09:27) Andy Chambers:
Well, I’m glad you brought up nicotine probably on par with nicotine really. Nicotine is super addictive stuff (NOTE: the addictive properties are very well documented and culturally understood, but this NIH page is a good primer on how the addiction happens).

(09:35) Phil Lofton:
Wow.

(09:35) Andy Chambers:
Right? Yeah. Even though when that’s an interesting thing to bring up too, because you know, nicotine’s not really intoxicating, right? There’s not really a Super Fun, high? That goes along with nicotine. I mean, people feel something but it’s not a Super Fun, high? Necessarily like all these other drugs. And so that, that’s just an example where the addictive property of a given drug is not really related to the intoxication. Right, right. So, so addiction is not about intoxication at all. So in contrast, you know, with alcohol you can get super drunk.

(10:09) Phil Lofton:
Yeah.

(10:10) Andy Chambers: 
But that doesn’t mean you’re addicted. So with nicotine, it’s another example of a drug, almost all regular smokers have nicotine addiction, but almost the only a minority of regular drinkers have alcohol addiction. So hence nicotine is much more addictive. And, part of that is like when you try to get people to stop, it’s a lot easier to stop drinking if you’re not, don’t have alcohol addiction. Whereas if you’re a smoker and you got nicotine addiction, very hard to stop. So let’s go to opiates because that’s, you know, so, um, you know, what, what makes different drugs have different degrees of addiction, a liability. And that’s true, you know, if you line up all these addictive drugs, really the three most addictive drug groups are nicotine amphetamines and, um, uh, opiates, opioids. So those are the three top (NOTE: Unable to find a citation for this particular ranking, but here you can read a paper discussing the addictive profiles of several substances).

(11:06) Phil Lofton:
Wow.

(11:06) Andy Chambers:
Yeah. And everything else has kind of lower, you know, um, cocaine’s a little bit lower. Although, you know, there are certain types of cocaine that get up with amphetamine. Marijuana is lower on the ladder, Alcohol’s lower on the ladder, but you know, they all have various degrees of addiction. So why are opioids among all these drugs at near the top? Um, couple of reasons. One is the effect of opioids in the motivational center of the brain is such that the addiction action happens through several converging pathways there. There are several ways in which opioids exert a cellular and pharmacological effect to generate this plastic change, right? So the same drug does it through different routes so that increases the potency of the addictive effect. So, another really interesting thing, um, that I think is probably somewhat unique to opioids. All there more research needs to be done.

(12:21) Andy Chambers:
And this is really fascinating, I think is it, you know, we all think about opioids and being pain relievers, right? That’s kind of the, it turns out in the last 15 years that we’ve begun to understand something very different is going on with the internal opiate system that we’re all born with. So we’re all born with this endogenous opioid system and we’ve understood that, that helps us internally regulate pain and other sensations without external drugs. When we’re young and, we’re attaching to our parents, same system is involved. So there’s actually a, the internal opioid system is actually part of the infant and the parent. Usually the mom beginning to form a basis of an attachment.

(13:12) Phil Lofton:
Serious?

(13:13) Andy Chambers:
Seriously.

(13:14) Phil Lofton:
Wow.

(13:15) Andy Chambers: 
Yeah, yeah, yeah. It is amazing. It’s part of it.

(13:23) Phil Lofton:
So attachment between a mother and the child helps the child develop resistance to pain? Well, we’re unpack that. What does, what does that look like?

(13:33) Andy Chambers:
Maybe to some extent. Yeah, to some extent, yeah, there’s data to back that up. But the way the way people began to look at this is that, um, so think about this. This is the easiest way to see it. Okay. Right. People looked at how the children react. You know, how to young children react like, you know, toddlers or infants in a room when you, when the mom leaves the room, what does, what does a young infant do, how do they, how does a young infant with a healthy, a healthy young adult react when the mom leaves him?

(14:06) Phil Lofton: 
Well they cry.

(14:06) Andy Chambers:
They cry and you know, they shake, you know, this is reaction. And so people began to look, wait a minute, there’s a lot of in what this baby’s doing that looks, you know, the blood pressure might go up a little bit of the baby cortisol, stress hormones go up and the baby, you know, is, not like crying but may seem some mucus coming out of the nose with the reaction red face, whatever, and, and along the way, someone` was like, wait a minute, that looks like opiate withdrawal, doesn’t it? It mimics a lot of opiate withdrawal. And so people started thinking about, you know, is there a way to understand the Bible, the brain biology of attachment to one’s mom that could relate to the functioning of the endogenous opioid system.

(14:53) Phil Lofton:
Wow.

(14:54) Andy Chambers: 
Yeah, yeah, I know. It’s cool. It’s cool.

(14:59) Phil Lofton:
So, um, to, to follow up on that, I, one of the things that, the research that you sent over to me know, really hammered home is that when it comes to addiction psychiatry, we need to do more research for sure. Um, there’s a huge gap of research, but what does that, what does that say about babies that are born with nas? How does that play…

(15:21) Phil Lofton: 
Hey, it’s Phil. I’m just jumping out of the conversation real quick. NAS, what I mean when I say that is neonatal abstinence syndrome. We talked about that in episode three with Dr. Litzelman and Carolina, it is a disease that affects babies of women who, uh, used opioids while they were carrying a baby. Okay. Just thought I’d clarify that back to the conversation.

(15:48) Phil Lofton:
Born with NAS. How does that play into it at all? It all. Does that play into it at all?

(15:51) Andy Chambers:
Well It’s concerning, isn’t it? And we. The thing that’s a troubling is that the current epidemic, which really got very large in very, very large in 2008, maybe even a little bit earlier and we’re still now, it’s gotten bigger since 2008. So I mean that’s a firm right now, a baby born and one that’s a 10 year old child. And we, we at that even in a way we weren’t really keeping good data about NAS babies. So at that time even it was happening were just not tracking it. Now there’s much more attention and we kind of have a better handle on what babies are now being born with NAS and there’s lots of them and so, but we don’t have the future result yet. Yeah. So we don’t really know. It’s not really well studied. What is the longterm impact of NAS.

(16:52) Andy Chambers:
I mean a parallel is, you know, fetal alcohol syndrome, but now we’re going to have something probably a little different than that. I’ve actually encountered, or beginning to encounter patients who tell me that they were, they were diagnosed with that as babies now who are in their early twenties. Right.

(17:12) Phil Lofton:
Wow.

(17:12) Andy Chambers: 
And that’s the first time I’ve encountered that. Right? I mean, so that person who I’m thinking about is in the early twenties, what they would have been born in late nineties.

(17:21) Phil Lofton:
Yeah.

(17:22) Andy Chambers:
Before the epidemic got substantial. And when I see this patient, you know, they have this patient I’m thinking about has a combination of mental health and addiction issues and it’s not possible for me to tease out what is the, what could be a residuum from NAS or what are the many other factors, right that are in this. So I think that’s a – I’m glad you brought that up because that’s just a huge unmet research need, man. That’s fascinating. Yeah. Okay.

(17:50) Phil Lofton:
So, um, I kinda want to glance off of something that you were talking about. Uh, you were talking about the longitudinal respect or the historical perspective of the epidemic and how it has evolved over time. One of the things that I’ve picked up in your work and your talks in your powerpoint presentations is how this isn’t necessarily entirely a complete and total responsibility of the medical system, but we sure didn’t help, right? I’m one of the words they use to talk about this as the iatrogenic origins of the opioid epidemic. So can you talk a little bit about that?

(18:27) Andy Chambers:
Yeah. You know, I, I have to say I do actually place a lot of responsibility, you know, it’s a complex puzzle, so it’s not, we can’t pigeonhole any one individual or group, but most of the responsibility for this epidemic does lie with the healthcare system, you know, and iatrogenic meaning, um, you know, causing harm or injury or disease while trying to deliver healthcare is, you know, a good description of this epidemic.

(18:58) Andy Chambers:
Um, you know, flatly the data is very clear that um, the over-prescribing, the mass prescribing of opioids in particular, but other drugs too, it’s not just opiates, but the, the mass prescribing of these drugs, you know, in, in the United States, really beginning this, started to really increase in the nineties, um, and got very large in the 2000s. So over…over about that 20 year span.

(19:27) Phil Lofton: 
What was wrapped up in that?

