Dr. Robert Bernstein Interview Transcript

Dr. Robert Bernstein is the Health Officer at Tuolumne County Public Health in California. This interview took place on August 27, 2018.

Jamal Khan: It would be helpful for the audience if you give us a brief overview of your role and the work you do.

 

Dr. Robert Bernstein: Okay, so I joined the Tuolumne County Health Department in April of this year as the county health officer. My background is about 30 years for the Centers for Disease Control, mostly on international assignments. So this is really exciting for me to be me. So when I arrived, I arrived probably be the almost one year period in the absence of the previous health officer. So, a lot of the work that had gone into the system with the HR, magnitude, the distribution, the currents, the hearts, and so forth or health problems in the county had been done in the year to prior 2016, they did that community health assessment. 2016-2017 based on the community health assessment, community health improvement plan was developed. But as I said, that plan lapsed for about almost a year in the absence of the health officer to kind of lead and manage the coordination between all the various stakeholders. But based on the community health assessment, 3 priority areas were identified in the final report of the community health assessment plan towards the end of 2017. Those three priorities were first of all: in a rural county, like a lot of rural counties everywhere in the world, is under-resourced. The first priority was to identify the limited access to the essential services. Of course, among those essential services, would be included services related to surveillance prevention, treatment, rehabilitation for opioid related substance use disorders. The secondary priority was identifying the epidemic itself in the Tuolumne County. At that time in 2015-2016, Tuolumne County had the third most serious rates of various indicators of problem of opioid use. Epidemic national -- opioid use epidemic here at Tuolumne so we were pretty high on the California scene in terms of the nature and the magnitude at the probable year. So that was identified as priority #2, and priority #3 -- actually all three of these priorities are inner-related. Priority #3 was the need to ensure the healthy development in the first 5 years towards adolescence -- for children in adolescence. So you could think of it as, you know three of these priorities as having some relationship to the opioid problem. Are you familiar with the term -- the acronym ACE? Adverse Childhood Experiences?

Jamal Khan: I’m not familiar. I’m curious to know more about that.

Dr. Robert Bernstein: So, back in late 90’s, just before 2000, the Centers for Disease Control and Kaiser did a major study of something in the orders that costed 20,000 people in order to develop -- in order to characterize the magnitude, severity, frequency, relation of adolescent adverse experiences in childhood adolescence. In that study and in the number of publications in studies since then, the principal investigator Dr. Vincent Sghiatti, whose based in San Diego -- close to you actually, you can try to reach him. It would actually be very interesting for you to reach him. And Dr. Anda at the Centers for Disease Control. But the two of them have characterized the public ACES (Adverse Childhood Experiences) and the initiation of subsequent health economic problems as a gross response relationship, in other words the more frequent, the more severe, the more long-lasting adverse childhood experiences are, the more likelihood in the gross response relationship that subsequently the person experiencing those problems are turning to substance use as one of the problems associated with that experience. So given those three areas of priorities, when I got assigned here, the need to work with partners who had participated in doing the health assessment for the county and subsequently work together to develop the implementation plan for our community health improvement. We began to get together to have meetings and discuss how to move forward. One of the ways that we are moving forward is previous man support to address the problems, winding down as we’re applying -- have applied for major grants from HERSA to address this problem. So that’s -- hopefully we’re going to be able to have some more resources to do that. And we held a major one day, four day conference on the 16th of Olden in order to summarize lessons learned and to have plans for next steps. That conference, the procedures of that conference were video'd, or recorded, and will be on our website -- on the county website and a public access TV website here in Tuolumne in the next few days. Dr. Sghiatti’s presentation is one of those. Just to summarize, we started from the position of high level impact here in the county. Some successes, just as the national epidemic is changing as successes like reducing inappropriately high provider prescriptions for opioids is going down here in our county as well as elsewhere, what’s happening is that heroin use and substituting illicit drugs for what was previously a prescription addiction is now beginning to recur here as well as elsewhere. And that’s reflected here in I think in some of the emergency room rates which would be on the climb. So that’s kind of a rough summary of what’s going on. We’ve had some successes in reducing opioid prescription rates. We’ve had successes in reducing those rates per person and hello indicators with prescription related outbreakers was being reduced here. But we’re experiencing increased emergency room visits and some of that may be related to some kind of … taking place nationally.

