Robert Valuck Interview Transcript

 

Robert Valuck is the Director of the Colorado Consortium for Prescription Drug Abuse Prevention. This interview took place on August 8, 2018.

Just to start off, for the members of the public that are not aware of the Colorado Consortium for Prescription Drug Abuse Prevention, could you say a little more about how that formed or started, or what kinds of things it does.

Sure, absolutely, the Colorado Consortium is essentially our statewide taskforce addressing the opioid crisis here in Colorado. It was formed in 2013, after about 9 months of strategic planning initiated by and coordinated by our Governor, John Hickenlooper.  After some data he saw in 2012, and hearing presentations and such, he realized this problem was growing to very large proportions here in Colorado and in many other places, and wanted to organize a response to it. (He) created a process to do a sort of bottom-up planning, gathering experts from all over the state, people from state agencies, and professional associations, providers, and law enforcement, treatment, and getting everyone together to create a strategic plan for what we would see as useful steps to try to stop the crisis in Colorado. In the middle of 2013 when that plan was finished, basically there was discussion on how to implement the plan, and rather than give it to a single state agency like behavioral health or public health, or regulatory or law enforcement.  The thought was to create a separate entity, the Consortium at the time was a 501-c3, to continue the work of the strategic planning groups, and focus on implementing the strategic plan. Work at something that does not require one state agency or one profession, but still everybody owns it, but nobody owns it, if you will, but a shared cooperative effort. We’ve been doing that now for about 5 years, and it has been proven here to be effective as far as keeping people collaborating and working on statewide responses, which we’ve done for probably 3-4 years of that in 10 different work areas. In the last couple years, we’ve been shifting our focus, to not only continuing to coordinate state-level responses, but to try to help push the work to the local level, and support local coalitions who are doing a lot of the work, very appropriately so.

 

How long have you been part of the Consortium or in charge of the consortium?

I’ve been working on a much smaller task force since 1987, when we identified this as kind of an issue 30 years ago, when we started with the opioids being prescribed and marketing after the often referenced “Portnoy and Jick” letter, and  we saw that back in the early 80s as potential problems and nobody was really listening at the time, didn’t become the issue that it has, and I’ve been involved with it for a very long time, and have directed the consortium for the 5 years we’ve existed. So I’ve been running point with this group for the last five years.

 

I see, that letter that you have mentioned, back in the 80s, is that the editor that was mentioned many times that reported to show that opioids are not so addictive, although later proven otherwise?

 

Exactly, that is the infamous New England Journal of Medicine letter, by Portnoy and Jick, and that at the time was not evidence. We realized at the time, that that was over-reaching at best, downright dangerous at worst, far from trying to characterize that as any evidence that people won’t become addicted, just because the few people they observed did not become addicted, that’s not really a study. So we didn’t view it as evidence, we viewed it as a letter to the editor, just like any letter to the editor would be, but we didn’t give it much credence. As it turns out, we found out that it had a lot of influence on the field, and it was used in many ways, some legitimate, some not so legitimate, but it convinced prescribers that the drugs were safer than they really are.

I remember, its amazing, at that time you were alert and aware to that possibility of that letter being misunderstood, intentionally or unintentionally. I know that in the 90s pharmaceutical companies were ramping up their marketing. They were deliberately marketing to doctors who were not as well read in that area, showing that it was fine and not addictive, exactly what you were describing.

Yes, exactly, very troubling.

For the Consortium’s 10 work areas, what are some examples of these work areas?

