Interview with Dr. Karyl Rattay
Besides being a pediatrician and preventative medicine physician, Dr. Karyl Rattay is the Director for the Division of Public Health and State Health Official in Delaware. This interview took place on October 17th, 2018.
To start off, it would be helpful to Introduce yourself and explain your role and how it pertains to the crisis.
My role in Delaware is the Director for the Division of Public Health. I also have the title of State Health Official, and I’ve been in this role for nine and a half years. I am a pediatrician and a preventative medicine physician. This opioid crisis wasn’t really on my radar when I began my role nine and a half years ago, but shortly when I began working in public health, I saw our data from 2009, and quickly realized we were in an epidemic--an epidemic that has worsened over the last nine years. My role in Delaware related to the opioid crisis has been a role of leading a group of individuals, so we created the Prescription Drug Action Committee in partnership with the Medical Society of Delaware. At that time, the data were really pointing toward this being driven by prescription drugs. Most of the deaths at that time were related to prescription drugs. We called this the Prescription Drug Action Committee, and we had many people from different sectors coming together whether they were health care providers from a variety of types, law enforcement, those in the mental health field, pharmacists, and multiple state government agencies. We came together and formed recommendations and simultaneously the crisis was evolving so heroin was becoming more prevalent. And of course, now fentanyl is taking many lives on a regular basis. It has gone from tragic to logarithmically more tragic over the time period as the crisis has evolved. As it has evolved, our roles have evolved, and when I began this role, public health had very little role in substance abuse and mental health. There is another agency in Delaware and most states--substance abuse and mental health agency. We’ve become more involved in the planning and convening of people and overseeing many interventions to address the issue. The Prescription Drug Action Committee that I mentioned is now the Addiction Action Committee which I also chair. As the crisis has evolved, the work has evolved as well.
What do you think make the opioid crisis different from other drug epidemics that have happened in the past?
First of all, more people are dying. More people are having more tragic, unexpected overdose deaths in comparison to other drug crises or drug epidemics in the past. Certainly, that has made it the public health crisis of our generation. The demographic of this crisis has grabbed the attention of many people--often times, drug crises tend to cluster in lower income populations which may not bring the crisis to the attention to upper class individuals or those in power. What we have seen with this crisis is that it affects everyone. Every socioeconomic class, every age, every racial/ethnic group is touched. For a number pf years now, most of our deaths have occurred in white middle class males between the ages of 30 to 40. Different people have come to the table then we see in the past because largely, everyone has somebody in their life that has been affected by the crisis.
In the work you have done, coming up with approaches to alleviate it, what is the most memorable experience you have had?
I am not sure I can point to one particular event, but I can say my most memorable moments have been conversations I have had with friends or family members who have lost loved ones or conversations with individuals themselves who are dealing with an opioid use disorder. One moment that comes to mind is when I spent several hours in a group home for women with opioid use disorder. These are amazingly beautiful and wonderful women who were very candid about their journey, how the system needs to be improved, and their hopes and dreams about the future. I bring these experiences--whether it’s families who have lost loved ones or the individuals themselves who are dealing with the barriers to get the help they need-- into the work that we do every day to try to make improvements to the systems to truly meet the needs of the people who are suffering from this disease.
Is there anything you came across in the course of your work, like data or anything else, that changed your perspective on the crisis?
