Interview with Rosalie Liccardo Pacula

Rosalie Liccardo Pacula is the co-director and senior economist of the RAND Center for Health Economics, a research organization that helps develop solutions for public policy challenges. This interview took place on September 27th, 2018.

To start off, it would be helpful if you gave a brief overview of the work you do and how it pertains to the opioid crisis.


I am the co-director of the RAND Center for Health Economics and have been the senior economist for 20 years now. The goal of our center is to provide non-partisan research to inform a range of topics in substance use and drug policy, an area of policy marred by anecdotes and perspectives on how people feel about drugs or law enforcement. We use data to inform policy to have more objective measures of which policy is the best. I’ve been studying drug markets: tobacco, cannabis, prescription opioids, methamphetamine, alcohol for the last 25 years and what influences the supply and demand for these very different, intoxicating substances provided in illegal, legal, quasi-legal markets or highly/less regulated markets. I examine the different market structures and consumer/seller behavior of opioids. Sometimes they are regular human consumers or patients. I started looking at how diabetes markets function. About 10 years ago, I’ve been looking at how the FDA, since 2002, has treated opioid addiction through methadone and other sources of therapy, which can be delivered in many medical offices. You can just go to your doctor’s office and get it, and it has evidence that it’s very cost-effective in general. Significant attention has been given to oxytocin, which is not necessarily appropriate for conditions; however, there have been other structural functions that have been keeping that in place, like the lull of insurance. We’ve been trying to see how these other alternative functions have played out in the opioid epidemic and how it has changed over time, and how public policy and private policy impacts that as well, and that’s what we’ve been working on for the last 3-4 years.


Was there anything you came across in the course of your research that changed your perspective on the opioid crisis?


There’s been a couple of things that have changed my perspective. One thing was the research into drug supply chains of cocaine and methamphetamine and synthetic cannabis; it has changed my thinking about this epidemic as being not just an opioid epidemic, but a drug epidemic, a broader movement. We need to not just focus on opioids today, but really need to focus on addiction and dependency. We looked into the average cost of opioids, and what we found over 2005-2014 was that the price had dropped substantially. It wasn’t surprising because the patented drugs had been more readily available. I mean the average out of pocket cost per month had dropped. The price of morphine was relatively stable, but over the same period, the price of opioid treatment had tripled. How do you expect people to be open to opioid treatment when the cost to do so is 3 times the cost of an opioid, the price of sustaining your consumption? How do we tackle this problem when treatment is so much more than the drug? We need to take a concerted effort to stand and reduce the cost of treatment. It can’t be treated as a typical medical burden. People won’t look into better treatment if it’s not affordable.


That’s really quite striking. I guess, it’s interesting, as an economist, you’ve looked at many different health markets, including illegal or imperfect markets. How would you analyze the opioid crisis from an economist’s perspective?


I look at prices and the price of the commodities. With insurance, the cost of the opioids is cheaper to patients than manufacturers, and normally that is a good thing. They don’t need to pay the full cost of their cancer drugs. It’s not a bad thing when you’re coming out of surgery. There’s many reasons why that isn’t a bad thing. However, there’s incentive for people who can get these drugs at a cheap price to sell them on the black market. If you can approach the opioid epidemic by getting another drug, like Oxycodone, or examine the impacts of the drug across different markets in different countries, where the drug Oxycodone is handled differently, like in Canada or Mexico, which has major unintended consequences. As an economist, I want to look at different policies so we aren’t just focusing on one type of drug. We’re seeing an upsurge in certain markets of meth and even cocaine, depending on what’s available. We have an addiction problems and so we want to focus on all the drugs consumers addicted to instead of focusing on just one. 


What do you think is the single biggest barrier that prevents people with substance use disorder from getting treatment?


There’s a lot of stigma with getting treatment, and it is two-fold. It’s not just the consumer and their usage, there’s a lot of stigma around doctors, especially people with comorbidities like chronic pain or depression. They need to be engaged for a successful connection to treatment.


You’ve looked at substance abuse in the military. Can you tell us a bit about referendums?


I really wish I could. Unfortunately, we were not provided access to all the data we needed to confirm all of the patterns we were getting. We would want to identify unreported drug use and prescription drug misuse. Healthcare insurance in the military is complicated and happens on and off base and it has a lower rate. We were not provided access to the health styles to be able to identify what is illegal or non-medical use or drugs obtained outside of the military healthcare system. It is harder to track in context of larger datasets and we don’t have sufficient data to do work. They use drug tests and we don’t know whether that is a valid measure.


You used to study the influence of naloxone distribution lines on opioid-related harm. Can you tell us a bit about that?


Those results have not been published yet. I can’t really speak to that one. There is a higher impact of laws but a lot of uncertainty on this, and there were a lot of unintended consequences with the law; are we doing anything, or are we setting up people to overdose again the future? There needs to be a lot more work on that. 


You’ve studied research on markets and privacy benefactors, can you tell us a little bit more about that?


I’ve studied insurance policies and how they implement ACTA, covering everything within the Medicaid system (because it is a major provider for opioid addiction) like how many visits, psychotherapy and the extent to which they support Medicaid agencies and access to different departments. There are also complications for coverage within insurance and doctors who take Medicaid. Additionally, there is an 8-hour task for doctors who want to get certified in pain education by the DAO. There are also limited referrals for doctors who do this; there are 30 at a time, then 100, then 275. They don’t want to deal with the limitations of the healthcare-financial system.