We start working through a lot of educational work, we have developed a public awareness work group, whose focus is educating the public about the problem. And we have a provider education work group, focused on educating providers about their role, whether it’s the proper treatment of pain, proper use of opioids, and how to use them when indicated, alternatives to opioids, how to do medication-assisted treatment in primary care, a whole host of things we are trying to educate providers about. We use the word provider pretty liberally, to mean anyone who is a prescriber or dispenser, or a nurse, or a behavioral health person, or anyone who is potentially providing care to a patient, who might be touched by an opioid, or at any point develop an addiction. We have provider education, we have a safe disposal work group, that works on developing and we have implemented, one of the things we know of, statewide systems, doing safe disposal and is state-run and state-funded for doing permanent drop boxes for people to collect their unused medication. We have a harm reduction work group, that started off with primarily focusing on naloxone, and increasing access, use of, and awareness of naloxone, but has grown to syringe exchange, communicable disease prevention. Now we’re exploring and studying the concept of safe use sites, injection facilities, depending on the lingo that people use. Were exploring that now, as an option here in our state. Trying to consider that whether we would include something like that at the state-level, at the community level, and a couple of those that are interested. We have work groups for treatment and for recovery, which may seem right now as two very separate, but are related and interconnected things. We’re trying to raise the profile of recovery support, for viewing it as a sort of distinct sort of work group at this point, not because it is separate from the continuum of care, but because people aren’t really aware if we just say treatment, people don’t think treatment and recovery, they tend to think 30-day increments of treatment, or medication-assisted treatment, or things like that. So we have a treatment work group, and a recovery work group, we have a heroin strategies work group, that we collaborate with law enforcement to work on the illicit side of things like heroin and fentanyl, we have an affected family and friends work group, to help advocate and give an educational voice to folks who are affected by this, dealing with addiction, or recovery, or various ways of dealing with this experience and are affected by the tragedy. Then we have a PDMP work group, which deals with prescription drug monitoring programs, and how to make ours as effective as possible, as a public health and clinical tool in Colorado. And then we have a Data metrics work group, that measures the extent of the problem, and tries to be aware of all the possible data sources, and track the size of the problem, and our progress to address it. I think that’s all, if I’m not mistaken.

Seems like this is a very comprehensive approach to addressing every aspect of the issue, and working on making it, and alleviating the crisis. In your role overseeing this, what was the most memorable experience that you have, whether it was something you observed, or heard someone say, something that stuck with you?

Sure, early on it was the power of people coming together to create a shared vision of what we were trying to accomplish, and the governor doing that. And the way he got people together, and collaborating, and then people have really continued to do this. I said, sure I would try this for a year, and see if we can even get people to continue to come to meetings, when they don’t have to. And it was all a voluntary process, an unfunded, voluntary process, trying to say hey can you work on these things and see how we can get people collaborating on them, even if I don’t give you any money, or I don’t mandate anyone to show up, but I’m asking you, will you collaborate and try to do this, and we all said sure we’ll give it a try, and the way it has grown into 5 years of collaboration, sort of has brand recognition in Colorado, to say ‘well if you’re dealing with opioids you should talk to the Consortium’ because they have resources, they have people that can virtually connect you to any aspect of the problem, if you’re interested in safe disposal in naloxone, treatment or MAT in rural areas, or whatever it might be, we can connect you to people on the ground doing that work, or at the state level or federal level trying to support that work. It has been getting people together that didn’t get assigned to one agency, really it was a collective, and we follow a model called a Collective Impact model to try to work on a complex social problem, a collaborative cross-sector multidisciplinary way, actually there is some emerging literature on different ways to try to get people to collaborate, and there is some evidence that it works to achieve benefit on complex social problems, so it has been very gratifying. I think probably the most recent example of things that were gratifying is that we got asked to present at the national conference of state legislatures, asked to present at our flagship national meeting, which is the national prescription drug abuse and heroin summit, a question of sort of how did you do that, how did you collaborate that, with no state agency mandate, no anything like that. How did you pull this off in a voluntary way? And so it’s gratifying to see not only were having some successes, but people are asking us now, how did you do it, can you come tell us that.

So they see you as a model, or blueprint, of what they themselves would like to do

Yes, we’re starting to see that in several states, and I’ve been asked to present at both state and national levels, to show the model, and potentially provide some sort of training, TA, kind of support to the states, that they wanted to consider doing something similarly. We have a lot of local coalitions in Colorado now that are emerging, just like they are in many states, taking our bubble diagram and approach with our work groups, and fashioning a response, to say that they might not be able to do all ten things, but well focus on these three, or these four. So the coalition is focusing on these three or these four, sometimes they’re the same, sometimes they’re different, what the community identifies as their particular needs, strengths, and resources. But it’s gratifying to see the framework we built seems to translate both at the state level and the local level, and provide a mechanism for this ongoing collaboration and cooperation across groups, and now were helping coalitions share and create a learning community across coalitions, vertically, from federal to state to local, or help them collaborate and support each other horizontally, from coalition to coalition. So we view it as an effective way to do that, again, it’s really gratifying to see that people are buying into it.

Over the years as this collaboration continued and strengthened. Was there anything that you came across over the course of this that showed your perspective about either the crisis or about how to approach it?