I feel it’s changing and evolving all of the time. It is so important that we are collecting data to see how it evolves. An example being looking at the death data to realize that although we started with 90% of individuals who had an overdose death were dying from prescription drugs, it wasn’t long after that, just a couple years after that, that we realized heroin was causing an increasing number of deaths. And of course, now we are dealing with many deaths from fentanyl. Having that information is so critically important to how we address the crisis. Many of our early efforts have been on decreasing prescription drugs or really improving the way prescription drugs were prescribed so that there was a better awareness of the danger of prescription drugs. We are still not really where we want to be in regards to safe opioid prescribing and better pain management. We also know that many people who have an opioid use disorder may be using heroin now, but their journey started with prescription drugs. We can’t walk away from the prescription drug part of this crisis, but it is also very important that as more people for example are using needles to get their opioids as opposed to pills, that we are looking at things like syringe services so we can prevent the spread of hepatitis and HIV as a part of this crisis. I can’t think of one particular day that I saw data that lead to a major transformation. I would say the most major was in 2010 when I saw our 2009 data and realized we were in the midst of an epidemic. I would say it is really important to learn from other states and learn from the evolving research to see what works, so in Delaware we can use that information to improve our work.
There are some regions of the country that have been trying out harm reduction approaches such as supervised injections, needle exchanges, or fentanyl test strips, what are your thoughts about those approaches?
I realize that harm reduction can be a difficult subject. Some individuals really struggle with why we would help people using IV drugs. One of the first things I want to say in regards to harm reduction is that we are dealing with a disease. Although many people see this as a moral or religious failing, it is a disease. For many individuals, their disease started when they were prescribed drugs for an injury or tooth extraction. We need to get out of blaming the victim when we deal with this crisis. When we are losing so many people to opioid overdose deaths in our state and in our country right now, the first thing we need to do is save lives so we can get these individuals into treatment and help support them in their road to recovery. Naloxone is a harm reduction approach that we embraced in Delaware. We want to save as many lives as we can. That means getting naloxone into the hands of friends and family members. Our data tells us 80% of overdoses are happening in homes. We want to make sure that the first person that encounters an overdosed individual can respond. So, friends and family members are critical, or the individuals themselves. We want to make sure they have naloxone so that a person around them can use it. Certainly, all of our first responders, so not just paramedics, but BLS, anyone who is in an ambulance, law enforcement, campus security, we want to make sure that any first responder has naloxone with them. That is one of our most important harm reduction approaches. When I began this job, because of stigma around IV drug usage, syringe services were only available in Wilmington, which is our largest city. As the crisis evolved, we have been able to change legislation in our state so that syringe services are able to be implemented across the state. This is incredibly important. Hepatitis C is increasing among IV drug users, and it is an incredibly expensive disease to treat. When we can prevent it, we help individuals from a health perspective, but there is a strong economic argument as to why we would want to do this as well.
In the effort to reduce prescription pain killers, there are concerns that the pendulum can swing too far the other way, and it can affect patients who are suffering from debilitating pain. What do you think is the best way to strike a balance between the two?
It is interesting because all along in the eight years I have been working on this issue that has often been a concern expressed when we talk about opioid prescribing. I think first it is important to state the fact that opioids aren’t very effective for long term pain management. They can be helpful around surgical procedures, they can be helpful around traumatic injury, but even in those situations it is critically important that they are used safely, and it really is minimal doses that are absolutely needed. The pendulum went so far in overprescribing opioids that it feels like a large ocean miner trying to turn the ship around so that prescribers realize that what they have been doing is not safe and not effective but also that the public realizes it as well. There are many alternatives to pain management that work better than opioids or are just as effective but are much safer. We are not where we need to be as far as opioid prescribing and pain management, but I believe we are making headway in helping people understand that there are other options available and also making those options available. An example would be chiropractic care or physical therapy. We passed a law in our state so that physical therapy or chiropractic care does not stop at twenty sessions if they are not ready for it to stop. We have also been working with dentists and surgeons in the state so that they are really only using opioids when they absolutely need to, and so they are looking at options like ibuprofen or Tylenol which can be just as effective after procedures instead of opioids. It really is a culture change. We don’t want people to suffer. There are people who need opioids to help control their pain, and they can be safely prescribed. We just want to make sure that the providers prescribing them are doing the right things for their patients to make sure that they are safe and using only the doses and quantities that are necessary.
When you say that you have lifted the cap on alternative pain management services, is that in the context of private insurance, public insurance, in what context has that cap been lifted?
