Interview with Jay Butler

Jay Butler is the Chief Medical Officer at the Alaska Division of Public Health. This interview took place on August 9, 2018.

 

In what ways do you think the opioid crisis in Alaska is distinctive compared to other states in America?

I think what is most distinctive in Alaska when it comes to the opioid crisis is the lack of distinctiveness. If you want to look at a barometer of how pervasive the opioid crisis is in North America, then Alaska is a good place to look because you see the same issues here that you see in Appalachia, that you see in Suburbia, that you see in the rural Midwest, yet it’s a new venue that is very unique, but unfortunately for the opioid crisis, we have not been too remote to have been impacted. We have had clusters of overdoses in some of our most remote villages.

In your role as the Chief Medical Officer, perhaps it would be helpful to the audience if you gave a brief overview of your role in terms of how it helps alleviate the opioid crisis.

It’s really been a journey just in terms of process. We started in 2016 once we really had the numbers in front of us; we really had not been spared in any way. The problem had snuck up on us a bit because it pertains to prescription opioids, and then we began to see heroin overdoses. When the public safety was impacted by the heroin epidemic, we realized we had a problem that we needed to address. We realized that there was going to be a need for changes in policy, so we put together a policy task force that abides the legislature and the governor and helps decide some of the things we need to do. The second phase was the governor asking “well what should we be doing?” He really recognized that this was a serious problem. We suggested to get things done quickly particularly to get naloxone available within the state that we have a disaster declaration. I think we were the second or third state to have an emergency declaration. The mechanism for us was to actually have a formal disaster declaration, and that did a number of things. One was that it provided me the authority to issue a statewide standing order for naloxone. We just received the federal grant to be able to purchase the drug. Then we had our own designed rescue tips that we began to produce and distribute statewide, and we’ve now distributed over 11,000 of those kits. And one of the most remarkable things is how much of this we didn’t really know what we were getting into, but we were lacking resources and personnel to assemble the kits, so we started calling for volunteers, and we have had multiple community based events where people want to know what they can do about the crisis. This is one of those things we say “you can do. You can help us assemble these kits.” Actually just yesterday we had the surgeon general here, and I’m sure you’re familiar with his advisory on naloxone. So we had a [?] with the surgeon general rolling up his sleeves along with a bunch of commissioned officers from the native hospitals, some of our state troopers, and a couple of my staff putting together these kits. The governor also issued an administrative order that created a [?] band structure. We actually have all of the cabinet level representatives around the table meeting with their governor and then working with their staff to have a coordinated response. We continued that since February of 2017. The third phase is getting into “what is our longer term game plan?” as we look at where we want to be 3-5 years from now. We’re starting to [?] on things like overdosed deaths, but we know that it’s not just a matter of focusing on opioids. We have to look at the bigger picture of the challenges we have with addiction otherwise we’ll be back in the same exact place in 5 years from now with either a surge in of methamphetamines which we already see the beginning of or some other psychoactive substance. So we want to take a big picture approach as well. When we first met with the governor and discussed an incident command response, we all agreed that we had the data we needed, and we didn’t need to gather the experts again; this was an emergency and just like a wildfire (when we have a wildfire, we don’t call the experts to tell us about the nature of the fire, we don’t layout the hoses to see how much we have, we don’t just count the helicopters and the six winged aircrafts, we put the white stuff on the red stuff and do everything we can to contain the fire and then we begin with the discussion of prevention). I’m a big prevention advocate, but we recognize that we could spend a lot of time in strategy whereas the immediate tactical measures were what we needed to do right away. That’s sort of been our immediate level of response: “how do we save lives?” We have also encouraged some of our community partners in ‘surrender needle’ service programs. We actually have now just in the past two weeks a mobile unit run by one of our partners that actually spends two days a week at one of our facilities. So far that has gone really well. We are also piloting fentanyl test trips because unfortunately fentanyl is entering Alaska just as many parts of the US. We are also thinking beyond “great, we’re saving lives” but “then what? How do we get more people into treatment?” That’s a challenge; part of it is having providers and facilities available but also trying to address the problem. That’s why I was asking if you had worked with Michael [Bodichelli] when he was director of ONDCP; I think he was a very articulate voice of some of the challenges that stigma related to addiction created, and those are barriers we want to remove. We’ve been working hard to change the dialogue about addiction; we’re not just talking about bad people who can’t say no, we’re no talking about just moral failings, but we’re talking about a disease that affects the brain and subsequently affects behavior in ways that impacts all of us. This is not a problem of those people; it’s our problem, and we all have to own it and address it. I think the long term impact is going to be addressing supply and demand where we all started on supply. In a very remote state like Alaska, we actually have more drug return boxes than we have ever had in the past. There are issues with drug disposal, so we have focused on putting drug disposal into citizens’ hands using the drug disposal bags that are made with activated charcoal and getting those around the state initially starting with a donation from [?] pharmaceuticals. We found that the program was so successful and such a great conversation starter that we actually purchased some of those bags ourselves and are continuing to do some of that work. Recognizing that there is a law enforcement role because it’s the movement of illicit drugs, we partner with law enforcement. We are a brand new high intensity drug trafficking area as recognized by the department of justice. We actually have the ONDCP director visiting us next week. This kind of year is when everyone comes to Alaska as you may have noticed. Ultimately, in the long term, looking at “how do we change the demand side” because we can address supply, but my law enforcement colleagues say that we can’t arrest our way out of that, and part of that is because of economics. As long as the demand is there, there is going to be another dealer there willing to step in. We have to work to identify “what are some of the drivers?” And not all instances of addiction are entirely preventable, but certainly we can reduce the list of addiction because of contact with the healthcare system but also addressing some of those drivers as it relates to what are the personal traumas like adverse childhood experience, social determinant of health that are creating pain that are mediated by any number of ways, working with our tribal partners and recognizing that historic trauma is something that has to be addressed as well because the demand side is going to be the long term drive. In convincing the policy makers that there is a long term investment in our future that’s occurring here, it’s the infrastructure that’s going to part of economic health in the future of our state. That’s easy to talk about if we’re talking about a gas pipeline off the North slope, but we also have to talk about the health of our next generation of workers. Just like that pipeline, investing in after school programs or visiting home nurses for new mothers; those are not things we’re going to see necessarily one or two years from now, but the evidence is that in 10-15 years we’re going to start seeing returns that are going to be important for the future of our state.