Yeah I think for us, its proven that cross-sector collaboration is very strong, and that if we can get people playing together, rather than going into our respective either workplaces or ivory towers or whatever it might be, our own silos for working, get your blinders on and do your own work, and do it really well-motivated, it’s hard to keep the cross-sector collaboration going. We’ve learned the hard way how much is too much, maybe we were meeting too often, or asking too much of people who are volunteering, but if we throttle back too much, people get antsy and we gotta do more, this isn’t enough, if we’re meeting quarterly or whatever, so we’re trying to dial in to the right amount of effort to optimize what we are doing, and have some short term successes in terms of the processes were doing, like building disposal sites, or number of pharmacies that offer naloxone by standing order, or all our different metrics our work groups have, and some of those have been relatively easier to obtain, successes in others have been very difficult to try to obtain, so it’s been really interesting in working with our legislature has been very gratifying in some ways, and very frustrating in others. Obviously it’s a very political subject, sometimes even if there’s good evidence for things, doesn’t mean it’s easy to implement, long-standing stigma, biases, preconceived notions, all kinds of things that we are trying to bust down, to realize how big this problem is and how much stigma there is and to be eradicated.

I can imagine that for some harm reduction policies, like safe injection sites, I can imagine that being difficult to explain to state legislatures. In your opinion, what makes the opioid crisis different from some previous drug epidemic?

It’s a created phenomenon, we did a lot of this that we didn’t have to do, things like an illicit drug. Doctors were not prescribing meth, they don’t prescribe alcohol, or cocaine, or anything like that, so this one is different when we have doctors and other health care providers involved. As most of the starting point for people is to start with prescribed opioids. And they need it for themselves and have problems, or are leftovers from somebody else’s but they rarely, but presumably should not have received that many if they didn’t need them, and there were that many leftovers to get that many people started on it, we still really have a problem that traces to the healthcare system, and prescribers, dispensers, payers, and all kinds of things, and governments that may or may not have creative perverse incentives with satisfaction surveys that reward people for pain scores, which creates a perverse incentive to prescribe more opioids, policymakers might have had a role, we sort of created this one, where the black market really created other ones, we did as a society, or health professions, legislatures, you know, concoct those problems.

 

That’s the tragic part of the whole thing, it’s sort of disappointing, and we were asleep at the switch for a long time, not seeing the warning in the telltale signs of what’s happening. Granted the latency period between first use (first narcotic use), and seeking treatment, or having an overdose death, range from 9 to 13 or 14 years, so it’s admittedly not easy to pick up on the warning signs, they can come and take a decade to show up, even when they started showing up, we have been, I think, too slow to respond, and I think we still are, I think the train is still moving away from us, faster than we are catching up, even if the train is slowing down, if you will, if that makes any sense, is the metaphor that I use, the train is rolling on such a breakneck speed, exposing so many people, causing so much damage, that the train is slowing and we are in our little pushcart, trying to catch up to the train, but our speed in catching up to it, I think, is woefully inadequate, the resources we are dedicating to the problem are woefully inadequate, the decreases in prescribing, while going in the right direction, are far too slow, still too many people being exposed to these things, these products at unacceptably high rates, so while we’re making progress, we stink less than we did five years ago.  It isn’t very comforting for me to say that, but we’re going in the right direction, but we’re still in a terrible mess.

I know there’s also a lot of tricky issues as well, I know there are concerns that efforts to reduce opioid prescriptions may adversely affect patients, who genuinely suffer from the chronic debilitating pain so I know it’s a bit challenging in terms in terms of bow you serve a balance between the two, not to overprescribe, but not to abandon patients who actually genuinely need that pain relief?