The legislation was to lift the cap for all insurance types in the state, so whether it is public insurance or private insurance. Some insurances are grandfathered anywhere you go and don’t have to abide by any of these laws. But really the goal was for any public or private insurance to lift the cap so that these services would be covered.
What are some of the unique features of the state of Delaware that affect the manifestation of the opioid crisis there? I ask because I grew up in the state of California, which is a very large state, and there are some parts of the state that are quite severely affected, and some parts of the state that aren’t affected as severely.
We are in the midst of a number of states that have been struggling. The northeast and mid-atlantic have been hit very hard. West Virginia is actually part of our region. We are surrounded by states that the I-95 corridor goes through. They are called high intensity drug trafficking areas, but the Philadelphia-Willmington area is called a HIDA by the DEA and Baltimore and New York City are as well, and Washington DC too, which are above and below us. We are in the midst of some high intense drug trafficking areas and that has certainly been problematic for us. It is also important to mention that Delaware has been one of the highest prescribers. For high dose opioid prescribing, we were number one. The number one state in 2012 when the CDC did an analysis using prescribing data. In this past year, 2017, we were the highest state in the nation. We have made some progress in prescribing, we have seen some decreases in high dose prescribing, but we are still the number one state in the nation for high dose prescribing. We also prescribe a lot of long acting opioids. A number of opioid prescriptions tend to be around 17 - 20th. We are not as high in the numbers of opioids prescribed. But we definitely have prescribing concerns in our state still. One of the positives about Delaware in comparison to a state like California or Texas, being a small state, we have the ability to bring people together under one roof to solve our problem. Recently we just passed a bill that is to create an overdose system of care. This would be compared to something every state has like trauma systems of care and stroke systems of care. These systems really bring law enforcement or first responders like EMS as well as emergency departments under the same umbrella to develop a standard protocol to use data to track what our system looks like to make improvements. It has been very effective. For trauma, as an example, using our trauma system of care, we have reduced trauma related deaths by 50% in our state. We are taking the same approach to bring law enforcement and first responders and emergency departments and substance use disorder treatment providers together under the same umbrella to really hash out the system that will work best for us and our state, to use the overdose as the opportunity to very quickly connect individuals to the care that is most appropriate for them.
For those individuals who are currently afflicted with opioid use disorder, what is your thought about medication assisted treatment?
Everyone has their own journey. It is important that treatment meets the person’s needs. MAT is well supported by a lot of scientific evidence as an effective approach to help individuals with treatment and successfully into recovery. There is a tremendous amount of stigma associated with MAT. For a diabetic, you would not tell them they can’t have their insulin, for a hypertensive individual, you wouldn’t tell them they can’t have their high blood pressure medication, and again, opioid use disorder is a disease, and MAT is an effective treatment. We feel strongly that individuals are offered and are informed about MAT to decide if that’s a pathway that will be fit for them.
What role or responsibility do you think pharmaceutical companies like Purdue should have in the efforts to alleviate the opioid crisis?
I haven’t really seen companies like Purdue be at the table to be part of the solution. And that is unfortunate. As I have mentioned in detail, we have been working very hard to change the culture around the role that opioids should play in pain management. But the reality is that opioid pain killers were really the driver of this crisis, and this is incredibly crisis. It is costly in lives and costly economically, so it is important that Pharma is at the table as a willing partner in finding and supporting solutions.
If somebody gave you a magic wand that allowed you to change any policy you wanted in order to more effectively alleviate the opioid crisis in your state, which policy would you choose to change?