 

Through that process, what was the most memorable experience that you have had?

Probably the most memorable thing was working with people in recovery. As a physician, I don’t see the good outcomes; I see the bad outcomes. My clinical background is in infectious diseases; I’ve taken care of lots of self injection drug users because of the causes most recently Hepatitis C, but also HIV, endocarditis. No one calls me at three in the morning to say “hey doc, I just celebrated my second year of sobriety.” I see the problems that develop. I’m beginning to understand what addiction is and that the inexplicable behavior of someone struggling with addiction is a not unlike the inexplicable loss of cognitive function that occurs in Alzheimer's that the brain is not working as it should. Unfortunately, the prognosis of addiction is much better. The one story that I think has stood out most in my mind in understanding addiction as a brain condition was a woman who was relating to me how she felt the first time she used, and she was someone who had a background of trauma, and she said “I felt like Jesus came and gave me a big warm hug,” and it just struck me that anyone of us, if we could experience unconditional love and forgiveness and we could find it in a pill or needle or syringe, we see that of course it’s not real in those forms. It just opened my eyes that she wasn’t making bad decisions, she was addressing an emptiness in her heart. It made sense as I was learning the neurobiology in addiction and sort of thinking about what was going on biologically in her brain.

You mentioned endocarditis, and I was reading that some patients who inject a lot, there’s a chance that it could lead to that condition which could be life threatening, and from my understanding, the treatment is also quite extensive.

Yeah, and it’s challenging because it generally requires prolonged intravascular access, and quite a clinical conundrum is “do you put vascular access into someone who is very likely to use that vascular access themselves?” I have come to believe that the complications that are occurring is because the addiction is not being treated. We need to do everything we can to treat the endocarditis, but we also have to make sure that we can treat the addiction. I see encouraging signs. For instance, at the infectious disease society meeting this year, I noticed that there’s a satellite meeting to get your [?] to be able to prescribe [?]. There’s clearly an interest among infectious disease providers to be able to provide that component of the needed care. I have an obstetrical colleague who was just telling me at the OBGYN meeting also got her x-waiver. She’s able to prescribe [?] to women who are in treatment during pregnancy. And that’s a big change. You know medicine tends not to change very quickly, but over the past two years, at least in my state, I have seen the general attitude go from “I don’t want those people in my waiting room” to a realization that those people are already in my waiting room and taking care of them is part of my job just like taking care of their diabetes or their high blood pressure.

 

In the course of your work, was there anything that you came across that changed your perspective on the crisis?