It is difficult and I would acknowledge, that chronic pain, though I think that a lot of that is confused with people confuse chronic pain with that when they had opioids for 3 years, five years, if you remove the opioids you have the pain renewed, when that pain is withdrawal pain that they experiencing, probably not uncontrolled baseline pain that had that caused them to get the opioids to start with, and they would not taper properly, didn’t have their anxiety managed, didn’t have pain managed particularly well to start with, even then I think the vast majority of people in my opinion, treated chronically with opioids, the data is clear, the data just are not very good to support opioids as effective for chronic pain, they’re just not effective for that, therefore virtually all chronic use is not indicated and probably people are just being managed poorly have become addicted or extremely physiologically and psychologically dependent, to get them off those opioids creates a lot anxiety, a lot of withdrawal pain, and people aren’t figuring out what to treat the pain with, and not doing a good job tapering or trying to get people to taper or do dosage reduction, and we’ve kinda got backed into a corner, and I agree there are cases where opioids are needed, and there are many contraindications to other meds that much actually work better, for arthritic pain, back pain, knee pain, migraine pain, things that actually work better than opioids that we really don’t try first, and people become dependent on the opioids, saying “well,l I tried those way back when,” but you can’t find any evidence of them ever trying, and they’re just legitimately afraid, “I don’t want to have my pain relief taken away from me,” and I agree with that. But I feel we did an abysmal job of trying to blame the benefits of which medications are the available, may things that are nonpharmacologic that we still want to manage your pain, take and explain to people that they pain they’re feeling when they’re trying to take the opioids away are symptoms of withdrawal, not even their syndromic pain anymore that they are feeling, and we don’t explain that very well to people then I think if we did in the trials that I’ve seen from Stanford and Mayo that try to help people with their anxiety and their pain management more holistically, that tapering rates are much higher and successful more often than not, if were able to manage it properly, I just don’t think we do a good job of it. I’m sorry, I kinda went off on a tangent there, but the whole chronic pain thing, I think opioids have a place, it’s a very small place that we used to think was every place, we had been taught over the years that everything is a good indication for an opioids, but rather they should be rarely be used, and only for those who need those and don’t have other options, other drugs do not work, other pain modalities do not work, but they need to have a legit trial of those modalities, and then you can probably convince me after their failure that opioids are ok. There may be a contraindication to a non-steroidal, they may need the opioids but then should still be managed very carefully. Because people can still become addicted, even from normal courses of using the opioids, even if they are doing things quote “doings things right,” there’s still a relatively I think relatively higher rate of people that can still become addicted later on, in the several percent range (from 1% up to 6%, depending on which study you read), which is still l unacceptably high rate of side effects.

Very good insight, I guess virtually quite a few people have developed a case of opioid use disorder where do you think the biggest barrier or bottleneck that prevents them from receiving professional help?

A whole host of things,really.  It’s been, people don’t know where to turn, where to go, doctors don’t know what to do, there’s a lot of confusion of what to do or how to treat patients, there’s medically assisted treatment in combination with behavioral therapies that are effective, and are the standard of care for this and not a lot people know them, there’s still a lot of stigma among doctors, I don’t want to take on those patients, when in fact, I always tell them, you already do, you already see them, they’re your patients already, you may not know you are, but you are already seeing them, and whether its family medicine, or orthopedic, whatever it is, you are already seeing patients with use disorders and you are not seeing it, and you need to be better aware of it, and become able to treat them.  Doctors don’t have any trouble, they already treat people with diabetes or heart disease, whatever, with are very complicated conditions to treat medically, where addiction is not as complicated a thing to treat, with medication assisted treatment, which is really straightforward to implement, and we have a lot of stigma, a lot of misconceptions, and a lot of education to do to get people to do the things we know they can do, but they just don’t do. Nobody knows about naloxone, about MAT, nobody tries either of them, even though they are effective, and naloxone is nearly perfectly effective and we don’t use it anywhere near like we should be.

I know that MAT, buprenorphine, I know there’s a federal cap on how many patients  a doctor can have, and a license to be able to prescribe buprenorphine, and there’s other limitations, I guess to deter abuse, or something like that, 26:50. What are your thoughts about these limitations, or just an idea to make it more accessible for people who need it?