(19:29) Andy Chambers:
Oh Gosh, several fundamentals I would say. So that talking about root causes. We have, in the United States had several things happen (NOTE: For even more discussion on this, see episode 2 and hear Kurt Kroenke’s discussion on pain as the 5th vital sign). Um, the mental health and behavioral health infrastructure. The workforce has been essentially a collapsing over about a 20, 25 year period. It’s not gone, but I’m talking, you know, hospital beds being eliminated, people going into psychiatry, the numbers diminishing, the amount of, uh, psychiatry that’s taught in medical schools. And it’s very ironic because of course our brain science has gotten richer.

(20:19) Andy Chambers:
So how is it that the clinical care of brain disorders in terms of psychiatry has been diminishing while our brain knowledge of it has only increased, but you know, health insurance coverage for these conditions has weakened and gotten harder to come by. So while that’s going on, um, you know, and that kind of big, it kind of began with deinstitutionalization in the sixties and seventies closing a state hospitals and um, at the same time you have the war on drugs, which was really of a political and cultural movement in the United States to decide we’re going to address the drug problem through criminalization. So think of those two things happening at the same time, right? The, the, the slow motion, sort of degradation of, of um, behavioral health care while criminalizing drug addiction. And no one knew that mental illness and drug addiction are biologically interconnected diseases of the brain.

(21:27) Andy Chambers:
So what you end up doing now is beginning to criminalize mental illnesses self. And as that begins to gather momentum, right? There’s even more stigma, right? More stigma creates more stigma. Fewer doctors want to go into that because these are criminals, not people who need, you know- or morality gets wrapped up in it. That’s part of stigma as you, you instead of viewing it as an illness, you view it as a moral problem and you don’t want to be around people with moral problems or associated with criminals or aid and abet, criminal activity, et cetera, et cetera. And so it really, um, I think created a setting where addiction is not viewed as a biomedical problem. It’s a moral and criminal issue and therefore it’s not in the domain of healthcare.

(22:17) Andy Chambers:
So if it’s not in the domain of healthcare, if. Right, yeah, if it’s not something doctors should be concerned with, then, you know, it’s not even a disease. Then you don’t have to worry about it. Right. So you just Kinda, uh, you might, you know, if, uh, if doctors aren’t aware of addiction, they’re not aware of the dangers of it. Not really being taught at some for jails and prisons to deal with then, you know, um, if you’re creating it, you wouldn’t even know it.

(22:48) Phil Lofton:
Right, right.

(22:50) Andy Chambers:
You know, I’ve seen documents where barriers to healthcare is a concern for addiction. Barriers for healthcare, you know, and these are federal documents, right? That and you know, from the early two thousands, that concern of addiction is a major barrier for people to get adequate pain relief or healthcare.

(23:14) Phil Lofton: 
So does that tie in pretty well with the idea that you talk about in some of your work of pseudo addiction?

(23:19) Andy Chambers: 
It does. Okay. It does, right. So pseudo addiction was a diagnostic construct that came about in the late eighties by some folks who felt that there are people in pain who need opioids and you know, they look like they’re addicted, but you shouldn’t even assume they’re addicted because that’s not humane. You should just go ahead and relieve their pain with opioids. And so if they look like they’re addicted, well it’s not real addiction, it’s fake addiction, pseudo meaning fake. So just you need to go ahead and diagnose fake addiction and give them more opioids.

(24:03) Phil Lofton:
Oh Man.

(24:05) Andy Chambers: 
So this concept gathered a lot of steam and a lot of people glommed onto it. And this goes along with, you know, the pain as a fifth vital sign movement. Uh, I mean, no one doubts that pain is, you don’t want health healthcare where we are concerned with pain because that’s just a general form of suffering we’re trying to relieve.

(24:26) Andy Chambers:
But what the alliance that occurred was a linkage between pain and opiates kind of being the sole solution. Right? And when we know, um, that there’s – opiates are far from perfect, they got major downsides and there’s also other treatments, lots, lots, lots of other treatments for pain. Lots (NOTE: We’re going to REALLY get into this later this season). Oh yeah. So, um, you know, so, so, but this is kind of where the forces came together, um, with this pain movement. And, you know, honestly, another dimension which kind of fits in with all this is that our healthcare system has gotten pretty big businessy, you know, just a little bit of profit motivated a little bit, marketing and commercial and, you know, so-

(25:18) Phil Lofton:
I was gonna say, you can advertise pharmaceuticals anywhere in the world directly to consumers, can’t you (NOTE: This is most definitely sarcasm)?!

(25:26) Andy Chambers: 
Exactly. Another change in our medical economy. Exactly right. So, uh, that’s another element to it. And um, uh, there’s, you know, I the paper that one of the papers you reviewed, uh, I think I sent you, um, it’s interesting because I had a little bit of a hard time getting that one published, right?

(25:46) Andy Chambers:
I had a hard time getting that published and one of the journals that ended up not accepting it until that one did you want to me to write something different. That was really… And they wanted me to write a big review article about how not treating addiction is one of the biggest businesses in America.

(26:02) Phil Lofton:
Oh Wow.

(26:03) Andy Chambers:
Right. And that’s a great topic. But that would take me five years to write and an even bigger, you know, that’s a big. That’s a big chunk to bite off, but someone else suggested that because it’s kind of true. Right. You know, and so, um, unfortunately part of the iatrogenic opioid epidemic is a lot about what’s happened to our healthcare system. Viz a viz how it operates and uh, you know, um, uh, you know, trying to grab market share, grab patients, making sure it’s as pleasant as possible, efficient, all those things, you know.

(26:43) Andy Chambers:
And so, um, and in many ways that’s, that sounds good, right? These are, they sound good, but I think the opiate opioid piece definitely was, uh, when you, when you leave out psychiatry and behavioral health and addiction, you’ve got a real crisis on your hands.

(27:00) Phil Lofton: 
So, I want to get to where you think addiction psychiatry comes in as far as, because I saw one of the diagrams from one of your powerpoints specifically discusses how addiction psychiatry is part of the fixed to this at multiple points in the pipeline. But real quick before we do, I want to loop around from this paper to a second thing that you talk about that’s just as much a part of the problem as pseudo addiction, which is one of the ways that we talk about how people use medicine, self medication. It is a term that is ubiquitous. It’s everywhere. From sitcoms to, to CW dramas to academic papers. It is the term and it’s bad, right?

(27:43) Andy Chambers:
I think so in a certain way. In sense. Applied to addiction. Yes. And how it all developed that. So self medication I think is an accurate term. Um, and under certain circumstances, you know, if I get a headache and I take an aspirin to relieve the headache, I have medicated myself. If I have a, um, you know, if I have a flu bug or if I have a flu and I’ll take a cough suppressant of medicated myself. Right. What’s happened in psychiatry is that the, the labeling of addictive drug use in mentally ill people has been labeled as self medication. The problem with that is it labels the behavior as a act of treatment when it’s actually that behavior is a part of their disease.

(28:41) Phil Lofton:
Yeah.

(28:41) Andy Chambers: 
So when you do that, when when professionals in psychiatry, for example, label someone with schizophrenia as self medicating with alcohol or cocaine or even nicotine, then it kind of gives them a way to label the behavior without having to treat it because they’re not even calling it a disease or calling it an act of treatment.

(29:00) Phil Lofton:
Right. But again, like just like you said earlier this podcast, to talk about that convergence of self-medication and addiction and how you’re creating this new mental disease in yourself, that’s horrible.

(29:18) Andy Chambers:
It is. In fact, the label is so inaccurate. Everybody has bought in to the label of self medication to describe drug using and mentally ill people. I’m talking about addictive drugs, so you don’t really call it addiction, but by definition it actually is. It actually is an addiction, so the drug use is causing even more harm.

(29:42) Andy Chambers:
Right? So you’re calling something as an act of medicine taking when in fact it is producing the opposite of what medicine is.

(29:51) Phil Lofton:
It’s not self-medicating it’s self harming.

(29:53) Andy Chambers:
It’s self harming. It’s self harming.

(29:56) Phil Lofton:
Wow.

(29:56) Andy Chambers:
Because it’s addiction. So it’s kept the whole construct of self medication is actually very similar to pseudo addiction in pseudo addiction, you’re calling something the opposite of what it actually may be in self medication. The same both involve addictive drugs. So you’re, you’re, you’re taking the eye of the medical community, one in psychiatry, the rest and pain treatment off of the ball, right? Which is actually a disease called addiction with both those constructs that are dominant. Or had been dominant.

(30:31) Phil Lofton:
Yeah. That is so interesting.

(30:33) Andy Chambers:
That part of this self-medication construct was actually propagated by the tobacco industry. Seriously. Pretty interesting.