It’s hard to say there was one thing. It’s been a continual learning experience. My best teachers are community members who are in recovery; they really do provide the insight that I need. Sometimes basically their technical assistants in a very unique way; one of the things we struggled with was “how much do we push the ability for prescribers to use [?] or [?].” vs. addressing diversion of that substance on that street, so it’s great to have someone to just call up and say “tell me about how you’ve used [?] when you were using,” and an example of one of their responses is “it kept me from getting dope sick, but if I thought I was going to get my hands on some heroin the next day, I’d struggle a lot because the [?] would really blump the effect of the heroin” which I think is a great definition of [?] as a partial agonist that has blocking properties as well.

 

In Alaska, what would you say is the biggest barrier that prevents those with opioid use disorder from receiving professional help with treatment and recovery?

I think there are two things. One is the lack of providers and facilities. But along with that I think it’s the perception of the measure of treatment and not recognizing that for some people, particularly the lower end of the [?] scale, outpatient management is a possibility. Another barrier is understanding that there are many paths to recovery. Some people just thrive and get their lives back on [?] or [?], so we have to throw that perception that you’re moving one addiction to another and that recovery is more than just being alcohol and drug free. It’s things like a roof over your head, a steady job, and a regular date on the weekend. Looking at the function of life in the community is probably a better of measure of what recovery is than whether or not you’re on medication. I think the data there is thought out that people who go to a three week detox and are released back into the community with people telling them “now you’re as good as new,” their success rate is horrendous, and oftentimes, unfortunately, they die because they’ve lost their tolerance, and they start using again and overdose. So I think changing those perspectives on what addiction is and what recovery is and recognizing that there is no one path or one size fits all treatment is critically important.

 

When it comes to harm reduction policies has the implementation been smooth or have you encountered some hesitation from certain parties about those policies?

I think it’s really a dynamic situation. We had a bill first introduced about four years ago to waive the liability to making naloxone in an opioid overdose. At the time it was not perceived as a priority. As the second year of the crisis progresses, I think more and more people will be in touch with this crisis in realizing that we got to get rid of the thought that this is a problem of other people; this is our problem. I hate to say it, but this has become such a big problem and has touched so many people; more and more people have realized that there is a loved one, there is a friend, there is a neighbor who is gone now and that it doesn’t have to be that way. The next legislative session, the authority under the emergency order is only really good for 30 days, so we had to get statutory authority to do that. We have an independent non partisan governor who I serve under. We have a republican controlled senate, and a house controlled by a body that is primarily democrat. So let’s just say things don’t move very quickly. From introduction to signage it was six days. It was so gratifying to see that people recognized that this was something that was going to save lives. We were very honest that this is not the solution, but being very blunt, dead people are never recovery ready. That was very gratifying to see how one legislative session to the next, the problem was recognized. For syringe and needle we often times think about what goes on in other states. We have had syringe and needle exchange programs that were run very quietly, but I think in the past year, we’ve recognized that people need to know about these things, so we have literally shined a light on them. We’d like to get more data on fentanyl testing as a harm reduction technique. I think in terms “what are we not ready for yet?” that safe injection sites may be pushing the envelope a bit much for us right now. So we’re following the experience in Vancouver very closely and in Seattle as they venture down this road as well. If we ever go there, we want to make sure we can learn from the experience of others.

 

There are concerns that efforts to reduce opioid prescriptions may adversely affect patients who suffer from chronically debilitating pain. What do you think is the best way to strike a balance between the two?

Our headlines which try to summarize our governor’s opioid bill describe that there’s prescription limits, and I think there are some ways that have posed limits. I think I would describe ours more as a speed bump or more of a checklist that a pilot would use if an unexpected event occurs in the flight or more so that a surgeon would use in the operating room. As we talked with both patients and physicians we realize that oftentimes the number of pills that are dispensed are kind of arbitrary and automatic, so the way our law is written is that if a provider wants to supply more than a 7 day supply, then they can do it, but they need documents in the medical record the reason why. It puts that step that requires a cognitive decision and requires the documentation of what you are doing. So someone who has chronic pain does not have to be cut off, and that’s an important part: the balance because I think that’s an important problem: what to do with the patients in chronic pain. Withdrawal hurts also, so it’s very difficult to withdraw those medications, so it’s important to us to help people realize that going cold turkey is not the way to go. They are going to do whatever it takes to either avoid withdrawal or to feed the addiction.

 

When it comes to pharmaceutical companies, what role or responsibility do you think they should have in attempts to alleviate the crisis?

