Interview with Dr. Christopher Ringwalt
Dr. Ringwalt is an Adjunct Professor for the Department of Health Behavior at the University of North Carolina, Chapel Hill. He is also a Senior Scientist for UNC's Injury Prevention Research Center. He has more than 25 years experience in the design, execution and reporting of research studies related to the prevention of substance abuse. His current studies examine the prevention of opioid abuse and diversion. Dr. Ringwalt has served on multiple NIH review committees and has over 100 publications in peer-reviewed journals. He is currently working on the development and international dissemination of curricula related to evidence-based practices in the field of drug prevention, and serves as the editor of the Journal of Primary Prevention.
To start off, perhaps it would be helpful if you gave a brief introduction into your background and the goal that you have right now?
Yes. I have spent the last 20-25 years in the research world trying to understand the initiation and progression of substance use and substance abuse, primarily among adolescents before recently, now also among adults. By that, I include alcohol and all other drugs, I haven't spent quite as much time on tobacco. But I've done a large number of program evaluations and have looked at the dissemination of effective prevention programs, particularly related to substance abuse nationwide. I became interested in opioid overdose prevention research about a decade ago, and I've done some for work for the CDC in that regard. I'm looking at the effectiveness of strategies to prevent opioid overdose from a variety of perspectives. That brings me to where I am today, which is that I understand a few pieces of the puzzle, but there are many that I don't, that I don't think the field does either. It's a changing field, an evolving puzzle, so it raises considerable complexities, and a lot of us are working together on how to resolve and understand them, and to find a way that that we can be of service.
Wonderful. So for around the past decade or so, that's when you really started to look more at the opioid crisis specifically, is that correct?
Looking at your body of research here, I noticed that part of your research looks at Medicaid control substance lock-in programs. For those members of the larger public who are not as familiar with that, could you tell us briefly about what that is and what that means?
There is a general belief, a general understanding, that patients who fill prescriptions for opioids at multiple pharmacies, and receive prescriptions for these opioids from multiple medical providers (doctors and so on) are at elevated risk for abuse. That the reason that they may fill prescriptions at multiple pharmacies (which is sometimes called "pharmacy hopping") and secure prescriptions from multiple providers (sometimes called "doctor shopping") is that they believe that the more medical providers and pharmacies that they go to, the less likely they are to be detected in their drug seeking activities. So, Medicaid has developed lock-in programs to identify these considerably harmless patients and to restrict them for a period of time, sometimes a year, sometimes longer, to a single provider that is a medical provider and to a single dispenser that is a pharmacist for the period, and to tell them "Well, if you try to fill your prescriptions anywhere else, we won't reimburse you." That's not to say that Medicaid recipients can't pay any cash, but that too creates a certain amount of suspicion that the patients securing these opioids are doing so for extra-medical reasons. That they will divert their medications to others, perhaps sell them on the street or give it away, but that they're not using it appropriately and for medical purposes. So, many states have adopted Medicaid lock-in programs with varying degrees of success.
From what you've seen in your research, and what these states who've implemented these lock-in programs have seen, does it look like they have, to some extent, been effective in preventing abuse or fraud?
Yes, but there's also some tantalizing findings that the we have recently published, that the patient's activity would have decreased anyway even if they haven't been locked into the program. So, it's a bit hard to figure out where the lock-in program is responsible for the decrease in opioid prescription filling, or whether it just was a natural occurrence and that perhaps the restrictions of the lock-in program helped to some degree. Anyway, this is an example of one of many strategies that are being tried to constrain drug seekers from dealing drugs that they look for and turning them to the street.
I know that when it comes to the fact that in some cases they may have not done that as much, is that because that state has already implemented a prescription drug monitoring program, or were there other factors involved?