(30:43) Phil Lofton:
Wow. Unpack that.

(30:46) Andy Chambers:
Well, this was actually unpacked by investigators who were taking advantage of the large tobacco settlement. Don’t know if you’re familiar with that, but the, um, the, you know, the states got together and Mellitus successful class action lawsuit against the tobacco companies for not being upfront about the extent to which they knew nicotine was super addictive. Um, so they had to pay the states and they still are. They’re paying Indiana millions upon millions or paying other states millions and millions of dollars in, in damages caused by nicotine addiction to the public health. This is still going on. Um, one of the things that they also had to do is surrender documents that documented some of the extent to which the tobacco companies were actually funding psychiatry and neuroscience research that was trying to promote the idea that nicotine is a cognitive enhancing and mood – mood, like an antidepressant for mental illness.

(31:58) Phil Lofton:
Wow.

(31:59) Andy Chambers:
Right?

(31:59) Phil Lofton:
Wow. So when we get that, like a visual, like we have in like the 1960’s in the 1950’s with the old movies of like, take the edge off a little bit. have a smoke. That’s where we get that from.

(32:10) Andy Chambers:
A lot of it. There’s something, there’s something really good for your psyche helps you focus or a, you know, it’s an antidepressant, helps you be in control, happy, powerful, anything. I think that’s positive. You know, it gets linked and you can see it on the cigarette. You can see this stuff on the cigarette marketing packaging. So this investigator, I’m actually, she at the time was at UCF SF. Her name is Prochaska. Jodi Prochaska was one of the authors on this paper that unpacked is to use your words, such a good one, unpacked this evidence showing that the tobacco companies were, were connected in supporting research that was aiming to paint tobacco and nicotine in a positive light for mental illness. And it affected a lot of things. A lot of money went into this and it kinda was the only game in town.

(33:11) Andy Chambers:
There was no other theory other than tobacco is in some way a medication for mental illness because that was the only hypothesis that was being funded, right? There was no other hypothesis. So when you, when that hypothesis is the only hypothesis that’s being funded and you’ve got all these researchers exploring that, um, it kind of keeps everybody’s eye off the ball of wait a minute. Might also be that nicotine is even more addictive in mentally ill people, right? It’s not right. So addiction and medication, they’re not the same, right? And so for years and years, people kept propagating the idea that smoking was an antidepressant, that it’s a cognitive enhancer. And if you look in psychiatric journals and the 19 eighties, the 1990’s, the 2000’s, anytime you find a paper that looks at smoking and tobacco use and mental illness and schizophrenia and depression, it’s always about tobacco being a medicine.

(34:14) Phil Lofton:
So one of the ways, I don’t want to jump too far ahead, but one of the ways that addiction psychiatry cuts through and gets the medical profession back on course is by proposing those alternate hypotheses. And saying maybe nicotine is causing another mental illness or is, is being, is, is creating a worsening effect of the mental illness. Maybe opioids aren’t this compassionate treatment for pain. And maybe you’re not a bad doctor for not wanting to give opioids to someone that is suffering. Maybe there’s another way, maybe you are avoiding giving them a mental illness by, you know, not giving them opioids.

(34:56) Andy Chambers:
Correct.

(34:57) Phil Lofton:
That’s really interesting.

(34:59) Andy Chambers: 
That’s exactly right. And here’s the, here’s the link that’s really crucial in the conversation. Um, so part of where this alternative view, this not, you know, this kind of addiction view, that’s not addiction psychiatry, that’s not self medication or pseudo addiction, is that the idea that if you have a mental illness, then any addictive drug, just because you have the mental illness, any addictive drug is more addictive for that person. Right? And we already knew this was kinda true, I mean this is what the epidemiology says, the epidemiology is very clear on that, because think about this right now in the general population, only about 15 percent of us smoke. Yeah. Only 15 percent of adult smoke right now. But 50 percent of all cigarettes are smoked by someone with one some kind of psychiatric illness.

(36:02) Phil Lofton: 
Wow.

(36:02) Andy Chambers:
Right? The rates of addiction to nicotine are much higher in people with mental illness.

(36:08) Phil Lofton:
Wow.

(36:09) Andy Chambers:
So let’s switch to another addictive drug. Different – totally different profile of intoxication. Let’s talk. Let’s go to alcohol. Yeah, we’re totally different from nicotine. Same thing, same thing, same thing. Let’s go to opiates. Yeah, totally different profile from nicotine, alcohol, same thing. There is a connection between mental illness and drug addiction. Right? So what we did the research in my lab and other labs in the early two thousands. So I started working on this in my medical school career and later on. Okay. If this is true, let’s do an experiment and we can’t do this with people because it’s not ethical, right? Because it has to be an experiment where you take a healthy animal, healthy subject and a mentally ill subject.

(37:03) Phil Lofton:
Yeah.

(37:04) Andy Chambers: 
And it’s very simple. You just ask, okay. If you expose both subjects to the same amount of, of an addictive drug, yeah. Which one is more likely to get addicted, addicted, and which one is going to have a worst case of it, even though you’re exposing both subjects to the same amount of drug. So we started doing this research with animal models of mental illness and Lo and behold, the mental illness accelerates – biologically accelerates – the disease process of addiction. And it has nothing to do with the psychoactive properties of the drug.

(37:40) Phil Lofton:
Wow.

(37:40) Andy Chambers: 
Right. So mental illness accelerates addiction and then addiction. When you start having it, it causes even worse. Mental illness. So there’s no room. You don’t need to talk about self medication in any of this conversation. Right? You don’t need the theory. It’s a, it’s a totally unnecessary hypothesis.

(38:14) Andy Chambers:
So, it’s not that you have to have a mental illness to get addicted. It’s not, you know. I need to point that out. Like because I’m not claiming that only people with psychiatric illness have addiction. I’m not saying that, I’m just saying that if you have the mental illness, your odds of getting addicted if you get exposed, is like two to six to eight times greater, like huge amplification. And we see that in the epidemiology. Right? And so you can begin to understand why is, you know, you can understand why this is on a biological level, not, not only, not only can you show it in animals that replicates the human, what we see in the human people and humans in the epidemiology, the American people, what you see on a big scale, and you can replicate the effect and individual animals, but the animals also give you the opportunity to get inside the brain to see how the diseases are more or less synergistically interacting.

(39:17) Andy Chambers:
Yeah. Right. And then that gives you a window into the disease of addiction itself, right? Because, you know, in any disease we study, we want to know what are the risk factors and when you understand a risk factor, you begin to understand part of the pathophysiology of it.

(39:33) Phil Lofton:
Yeah, yeah, absolutely.

(39:35) Andy Chambers: 
Yeah. So, so when you kind of get to that link, that mental illness just, rather indiscriminately, accelerates addiction and it’s not drug specific. Yeah. Then you see this linkage between an addiction and mental illness and you’re like, oh my goodness, you have to treat both aggressively simultaneously in the same coherent treatment plan. Right.

(40:08) Phil Lofton: 
So I think that goes to a pretty obvious place. You’ve got some good theories about what that looks like, that sort of intersectional care. Right? And it’s called the two by four model.

(40:21) Andy Chambers:
That’s right.

(40:22) Phil Lofton:
So tell me about the two by four model.

(40:23) Andy Chambers:
Okay. Well the two by four model takes that, that neuroscience, that basic neuroscience from the rats takes it from the epidemiology and says, you know, if these diseases are that tightly connected, we should have a network of clinics throughout Indiana, throughout the country that are capable of treating both conditions in an integrated way in one clinic by one treatment team. There should not be a segregation of mental health care from addiction care. Unfortunately, that’s what we got right now. But there’s no reason we can’t move to this integration within behavioral health where patients with basically any major addiction in any major mental illness can get, can walk into a building and get all that treated in whatever combination that got it without going somewhere else, without needing to do that. And if you do that, the care is going to be better and have more effective, better outcomes.

(41:25) Andy Chambers:
So to do that, you have to have some things. One of elements is the professionals on the team actually need to know how to do both. So you need psychiatrists that are trained in addictionology, those, that’s addiction psychiatry, those are addiction psychiatrists. When you have those individuals, they can train the nurses and the therapist to be cross proficient to treat mental illness and addiction. So really the addiction psychiatry group is fairly important. Keystone to this. But you know, you want all the professionals on the team in this kind of clinic to be comfortable and competent and in fact expert at both mental illness and addiction. So you have this professional group. It’s a team. What happens is any combination, the patient presents with PTSD and nicotine addiction, alcohol, bipolar disorder, Nicotine, OCD, schizoaffective disorder, any of these combinations, they come in the door and that same team can do it all.