 

 

Jamal Khan: I see. With regard to these emergency room visits, is this generally like people who have had an opioid overdose or are some of these cases a matter of someone who may have opioid use disorder and they’re going to the emergency room perhaps to try to get access to some kind of opioid based painkiller, such as Morphine?

Dr. Robert Bernstein: Well, that’s a good question. When we get …. We’ll do some macro record reviews to analyze the data and understand better what the reasons for the emergency room visits, what the demographic characteristics of the individuals affected and so forth. But at this point, all I can say is I would be just at rage with numbers I should say, climbed from somewhere in the 20’s in the period between the first and the fourth quarter of 2015 to 35 -- more than 35 visits in a 12 month period in the fourth quarter last year. Now, I don’t have enough details to really characterize the reasons behind those increases. But they are related to opioid overdoses and possible near fatal opioid related events.

Jamal Khan: Oh, okay.

Dr. Robert Bernstein: Our county, like a lot of other rural counties that are under resourced, doesn’t have a medical examiner. We depend on the sheriff’s office to handle near fatal events, investigate those events. And one of the ways in which we plan to implement the Hersagram, if we did it, is with a stronger partnership with the law enforcement, drug lords, probation officers, and mental public health services.

Jamal Khan: Okay okay, and were there any, I guess regarding your second priority are about data indicators, were there any other indicators that jumped out at you as being significant or striking, in terms of how they portrayed the state of the crisis right now in your county?

Dr. Robert Bernstein: In the county has a total population of something on the order of 50,000 people so near fatal and fatal events occur as numerator events that the denominators and the numerators are small so trying to make interpretations from changes -- well from apparent changes and rates over time is difficult because for one of the zipcodes in our county appears to have the highest rate across our county; but because that rate involves very few cases and very few people in the county, its not clear that that’s really --- that that geographic area is really a much higher risk area than others. So theoretically, it’s difficult in a county of this size even if we had an analyst, which we don’t, to regularly monitor or track ……. To draw conclusions about what’s happening and why. Another of the areas that we hope to improve on with the Hersagram is to hire a full-time coordinator for the coalition that we have here in the county. And in addition to the coordinator, an analyst to work with the coordinator to better track and investigate and understand -- try to get ahead of the problem.

Jamal Khan: Regarding the first priority area that you mentioned about access to treatment, what do you think is the biggest barrier or bottleneck that is preventing people from having access to professional help?

Dr. Robert Bernstein: Well again, it’s an under resourced county and we’re actually losing a large number of providers for at risk populations. We have a Native American Indian population and fortunately, we have several clinics that derive resources from the Indian Health service that are serving the needs of that population. Those services are bolstered by National Health service court assignees who spend a year or two and then may arena had to remain in the area on assignments to pay back some of the medical school tuitions that they had. Those clinics operated primarily for Native Americans also provide services for others but overall, we are losing providers who previously had operated clinics serve the needs of substance use disorders. Again, this is something that we hope to address if we’re successful in getting the hersagram.

Jamal Khan: This is a grant that’s open to various counties and so, is this something that different counties apply for and one or more end up receiving?

Dr. Robert Bernstein: The grant would be awarded -- I think the number of awardees will somewhere around 75 counties around the country and it’s entitled to rural counties opioid response planning grant. The resources are going to be rewarded to a total of 75 counties across the country. So for a rural county, in order to apply for it, you have to meet their criteria, which has to do with your heads of metrics about population size, infrastructure, and so forth. We’re hoping that we’ll be one of the awardees.