I feel very fortunate to be in a state where we have great support from our general assembly to enact the policy changes that are necessary to address this crisis. Every year we have worked with our general assembly to pass multiple pieces of legislation to support our effort. This year we have multiple pieces of legislation that are critically important for helping us address the crisis. I feel really good about how our state has been able to put the policies in place that are needed. One policy I would really love to see changed is at the federal level. First and foremost, it’s been very helpful to receive federal funding to address the crisis in our state. Both the combination of state funding and federal funding has been critically important and we need to continue down this pathway of adequately resourcing our response. One policy barrier at the federal level though, that is a barrier to people getting engaged in treatment appropriately is around medication assisted treatment. I mentioned to you the overdose system of care. The evidence is certainly growing that the individuals who have overdosed are offered and initiated with buprenorphine in the emergency department are successful with treatment in recovery is greatly enhanced. This is because individuals who have overdosed and received naloxone are incredibly uncomfortable physically. It is a very bad physical and mental experience to go through opioid withdrawal secondary to naloxone. Buprenorphine initiation can make an enormous difference for an individual. Using this as a reachable moment to initiate treatment as opposed to using this as a moment where they run back out on the streets so that they can as quickly as possible address their opioid withdrawal. The policy that’s in place right now makes it so that an emergency department can dispense one dose of buprenorphine but if an individual doesn’t get initiated into treatment right away, they won’t’ get a second dose of buprenorphine. One thing we’d love to see is emergency departments being able to dispense or prescribe 48 to 72 hours of buprenorphine while an individual is getting integrated into a treatment that’s best for them. We’re working around it in Delaware. We’re certainly working very hard on getting individuals immediately taken into a treatment center that’s appropriate for them. Our emergency departments are seeing individuals getting trained so they can initiate them with one dose right away. But I believe both at a state and national level that that’s a policy that can make a really big difference in using the overdose as an opportunity to safely engage an individual into effective treatment.
You mentioned that you’ve had a lot of great support from the general assembly for legislation at the state level. Were there any particular committees or individual law makers who really stood out in terms of introducing bills or getting bills out of committee and getting them passed?
There’s been multiple legislators who have been incredibly helpful. Our now lieutenant governor was a state senator and at that time she led the senate health committee. Now she is leading efforts in our state around mental health and substance abuse. Lieutenant governor Bethany Hall Long has been a great champion for us in Delaware to get policies passed that are needed to support this crisis. When she moved on to become lieutenant governor, her senate seat ended up being filled by Senator Stephanie Hanson, who is incredibly passionate about this as an issue, and has been a great partner to work with to really problem solve and to move some legislative items to support the effort.
Where do you see things moving forward? Do you think things are turning around or do you think there are still some daunting challenges ahead in the state of Delaware?
First, I’ll say Delaware, like most states, wasn’t prepared for a crisis of this enormity. We had no staff in the division of public health that were working on substance abuse at the time. My sister agency substance abuse and mental health will certainly readily admit that our treatment system was not prepared for a crisis of this enormity. I am really happy to say that I believe that thanks to federal funding and state funding and a number of policies that have been enacted, I feel like we have the right pieces, resources, people to help us make the movement that we need in our state. I mentioned the overdose system of care which I think will be critical. Our sister agency, the division of substance abuse and mental health, has just launched the start initiative, which is really focused on comprehensive and coordinated evidence based person centered treatment and recovery, and I think it is going to be a game changer for us. It uses the roles of peers, peer counselors, who will help people through their journey, so they are addressing the needs that are unique to them. It may be housing that is one of the key issues preventing a person from being successful in treatment, it may be the vocational skills that they need to have a job to pay for a home or to really have the self-esteem needed to get on the path to recovery, maybe legal issues that are preventing them from being successful in their recovery. There is no one type fits all. The start initiative will help us transform our system so we can meet the needs of unique individuals and also very importantly help them transition from one part of the system to another so they don’t fall through the cracks.
This is a collaboration between your agency and the agency of mental health services.
Absolutely. As a state government, we are taking a very strategic and collaborative approach. Agencies are coming together and working together that haven’t really worked together before. We haven’t really worked with law enforcement like this before. We’ve worked with our department of corrections before, but certainly not this closely. I think the coordination of cross state agencies taking a collective approach is critical. We have a strategic team that I lead with my partner at the division of substance abuse and mental health, Elizabeth Romero, that is helping us operationally coordinate our efforts. But certainly, this addiction action committee which I mentioned which is a public-private entity is helping us bring expertise across the states through a public-private partnership to problem solve and move us forward.