(42:36) Andy Chambers:
So what does that team need? They need four components as to why we call it the two by four Model. Two on one dimension, meaning take care of both mental illness and addiction. Four, on the horizontal dimension is there are for treatment components. The clinic has got to have to to do this kind of care. First of all, they need the right diagnostic tools, which means that the diagnosticians, the addiction psychiatrist, the other team members, when they do assessments, they need to pay attention to the full spectrum of mental illness and addiction. You know, they can’t say, well, this is a bipolar treatment clinic, so I’m not going to even pay attention to your drinking. Yeah, or they can’t say I’m here to treat your opiate addiction, but anything, any other addiction you got or any other mental health, that’s not my job, so I’m not paying attention to that, that, that’s over in this clinic. We reject that, right?

(43:38) Phil Lofton:
Yeah.

(43:39) Andy Chambers: 
So a full comprehensive workup and then, um, diagnostic outcome measures, right? So constant urine drug screening, constant prescription drug monitoring with INSPECT or whatever the system is

(43:55) Phil Lofton:
just for our listeners that aren’t in the profession, what is INSPECT?

(43:58) Andy Chambers:
INSPECT is a way for us to monitor the way patients are being prescribed controlled substances over time actually. Um, and you know, other other outcome measures, you know, they’re rating scales you may use periodically, but you know, really repeated exams, you know, it’s not that you initiate treatment, you never reexamine the patient. I mean, in a way, I’m just describing the way the rest of medicine works. So when I’m kind of saying is can we, can we actually have behavioral health operate in the house of medicine with the kind of same standards because it is a, these are medical issues of the brain.

(44:35) Phil Lofton:
You know, what a revolutionary idea.

(44:37) Andy Chambers:
And so, so then there’s, that’s the diagnostic. The next dimension that, you know, one of the four key domains of components is psychotherapies. You have to have an array of psychotherapies that are evidenced based for treating mental illness and drug addiction groups and individual therapies and different subtypes. So that’s the way you individualize the care you can. Some patients are going to have individual psychotherapy, some are going to have groups, some are going to have both, some are going to have neither it individualized to the patient. It’s not about, you know, a system that only gives one treatment to everybody, one size fits all because that doesn’t happen anywhere else in medicine. Why should that be the standard in paper health? Right. So, right, okay. The third, third component is medications.

(45:33) Andy Chambers: 
You have to have medications that are evidence space are FDA approved for the entire spectrum of addiction and mental illness. Why should you have a clinic that only provide w w rather when you have a clinic that only provides one medication for one illness? Then that’s kind of this factory rubber stamping, not individualizing care, inflexible can’t really treat most people

(46:04) Phil Lofton: 
And it Kinda is the model that got us into this situation, right? It’s like pain clinics that operated as pill mills?

(46:11) Andy Chambers:
In part, right? Just throw opiates at everybody walks in the door. So you kinda need a medications that treat the full spectrum of mental illness and the full spectrum of addiction. That’s, that sounds revolutionary, but why should it be? Because if you go to a primary care doc, it’s not like they’re going to just prescribe everybody the same antibiotic no matter what you come in with, right?

(46:39) Andy Chambers:
Right. At primary care docs know how to prescribe all kinds of stuff and know how to do all kinds of diagnostic. So in a way I’m describing a integration of behavioral health that is broadly capable of treating all these problems under one roof by one team. So the final piece, this fourth component of the two by four model is the docs, and the team members, the addiction psychiatrist and the other, you know, nursing therapists need to be able to communicate to people on the outside of the clinic to be proactive in protecting the treatment of their patients. They have to be communicated, they have to be talking to the criminal justice system, they have to be talking to other doctors, they have to be active in communicating to recruit the right support for the treatment mission that’s happening within the clinic. And this is really important because the war on drugs and the criminalization of mental illness and addiction is not a treatment approach.

(47:46) Andy Chambers: 
It’s an anti treatment. The iatrogenic epidemic is the inappropriate prescribing controlled substances. So we have to be proactive to stop outside doctors from relapsing our patients. We have to be proactive in communicating with insurance companies to try to get them to support what we’re doing instead of blocking it. Right? So now imagine what’s happening in the two by four model on the two dimension, two by four, all mental illness, all addiction in whatever combination being treated by the same team who’s doing the diagnostic tests. Providing a psychotherapy is providing the medications and the outside communications and consultations all one team. So all that data is integrated. Yeah. And the patient, the team takes full responsibility for the patient. There is no other, you know, in, in a fragmented system, a patient comes in and has mental illness. Well, if there’s an addiction in a fragmented system that only treats, for example, schizophrenia will, if the patient’s using cocaine, marijuana, well we don’t treat that, you know, we only treat schizophrenia. So if they’re not doing well, that’s not really on us. So we’re just keep treating the schizophrenia regardless of the outcome. Right?

(49:08) Phil Lofton:
Yeah.

(49:08) Andy Chambers:
We just kind of add more meds for schizophrenia. It’s kind of what we do. That’s the lever we press. If the patient doesn’t do well, because their addiction, well, you know, that’s not on us. We are building is about treating schizophrenia. You see what I’m saying? But wait a minute, but they’re using marijuana and cocaine which worsen schizophrenia, you know, or, or let’s go to the addiction side. Right? So, you know, a patient who is really having a hard time with addiction, um, they’re, they’re having trouble with compliance, they’re acting strange at times. Well, you know, that patient, I don’t know what’s going on with them. They just don’t want it. They don’t want to participate in care. Yeah. You see what I mean?

(49:50) Andy Chambers: 
Because, when really what’s going on is there’s a mental illness that’s part of the picture that, that treatment system is ignoring. And so they don’t take responsibility for that part. They kind of blame the patient and they themselves never have to get better. They don’t have to take responsibility. So the patients aren’t being taken care of. No one with these patients is stepping up saying this is our job to take care of this person and to, you know, do our best to keep them well holistically, to tell the criminal justice system, hey, we got this person in our care. You don’t need to punish them. We got this.

(50:32) Phil Lofton:
Yeah.

(50:33) Andy Chambers:
Or to, you know, call up the hospital, look, we’re, you know, we’re taking care of this mental illness. We’re taking care of this addiction. So pleased when they come to the ER, do not prescribed that hydrocodone and they show up.

(50:45) Andy Chambers: 
Right. But see what I mean? So imagine if you had clinics like this in a region statewide, nationally. It would be-

(50:57 ) Phil Lofton: 
It’s pretty revolutionary.

(50:58) Andy Chambers:
Hopefully.

(50:59) Phil Lofton:
Yeah. Wow. Wow.

(51:02) Andy Chambers:
So the two by four model concept, it’s been around. Integrated dual diagnosis care is the, is the term and there’s evidence for it, but it never got adopted. Just never adopted. Evidence doesn’t translate well on behavioral health. Just doesn’t, I mean, you know, lottery. Okay. The silo between science and clinical care. Yeah, it’s there in behavioral health, lots of evidence for all kinds of things that never ended up being done clinically. So there’s a whole other set of problems with that. But you know, again, lack of funding, lack of insurance coverage, lack of, you know, emphasis on behavioral health as a core part of primary, primary preventative medicine as well, which is what it is. So all these things. But I think the other, the other thing that wasn’t quite in place was this biological link now, right? We really have a better handle on knowing that mental illness and different addictions are connected in the brain so it doesn’t make sense to provide care that split out.

(52:23) Phil Lofton: 
Yeah. So the, I usually ask this question towards the end of the interview and it’s super obvious with yours, the usual question is, well, what comes next and addiction in addiction, psychiatry, and it seems like the obvious answer at the end of this interview is we need to invest more funding in two by four type model clinics. We need to change the way that we compensate so that those sorts of clinics can be incentivized so that they can receive the proper, uh, you know, compensation to operate because it is, it is specialized. It is unique because it’s specialized and unique, it’s powerful and it can get good outcomes. Okay. What else?

(53:05) Andy Chambers:
Well, and along along with those things, because in a way you kind of mentioned, you know, the insurance reimbursement for this kind of care needs to be stepped up and bear barriers that would prevent the proper reimbursement for the care removed, I think. I think, you know, trained workforce. So in behavioral health we have to really look bringing more people in psychiatry into addiction, psychiatry, getting more people in psychiatry and understand that it’s really hard to treat the spectrum of illnesses that you’re interested in without being open to treating the addiction side of it as well. Yeah. So, you know, and that people need to be trained in that. This is not something that, um, it, it really is a skill. It really requires formal residency and fellowship training and it requires certification, you know, so that people know who’s been properly trained.

