Interview with Paul Krupski

Paul Krupski is the Director of Opioid Initiatives at the Wisconsin Department of Health Services. This interview took place on August 16, 2018.

It would be helpful to the audience if you briefly described your background and your current role.


Sure. So in the fall of 2016, Governor Walker through executive order established the Governor's Task Force on Opioid Abuse. The Governor's Task Force on Opioid Abuse since then has put out multiple reports that have included recommendations for how the state could best address the opioid crisis in Wisconsin. Included in that first round of recommendations was the creation of my current position, which is the Director of Opioid Initiatives at the State Department of Health Services. The thought behind that recommendation was that the Department of Health Services is the receiver of the vast majority of discretionary funding that is coming from the Federal Government. Both the Health and Human Services and SAMHSA and also the CDC. So, the Department of Health Services in Wisconsin oversees many efforts, programs, projects to address the opioid crisis, and having somebody in this role to better coordinate those efforts - coordinate everything that's happening within the department to act as a liaison to our other state agencies, that obviously have their own role in this crisis and efforts that they're involved in. As well as a liaison to our many stakeholders throughout the state, so our county system, health systems, treatment providers, entities like that, that obviously have a role in overcoming this epidemic as well. So that is kind of a high-level overview of my role. I have been in this role since October of 2017, so not quite a year, about 9 months. Like I said, it is a new position here at the Department of Health Services, so I'm the first individual to be in this role.

Ok. So a lot of it seems to be coordinating between a lot of different agencies, and parties, and stakeholders, and helping to bring various resources there on certain priorities.


Good, so I have to say first and foremost, it's really coordinating everything in-house here at the Department of Health Services. We have so much that we do internally, making sure that all of our different divisions are coordinated and streamlined, so that we aren't duplicating efforts. So that we are all are of what we are supporting statewide. But then, to your point, yes, secondary serving as that liaison to our other state counterparts and other statewide stakeholders, so that we know what they're seeing locally. How we can help them overcome any barriers or challenges that they are seeing, so that we have - you know - our other eyes and ears at the local level, and can work to best support that with the resources that we have available at the Department of Health Services.


Great. Since you started in October 2017, what was the most memorable experience that you had in this role, whether it was something you observed, or something that you heard someone say. What stuck with you?

Well, I think it might be hard to nail down a specific incident or situation, but I think I can say that in this role I am out and about a ton. I travel around the states, sharing all the information about what the Department of Health Services is doing, how the state is addressing this crisis, listening to individuals, stakeholders around the state, and hearing from them on what they are doing, and like I said, how we can help. So I think what's been most memorable about all that is just really seeing at the forefront, at the frontline, how many people around this state are invested in combating this epidemic and this crisis. There are an unbelievable amount of individuals of in all the different sectors around this state that have a friend in a circle, or whatever might be a good explanation to you there. That are trying to make things better, to come together, to work together, to overcome the unbelievable amount of unfortunate impacts that we are seeing at the local level, at the county level, and statewide. So, I think that's been, you know, the most memorable experience. It's just really seeing how many people are coming together to work on this.

In your opinion, what makes the opioid crisis different from previous epidemics?

So, I think that the scope of this specific crisis is extreme. It knows no bounds, it impacts everybody. So the scope of this crisis is just so large, and I think for a lot of people on the outside, it can be difficult to really wrap their arms around how big of an impact it truly has. The other interesting piece of it that I think makes it different, is that since the opioid has really began affecting this country - it's evolved, and there's been different stages of the epidemic. Everybody is well aware this really began around the misuse and abuse of prescription drugs. But that was what SAMHSA  and the Federal Government characterize as Phase 1 of the opioid crisis. Then Phase 2 we are seeing the rise in the use of heroin, as we have learned and seen now that many individuals that begin to struggle with addiction on prescription opioids, they transition to heroin. Now, in Phase 3, what we are seeing in Wisconsin, as well as many other states nationally, is the introduction of fentanyl and other synthetic opioids. All those different stages create different challenges for how we go about addressing those. While we have made good inroads and are seeing positive outcomes and changes on the prescription drugs piece, we are not done addressing that issue. We need to continue addressing prescription drugs, but we need to make sure that we're addressing the heroin and fentanyl and other synthetic opioids issues as well, because those are rearing their ugly head. We are seeing just as much impact from those whether it be the death numbers or just the other impacts we are seeing in our treatment system from those types of opioids. So that would be - you know I think - the differences between past the other epidemics around substance abuse issues that we've dealt with in the past.

I see. Regarding what you were saying about efforts to reduce opioid prescriptions, I know that there are concerns that the pendulum might swing too far the other way, and it could adversely affect patients genuinely suffering from pain. What do you think is the best way to strike a balance between the two ends of the spectrum?

I think that different states have chosen to address this in different ways. In Wisconsin, we have not passed any type of legislation around the prescribing limits of opioids. We have focused primarily on providing education and resources to our providers to assist them with prescribing opioids to their patients. Wisconsin has a very robust Prescription Drug Monitoring Program, or PDMP, and we did test legislation that requires prescribers to use that. Additionally, our Wisconsin medical examining board has also issues opioid prescribing guidelines for providers, and this is to really help them make informed decisions about how to address acute and chronic pain with opioids. It's very clear in these guidelines and in again, other education and resources that we try to provide, that patients suffering from cancer, or that are in palliative care, or other end-of-life care, or other certain conditions that may be leading to chronic debilitating pain fall outside of this. That is part of the education that goes into our providers received. It's really the doctor and the patient relationship that is most important, and determining the appropriate form and level of care and treatment that each individual needs. That is what we try and stress, and again, by providing certain education and resource materials, that is how we try and help our providers that are prescribed.