Do you find that there’s been any communication between your state and surrounding states about touching base, looking at data for that region, comparing best practices?
Absolutely. That’s critical. We’re in HHS region 3, and our health officials talk on a regular basis, and this for years has been at the top of the priority list of topics of conversation. I know the substance abuse agencies also collaborate on a very regular basis around this topic--in fact there’s a call going on right now that includes the region 3 substance abuse officials and state health officials so that we can learn from each other. One of the technical pieces that has been helpful is our prescription monitoring program. For quite some time, the systems didn’t really communicate across state lines. For us in Delaware, we had many people who were crossing lines to Maryland or Pennsylvania or New Jersey on a regular basis, and we had no way of knowing that they may be getting prescription drugs in one of those states and in our states. Now our prescription monitoring programs speak to one another so people can’t hop across state lines to get opioids without us knowing.
So, it is a prescription monitoring program that is not only within the state but also in surrounding states?
Correct. For us it was obviously most important that we connect with our surrounding states as quickly as possible. But now we are connected with 22 states. We’ve seen with our prescription monitoring program that people will go as far as 300 miles to get a prescription filled. People will travel far to go to a place where they can get prescriptions filled. Now that information is much more transparent.
I know that in some states there has been some grassroots coalitions that have come up like opioid safety coalitions at the community level. Have you seen anything like that in your state?
Absolutely. I think we probably have one of the best coalitions in the nation called Attack Addiction. It was founded by parents who had lost their children. When I speak about some memorable moments in my journey in addressing this crisis, many involve our friends, partners, colleagues from Attack Addiction that have been amazing humans stepping forward during a time of personal tragedy to change the system to prevent others from losing their children to this crisis. Many of these policies that I mentioned that Delaware has changed, Attack Addiction have been advocates, they have supported us and in many cases, lead policy efforts in our state. These leaders are incredibly well respected and listened to in our state and that makes an enormous difference.
It seems like government, society and initiations are working very smoothly together to alleviate the crisis.
It’s not easy and we’re certainly not where we want to be. But I think we’re fortunate that we have amazing people in our state who want to work collaboratively and really want to fix the problem. I believe we will make a lot of progress in the coming years, but we are losing a lot of lives to fentanyl and we feel desperate about getting this turned around.
The opioid crisis has shown up in all fifty states, and in interviews I’ve done with people, the state of Alaska, the state of Kansas, the state of Wisconsin, we get to see how it’s such a big issue everywhere, something that seems to be quite unprecedented.
It is tragic. No one is untouched. And whether individuals feel they don’t know anybody that may not actually be the case. In any way, we are all affected in some way, shape, or form. If there is any silver lining, which I am hesitant to even say there is a silver lining, I think people are really starting to see addiction as a disease through this crisis. That is good for people to recognize that this is a physical condition and not about a lack of willpower.
There are data that show that individuals who have had adverse childhood experiences or a mood disorder or a genetic predisposition are more likely to develop opioid use disorder. Is there a way for prescribers to be aware of those risk factors before they choose to prescribe opioids for those patients?
You mentioned a couple of important things there. One is that there really are prevention opportunities. There are individuals who are at greater risk. It is important that our mental health system is tuned in to trauma and the impact that trauma has on individuals, and that people are receiving trauma informed care as needed in their lives. There are risk assessment tools that prescribers can and should use to understand if an individual may be at higher risk of addiction. Certainly, that is important to talk to patients about. The reality is, we know no one is immune to opioid addiction. Although some individuals may be much more susceptible, and it’s important for prescribers to know that it’s important from a blanket perspective that we are using opioids as safely as possible and really prescribing as little as possible so they’re not overflowing in people’s medicine cabinets in their homes.