(54:02) Andy Chambers:
And so I think building up the workforce, building up the infrastructure and making sure insurance coverage happens for this care. Now, a lot of people are gonna say, well that is huge amount of money. You’re talking about huge investment and what I can say that as, are you kidding me? Our healthcare system spends double any other country in the world and we’re getting worse outcomes. And what, what’s the real root of that? You know, to what extent is that related to our opioid epidemic? You know what, to what extent is all this? Addiction isn’t the number one cause of premature illness and death. Yeah. Right. And we’re doing very little for that and yet the expenses of treating the medical consequences of all this addiction and mental illness that we’re not treating is, is vast and it’s unsustainable. Think about like the part of our state budgets, right?

(54:58) Andy Chambers:
That go to building prisons and delivering medical care for the consequences of untreated addiction. We’re, it’s eating up our state budget. So what, what are, what are state governments doing? They’re basically putting education on the backs of, of citizens. So it’s affecting all of us, you know, our, our, our ability to, to go to college to go to professional school. It’s more on the backs of individual families because the government can’t afford to help. Help us out with that education. Right? Because our governments are spending incredible, vast sums of dollars on prisons and runaway healthcare costs for not treating addiction.

(55:41) Phil Lofton:
Right. Fascinating. Wow. There is so much down back in that conversation. The way that we split medical care that belongs together, the way that we’ve approached and discussed addiction. I could go on, but one thing jumps out to me right now is the way that we track patients’ information across health systems. There are serious blind spots in the way we record patient data that we need to address. Join us next time when we talk with some of the leaders in medical informatics and data science about how we can change the way we use patient data to make a dent in the opioid crisis. We’ll see you then on The Problem. Music this episode was from Everlone. Our theme and additional musical cues in this episode, were written and performed as always by Susanna Washington and the Scaredy Cats. 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 regenstrief.org And see bonus content from this episode, including sources, pictures and more at regenstrief.org/theproblem.

Bonus Content

Andy discusses addiction psychiatry with IU Health: https://iuhealth.org/news-hub/dr-chambers-discusses-mental-illness-addiction

A presentation from the 3rd Annual Prescription Drug Abuse Symposium Targeting Strategies to Curb the Epidemic in Indiana Indianapolis, December 19, 2012: https://www.in.gov/attorneygeneral/files/BreakoutChambers.pdf

Episode 4: The System

Learn how large-scale health systems are doing their part to combat the opioid crisis. This episode feature Ashley Overley, chief executive officer of Eskenazi Health Midtown Community Mental Health and vice president of mental health operations at Eskenazi Health.

Transcript

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

Bonus Content

Eskenazi Opioid Response Packet
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Further Reading

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

https://www.hhs.gov/opioids/about-the-epidemic/index.html

https://www.hrsa.gov/opioids​

Episode 3: Boots on the Ground

Sometimes we need someone who’s walked the same roads as us to help us with our health. Learn how Community Health Workers are moving the needle on addiction in Indiana.

TRANSCRIPT

It’s been awhile since you were in the doctor’s office. When you were there last time, she gave you your diagnosis and she wrote you a prescription. It seemed serious. She asked you if you had any questions and of course you did, but in the moment it all seemed a little much, a little overwhelming. She told you to call the office if you thought of anything else that she was happy to help. You started the long drive from the city back to your home in the sticks and then you got back to life.

Months go by. You take the medication as best you can. Sometimes you go to groups online that talk about your diagnosis and they seem pretty helpful for answering questions. You try and change your habits and in a few months you had back in for a follow-up. It’s gotten worse. Your doctor tells you some other changes you should have been making. Changes the groups never even discussed. She tells you the foods you should have been avoiding, exercises you should have been doing. It’s all brand new information to you. A lot of brand new information. You go home and you keep trying. Who knows what she’ll say next time from the Regenstrief Institute. This is The Problem with Phil Lofton.

Millions of Americans live with limited access to medical care. It’s estimated right now that nearly one in six Americans live more than 30Millions of Americans live with limited access to medical care. It’s estimated right now that nearly one in six Americans live more than 30 miles away from a hospital with emergency services.

That number is not expected to go down. That’s just the tip of the iceberg, too. About a third of women who live in rural areas have to drive over half an hour for OB-GYN care. Scarcity of mental health, dental and other specialized care can even lead people in rural areas to load those responsibilities onto their family doctor, many of whom don’t have adequate training to deal with those needs, and that’s not even mentioning the gaps in communication that can lead to serious medical misunderstandings. After all, what if a doctor and patient can communicate well about the seriousness of the condition? What if there’s a serious roadblock and how those two parties talk about health goals or nutrition or exercise. It helps to have someone in the community from the community that has a similar background. Someone who can visit folks in their homes and see how they’re living day to day.

That’s where community health workers come in. Community health workers, who were called the new professionals when their profession was first recognized, are part of the medical tradition that goes back to the early 20th century in China. The barefoot doctors of China were individuals who received about six months of trainingFor 50 years, a total of nearly 2 million barefoot doctors serve the poor and rural areas of China, providing public health services like family planning and medications as well as eastern medicine treatments. These weren’t just city people who were dropped into the country, though most of them spent around half of their lives as farmers, so they were very aware of the context of the lives of the people that they treated. Other countries and other organizations saw the benefit of this model and they gave it a shot in Bangladesh. BRAC, formerly known as building resources across communities, trained and mobilized locals to become paramedics. In Iran, BrazilTanzania, and more community health workers have been mobilized to help reduce infant mortality to astounding effect. But what’s that got to do with opioids and what’s that got to do with Indiana? Meet Deb Litzelman.

They are not social workers, they’re not nurses, they’re not public health workers in any way. They’re trained as health coaches. … And they really are coaches. – Deb Litzelman, MD

I am a professor of medicine at IU School of Medicine. I’m the associate director for Health Services Research here at Regenstrief Institute and I am the director of Education for the IU Center for Global Health.

Over the past few years, she’s made an impact getting community health workers out and involved in central Indiana through a series of projects.

The community health workers that have been involved in the projects that I’ve worked with here in Kenya and in Indiana, are lay workers. So they are purposely intended to be people who come from the communities in which they’re working in serving. They’ve grown up in the community, they know the nuances of what it’s like to live in the community. They look and talk like members of the community, so they’re embraced by those that they come and knock on their door, are engaged in the community. Our community health workers here in the United States, in Indiana on our projects are maybe high school or GED equivalent. Some of them do have a little bit more, a formal education, but that’s not required and in fact it actually sometimes it makes them less approachable. So we have carefully selected them for their skills, their empathy skills, their ability to want to serve and be out there and about, but those are the most important aspects of our community health workers. 

They are not social workers, they’re not nurses, they’re not public health workers in any way. So they’re trained as health coaches. So that’s another name we have for them. And they really are coaches. They’re there to be supportive. They are trained, so they have information on our five pillars on smoking cessation, on food insecurity, obesity, on substance abuse, mental health disorders, anxiety, depression on safe sleep practices for infants and on breastfeeding. So those are our five pillars that they focus on and they have resources and information on all of those. They also are connected with a lot of the community resources so they can get more mothers and grandmothers and fathers pack and plays for safe sleep and sleep sacks and they can help them get signed up for WIC and tell them what they need to take to the office to get that done, et Cetera, et cetera. 

So they’re quite competent lay workers who are really connected. They are known by the community, they’re accepted by the community members. There is no barrier between them and the healthcare system or them and somebody with a white coat or somebody who they perceive as being an authority who might judge them, who might, you know, just not be available for them when they most need them. And they’re out in the community, so they are out and about doing home visits. So they meet the folks anywhere they want to meet – the laundromat, etc. Our first responders are connecting them. So these are folks who never make it to the door of our clinics and our hospitals. So they’re very key to accessing those who are most in need, who don’t ever show up on our doorstep or show up too late. 

A while back, Dr Litzelman started with WeCare. WeCare recruited new mothers, then partnered them with coaches who would help them form good habits. What’s more, participants regularly receive text message updates about local resources like free diapers, free food, and more. It was very effective, but they started to notice a pattern.