Regarding individuals who are currently struggling with Opioid Use Disorder, what do you think is the biggest barrier or bottleneck that prevents them from receiving professional help?

Again, speaking for Wisconsin specifically, but I believe that it tends to be the number one issue nationally, is just access to treatment. Statewide treatment capacity overall would tend to be the biggest barrier. This is why this is a priority for the State of Wisconsin Department of Health Services to increase access to treatment for individuals by building our treatment capacity statewide. With much of the grant funding (the Discretionary Grant Funding that we received from the Federal Government) this is what we have tried to do, by awarding grants to health system treatment providers, other entities, to increase access to Medication Assisted Treatment, or MAT. Something that's been informed was that we really try to prioritize increasing access to all 3 forms of Medication Assisted Treatment - so methadone, Buprenorphine products, and Naltrexone. So by identifying high-need areas in our state, targeting those areas, specifically with the grant funding, that is what we have tried to do to build our treatment capacity statewide. Like I said, that's a priority of ours, and really the number one issue I'd say in breaking that barrier, was going to provide those diagnosed with Opioid Use Disorder to receiving the help that they need.


What are your thoughts about any proposal to more help individuals through, let's say, Medicaid expansion, so that Medicaid reaches more individuals, which would make MAT more easily accessible for them.

So, in Wisconsin, our Medicaid program does cover all 3 forms of Medication Assisted Treatment for Opioid Use Disorder. That's something that we obviously already do cover. You know, we're always looking at ways that we could better improve that, but it is something that we already cover as well as all the components on the behavioral health side, that truly makes Medication Assisted Treatment a evidence-based treatment approach to Opioid Use Disorder.


So the people who are currently covered under Medicaid, they have access to Medication Assisted Treatment - is that correct?

They do, yes.

Ok, ok. So from my understanding, if there were to be a Medicaid expansion under the Affordable Care Act, that would allow more people to be covered by Medicaid - would that be accurate?

I'm not really able to answer that. That's not my specialty in the Medicaid world. That would be something that I could check with our Division of Medicaid around, but I'm not able to answer that.


No problem. So, I know that some regions of the country are implementing harm reduction policies, for example, making naloxone more easily accessible to the public. What are your thoughts about that?


Yes, so again, increasing the access and availability of Narcan or naloxone  statewide is another priority of the Department of Health Services. This is something that we have been working on for several years now. The State of Wisconsin, like many other states in this country, have put in place a standing order that allows individuals to go into pharmacies - So pharmacies have to sign onto the standing order, so individuals can check our website at the Department of Health Services, one option where you can find which pharmacies around the state have signed onto the standing order - that allows individuals to go in and receive Narcan and naloxone  without a prescription. The standing order serves as a prescription for the individual. Then we have also looked at, with the discretionary funding we received from the Federal Government, ways to get Narcan and naloxone into the hands of individuals who need it the most. Including: active drug users, family and friends of active drug users, community-based organizations, first responders, such as law enforcement and EMS staff. We have done so with several grants. We have counties that we have contracted with, that are providing training or education to all those different groups that I just read aloud, and work with me to expand that with future funding. Then we have also awarded funding to the AIDS Resource Center of Wisconsin, and they have officers all around the state, and in 2017, I know that they were able to train over 6,000 individuals over Narcan and naloxone  and obviously, like I said, get that in the hands of those individuals that need it. Again, expanding the access and availability of the drug is a priority of ours, and something continue we work towards improving.


I know that news articles often contain scores of statistics about overdose deaths or the economic cost of the crisis, and I'm curious about how can we present the crisis in a way that's less abstract or more personal, something that the general public can relate to.

We do use the death data, primarily because it really is about saving lives and about people, so it does help put in perspective the severity  and the enormity of the crisis, and how many people are functionally losing their life to this epidemic. Trying to use comparative statistics, something that we typically compare it to is the number of deaths due to automobile accidents to show that more people are dying from opioid overdoses than fatal car accidents. We also try and supplement that with other types of data - we do show the number of emergency room visits, the hospitalizations related to Opioid Use Disorder. So trying to, in the words that you used, better explain to people what it looks like, and how many people truly are affected, and what it looks like across the state of Wisconsin.

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

I think that what we've learned in Wisconsin, as well as other states and nationally, is that to overcome this epidemic and to really turn the tide, we do need an "All Hands on Deck" approach. So that includes: State, County, Local governments, our medical community, law enforcement, faith-based groups, schools, all the different sectors that are out there, and that obviously includes the business community, and the private sector as well. They definitely play a role, and being involved in efforts with all of the other different groups that I mentioned before, and finding ways to partner is what it's going to take to achieve the goal we're striving toward.

If somebody gave you a magic wand that allowed to change any policy either at the state level or at the federal level, in order to more effectively alleviate the crisis, which policy would you choose to change?

I think that is the purpose (specifically speaking for Wisconsin) of the Governor's Task Force on Opioid Abuse. That is why Governor Walker created that body. To determine what policies can be amended or what new policies need to be put in place to best adjust the crisis. It's probably much too difficult to say this one thing will make the change, because I think if there is something we do know, there is no silver bullet. That's something that we learned a long time ago - Several years ago, at the beginning of this crisis, that it really wasn't gonna be just one thing. Obviously, if it was that simple, we would not still be dealing with this nationally. I think that's why we have the task force in Wisconsin, that gets imports from all other sectors as well as their legislature, and I know that many other states across the country have put in place something very similar.

That's basically all the questions I have. Were there any additional facts or ideas you would like to share?

I don't think so. I think we covered a lot and highlighted a lot, so thanks for the opportunity.