Do you think the efforts to combat diversion has made any difference in the state of Delaware?
I’m not sure that they’re different in the state of Delaware. It certainly has been important to address diversion. Educating parents about the fact that not that long ago prescription pain killers were very prevalent in use recreationally by youth. That’s now decreased significantly over the last few years through education, but education also has to include things like making sure to dispose of any medication, but especially controlled substances, when you no longer need them. When I began this work, there was nowhere to take them. Now we have pharmacies and police stations across the state that will take back any medication, but of course we especially encourage controlled substances to be disposed of when they’re no longer needed. Another component of diversion is prescribers should only be prescribing the quantity needed. Instead of 120 pills after a minor surgery, which is something we continuously heard when this began, often times seven pills are adequate, and sometimes even those seven are not needed. Changing the quantities so there’s less available is a key piece of this strategy. But I can’t say Delaware has does anything uniquely different in that regard.
Given your background as a pediatrician, I know that there have been reports in the press, there was an article called the “Children of the Opioid Crisis”, and it was talking about kids who are living with a relative, grandparent, and how some parts of the foster system have been strained, and there wouldn’t be a lot of capacity and they’d be sleeping in offices of child protective services agencies for a certain period of time because they were looking for places for them to go. Given your background working with children, what are your thoughts on the toll it takes on children?
This crisis has strained every aspect of our system. As it relates to our youth and family services, and that includes the foster system, that system is beyond strained. The crisis has a lot to do with that. We have seen a tripling of neonatal abstinence syndrome rates in our state and we have a very high rate of neonatal abstinence syndrome in Delaware similar to our surrounding states. One of the things we have worked very hard with partners on is a plan of safe care in the birth hospital before the baby is sent home. Pregnancy and delivery can be a reachable moment for a mother and a father who are dealing with a substance abuse disorder. The literature is very supportive of children doing best when with their family. Taking those together, knowing that this is often a time when a mom is much more open to treatment, we are working very hard, and when I say we, it’s multiple agencies and partners, to ensure that families get an appropriate assessment and plan of safe care at the time of delivery, or before if possible, and that the services needed for the mom, for the family, for the child, are being met through our services available in the state. Our children’s department in the state have put a social worker in every birth hospital to ensure these plans of safe care are being created and these needs are being met. This may be veering into a strange topic, but we also found that pregnancy in women who are struggling with opioid use disorder are not intended. About 90% of these pregnancies are unintended. We want to make sure that all women, and that includes women who are struggling from substance abuse disorder, have access to effective contraception, so that when they have a baby, they are ready for it. That may also help address the prevalence of substance exposed infants, so that the family is ready and a woman who has substance use disorder is in treatment and recovery when she has her children as opposed to when her life is more chaotic.
A lot of media reports will focus on statistics like overdose deaths or the economic cost of the crisis. How do you think we can portray the crisis in a more anecdotal way people can relate to?
I think that’s important. I am a data geek personally, so I spend a lot of time looking at the data and interpreting it to help us with our implementation efforts. But the reality is, that’s not what resonates with most people. But most people are in some way connected to somebody who’s lost their life. We have numerous stories here of high school football stars, or people who excelled greatly in academics in college, or were very successful in their careers, who then, for whatever reason went down a pathway of developing an opioid use disorder. Those stories are often the ones that connect more with people because they begin to think “that could be me” or “that could be my child or grandchild” because this can happen to anybody. I think that adds a more humanistic dimension to this when people realize that it could be any of us that are directly impacted. I also think it’s really important for people to hear success stories as well because I certainly have met many individuals in Delaware now who have successfully found their way into recovery who are thriving and doing great work contributing to society in many positive ways, who are successfully raising their families, and I think it’s important for people to realize that a person using IV drugs today could also be changing the world for better tomorrow. These are beautiful people who have hope or for whom there is hope for a better future. We have to remember that.