Interview with Meghan McCormick

This interview took place on September 28, 2018.

To start off, could you give us a brief overview of your role in working with the opioid crisis?

I’m the lead epidemiologist for the drug overdose prevention program in the Rhode Island Department of Health. I analyze multiple data sources that inform our performatic activities Mostly I use data from the prescription drug monitoring program and our own 48-hour reporting system which is where hospitals are regulated to report an overdose to the Department of Health within 48 hours of that patient being treated but we also inform our work through the medical examiner and the EMS data as well.

How long have you been in that role?

Two and a half years.


What was the most memorable experience you had in the past two and a half years, whether it was something you observed or something you heard from someone?

So in December, we had a large summit with representatives from every municipality in our state and we did a few brief presentations on the state of the epidemic in Rhode Island however we broke them into groups based on their municipality or town and asked them to get to work on developing an overdose emergency response plan for their city or town. The energy in the room was really inspiring. We are a small state but we have a lot of people power. Everyone in that room was there because they wanted to do anything they can do to help in the crisis. It has been really easy to fall into a trap of thinking that the epidemic is too large for one person to address and we seen compassion peaked as well as people who work on this everyday but that day in December was a really great reminder for me that none of us are in it alone and there are so many people who can bring their expertise, and resources, and passion into coming up with a solution if we can just invite them to the table.

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

Yeah a little over two months ago, a friend of mine died of a sectional overdose. His death made the opioid epidemic a little personal for me and my knowledge of the last 10 years of his life and the conversations with his sister after his death have given me an insight into one overdose death that I would have never been able to extract from any data set or any medical examiner's file. And his death really reinforced two aspects of the epidemic for me. The first is the need to mention about counterfeit pills. He died with what people believed was a war cap 10 which he has probably taken many times in the course of his life but this time, it was a counterfeit that he purchased and it contained sectional ONT and unfortunately, passed away after taking that counterfeit pill. And the second is that, Scott really thrived on social interaction and he could carry on a conversation for days. But the last few years of his life while he was fighting his battle with … disorder, he became very socially isolated. No matter how many times I heard that the opposite of addiction is not sobriety, it is connection, I never really fully understood it or fully believed it until my friend died.


There are some actions made in the country for harm reduction such as test strips and other ways to combat this, what are your thoughts on this?


About harm reduction policies? Like, Rhode Island has really focused on walkzone and has made the walkzone accessible to public since 2012 with standing orders from pharmacies. We also piloted the ability of walkzones in public settings such as the locks box. When possible, the locks boxes are installed next to ADDs. ADDs are available in public spaces in case of a cardiac emergency and we want a lockzone available in case of overdose emergency. Harm reductions is one approach that can help some people and it is easier to rescue people from overdose and it helps them gain access to resources that can help them get on their path to recovery. We have no evidence that is publicly available with the lockzone that encourages people to use opioids so we really pushed the lockzone as a way to combat the crisis in Rhode Island.


From your perspective, as an epidemiologist. What makes the opioid crisis different from previous drug epidemics?


So the difference here is between an opioid we're currently in and other epidemics is really a threefold. Persistence, potency and death and persistence is that with most of the other epidemics we see people who are affected by the disease and passed away and move on with their life. And in this case, and the overdose crisis there is a physical dependence on the drugs, so he did some stuck in the epidemic because people are in this cycle of either going into recovery or passing away. The other aspect is  potency. Over time, people build tolerance to opioids of course, and they are trying to have a memory to experience the same desire effect and they're trying to recreate that memory of that first time they took the opioid and this leads to an opioid increase. This increase is very high and it is very dangerous and illicit opioid fentanyl has increased the potency of opioids and opioid tolerance within our population. Then of course there is death which is where there is a wide range of people who have lost to overdose. There are people from all social economic classes and all ages and recent data is showing that we're really starting to even out the rates of overdose among both males and females.


From your perspective, what is the single biggest barrier or bottleneck from those suffering from opioid addiction from receiving professional help or treatment.


The power of the  drug can really hold the person back and the person that um, it is far more than the person reaching out and getting access to help. Once there's a window of willingness to go into recovery, we have to do what we can to pull the access to support services and help them on a journey to recovery. It is really more the idea of recovery than the hold that the drug has on the person or any specific bottleneck within the system for treatment.


What are your thoughts about medication assisted treatment for those who have opioid use disorder?


Yeah, for sure. Medication assisted treatment is powerful and one of the best strategies that we have to save lives, it's an evidence based treatment for chronic brain disease, which is what opioid use disorder is. Misperceptions of MAT can really limit people from starting on their journey toward recovery. People with substance use disorder takes medication to control their disease. People with diabetes takes medication to control their blood sugar and people with asthma take medication to control the inflammation in their lungs. People aren’t judge for having chronic diseases like asthma, heart disease, and we shouldn't judge people with opioid use disorder and we should support people with opioid use disorder to contract with MAT.


There are concerns with efforts to reduce opioid prescriptions, it could adversely affect patients who genuinely suffer from debilitating pain, what do you think is the best way to strike a balance between the two?


We expect all prescribers to treat patients with compassion and balance the risks versus the benefits of opioid. Prescribers need to choose the safest pain management therapy for their particular patient, and that may include opioid prescriptions for pain medicine, it be not opioids or not in non pharmacological approaches, physical therapy, chiropractic care, acupuncture and massage. There are other alternatives and we really expect the prescriber to choose what's appropriate for their patient. There is a requirement in Rhode Island for prescribers and patients will have a conversation about the risks of opioids before a patient is prescribed an initial opioid. The regulation went into effect in July and it underscores that prescribers have a quality conversation with patients about opioid risk/benefits, opioid side effects, non opioid alternative and safe storage and disposal of opioid medications. The physician-patient relationship comes first and it's important that that relationship makes the decision about opioid use and treatment of chronic pain or debilitating pain.