No, almost all the states with the possible exception of Missouri (which may have come online by now) have had prescription drug monitoring programs for some time. The top explanations for the sort of natural decrease in this behavior are fairly complex and I don't think they'll fully understand. In there, this was a drop off after the patient was identified, but before he or she was formally locked in. It leads you to wonder "What's going on here?" Is it the lock-in program itself or concerns about it that is making the difference, or did patients who were drug seekers have a lot of activity over a short period of time, and then decrease it naturally?
I've noticed that you have another paper where you're looking at using a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices. I know that in the media, there were these reports of so-called "pill mills", where there were doctors who were prescribing unusually large numbers of controlled substances. When it came to developing algorithms to identify these kinds of prescribers, was there anything that jumped out at you in the data?
Well, this is a fairly assaultive way, I think, to constrain over-prescribing, particularly if the prescriber is concerned about coming to the attention of the state medical authority, the medical board, and it probably has some pretty good effects in constraining prescribing behaviors. There's also concern that we don't know a whole lot about as to whether medical providers with a large practice in paying management may be either declining to take new paying patients, or pushing their current paying patients out of their practices for reducing their prescription for opioids quickly. Rapidly, too quickly, too rapidly, sometimes called "rapid tinkering," for fear of being detected by the medical board. So there could be adverse consequences to all of this. There's anecdotal evidence, few movements, that this is the case. You talk to paying patients who say that they are now being treated with great suspicion by their physicians, and are concerned about where they're going to get their continuing supply of opioids to manage what may be an extraordinary level of pain that people would live with in the absence of these analgesic drugs.
This adverse consequence, or this unintended consequence, does sound concerning. I remember listening to an interview where someone with say, a chronic condition that caused him to have pain in the long term, was saying that his doctor had prescribed him opioid-based painkillers for years, but then all of a sudden his doctor was saying things like "Well, you know that I told you that you shouldn't take too many of these drugs, because you could develop dependence." Then he was saying that "I don't remember my doctor saying ever that saying that before, but suddenly my doctor shifted her tone very fast, so it seems like something external made her do that.”
Indeed. This is the example, and to the extent that I have contributed to this problem... I really regret it. We don't know. We don't know the extent of it, although we are trying to do some investigations. This is a reasonable area of research because you can just look at a whole series of medical records, and tell by health insurance, and see if tapering for opioid analgesics acted on a high level for months, or even years, of which some people had. If their physicians are now cutting them way back and too quickly.
I would imagine that if patients have developed expectations of a certain amount of drugs over time, and if it's pulled back too quickly, that abrupt change in access to some of these medications would possibly trigger them towards trying to find it somewhere else.
That's exactly right. A lot of suggestions that people who are being precipitously tapered from drugs on which they are dependent as chronic pain patients, head to the street and ready supplies of heroin and now fentanyl for relief. This problem is a monstrosity, really. The challenges that people who are caught up in it - patients with chronic pain - are very considerable.
What are your thoughts about the change in some of the guidelines at the Medicare level that people on Medicare, they're also looking to change some of the guidelines for prescribing and making it so that people are not as easily able to do it. People can get a waiver but I think it has to be renewed as often as every week.
You may know more about this than I do, but I do think you need to have a sea change - that is, a very substantial change on how we treat pain, and what mechanisms we use to treat it. To rely much, much less on opioids, which I increasingly think are dangerous frankly for anything more than very short term use, and to find other appropriate strategies to deal with the pain people have. Other strategies, all I know, will they work - I don't think they know very well.
When it comes to non-opioid based painkillers, are there some valuable options that can be used, or is there a particular gap only opioids can fill when it comes to pain management?
I think that's an excellent question, and I'm not gonna even try to answer it. I don't know enough.
When it comes to prescribing opioids to Medicaid patients, I know you have a paper that looks at racial disparities across provider specialties. I guess I'm curious to know a little more about that.
Well, we do know that white patients fill much more prescriptions for opioid analgesics than black. We don't know why. I will be very reluctant to call this any kind of racism without a much deeper and richer understanding of the issue than I can personally bring today in this conversation. So I'm not very able to share much light on the reason for our findings, but we did report what we saw.
