Interview with Michael Langer

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

My name is Michael Langer. I’m the Deputy Director of the Division of Behavioral Health and Recovery within the Health Care Authority in Washington State. In terms of the opioid crisis and the impact on our state, our division coordinates with our public health colleagues, with the University of Washington, and with several other state agencies including Corrections and the Attorney General’s Office and Education and so on, to create a state plan to address the opioid crisis. Our plan looks at a continuum of services, so we have a component of the plan that looks at prevention, and we have other components that look at intervention and treatment efforts, both in counseling and medication assisted treatment (MAT), and certainly recovery support and the use of peers as well. Part of the plan also looks at overdose reversal and the use of naloxone and trying to get that into the hands of the folks who need it. And we also have a group of folks who pay very close attention to surveillance and the use of data, so we can identify the impact of this epidemic: where we’re seeing drugs most often used, keeping track of trends, overdoses, overdose deaths, and so on. So, the overall plan is prevention, treatment, overdose reversal, data, and now we’re doing more work also with the juvenile and criminal justice systems.

It sounds like you have a fairly broad view of the crisis and its many aspects.

We’re trying to learn as much as we can from others around the country. We’re working together across agency lines. And with the leadership coming out of Governor Inslee’s office, we’ve done a really good job, I believe, in terms of really putting an integrated plan together, and continuing to work daily and weekly with our partners. So, we feel good about that. The challenge is large. It’s very big. We need the partnerships at the federal level, state, and tribal levels, and certainly regionally and locally. You probably recognize that from other parts of the country, but our approach is to get the right resources to the right places as swiftly as possible. The solutions are going to come from the community and families and neighborhoods.

In your role, you’ve interacted with many parties and stakeholders. What was the most memorable experience you had, whether it was something you observed or something you heard from someone?

I think it’s the idea that with folks who have struggled for many years with opioid addiction or other substance use disorder, we can bring together the counseling efforts that have been going on for decades with our medication assisted treatment (MAT) prescribers, the prescribers of Suboxone or Vivitrol or methadone. We have the resources to put out incentives for those two sectors in our community to come together and truly develop a working plan. That’s been very significant. We’ve seen many more folks have access to MAT, which really allows it to be a patient driven process. They can, if they choose, have a medication, have access to it. If they choose to have access to counseling as well, that works.

I’ve heard individual stories of people who have been struggling for years and decades, who now come forward and say, “This is what’s made the difference. I’m able to go on with my life and work to feed my family, communicate once again with my family, to get a job.” Having all those things that we want people to have. I think what’s more devastating would be the individuals who find themselves in a local jail addicted to opioids, not having the resources to become induced on an MAT medication, going through withdrawal, getting out, not really having a connection to the community to get into treatment, and then starting the process all over. I think the more that we can prevent that by giving resources to people who need them when they need them, the more we can make a difference. That’s what we’re hoping to do.

In your opinion, what is the biggest barrier or bottleneck that’s preventing these individuals from having access to MAT?

Here in Washington State, it seems like we’re making really good progress. We have well over a thousand, perhaps 1300 or 1400, prescribers in the state who’ve gone through and gotten their waiver to be able to prescribe Suboxone, for example. And so, I think we’re finding more prescribers willing to do so. Some of the limitations there are caps on how many patients each one can have. For some prescribers they need nurse care managers or care coordinators to be with them so they can actually see enough patients in a day.

And so, progress is being made, but we still have some deserts where there are not prescribers. Individuals with Opioid Use Disorder (OUD) who want resources like medication and counseling may have to drive or catch a bus to somehow get to a methadone clinic, which could be many miles away. There are still some transportation barriers. We want to continue to work harder to communicate better where there are prescribers, who has room in their cap to take more patients. We’re putting systems in place so people have better information in a quicker time about who’s available to take them, and when and where.

When it comes to methadone, buprenorphine, etc., are these medications generally covered by Medicaid and/or private insurance, or are there still gaps where patients must pay out of their own pocket?

I think mostly they’re covered. One of the things that our partners at the Substance Abuse Mental Health Services Administration have done, most recently with a couple of their larger grants, the STR grant and now the SOR grant, is ask the states to put aside some of their resources to help folks who may have insurance, and the insurance may pay for some of the medications, but they don’t have the resources to use their insurance because of the high deductibles and copays. And so we’re able to use some of the resources to draw those down, which then allows those folks to have access.

I will say that in terms of medication, I think in our state, the Medicaid or the insurance companies will generally help, there’s some resource for that. With naloxone, which we certainly want to put in the hands of everybody who is in, or knows someone in, a potential overdose situation, there are still some price challenges. We’re doing the best we can to get it out there, basically for free at syringe exchanges and other places, but if one were to go into a pharmacy to buy it, it’s pretty high. Folks are putting out 75 to 100 to 150 dollars, and we’d like to see that come down.

News articles contain scores of statistics about overdoses and the economic cost of the opioid crisis. How can we present a less abstract portrayal of the crisis that the public can relate to? Four out of every five users of heroin started by taking prescription painkillers. How do we make their stories heard?