On the subject of medication assisted treatment or different modalities being tried, I know that some advocates of marijuana usage might reduce physical cravings for opioids; what is the research on that? 

That is a really fun and complicated area of research I’ve been working on in healthcare systems in being able to provide the resources required. There is clear scientific lab work that shows that some cannabinoids are effective for typical types of pain. It varies on which types of pain we’re talking about. It’s true that cannabis does help with certain types of pain, and marijuana laws have an impact on opioid mortality. It varies depending on which type of pain you’re talking about: neuropathic pain or just cancer pain in terms of the actual relative benefit of the cannabinoids over the opioids. Where dispensaries are open for people to get medical marijuana, there is a reduction in opioid overdoses and poisoning. While many patients do get relief from cannabis, they have reduced the number of opioids they consume. They don’t completely stop the use of opioids. The risk of overdose is still there because they are still using it; we haven’t done enough of the work; there is still some work from the New York State that is showing whether or not opioid use is actually decreasing by certain thresholds on a patient by patient basis. We need more science to demonstrate that. Cannabis is therapeutic but a lab did a pain test giving patients both cannabis and opioids, and people were more dependent on opioids. It is a useful tool but it won’t stop the opioid epidemic. 


I see. It’s interesting that you mentioned that it costs three times as much to pay for an opioid treatment out of pocket versus an opioid. It’s almost rational to choose the latter over the former. 


John Kearney brought this up too among the people he was interviewing. It was cheaper for them to get a prescription than do the treatment. That’s what is interesting about the cannabis story in comparison to the others; cannabis isn’t as cheap because it’s not covered by insurance. It’s not an ideal solution; the epidemic today is being driven by heroin and the cannabis won’t stop them from being dependent. 


What responsibility should pharmaceutical companies like Purdue have in alleviating the opioid epidemic?


As an economist, I would oppose the traditional cost/benefit type of calculation to the extent that the over-promotion of a drug could affect the opioid epidemic in the early stages. There are a number of structural issues that contributed to a genuine sense of liability there and the epidemic that enabled the information to spread.


If someone gave you a magic wand that allowed you to change any policy to effectively alleviate the opioid crisis, which policy would you use it on?


I would make drug therapy free and paid for by the government because it would get rid of demand.


Based on the research you’ve done, does it look like things are finally turning around, or are there some significant challenges ahead? 

It’s been dynamic. There are significant challenges ahead. People gravitate towards specific members of it and they focus on the number of prescription drugs. I like to give examples of specific people and if we could stop a specific person from dying. The answer is no; mortality is just an end. Black market drugs and injection drugs are more frequently ingested. Injection drugs have led to an increase in Hepatitis B and HIV. Unfortunately, these people aren’t getting tested for Hep C or HIV before they get into sexual relations. Hep C is treatable at this point and HIV is manageable if it’s treated early. People are scared to get tested and we are creating a large public health problem. The cost of this epidemic is going to increase until we enact policies that are less hazy. I want to focus on how we treat people immediately so we prevent contagion and the consequences. 


Were there any additional ideas or thoughts you’d like to share?


From a less academic viewpoint, I think people need to understand that addicted people are grandmas, moms and dads, and teenagers after surgery. Maybe the doctors prescribed too much. Patients aren’t getting treated as the whole patient. We should reconsider how the healthcare system is structured so we can absorb these problems. Hopefully we can get past these problems and conquer this most recent drug epidemic. Otherwise we’re just setting ourselves up for more problems in the future. 


It’s great to talk to someone who has really gone into this research and contributed to it. You can talk about it in a more in-depth way. It’s insightful to hear about it from someone who is studying it for years. It’s more informative than a soundbite on the news. 


It’s not a soundbite. Most things aren’t so simple that we can just stick to one thing and have it be all gone. If that were the case, we would have fixed it a long time ago. It’s the complicated nature of them and ID-ing all of them and working with them in a productive way. It’s good to have conversations about it. I am quick to answer but there is no one answer and there has to be a comprehensive approach. 


I guess that’s not an answer a lot of people would like to hear; there’s no magic wand or easy 1 or 2 step solution. It’s exactly what you’re saying; it takes a comprehensive approach that addresses multiple problems in this crisis.


We can’t just look at stuff in the rearview mirror; we need to look at it going forward. It’s not just about stopping death; we need to stop Hep C and HIV. We need to consider different factors and solve them with different policies.


The opioid crisis has contributed to the spread of Hep C and HIV. I’ve been reading about a bacterial infection called endocarditis, which is dangerous and costly. It’s going to cause major public health problems.

Rosalie: I believe in treatment. I really do. It’s not that effective. The average person needs 3 doses of treatment in the interests of recovery. It takes 3 shots of treatment. People need to be prepared. This is a lifelong addiction. The government and healthcare providers are always thinking about it from a chronic disease perspective. They talk about it from a chronic disease perspective in terms of management and tools we have available, even how characterize depression can be applied to addiction. That’s something we need to be aware of. 


It can take 3 shots of treatment. It’s good to be aware of; maybe the public can have more empathy towards people with opioid use disorder. The individuals can have hope that if they relapsed they’re not a failure.


For blood pressure, A1C, or therapy; when there’s a problem with that; we just go onto the next one. That’s really different then when it comes to drug addiction and maintaining that same perspective. We need a long-term solution.