It's interesting that I know people have mentioned that this is a crisis that affected all 50 states and it's affected almost every demographic whether it's rich, or poor, whether it's rural, or urban, or suburb, and whether it's black, or white, or brown. I know that for a large part, it primarily seemed to be affecting the white population, but recently, there has been an uptick in parts of the country in the African American population, and other racial minorities, in opioid dependence. Is that something that you've come across?
Well, I can't really speak to that either. It is indeed a problem that affects all sectors of our society, and all sectors have to come together to figure out what the solutions are. There are many, many potential solutions, but the trouble is, you try one, and it has an adverse effect on another. You try to constrain or restrict the supply of legal opioids used for medical purposes, and then people who are dependent or addicted turn to street heroin or fentanyl, which is becoming increasingly a drug of choice. Some users are skipping heroin entirely, and went straight to fentanyl, which is an extremely dangerous drug. I'm curious as to how many of them, and I don't think anybody knows, may have started out as patients who've filled prescriptions for opioids that they got turned away from. The fentanyl epidemic is taking off, and one year's report is now heroin or fentanyl being combined with amphetamines. There's evidence of that. This is just terrible.
Yes, I remember reading somewhere that someone would take opioids mixed with amphetamines. I guess the opioids would have their effect, and he would take the amphetamines to keep himself awake.
I just understand that one’s a depressant, so you would think "Why would you ever want to take them together?"
In the same way some people take energy drinks that mix with alcohol and caffeine, I guess. I know in some cases dealers are mixing fentanyl with other drugs, and not mentioning that to the people who are buying the drug. I know it's been found even mixed with cocaine and substances like that in some states. That's obviously another big cause for concern, especially if someone who has been taking other drugs has never taken opioids and they take something with fentanyl, and that can very easily lead to an overdose. I noticed that you have a paper, "Statewide Evaluation of Seven Strategies to Reduce Opioid Overdose in North Carolina". I was wondering if that includes things like making naloxone more easily accessible to the public?
It does. Naloxone is now very widely available in many spots across the country. First responders routinely carry it, and it's increasingly being implicated that people like you and me can own it as well in case we have a reason to use it. But certainly, people who are around others who are using these opioids need to be equipped with the means to bring them back from the brink of death when their breathing is suppressed to the point where they are in danger of dying.
I remember reading that in some communities, particularly some communities that had more traditional views about substance abuse, I know there was some concern that if naloxone was widely available then it could misalign incentives, and have the unintended consequence, a "moral hazard", where people would be not as careful with the drugs they were taking because they knew they could simply be revived with this anti-overdose drug, naloxone. Has that concern been thrown out, or would you say the benefits far outweigh any downsides?
Well, I'd think the benefits infinitely outweigh any risk. It's similar to the argument to provide people with condoms - kids with condoms don't have sex more, there's evidence to that item. These are all prevention mechanisms, and the more we get naloxone out to the friends of people who use, the more lives we will save.
I've noticed that when it comes to medication assisted treatment, whether it's methadone, buprenorphine, or Vivitrol, that in some cases there can be limitations - with buprenorphine, there's a cap on how much a physician can prescribe and how many patients they can prescribe to. First, they have to have a license to do it. Then there's a federal cap. Is that something that is a barrier or bottleneck for people who need medication or assisted treatment, or is it a good safeguard?