When we looked at the 1500 people we were following for WeCare and WeCare Plus, 15 percent were self-reporting concerns about, or reporting use of, illicit substance medications that were not prescribed to them. Opioids were among the list, but there was also methamphetamines, a lot of marijuana, and this is separate from smoking. Smoking is another huge addiction, a concern that we have for our, our moms and women. So that’s in brief why we decided that this was a perfect opportunity to overlay the concerns around opioid addiction and substance use disorder. On top of WeCare and WeCare plus.

CarePlus is a new program recovery coaches approach women at local hospitals who have recently given birth to a baby suffering from neonatal abstinence syndrome.

NAS is neonatal abstinence syndrome. So that is the syndrome, that, a baby shows at the time of delivery if the mother has a substance use disorder and has been actively using during pregnancy. It can be that that woman was actively using illicit substances or might have even been on suboxone or methadone and the baby because it’s in their system, will have withdrawal symptoms that could be minimum or severe, severe enough to put that baby in the intensive care unit for sometimes several weeks if not more. And so those, those women who deliver often need a lot of support, a lot of care, a lot of training on how to attach with their child who can be quite irritable and very hard to calm just because of the withdrawal. The mothers often feel like they’re guilty and are shamed and then also feeling like they don’t have the skill sets to take care of that baby. So everything we can do to help them gain those skillsets and keep the mother baby together as long as it’s a safe environment for the child. 

CarePlus works with these mothers, they recruit them into the study and then they start to help them.

Well, we measure at intake the risky behaviors. And then the follow-up is documented by our community health workers. So if somebody screens positive for smoking, for example, the community health worker will follow up. They will use motivational interviewing methods that they’re trained in to assess the person’s interest in readiness for change at the right time. They were already interested. They can refer them to a baby and me tobacco free programs where they can get free diapers for staying off cigarettes. Their partners can also be part of the programs and encouraged to be part of that. So, we have measured a, a percent decline in smokers have pregnant and postpartum women. We measure using validated tools, depression and anxiety, for example, and again, over the period of time of followup, we’ve shown a decrease in scores from higher to lower being a better outcome. So that’s occurred. We’ve had more women getting emergency food packs for food insecurity, connected to food pantries and things. More importantly though of those that were, who screened positive for food insecurity, 60 or more percent of those women had gone on to get officially got enrolled in WIC and SNAP or food see sustainability, security for their families and themselves. So these are the kinds of things that we’ve measured for. Those are three examples.

A big part of why the WeCare related projects like CarePlus have worked is because of the people who have given their time to help others. People like Carolina. She’s a recovery coach and care plus she recruits mothers into the program, gets to know them and their family and helps them do life.

My job is just to be a support, right? But, I guess when I’m able to actually see that in someone’s life, it makes a big difference, because you can see, you know, that this person knows that there’s someone that’s going to help them, that’s someone that I’m going to understand them and that they don’t have to feel too alone. Also, you know, me providing resources, gives them hope and gives them kind of like, not a way out, but they can start looking for those resources themselves now that maybe I’ve given them a few and they can start, you know, just building their life, you know, from where they were. 

Carolina was hired early because we, even before the grant got started, we saw that she was such a gem, in terms of her empathy and caring and her experience. So she’s had a year of work in a methadone clinic in New York, Harlem, and a year of work at the methadone clinic here in Indianapolis doing individual and group counseling. Again, those jobs are slightly different than the expectations for an addiction recovery coaches, but it certainly demonstrated her interest, knowledge and experience with, with people with addiction and the ability to, be a year, two years into this to really be committed. And so she was hired, she went through a special training to become an addiction recovery coach and is now already being a resource for our current. WeCare coaches to refer to her, anyone who’s interested in having extra care or concern around their addiction. 

Plus she’s doing her own independent recruitment from treatment centers and now currently through the care plus program funded by Fairbanks. We’ll be recruiting mother babies, have babies who are born with neonatal abstinence syndrome out of one of our, our local and icu neonatal intensive care units. Through the work of people like Carolina, community health workers can have a huge impact on lives. Lots of times though, success can be bigger than just one person success. To me, I’m on a project this large with a problem, this big is any step toward improving positive behaviors in diminishing negative unhealthy behaviors. And we’ve done that. We’ve done that in all five of our pillars. The next layer of success is healthy birth weight, because a low birth weight baby as at risk for infant mortality, but even if there’s not a mortality outcome with that, a low birth weight baby might be in the NICU for a long periods of time, may have developmental delays, may have learning disabilities, etc. 

So anything we can do to get a baby born over 5.8 ounces is a major outcome for us. So that’s the second layer. And then ultimately with the WeCare , WeCare Plus, our major outcome is decreasing infant mortality, which is a major problem in this state. So those are all successes add to CarePlus then the overlay with women with substance use disorder often comorbid with mental health concerns, depression, anxiety, and even more serious mental health issues is getting them connected to behavioral health folks and in recovery counseling, whether it be formal with in or outpatient addiction treatment centers or the major informal networks with narcotics anonymous alcoholics anonymous around the city, which is free or if they’re still afraid of that, not ready for those big steps to just meet with our coaches who we have a special force of community health workers who get extra training in addiction recovery as addiction and recovery coaches so they can serve in terms of a supportive role, encouraging, helping them stay clean, helping them get clean, helping them connect, get over their fear of approaching a treatment center, if they relapse to not shame or blame them to be there for them and get them back on track. So we, we are quantifying, measuring all of that and that will be our measures of success.

I think definitely if a mom is still struggling with using heroin or any other drug, the fact, you know, that they started thinking about not using anymore about understanding what they need to do to stop using, you know, like not hanging out with certain people or eating healthier, or seeing me more often or looking forward to seeing me, that, you know, because if mom starts making those changes, then that baby, you know, it will be taken care of. Another big success is if Dad is part of the family and the Dad is supportive of mom, you know, because a lot of times, again, you know, if they don’t have any support, they don’t feel that they can do this. Right. , so if there is people in the family that supports moms or dad, you know, then we also know as a health worker or a recovery coach that you know, there’s someone else in that child’s life that you know, it’s going to take care of. It’s going to be part of that baby’s life in a positive way. 

One of the biggest ways that community health workers succeed is through the trust they build with their clients. That trust is built on empathy. Something Carolina says we could all use a little more of when we talk about folks with substance use disorder.

I think a lot of people focus a lot on, you know, they made that show ways that’s their fault. But I think, you know, we fail to understand that once they are kind of like too deep in their addiction, you know, that it’s not just one decision of say, okay, I’m going to stop using because at that time, at that point, your brain has adapted to that specific drugs. So it’s not just, you know, that person is going to stop using right away. So, you know, more like this stigma, I think, you know, kind of hopefully… I don’t want to say can go away because it’s not just going to go away. But, you know, I guess more education, and ,you know, a lot more support too. 

Well, community health workers can make personal impacts on opioid addiction and family health. They can’t fix it all.

Sometimes, as a recovery coach, we can feel useless or powerless. I think that’s a better word, a powerless, because there isn’t a lot of help out there.

For starters, the field is often understaffed, under equipped and underused, but when they’re used well, community health workers can be a powerful addition to healthy, robust larger scale solutions like health systems and hospitals. Come back next time when we zoom out a little bit, we’ll talk with Eskenazi Midtown CEO Ashley Overly about how health systems can make an impact in fighting the opioid crisis. Join us then on the problem, our theme and additional music cues. In this episode, we’re written and performed as always by Tessa White and the Natchez Trace. The problem is produced at studio 132 in the Regenstrief Institute in Indianapolis, Indiana. We connect an innovate to provide better care and better health. 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/theproblem.

Bonus Content

Most of the CarePlus Team standing for a portrait
Most of the CarePlus Team

Episode 2: Ow!

How does the way we talk about pain affect our society? We’ve been told that certain drugs are the most effective ways to relieve pain, but is that true? Featuring interviews with Kurt Kroenke, MD, MACP and Marianne Matthias, PhD.

Transcript

Phil Lofton:

From the Regenstrief Institute, this is The Problem. The Problem is an anthological podcast dedicated to fighting the Hydra s 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 and what’s being talked about and the trials and triumphs of those involved clinically and personally. This season is all about opioids. Over this series of episodes The Problem willl 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 how they’re 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.