Jamal Khan: From what you have seen in your position, what do you think makes the opioid crisis different from previous drug epidemics?

Dr. Robert Bernstein: Well, I wish we could answer that question with data but i think the famous management expert has said that in that absence of data, all you have are opinions. So, I can tell you what my guess is. There are a number of reasons why rural communities might be at higher risk. In some ways with urban communities -- within in urban communities that represent high risk, high rate ares but in rural communities, employment levels vary, especially in a community that depends on agriculture. The government is the major employer in our community. We have a mostly Caucasian population. We have awkwardly small number of American Indians, black African Americans, and about the same number of Asians. We have of about 11% opposition is Hispanic or Latino. Employment levels in the community have gone down. The household income levels in the community are dropping lower. There’s a decrease in population in the community, as there is the in the nursing providers as I mentioned earlier. So, there are a number of demographic and socioeconomic characteristics that contribute to the increased risk in rural communities. Ours is not very different than others in that regard.

Jamal Khan: Regarding the third priority area that you mentioned about adverse childhood experiences, I remember reading that people who have had ACE or who are characterized by other factors such as having a mood disorder or some kind of predisposition are at greater risk of having opioid use disorder. Is there any way for a physician to be aware of some of these risk factors when deciding what to prescribe or whether to prescribe at all?

Dr. Robert Bernstein: Yeah, that’s a good question. The results of the first basis study characterized the problem and the relationship has been the basis for developing screening questionnaires that can be used a primary care setting. If pediatricians or primary care providers can take the time to use make use of that kind of instrument but unfortunately in the United States, unlike a lot of developing countries, we don’t have a national system of health care that encourages preventive services. As a result, physicians will be reimbursed for the services they do provide, spending minimal amounts of time on taking histories and making use of screening questionnaires. There are instruments available to characterize the risk factors. Social services deployments, like the one in our county, can undertake work like that if they had resources to do community-based survey work. But in California, the overall prevalence of ACES has been characterized state wise and the larger urban counties actually have -- counties specific needs of prevalence within the population of people who have experienced one or two or three or more ACES in adolescence or childhood.  Our county doesn’t have the data of that kind for the county. The data that characterized the more popular county come from two sources. One is a routine annual survey that the Centers for Disease Control carries out called the BRFSS or Behavioral Risk Factor Surveillance Survey. In California, there’s a childhood survey as well but counties with small populations, the rates are not available because the problem I mentioned earlier about the size and the denominator and the size and the numerator are too small to give what would be characterized as a stable statistically significant rate.

Jamal Khan: Earlier you mentioned that some progress has been made in reducing opioid prescriptions in the county. I know that there have been general concerns that efforts to reduce opioid prescriptions could adversely affect patients who genuinely suffer from chronic debilitating pain. So I was curious as to what you think is the best way to strike a balance between the two?

 

Dr. Robert Bernstein: Well, I have a medical degree but for most of my 35 year career, I was serving as an advisor to ministers of health and directors of programs, not taking care of individual patients, and in particular, not taking care of patients with substance use disorder problems. What i can tell you from the literature is that there are ways to address chronic pain -- acute and chronic pain that can be handled in a manner that will not lead to addiction. Pharmaceutical companies in the United States have participated and contributed to the addiction problem that we have by inappropriately characterizing the use of opioids as a harmless, non addictive approach “if used properly.” But then they went ahead and inappropriately prescribed. We’re suffering from a problem that the use in part is derived from the inappropriate actions of pharmaceutical companies and in some cases, pharmacists. But that’s changing because in recognition of that problem, ideas have been developed in the Centers for Disease Control, for state health departments, for pharmacists, and for providers and that’s being reflected in the way that prescriptions are being used. Your question relates to alternatives to prescribing opioids and there are other ways that chronic pain can be handled. But it has to require enough time in the case of a provider to understand the patient and the patient’s motivations n=and ability to handle pain and to accept a prescription other than opioid and a prescription for using physical therapy and counseling and behavioral modifications. This kind of advice for patients requires time. Again like I said, in the United States, we don’t have a system for healthcare. So, insurance coverages for physicians’ time in many cases doesn’t encourage physicians to take the time to really understand what’s really going on. There’s an issue on the side of the patient as well. A lot of patients come into physicians’ offices expecting and even demanding some kind of medication and if they don’t get it from the prescriber, then they go out on the street to get it. That’s why the problem is much more difficult to handle than it might otherwise be.