I'm not going to comment on the wisdom of the cap. I think what we need to do is promote buprenorphine training and credentials among physicians. That is, we need to increase the supply of physicians who are credentialed to use buprenorphine, while they increase the caseload of those limited numbers of medical providers who can do so now. I'm a strong advocate of buprenorphine maintenance, and I'm also a very strong advocate of the notion that we need to be equipping our first respondents with buprenorphine, especially EMTs, and they’re just your medical technicians, EMTs, and they show up at the scene of an overdose and begin buprenorphine administration level A. Not only for people who may have abused naloxone and may be rescued from an overdose, and we got some people who may want to free themselves from the tyranny of drug attendants and the treatment. There's no reason that we should tell them they have to stop using heroin first or that they have to wait and not use heroin while we find a medical assisted treatment program for them, instead of administering this drug right away, which greatly reduces cravings for opioids. It's a fairly radical idea, but it is being tried in several cases now, and we don't know what's successful yet, but building a bridge for people who are drug dependent to medically assisted treatment is really, really critical. To do it for as many people as possible, people who say, "I need help", but for whom help is not immediately available. By law now, you can administer buprenorphine to people, on a daily dose, for up to 7 days. During which time, you can get them into a MAT program. Let's capitalize on that, and get buprenorphine out there and into people who need it as quickly as possible.
So, I guess when it comes to what's preventing your vision from being fully realized - Do you think it has to do with limited resources, or does it have to do with societal attitudes, like a stigma against what will be considered a sort of substitution kind of thing, where people say, "Well, you know buprenorphine is an opioid?”
I think it's a new idea, and I think it will be adopted quickly, since the notion that a first responder, like an EMT, could administer buprenorphine directly without a doctor's orders - it's a new idea, in the same way that several years ago the notion that first responders carrying naloxone and administering that was a new idea that was adopted fairly quickly. I think our crisis is so great at this time, that we'll see this idea, this buprenorphine administration, as a bridge to medication assisted treatment, catch on fairly quickly. At least I hope so.
I know some jurisdictions thought about going further with harm reduction policies and having supervised injection sites where naloxone is easily available to help with overdoses and things like that. In your view, is that something that could help save lives?
I suspect yes. Will it save lives or will it delay death? The saving lives is good, of course. Let's do more than just save a life, so that we use it to figure out and prevent someone from putting herself at risk once again. Let's see if we can get users on a path to treatment, and let's also say, “Ok, if this buprenorphine works for you, then we can support you on it for the rest of your life so you can function as a productive member and a happy member of society.” There's no reason to think that medication assisted treatment can't last a lifetime. Particularly now, as there are now mechanisms to deliver buprenorphine through monthly injections. It's no longer a drug that's only available if you take it on a daily basis.
Right. I know that for some patients, either it's because of their particular biochemistry, or in some cases there are some that don’t really respond well to buprenorphine, or it does not give them the relief it gives to others who have opioid-use disorder. Are there any other medication assisted treatment options for them, or do they have to basically find a different means that's an abstinence-only approach?
I don't know enough to answer that question. So that one's not for me.
In the course of your research, what was the most memorable finding that you came across, that sticks in your mind? That just really surprised you, a finding, something unexpected, an outcome of something, or maybe some statistic you came across.
Well, that's a good question, and I would imagine that the disparities that we talked about earlier between prescribing prescription opioids to black and white patients. I think that was actually quite stunning. I wish I knew about this area, and it really was quite a shocker.
I remember speaking to a friend who is a physician, and he prescribed to both black and white patients. He was saying that in some cases with the black patients, there was sometimes a reluctance to always follow through with taking all the medication that he prescribed them. He said he was not sure whether it was a trust issue or if it was some other kind of issue. He did notice that sometimes among black patients there was that hesitation sometimes. He said he was not sure what the historical reason for that might be.
That's a little different from what we found; they're looking at filled prescriptions. So I suppose it's possible that medical providers, physicians, could be prescribing these drugs in equal measure, but black patients may be filling them less than their white patients. There could be economic reason behind this. This begs for further investigation, I don't think we know that much. At least, I certainly don't.
Over the course of your research, was there anything that you came across that changed your perspective on the crisis from what it had been before that? Or that made you look at the crisis in a new way?