[OW Sound Collage]: 01:12 [OW Sound Collage]

Phil Lofton: 01:27

Ow! it’s one of the first words we learn as humans, but we learn the principle behind it even earlier. I’m in pain and I would like it to stop. We communicate it in the simplest, most elemental ways possible with an ow or a scream or a cry. Then we get older. As we grow into our bodies and begin to understand them better, we grow our capacity to communicate or pain with people who can help relieve it. I’ve got an Owie becomes, ‘Hey doc, my knee’s been hurting since I fell on it last week’ and that greater level of communication opens the door for more effective treatment. Health Communications is the study and practice of communicating health information that can mean broad public health campaigns, targeted promotions and communities. We’re exploring the ways that doctors and patients talk about health with each other. These are all pretty primal essential ideas that have been wrapped up in the practice of medicine since day one, but the field wasn’t officially recognized until the 1970’s when the International Communication Association acknowledged it.

Phil Lofton: 02:26

In the clinic, health communication is all about making sure that patients have the ability to accurately describe their symptoms to their doctors and that doctors have the ability to make their patients understand what treatments they’ll be receiving, how their diseases will affect them, and any associated side effects. On the public health level, health communication tries to get community members to understand things around them that might be affecting their health or behaviors that are spreading in the community that should be avoided. One of the big ways that health communication measures success Is through health literacy, understanding the necessary health free of jargon. This health literacy is measured a few different ways a researcher might have the patient take a short quiz before and after receiving a flyer or watching a video, in other instances, the researcher might have the patient describe the health information back to them.

Phil Lofton: 03:15

This is called a teach back. No matter how the information is collected, the standards for success are the same. If the patient has become better at understanding and communicating the health issue, then it’s a job well done.

Phil Lofton: 03:27

In this episode we’re talking to two scientists who are working hard to improve the ways we approach pain in the clinic. We’ll learn about the history of how we talk about pain, how it’s contributed to the opioid crisis, and how changing the way doctors talk to patients about pain and about medicine can lead to better lives. From the Regenstrief institute, this is The Problem. I’m your host, Phil Lofton.

Phil Lofton: 04:12

Kurt Kroenke is a legend. If you’ve ever been screened for depression, there’s a pretty big chance that your doctor used a tool called the PH-Q 9 that was developed by Dr Kroenke and his team,

Phil Lofton: 04:24

But it’s pretty likely that some of you, even those of you who have taken this screening tool, have never heard of it. So let’s unpack it real quick.

Phil Lofton: 04:33

The PH-Q 9 is a quick, simple nine question questionnaire that helps doctors monitor depression. Patients respond to questions about how often they’ve struggled with depressive symptoms like trouble sleeping or suicidal thoughts. At the end they tell their doctor how difficult the symptoms have made their life. Dr. Kroenke is a clinician, meaning he’s a doctor who sees patients on a regular basis in the clinic. He’s also had a long and successful career in research.

Kurt Kroenke: 04:58

I’d had a, the first half of my career, I was a physician in the army. I got in because they hit a program they paid for your medical school and uh, then I enjoyed what I was doing. So I stayed in about 20 years at four different teaching hospitals. And then for the last 21 years I’ve been at Indiana University, so it sort of divides itself in halves and a part of that time in Indiana University I sort of took care of veterans in the VA Clinic as well as patients outside the VA, in Eskenazi.

Phil Lofton: 05:31

Over the course of his career, he’s focused on symptoms, the way we measure them, the way we talk about them and the way we treat them.

Kurt Kroenke: 05:37

Yeah. So you’re correct. I got interested in symptoms by the way, because it’s about half of all the reasons people come in to see a physician, but a lot of times we focus on diseases and sometimes the symptoms as representative of disease and sometimes it’s what I call a “symptom-only diagnosis” like headache, fatigue, pain. I got into pain in particular the last decade or so, because, first pain accounts for half of all physical symptoms, headache, chest pain, musculoskeletal pain, back pain. So it’s the most common and there’s been a lot of emphasis, especially the last 20, 25 years on, on better treatment of pain. And more funding for pain. I’m a researcher, so it tended to be a more popular symptom.

Phil Lofton: 06:22

In the past few decades. Dr Kroenke has seen a large shift in the way we talk about pain.

Kurt Kroenke: 06:26

Say there’s been a couple waves. So when I first started out, pain was always felt to be an indicator of something else. Something specific. As I mentioned earlier, there’s this disease model. We think everything crosses back to a disease, but there’s a lot of pain that’s mainly a symptom somewhere in the body and we are testing doesn’t help us, you know, MRIs, blood tests and so forth. So then a little over 25 years ago, the early two thousands, there was a movement to represent, to recognize pain as an entity onto itself and a more humane approach to pain. So there was a big push to recognize pain, better treat pain, look at pain as any other disease because it causes a lot of suffering. So there was a big push to screen for pain, treat pain. And along with that came the issue of using more opiates.

Phil Lofton: 07:27

Now that’s true. In fact, Americans consume 99 percent of hydrocodone. The US also leads the rest of the world by a very comfy margin for total opioids prescribed. But why?

Kurt Kroenke: 07:38

Yeah, there’s different theories for that. One is we had this particular push advocacy movement, which was a good one to better treat chronic pain. And maybe the thing we didn’t understand so well is the downside of opioids. And also, we always call them strong painkillers, but when you compare them to other non-opiate pain medicines we have, they aren’t much that much stronger than we thought. So there was a certain that there is a certain mystery about the fact they were stronger than we thought. And uh, the downside was less than we thought. I think that’s second reason ends up being probably partly true, the conspiracy theory that the pharmaceutical companies that marketed the opiates were pushing him and there’s probably some truth that they were heavily marketed in the US. And so you had these two forces. One was pushing doctors to say you everything you can to treat chronic pain. And the thought was, here’s, here’s the strongest painkiller we have. And then there was probably a marketing push too. and the two together led to over prescribing.

Phil Lofton: 08:52

And even more interestingly, while we were being told that these pills were the best and most effective way to reduce pain, it turns out that’s not the case.

Kurt Kroenke: 09:00

So that trial, the SPACE trial, was published in Jama this year. The lead author is Erin Krebs, who used to be a fellow and faculty here, worked with us as part of our team and then moved to Minnesota, Minneapolis, the VA there, and planned a study here and she completed it there. And what she found out very simply as she took several hundred primary care patients, veterans with chronic pain and who his pain was such, it hadn’t been well treated by other treatments. And so, in an older world we might’ve started opiates and a randomized or allocated half the patients receiving opiates for a year and half of the patients receiving pain medicines that were not opiates. Okay. And the outcomes were equal. So both groups got improvement in pain and the improvement was not greater in the opiate group than those who didn’t get opiates.

Kurt Kroenke: 10:02

But the side effect rate was a little higher. Take home message, which people had already started to believe, this kind of really put the icing on the cake, was that we probably should be reluctant to start opiates and chronic pain, especially early because the mystery we had about opiates are stronger if you use the right combination of other pain treatments, you may in the average patient get nearly as good outcomes.

Phil Lofton: 10:32

Gotcha. And so that’s why this was such a landmark study was because it opened up conversations into symptom management. It opened up conversations into different pharmacological routines, into alternative pain treatments. Like how Matt Bair is doing this. It seems like this was a really, really big study.

Kurt Kroenke: 10:51

It was really important because first of all they’ll probably never be another study done like that again because the whole issue with opiates, there’s so much less use. So the timing was right and, and the outcomes were important. You alluded to something because this study just focused on pharmacologic medication treatment and showed if you used the right combinations of medicines other than opiates and compared them to opiates on average, you could get about equal pain outcomes potentially with less side effects, but it didn’t study nonpharmacologic treatments. So there was this all evidence for exercise cognitive behavioral therapy, mindfulness based treatments, acupuncture, Yoga, chiropractic, which also have evidence. So probably the take home messages with a person with chronic pain, we should use a combination of the right combination of non-opiate medicines and behavioral nonpharmacologic treatments. And then opiates would have a very small role in the treatment of chronic pain.

Phil Lofton: 11:53

Which raises the question, where does symptom management go with that information?

Kurt Kroenke: 11:57

There’s a couple schools of thought out there. So I think there’s two tracks. Okay. Not, just one track, one track is for the patient who’s a chronic pain, who’s never been on opiates. I think moving forward, only a very small percent of those should ever end up on opiates. And that’s mainly if we’ve appropriately tried a series of others, finding the right combination of medicines and behavioral kinds of treatments. On that track, there are issues of reimbursement and access for behavioral treatments and it takes some time. And so I think in primary care where I work, where there’s not enough pain clinics out there to treat every bit of the pain, we need to find the right kinds of time and primary care and the support for it. We found models of working with nurse care management and telecare. So I think having access to those treatments and having a systems of care, where we can adequately follow the patient.