Jamal Khan: What role or responsibility do you think pharmaceutical companies, like Purdue, should have in the efforts to alleviate the crisis?

 

Dr. Robert Bernstein: So to mention Purdue, you’re surely familiar with the suits that have been brought against them. The issue for pharmaceutical companies and for the administration -- in uber side of pharmaceutical companies, they’re a lot cooler now than it was in the time when Purdue carried out such egregious behaviors. So, things have changed and they are continuing to change. But you know, the problem with … there but now being translated into one where the nature is private care. Lack of system of healthcare in the United States makes it difficult for physicians to take the time necessary to address the needs of a patient in pain. There are certainly times opioids are the appropriate medication and should be issued in limited quantities with behavioral health and mental health counseling integrated into the prescribing of opioids so that the patient who takes opioids can understand the risks and can accept the need to make use of alternatives and different approaches. In California, we have systems that enable empower pharmacists to recognize potentially abusive use of prescriber practices. A pharmacist can use what’s called a CURES -- they use that in California to determine whether a patient coming to the pharmacist with a prescription is also getting similar prescriptions from other pharmacists and can advise the patient and even deny the patient a prescription. Another thing is that pharmacists are advised, guided, and to a certain extent, required to offer a patient whose been given a prescription for opioids -- to offer that patient a co-prescription Oxidin so that patient recognizes and the patients’ similar to others can recognize and make the use of. If an overdose situation arrives, there would be a lot of things going on that in the long run will help to address the opioid crisis. Are you still in the presidential fellowship program?

Jamal Khan: So, that program has been completed.

Dr. Robert Bernstein: Oh okay. Well, in the current administration climate, there’s certainly a need to provide further funding, like the HRSA grant for example. SASSA grant -- HRSA grant, SASSA grant, U.S. Department of Agriculture grants. Our role contributing resources, especially directly to rural communities, to try to address these problems we’ve been talking about. Hopefully those resources will not be ending in the near term. For example, the HRSA grant we applied for is a 1 year grant. Our intention in the application is to make use of that grant, to be able to hire somebody resourceful that we don’t currently have in the county. And as you can imagine, a person who’d be qualified to take kinds of positions that we’re going to be recruiting for may not be interested if the grant is only for one year. So a lot of things going on that need longer term attention.

Jamal Khan: If someone gave you a magic wand that allowed you 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 change?  

Dr. Robert Bernstein: That’s a great question. If I had a magic wand for only one policy, I think I would give up the magic wand because what’s really required is an integration of policies of several sources. My response to your question about priorities on number 3 are closely related to each other and there wouldn’t be any one policy enable a under-resourced county, like ours, to address some problem of limited access to essential services plus the opioid epidemic and the problem of ensuring healthy beginnings in adolescence. But okay let me take that wand in my hand, if i had to choose one policy, I would say that it would have to be a policy of strengthening and sources of evidence and information about the nature, extent, and severity of priority problems in a given community when you don’t have the good meanings to collect that analyzed data that we need to make decisions at the county level. If I had the magic wand at the federal level, I would continue to support, unlike the current administration, the Centers for Disease Control, which is the best agency for strengthening state and county capacity to address problems of this kind. Unfortunately, the resources being allocated to the Centers for Disease Control have been reduced under the current administration.

 

Thanks for the interview and it’s been interesting on my side as well. Good luck on your work.