Yes, which was the challenges that we faced in getting people who are dependent on these drugs into medication assisted treatment. That's one thing, but also the other thing is, that there's two pillars to MAT - there's the medication itself, that it could be buprenorphine, that it could be Methadone and Vivitrol, and then also the treatment, which is some kind of counseling on the individual or often at the group level. What surprised me was that, what really seemed to make the difference is the medication itself. Not so much the treatment part, the counseling part. So, all of this suggests that what we really need to do is to be getting people who are dependent, getting the word out to them, that there is another path that will mitigate their cravings. That won't give them the high that they may have enjoyed, but will mitigate their cravings, and that this drug can be administered monthly. There's no reason why they should not continue on as far as we presently know, for the rest of their life. They may choose to take it and start not to take any, but there is an open path. It's not either dependence or sobriety - it is controlled use.
I know that many opponents of medication assisted treatment compare it to chronic disease, and it's sort of like making insulin available to diabetics.
Precisely. I am a diabetic and that's exactly what I was about to add. I take Metformin twice a day, and I expect to take it the rest of my life. I will consider this to be a way of maintaining my health - buprenorphine is a way of maintaining your health.
Many news articles that I've come across have have lots of statistics about overdose deaths or about the economic cost of the crisis. I think that what gets lost in all the numbers is the individual stories of the people who are just struggling with opioid use disorder. What would you say is a good way to present a less abstract portrayal, a more human portrayal, that the public can relate to?
I think people have to tell their stories. Their personal stories, the stories of their family members, the stories of their friends. We have to talk about the kind of help that they have received, and so on. I have the nephew of a friend of mine that is a success story - I'm astonished! He went from being an addict to being clean, and I don't know how he did it. That's a story to tell, but it’s not by any means the only story. It's just that if he became clean, other people can too. Well, some can, some probably can't. Some people with diabetes control their condition with diet and exercise. I do it with with a combination of diet, exercise, and this drug Metformin, which is a wonder drug that works for me. May not work for everybody - different paths for different people. Whatever path you may choose to take, as long as a person with an opioid use disorder, you find a path that's right for you. If you occasionally relapse, as I occasionally will dig into a bowl of ice cream with great relish and guilt. Then, that's ok. Pick yourself up, get yourself up, and go back to your regimen, which is what I do.
I remember reading that the average person with opioid use disorder can relapse several times before they can get onto a sustainable recovery.
I expect, actually, to relapse periodically for the rest of my life. I know it's not an exact analogy, but I expect it, and I know what to do after I relapse personally. Get back on your diet. Go out and take your dog for a walk.
Another thing I was wondering about was when it comes to pharmaceutical companies like Purdue, what role or responsibility do you think they should have in the effort to alleviate the opioid crisis?
There are several suits that are moving forward in the United States: regions, municipalities, government and non-government entities, and I wish them all well. I think that these pharmaceuticals that produced and marketed this "wonder drug" in inappropriate ways and largely created the problem that we are facing, are profoundly liable for the damage that they have caused. No number of earnest full-page advertisements in the New York Times can begin make to up for that. I want to see the pharmaceuticals, and Purdue is certainly prime among them, pay. Pay to reimburse the government, local and state, to the extent that they can, for all the damage that they have caused, all the harm they have caused, the cost to governments and society at large for treating these patients. Also, investing in prevention practice and treatment nationwide. They have a huge responsibility. We'll see how these suits progress. I'd like to see a settlement that is analogous to that of the tobacco industry. I suspect it will come in the next year or two. I hope the money is spent wisely.
I know there are some concerns that people who look back at the settlements with the tobacco industry, some of those funds were used for clean-up programs to help people who would be harmed by tobacco, but some of the funds were used for other fiscal priorities by various states.
Filling potholes over, yes absolutely.
Hopefully with these upcoming settlements, the larger part of these settlements will be used to help individuals who are affected by opioid dependence, and things like that. In terms of the questions I have, I think I've run through pretty much everything I have. Did you have any, given your decades-long experience, specifically researching this area, were there any thoughts, any inside stuff, you wanted to share?
No, I think we covered the ground pretty well.
Great. This has been a super-informative interview.
Thank you so much.