I do think that story has gotten out there, although not to everyone. There’s a lot of effort placed on new prescribing guidelines within states and jurisdictions, looking not just at primary care but also sports medicine folks, dentists, anywhere where the prescribing was happening very readily, and doing a lot of education and training and so forth. Also, a lot of states, including us, have been doing public education campaigns about when to accept medications, where to store them at home, how to dispose of them properly. I think that’s one of the reasons it’s getting the attention it’s gotten, although we still have far too many people dying from overdose situations.

It’s not somebody else’s family. Many of our families are being impacted by this because of these simple things: the trip to the dentist, the sprained ankle or broken leg, or the injury from an athletic activity. All of which leads to a prescription which then leads far too many folks to become dependent on those and then move on to heroin. And now with the fentanyl and carfentanil and some of the other stronger synthetic opioids, it’s devastating. It’s tearing families and communities and whole regions apart. Many extended families have seen someone impacted, and in most cases, it started with prescriptions.

I can see why fentanyl is increasingly becoming a concern, given how potent and dangerous it is.

And how cheap it is. I was in a meeting with the four northwest states, and we had experts in there talking to us about different pieces of this issue. Dealers are basically cutting in the fentanyl with other drugs and it’s very cheap, very potent, and very lethal. So, we are worried about it for sure.

You mentioned the effort to cut down on opioid prescriptions. I know there are concerns about the pendulum swinging too far the other way and adversely affecting patients who genuinely suffer from chronic, debilitating pain. What’s the best way to find a balance?

I think that’s what our state and country are facing right now: how to strike that balance. I know the medical community is looking at alternatives to pain management. We’ve heard from Health and Human Services nationally that one of their priorities is how to address this issue without the medications. Probably the area that I’m less informed on, in terms of alternative methods, is that I do know we have physician helplines where somebody has a pain issue going on, and they would like to do something other than opioids. We have some consultation available. Being open, I guess, to traditional and nontraditional methods of addressing pain. Lifestyle choices and exercises to take care of the mind and body are what people are starting to rely more on

What role or responsibility, if any, should pharmaceutical companies have in the effort to alleviate the opioid crisis?

Two things on that.

First, I think we all have a responsibility to address this crisis, whether it’s talking to our kids when they’re young about the risks associated with opioids and other drugs as well, to understanding where resources are and making sure that you lend an ear to your friends and be a source of support and try to get them help, and help them stay in recovery.

Second, in terms of the pharmaceutical companies, I think they have a responsibility to make sure their marketing practices are fair, their public information campaigns are fair. Washington State, many of our local municipalities and many of our sister states around the country are certainly taking steps to hold the pharmaceutical companies accountable, and I’m not really at liberty to say too much more about that.

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

When you start knowing more and more people both in your personal and professional life who are affected, that certainly does a lot to frame your perspective on it. Also, the sheer numbers: the number of overdoses, deaths, people reporting opioids are their primary drug of choice. You can’t help but be impacted when people you know are hurting.

But also, we have some tools to address it. Many people have recovered or are in recovery from opioid use disorder, and our systems are doing the best they can do. Today we have these medications, and more understanding in the communities not only for treatment, counseling, and medication, but also recovery support like housing, education, employment support, and those types of things. And they’re optimistic. I’m glad about the resources we’re able to provide. The challenge is getting them out to more people, and quicker.

With naloxone, everyone who is at risk of an overdose should have it. And their family members, those who are close to them, should have it. Today, that isn’t yet the case. I think we have the tool, but in most cases we just need to do more of it.

I am worried about the fentanyl coming in. Trying to think: what are we not doing? That’s why we’re staying in close touch with partners around the country to find out what’s happening. And if they’re finding success with something, we need to grab it as quickly as we can and get it implemented.

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 think it would be to remove some of the limits to the prescribing of the lifesaving medications. I think they need to break down any access barriers if possible. I understand that there are certain human limitations to how many patients any one person can serve. But I think if we have clinical offices with the right supports in them, we can serve a lot more folks than we do today. So, anything that can take away some of those limits.

You’re referring to medications like Suboxone?

Yes.

I remember reading somewhere that the federal cap is somewhere around a hundred patients. Is that the current level?

They have increased it. It’s 275 now, but you start off with 30 and it goes up over time. There are also midlevel practitioners who are able to do some prescribing. But we are making some progress.

I’d also like to get upstream and see that every school and every community has the prevention resources they need to work with youngsters so they have the support they need to grow up in a healthy environment and not make the choice of getting involved in alcohol, tobacco, marijuana, and certainly opioids.

It seems like some of these issues are intertwined.

With opioids, it used to be that young people would start off with those other drugs, alcohol and marijuana and tobacco. Normally you wouldn’t see young people starting with heroin. But with the prescription opiates, obviously the youngsters get more access to that, and it has led to some problem behaviors. Quicker access can transition into heroin. You see some, but not a lot, in the early grades. It’s certainly a young adult and adult problem.

Any other thoughts you’d like to share?

I feel very privileged to be in a position to do my best to make a difference. And that means getting resources into the local communities, right down to the neighborhoods and local clinics, so they can serve as many folks as possible. And also we have a little bit of the power of the pulpit: education campaigns and media events and things like that to educate the general public. Being able to be part of the solution is something that I really appreciate.