Interview with Greg Lakin

Greg Lakin D.O., J.D. is the Chief Health Officer and Medicaid/Medical Director for the Kansas Department of Health and Environment.

It looks like before your current position, you were a state legislator. Is that correct?

Right. Well, I can go back even further. First, after my undergrad I was a police officer. You know, I got to see basically what drugs do to families out on the streets. I would arrest the same people over and over, and a lot of them were actually pretty good people when they were sober or off drugs. And so I went to law school, as you did, and I was a prosecuting attorney for seven years in Hawaii. There were a lot of gangs and different drugs, and back then it was methamphetamines over there. They had their fair share of drugs in Hawaii. Then I went off to medical school, and I’ve been treating opiate addiction for the last 20 years in Kansas. So that’s my deal.

You have such a unique background. You’ve been able to see the effect of drugs from a law enforcement perspective, from a legal prosecution perspective, and then from the perspective of a doctor. Throughout your experiences, you’ve been able to look at the crisis from multiple angles.

Yeah, that’s true. I would be out on the streets, and we’d arrest people who were doing burglaries or theft or even stealing from their own family members. They really were good people, and they actually usually weren’t on drugs at the time, but they had a $200-300 a day habit, and they had to eat. And after you lose your job and everything else, that’s what you have to do because you don’t want to get terribly sick, especially with opiates, so you can see where that ties over as a prosecutor. If they had drugs or alcohol addictions, we would often basically force them to get treatment. Or we would sentence them to a certain amount of jail time, deferred on the condition that they would get substance abuse treatment. So we’ve had some pretty good success with that early on, and of course treating the mood disorders is paramount as well. For the past twenty years I have always embraced treating the anxiety, the depression, the bipolar, the borderline personalities: whatever it is, whatever it takes to get people out of that reactive fight-or-flight mindset. So we have had good success, I think. Our outpatient treatment center is the largest in the state, and there are a couple of other treatment centers as well.

During your time as a state legislator, was there any legislation that came up that was related to the opioid crisis that you were able to have some exposure to?

A little bit. I pushed a couple of bills. One was just making sure our first responders had Narcan in their possession. We were one of the few states left that didn’t have a special provision in there for first responders: fire, rescue, and police. We wanted to make sure they have the ability to have it in their possession and actually know how to use Narcan on the scene to save lives. Only three states were left that didn’t do that. They still need to pass a more comprehensive Good Samaritan law to protect people, help them call in authorities for treatment, or helping with addicts.

 

On the chair of our Governor’s Public Substance Abuse Disorder task force, we have to give a formal report here at the end of this month with regard to what our statewide action response team is going to be. That involved many different bureaus and a lot of state agencies from corrections to law enforcement, to children and families, and to hospitals. We tried to include everybody to make sure it was a well added plan and well thought out. We wanted to make sure it didn’t penalize those who actually need help from opioids for pain management. We beefed up our prescription monitoring system, and there’s a little more oversight to that as well, but we’ve done some things that I think will have a pretty large effect.

I know that there have been some concerns with regards to prescription monitoring: what if the pendulum swings too far the other way, and there are patients who genuinely have debilitating pain who may not have sufficient painkillers to help them with that. What’s the best way to strike a balance in your opinion?

In some states, they were very quick to act, and I think it’s maybe caused a rebound effect of penalizing people who do have chronic pain issues and need opioids for their pain but can’t get it as easily. So there’s always a balance that needs to be struck between making things too easy and not prescribing enough. Luckily, in our state we see this epidemic coming from the east and west coasts, and by the time it hits here, we’ve got different state models to emulate or to shy away from, so I think our plan is well thought out: it’s not going to penalize those prescribers that treat pain too much. There’s still fear out there for prescribers because it’s going to be overly restricted, but when they find out the changes we’ve made, which are the Medicaid system and some of the guidelines we follow like John Hopkins and CDC guidelines, there’s not too much they can say.

 

Do you see there being a major role for medication assisted treatment, or do you see more of a role for things like counseling and peer support, or do you see all of the above?

We’re certainly going to attack it from all angles. It will be interesting to see which modalities have the most efficient results. We’re focusing on medicated assisted treatment including buprenorphine products as well as methadone and even other modalities like physical therapy. A lot of it is provider education too. We have to get providers to step back and look at other modalities and reassess people more often at first, until they have a better grasp on just what kind of pain they’re dealing with and how to best treat it.