What role or responsibility if any, should pharmaceutical companies like Perdue have any efforts to alleviate the crisis?


We need to encourage pharmacy companies to develop medication to treat pain without the potential for addiction. Pharmaceutical companies can also stop promoting opioids for the management of pain for prescribers and patients.   


How has the opioid crisis manifested in Rhode Island? What has the crisis look like in the state given the state’s sort of unique nature in regards to the counties and how it varies among how many people are in the counties? I’m kind of curious how the crisis looks like in the a state like Rhode Island?


Yeah we have seen some geographic variation for the crisis here in Rhode Island, but we are a very small state. We're about 30 by 40 miles. It's very easy to get from one part of the state here to another part. You could live in one part of the state the and work in the corner. We don't see quite as much regional variation or variation as other states, but we do have geographic regions that are slightly higher than other geographic regions. We have noticed that the trajectory of the overdose crisis in Rhode Island for fetal overdoses has reached a plateau here in Rhode Island. It's tiny, slight decreased over the past year and non-fetal overdoses reflective, kind of a similar pattern, kind of plateaued. There are definitely some significant challenges ahead here in Rhode Island. We need to address this addiction and misperceptions with medication assisted treatment which prevents people from getting across the road of recovery and we're continuing to look at where our prescriber habits might need to be improved or addressed, but we don't quite see the same geographic changes as other states do.


It is interesting how you mentioned the decrease in overdose however, there has also been an increase with overdose fentanyl. What can you do to help protect to this newest threat for public health?


So the threat being fentanyl?


Uh, yes.


Yeah, so to protect against the newest threat to public health, which is fentanyl, we first need to prevent the future of the problem and we need to limit the number of people exposed to illegal or legal opioids. One exposure to opioids can cause individuals to be addicted. One exposure that is essential to someone without a tolerance who'd results in fatal overdose of that individual. So we need to limit the number of people exposed to opioids. And we need to screen people before prescribing opioids to see at a higher risk of developing opioid use disorder which is part of Rhode Island’s Discharge Planning Law, which requires hospitals and emergency departments to screen patients for opioid use disorder. And you also need to create access to naloxone to prevent overdose, death.


Okay, if someone gave you a magic wand that allowed you to change any part in order to effectively alleviate the crisis in Rhode Island, which policy would you zoom in on?


Honestly, at this point, if a policy could be changed to relieve the epidemic. The magic wand would have been waived and some policy would have been changed already. There is no single strategy/magic stick to this one. The crisis is multifaceted, the individual factors that result in someone developing substance use disorder are multifaceted. And we need to think about how we treat pain and addiction and how we address stigma and we need to think differently about how we view and think about each other. We need to accept that substance abuse disorder is like every other chronic disease. It has real effects, on real people with real families and we need to increased connectedness in the recovery community and increased connectedness in society overall, as I mentioned earlier, had come to truly believe that the opposite of addiction is not sobriety, but connection and connection and community and understanding will reverse this crisis, not a magic wand.


What advice would you give to someone who is starting a public health program who would like to go into epidemiologist, essentially what professional or career advice will you give them?


Absolutely, I often talk to people that are looking at the becoming epidemiologists and I make sure they understand the reality of what that means and that we do a lot of data work and there's a lot of data analysis involved in that. But if someone was already on the path and doing a masters of Public Health in epidemiology. I would say determine what you are passionate about and what you were going to want to go to work everyday to address and really take every opportunity in that field to learn about and become a subject matter aspect of the epidemiology or that aspect public health. Take any internship in the field, take any class you can. Find the experts and connect with them and just make yourself a subject matter expert in the field where you be a subject matter expert.


I know that there were some states where it was not clear how many people died from an opioid overdose because it is not always attributed to opioids, I think there is a similar case or situation in Rhode Island as there is not always a clear standpoint on how many deaths were actually due to that.


We are fairly comfortable with our number and feeling like we are correctly identifying overdose deaths. Here again, we're a small state, but we have a really fantastic medical examiner and the team that often do the full investigations and do autopsies on these overdose deaths. And we feel very comfortable that when we worked with the medical examiner and we get their numbers from the toxicology report during the investigation, that is the correct number of us here in Rhode Island. We do know other states have different medical examiner or the coroner's office had to rely more on death certificates. We worked very closely with our medical examiner, so we're very comfortable in our numbers.


I think that is all the questions that I have. Are there any additional thoughts or ideas that you would like to share?


No, I just want to thank you for inviting me to be on this. This is really great to share what we're doing here and also to be able to share a little bit about the story of my friend who recently passed. It affected my view on the epidemic.


I can imagine. It’s all about economic costs of the crises and overdose death without the intangible effects of families and friends who have been lost to the crisis and that also takes such a toll on the public.


That’s right. I would say at this point it would be pretty hard to find someone who hadn’t had a personal connection to this epidemic in one way or another, which is a sad state of where the epidemic is.


Definitely, thank you so much for providing such a great review on the state of Rhode Island and everything that is done to alleviate the crisis. This has been a very informative interview and I appreciate it.


Thank you Jamal and thank you for having me.


Thank you, and we will be in touch with our next steps in regards, to all our transcripts prepared. I will send it to you guys if you want to make any edits.


Wonderful, thank you so much. Have a great weekend.