They need to market their products honestly. We want the free market to thrive but also it’s very important that people have the accurate information on the risks and benefits. It’s always interested me that as we saw the rates of prescribing climb and the rates of overdose climb, we saw no evidence of the prevalence of pain in the population decline. So I think the idea that opioids are the best way to manage pain is highly flawed in really it’s not evidence based.

 

If somebody gave a magic wand that allowed you to change any policy in order to more effectively alleviate the crisis, which policies would you change?

I think one of the policies in a response to the addiction crisis is that there is going to be a silver bullet, the one thing that will make a difference, and of course we all want the latest shiny object, but it’s really going to take gunshot to take down the beast we have before us. I really hesitate to say what is the one thing that I would do. Just in terms of immediacy of response, we have focused on saving lives because once someone has overdosed and is dead, the opportunity of recovery is gone.

 

In your opinion, what do you think makes the opioid crisis different from previous drug epidemics?

That’s a great question because we have seen this movie before. The biggest difference is the foundation of this crisis that lies in this being a healthcare quality issue. The promotion of flawed concepts and really non evidence concepts led to overuse of opioids. Campaigns like “just say no to drugs” don’t make sense at all when people become addicted because they are obtaining the medication from a trusted healthcare provider not some shady character in the Walmart parking lot. That is the most profound difference because there are people who are struggling with addiction now who would not be struggling with addiction had it not been for their interaction with the healthcare system. I very much see the opioid crisis as somewhat analogous to the challenges we have with emerging antibiotic resistance. The medications are in and of themselves good and useful, but they have to be used very carefully, or problems will develop.

 

Did you have any additional thoughts or ideas?

It’s important to recognize that this is not just a health problem, it’s not just a law enforcement problem, it’s our problem, and it’s going to take an all hands on deck approach to address it. It’s going to take everyone working together. The second thing that I would want to leave people with is that we talk about an opioid crisis or opioid epidemic as an infectious disease at the [?] clinic, and I’ll agree with that anytime you have a single cause of death that is increased multiple fold over a period of a few years; that is an epidemic. But when we talk about the crisis, we also have to recognize that we have an addiction crisis, not just a crisis with opioids. And even as we’ve been having this conversation and addressing opioids, we see an influx of methamphetamines into our communities as well, so we have to look at the broader issues as it relates to substance misuse and addiction, or we’re not going to be making progress; we may be exactly where we are now five years from now.

 

With methamphetamines I remember hearing that some of the long term health effects can be quite severe like people can actually have some neurological issues.

Meth in 2018 is different from meth in 1998. It’s not being produced as much in small labs, and that’s why we don’t care about remote cabins blowing up because they’re actually meth labs, and it’s not nearly as much as it used to be. More of it is being produced in larger scale labs which is often outside of the US and oftentimes opens up opportunities for contamination of the product. One of the concerns we see is people dying with [?] and methamphetamines on board, and it’s not entirely clear. We know that some of this is intentional [?] of opioid, but it also raises concerns about contamination and unintentional exposure to [?] to someone who thinks they’re using methamphetamines and maybe naive to opioids, and they actually die of opioid overdose that they don’t realize that they’re using.

They say in the US, fentanyl comes from China, and black tar comes from Mexico. In Alaska what would the source be?

It’s probably following some of the same routes. One of the unique is that it’s more likely to come in either through the air or through the maritimes system. Many places in the West, we probably see more black tar heroin.

Statistically an increasing proportion of overdoses are due to fentanyl.

That’s certainly true in our state. For two years in a row, we’ve seen a decline in the number of overdose deaths related to prescribed opioids. In this past year we’ve seen a decline in deaths related to heroin. Unfortunately, all of those declines have been obliterated by the increase of deaths relation to fentanyl.

I’ve heard that for some people who are deep into addiction, if they hear that if a dealer gave a drug, and there was an overdose, then they actually in some individuals will actually seek out that dealer because it means that they have a powerful drug.

Yeah, and I’ve heard similar stories.

For certain individuals, when it comes to certain drugs aren’t as effective for them. For those patients, is there any hope for them in terms of alternative routes to coming out of addiction?

It’s important to recognize that there’s no one treatment that works for anyone. There really are many paths to recovery. If [?] is not a successful path, then we have at least 2 other medication assisted approaches. Medication alone has its advantages, but it’s important to look at the individual and recognize that there’s the psychosocial component to addiction that needs to be addressed. There’s a crucial role for peer counselors, people who are in recovery that can assist someone who is going down that road.