 

In your opinion, what would you say is the biggest barrier or bottleneck that prevents patients with opioid use to being able to have access to resources and treatment? What’s holding them back?

A lot of it is fear-based. It seems like there are treatment avenues available to them if they really want it, but I think oftentimes they don’t want it yet. So I don’t know; how do you motivate people to feel in control? What happens when you take these opioids for a while, especially the short-acting, is it gets the into a reactive state: it’s fight-or-flight all the time, and their brain is just overactivated, and everything is a crisis and urgent, and everything is only about the next 10 minutes, so they don’t really think about tomorrow or the next day. There’s 100 voices telling them, “Just take a pill and forget about tomorrow.” I think that’s where the medication comes in handy too. We can start working on stabilizing their mood and getting them out of that fight-or-flight mindset that they tend to start to live in, and then they can start making more responsible decisions. But getting that first step in there seems to be difficult because we’re too scared to take that first step.

In your twenty years of practice, what was the most memorable experience you had, whether it was something that you observed or something that you heard someone say?

In Wichita where I’ve been for 20 years, I ran into former patients all the time. They’d catch me at a restaurant or catch me at a store. And they’ll just say, “Hey I just want to let you know I’m a coach now, I’m teaching kids in the 7th grade,” and it happens quite a bit now, so it’s pretty rewarding to hear that.

Is there anything that you've come across in the course of your career that changed your perspective on the crisis?

There were patients who, I worked the ER for a while as well, and there were patients that I knew that either dropped out of treatment or decided to go out and binge, and we lost them. They ended up in the obituary. Especially now with this fentanyl stuff. A lot of them think that they are experienced and they have been doing it for 10 years and they know their tolerance. But if you run into something laced with fentanyl, it can fool you and trick you and the next thing you know, you're dead. This last former patient that I had went out on a binge with this black tar heroin with his brother, they just thought it was the best stuff. And one of them ended up overdosing and dying. And in the autopsy, it had no opiates in it whatsoever, it was strictly carfentanil laced with some kind of filler and that was it. People like to think that they're too smart and experienced to be fooled.

 

Has the state seen an uptake in drugs that have been laced with fentanyl or carfentanil? Has there been a noticeable increase in that kind of thing happening in the state?

Absolutely. Our prescribing rates have gone down with regards to opiates. There are fewer doctors prescribing opiates. The people on prescription pills have gone down. What percentage of that has inadvertently turned to heroin, which is cheaper than ever and potentially more potent, remains to be seen. We've had more overdose deaths on illicit drugs than we do on prescription pills. That's really what our focus is.

 

Given your experience in Hawaii, where it was generally meth you were dealing with as opposed to opioids, what makes the opioid crisis different from other drug epidemics?

Opioid patients seem to be very high-functioning. Many of them have jobs. Our outpatient clinic is open at 5 in the morning because they have to be at work by 6 or 7. They'll come in and take their Suboxone or methadone and know they're good for the day. But with methamphetamines, there are patients out there, their brains are fried for life: their behavior will never turn back to normal. They have twitches and mannerisms that will never improve.

In some respects, opioids can be very deadly, but in other respects it has no class. You'll see it in the middle class, you'll see it in the white collar, you'll see the opioid addiction in the middle-aged. It's just more widespread in the people that it affects, but most people can improve with mental and physical treatment. But with methamphetamines, I just think that's a very toxic poisonous drug: people never recover from that.

 

I noticed that news articles about the opioid crisis usually include statistics and numbers about overdose deaths and the economic cost of the crisis. I was wondering, for someone like you who has been on the front line, how do you think the media can present an image of the crisis that’s less abstract, something that the general public can relate to?

I would love to have the newscast or articles telling the life stories of our patients who have had to battle with addiction and join them on the journey of recovery. The best way to really connect with people is to tell them a very real story. I don't know if statistics do that, but certainly a personalized story would, in some respects, be able to connect with people more than statistics. There are just so many statistics out there in the news.

 

One thing that really jumped out at me was when I read that 4 out of every 5 heroin users started out by taking prescription painkillers. I find that statistic surprising because these are people who were prescribed something, or had access to pills that were prescribed to someone else, and then some of them became too dependent on it and that led to them moving on to substances like heroin. That really impacted me a lot because many of them were just normal, everyday people.