Kurt Kroenke: 12:57

We need that for the patient who’s never been on opiates, which most patients, we have about five to 10 million Americans with chronic pain on opiates. And they feel a little beleaguered because there’s this big movement to get everybody off. And so they feel they were started in good faith, most don’t abuse. So I have a little different view about if their patients are doing well with this group of patients that we started at opiates often years ago. We shouldn’t immediately pull the plug, we should humanely manage them. A lot of the regulations that have come in have been very sort of onerous because of the addiction problem. So I guess there’s a third track. The third track is the opiate addiction in this country and the opioid addiction in this country largely is a lot of people without chronic pain. It’s a separate problem and that issue is pretty clear.

Kurt Kroenke: 13:49

We have to have good opioid treatment programs. We cannot stigmatize them and there’s a lot of movements going on. So I guess at the end of the day there’s three tracks. So the people who’ve never been on opiates with chronic pain, very few, should end up on opiates. The patients with chronic pain on opiates often for years. We got to be careful about pulling the plug too soon. And third, a somewhat separate issue, is the opiate addiction crisis that we have. And there’s a, that’s another area where policy and, and regulations and reimbursement play a role.

Phil Lofton: 14:26

After the break, we’ll talk to Marianne. Matthias, she’s a health communications researcher working on tapering opioids. Learn how doctors can get patients off of opioids effectively or not. Start them down that path at all. When we return on the problem.

Pathways Ad: 14:40

Approximately 80 percent of people in the United States will hold a phd degree in the biomedical sciences are not tenure track faculty. What jobs do they have and how did they find them? Are they actually using their doctoral education and they’re not academic careers? I’m Randy Rundquist, Associate Dean for research and graduate studies at the Indiana University School of medicine. Welcome to Pathways. Here, we do more than just tell you what nonacademic jobs you could potentially have with a phd in the biomedical sciences. We talked with those who are actually in these positions. What do they do, and most importantly, what was their path to ultimately land their job? Join us as we explore the many possibilities to use your biomedical Phd Degree in a career you perhaps did not even know it was out there. Pathways will take us there.

Phil Lofton: 15:38

Hey, welcome back. So we’ve learned some of the reasons why health communications led to a boom in opioid prescription, and more importantly, we’ve learned that opioids may not be as effective in relieving pain as we might have been led to believe. So what do we do? One of the ways forward is discussed by Marianne Mathias. I sat down with her to talk about her new paper: “I’m not going to pull the rug out from under you”.

Marianne Matthias: 16:01

Well, the paper is about opioid tapering and that actually is a quotation from one of the providers in the study. When in the clinic visit they were tapering the patient and they wanted to make it clear to the patient that they’re not going to abandon them. I’m not going to pull the rug out from under you. So that’s where we got it. We had really three sources of data for that study. We we recorded, we audio recorded primary care visits with patients and their providers, patients who were taking opioids for chronic pain. And then later on we interviewed the patients and then separately we interviewed the providers and from that study we were able to uncover what you might call best practices for communicating about opioid tapering. And we learned from that study that patients really value having some input into the tapering process, even if in a lot of cases these patients were being tapered because they had to be tapered either because of a state law or because of an institutional mandate.

Marianne Matthias: 17:12

So the provider might not have had a choice about tapering, but if patients could be given some input into even like the rate of tapering, how fast their doses go down, patients and providers felt better about it because it gave them some control and some sense of ownership of their own health in their own treatment. Another thing we learned from that study is that patients really needed to know that they weren’t going to be abandoned by their providers. So they needed to know that their providers weren’t just going to cut their opioids and then leave. And we observed a lot of cases both in the clinic visits and in the interviews of providers, especially reassuring their patients, you know, I’m, I’m not leaving, I’m not going anywhere. It’s not going to happen. I’m going to be here with you through the whole time.

Marianne Matthias: 18:06

So those types of things we found were just, they helped facilitate, I think, smoother tapering because the patients really felt supported and they felt like they were, you know, in it with their provider and that they were, they were working as a team instead of it being some kind of adversarial thing where, yep, we’re gonna, we’re gonna decrease your opioids and here’s how it’s going to be. So both feeling like they had some input and feeling like they were supported, I think was really important during the tapering process.

Marianne Matthias: 18:41

I think that even before there was a declared opioid crisis, I think communication about opioids was always perceived to be a little bit difficult by providers. And often my patients, and there are reports from, you know, we’ve done prior research, other people have done research where patients report feeling like they’re being treated like they’re drug addicts, providers report that all they want is opioids, they don’t want to listen to anything else. So it’s been a source of conflict for quite some time.

Marianne Matthias: 19:16

And so I think with the, in some ways the declaration of an opioid crisis, I think based on our latest work, some providers feel like it has, I’m liberated them a little bit and I say that meaning there are now state and oftentimes institutional mandates to reduce opioid doses and to have opioid agreements or some people call them contracts with patients that say things like, I can’t get prescriptions from another provider. You know, they have to follow this set of rules. And so I think in many cases providers feel empowered a little bit more to say no to opioids when they’re asked about them, which before they may have felt like it wasn’t the best option for the patient. But they felt a lot of pressure. Now they, they have the supportive institutions of state laws of the public because it’s so, you know, the opioid crisis is so well known now, so I think it’s been, it’s been helpful in that way.

Marianne Matthias: 20:19

And I think another way that communication plays into this is because sometimes opioids are off the table now as a treatment option, there’s a lot of room for shared decision making, which is an important part of any kind of treatment because if a person can’t have opioids, if they’re or if they’re opioids are being reduced or taken away, they need to find other sources of treatment. And there are, there a lot of options for pain management. There are, you know, complimentary and integrative health options like acupuncture and meditation and things like that, but they’re more traditional options like physical therapy and there are often integrated pain management clinics, but that kind of, that kind of thing needs to be talked out. And the options need to be weighed. Pros and cons needed to be discussed. Some patients, for example, can’t go to physical therapy. Maybe they have transportation issues or they can’t get off work. So all of that requires good communication and negotiation in some cases. So I think that a communication permeates both opioid prescribing and just pain management in general because so much of pain management, whether it’s opioids or not as communication.

Phil Lofton: 21:40

So can we unpack that a little bit? So how has the way that we talk about pain as a society, do you think that’s played any role in the opioid crisis?

Marianne Matthias: 21:50

I think anecdotally in our society maybe is a little bit more averse to pain than maybe other cultures. And I think that if you look at opioid prescribing in European countries for example, they frequently don’t even prescribe opioids after surgery, which is pretty standard in this country. So I think another example is childbirth. Most childbirth in the US is in a hospital setting usually with some kind of pain management. Frequently in European countries as well as other countries. Childbirth is, it happens more frequently outside of the hospital, maybe in a home setting without pain management. Not all the time, but it is more common than in this country. So I think, I think just as a society, we are conditioned to avoid pain when many would argue pain is a part of life.

Marianne Matthias: 22:49

When you’re managing pain, especially in an environment where opioids are seen as presenting more harm than, than probably helping patients, the patient provider relationship is critical and that’s regardless of what the policies are. And it may be especially true when there are policies that demand that opioids be discontinued or not started or reduced, uh, and time after time again and work we’ve done, whether it was focused on opioids or whether it was not focused on opioids and just focused on pain management in general patients really respond well when they feel like they have a provider who genuinely cares about them. We did a study years ago before anybody uses the words opioid crisis and patients responded to provide saying no to opioids or providers decreasing opioids if they proceed, they’ve responded well to that. If they perceived that their providers were doing it out of genuine concern for their health, that they were on the same team as opposed to their providers feeling adversarial. Like, I think you’re a drug addict or I can’t prescribe this to you, I’m endangering my license. So when they felt that alliance, that bond with their provider and felt like they were really playing on the same team, then it gave a lot. It gave providers a lot more latitude in terms of what they could discuss with patients because again, patients knew that they were looking out, their provider was looking out for them and their best interests.

Phil Lofton: 24:38

So with regards to tapering and to pain management, a developed attentive relationship, it makes a world of difference. True honest communication helps doctors provide effective care. Join us next time when we talk about community health, a field of boots on the ground health workers that’s built on communication just like this.

Music in this episode is by Everlone with an additional sound collage by the central state singers. Our theme and additional musical cues were written and performed as always by Mississippi’s own, Eldon O’Shaughnessy and the down and out quartet. 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 regenstrief.org And see bonus content from this episode including sources, pictures and more at regenstrief.org/theproblem.

Episode 1: Little Seeds

In the first episode of The Problem, learn the history of opioids, get a brief overview of the opioid addiction crisis, and more.

Read More