That's very true. I found that to be true. You know, a majority of our patients start off on pills, and about half took it for legitimate reasons like an injury or two. And about half just took somebody else’s pills or bought somebody else’s pills for recreational purposes. But it’s always those short-actings that they get started on, and the next thing you know, they need to take 10, 20, 30, 40 a day, then they’re on Oxycontins. And they don’t get help in the meantime, it doesn’t take long until they go onto Oxycontin IV or even heroin. I would say the majority of our patients started with prescription pills, which may not have been theirs. Usually when people start straight on heroin, I ask, “Where are you from?” And they’ll say the east coast or west coast where heroin is much more available. I would say a majority of people start on pills, and about half of them, like you said, were legitimate users that just fell in love with euphoria. Some people say it helps them feel more normal. So we have to look at underlying mood disorders, or an anxiety component, or some other mood disorder that we can treat and increase our chances of getting off and staying off.

I remember reading that people are more susceptible if they have a previous mood disorder or previous trauma in their life or some sort of genetic predisposition.

Yeah, that’s what I’ve seen as well. You’re exactly right. The thing about opiates addiction: these are high functioning people. A lot of them are 150% and like to be very constructive and have jobs and are business owners and give 150%, but when it comes to taking pills, they’ll do 150% of that too. It’s going to be very Type A or active people. They’re very successful, but they waste it on drugs.

 

What role or responsibility do you think pharmaceutical companies like Purdue should have in the effort to alleviate the opioid crisis?

I can tell you that I was around 10-15 years ago, and they would really push on the providers to treat pain more adequately. There were complaints that these providers weren’t treating pain adequately enough, and it was the fifth vital sign. We were actually being told by the pharmaceuticals that these providers were being sued for under-treating patients. And some of the brochures were very, very deceptive. I don't have a lot of sympathy for some of the marketing these companies did. This is part of the problem as well.

If someone gave you a magic wand that allowed you to make any policy change at the state or federal level to more effectively alleviate the crisis, what would that policy change be?

I honestly think prevention has to be the focus, and empowerment has to be the focus. We have to empower people to effect their own change and to be responsible for their own health. Granted, there are temptations out there and even deception out there. But at the end of the day if a person doesn't want to get better, they're not going to, and if they want to play the victim role, then they're going to play the victim role. And everybody can’t be a victim. Society won’t work that way. So, I think it's how we empower people to take that first step and take responsibility and become self-aware and in control. It’s more philosophical, perhaps more than something that we can actively grasp, but it's kind of the direction we have to proceed in, I think.

 

When it comes to people's reluctance to get treatment, do you think part of it is an unwillingness to take responsibility, or do you think part of it may be the fear of the stigma of being labeled an addict? Could there maybe be more than one reason they are reluctant to seek treatment?

I think you’ve mentioned the two primary reasons: the fear of being labeled and the fear of facing up to their own issue. It’s also work: it’s not easy, especially when your brain is just telling you to just get through the day, and don’t worry about tomorrow or your family, or your children, or your job.

 

I was reading somewhere that the average person with opioid use disorder can relapse as many as 5 or 6 times before they are able to get on a sustainable path to recovery. Has that been something you have observed, or have you observed something different?

I do think so. We always counsel and educate our patients as though they’re going to potentially relapse each time. You know, “don’t get discouraged” and “don’t be so hard on yourself” and “if you do relapse, come back earlier when it’s easier to treat.” So yeah, sometimes it takes a few moments for them to get it down, but they become more self-aware and have a little more confidence that they can do it and get help.

 

Part of my objective with this podcast is to educate the public about what the crisis is about, but part of it is also for those out there who are suffering from opioid use disorder, for them to receive the kind of information that you just said like “don’t give up” and “don’t lose hope” and “keep trying,” hopefully that can be a source of inspiration for them as well.

You would surprised who’s out there right now who I’ve been honored to know. We’re talking attorneys and engineers and health care providers. They receive treatment, and in some respects I think they’ve come out of treatment stronger than ever and are more self-aware. If it doesn’t break you, it can make you stronger, and some people have treated it like that. They should be hopeful that they can do it just as well.

Are there any other thoughts you would like to share?

I think you’ve covered it. I appreciate you getting involved and trying to get the word out. That’s step one.