It is, it’s very difficult, for doctors.  I liken it to “we hand out lighters,” it’s easy for a doctor to apply for a DEA number, and to start prescribing opioids tomorrow. You can just start providing Vicodin, oxycontin, whatever, tomorrow, as much as you want. You can give it to any number of patients you want, in any dose, for any purpose, you can just start prescribing opioids as soon as you get a DEA number. You can start prescribing all day, all you like, no extra training. But if you want to use a fire extinguisher, were gonna make you have a whole day class on how to use it, to put out the fire that you yourself probably started. You have to have special training for that, you’re gonna have to go to this special class, and it’s gonna be some hurdles your gonna have to undertake, to use these. But the version that you hear of that, like buprenorphine or suboxone, but doctors can prescribe methadone for pain right now with no additional training, the only thing they need additional, special training for is for buprenorphine or methadone for people with substance use disorders.  They cannot prescribe it for them for those medical conditions (yes for pain, no for use disorders), so it has to do with the stigma associated with the patient population, not with the drug itself. Although when these drugs are used for pain they are still just as divertible, by itself, doctors cannot provide it without extra training for use disorders, because of its diversion potential. That makes no sense to me. I believe it is because of the people who are addicted have the stigma associated with being bad people who made bad choices and aren’t reliable and they are gonna divert and steal and all these things that are largely proven to not be true, and this is due to the drug being diverted to legitimate, look legitimate to just get the stuff and there it’s addictive, this stuff that has street potential and value. For example, there are cases where a little old lady went to get prescriptions for oxycontin, every month for several years, and sold all of it to make rent, and they’re not addicted, but they’re diverting, and they get the drug for pain, but they don’t have a diagnosis for addiction, so it is relatively easy for them to get the prescription, so diversion exists no matter what, I find that argument to be specious at best, if not downright misinformed by bigotry, prejudice and biases, which is really what it is, and by stigma. That policy, and I understand that we want safe treatment, and originally when we started in the 1970s we started with methadone, it was very concerning we don’t want methadone clinics to be places that promote crime in the neighborhood and all that, but none of that has been proven true, none of it.  “These methadone clinics create crime,” there is no evidence of that at all. In fact people have to be very dependable and well-behaved to continue to get their methadone, and they want to continue to get their methadone, because it keeps them from withdrawals, people are extremely well-behaved at methadone clinics, because it’s keeping them alive and from withdrawal, so there is virtually no crime. No more in methadone clinics than in other clinics. So we have a lot of stigma, the number one enemy in success in treatment, and that’s in patients, doctors, everybody, our number one chief enemy we’re fighting is stigma.

I can see that relative to the really great metaphor, in terms of the lighter and fire extinguisher. That double standard also seems to exist looking from the insurance angle, because I remember reading an article where someone who had been prescribed opioids, insurance covered the opioids just fine, but when she tired to get MAT, her insurance company did not cover it, and she had to pay for it out of her own pocket, and that seemed to harm her financially, and it seemed a double standard, you can get the opioids just fine, but he MAT the insurance company was not as willing to cover it. With Medicaid or private insurance, when it comes to things like methadone, buprenorphine, are people able to get that covered by insurance, or is there co-payments to get to those?

It is very uneven. Some Medicaid programs cover it, some don’t, most do not cover in the case of inpatient treatment, in Medicaid, a few states have gotten to do that and draw down the federal benefit but its an optional benefit to do detox (or medical withdrawal management), inpatient treatment, most Medicaid program will cover outpatient treatment to some extent.  That’s partial treatment, not sufficient for everybody, many people also need medical withdrawal management and inpatient treatment. Our state we passed a law just this past year a couple months ago in June, that will require our state Medicaid program to go ahead and apply for the federal benefit and draw that down and reallocate to state matching portions, from our legislature, so we will be able to get about $175 million a year more for withdrawal management, and inpatient residential treatment, under Medicaid to be able to pay for it. The number one payer for folks with OUD is Medicaid, because most people end up spiraling, downwards with an addiction like this, they have difficulty gaining or keeping a job, family relationship, or housing, and often end up in Medicaid, therefore Medicaid is the number one payer for treatment. So we identified that as the single major gap we need to address it, payment and coverage issues in general are problematic, because they are uneven, we really do have laws in the books about parity, from 2008 and 2013, they’re federal laws about parity already existing, that say you have to cover behavioral health issues, and substance use disorders, at parity with physical health and somatic health conditions, but I’ve seen very little enforcement and it’s discouraging to me that attorneys general or state insurance commissioners have not gone after insurers, payers, because look you got to cover this treatment, this treatment for this chronic relapsing, remitting brain disease also called addiction, which the national institute of health, NIDA, has said this is a chronic relapsing remitting brain disease, first use is the choice, addiction is not a choice anymore, it is a disease, as you need to cover it like a disease, it is a chronic relapsing disease like diabetes, it is a chronic relapsing disease like asthma, you need to cover it just like you would asthma, you don’t just get 30 days of asthma treatment and no more, or 30 days of diabetes treatment and sorry, you didn’t stay abstinent from sugar and we won’t give you your insulin anymore, which is what happens to people with use disorders.

Logically it’s a neurobiological disease, we don’t cover it that way, we don’t treat it that way, we don’t converse about it that way, and we’ve completely been missing the boat. Again, I think stigma is the number one culprit in that.

I know that what you’ve been saying about inpatient rehab center, detox centers, I know in some states, like in Florida, for some of the centers, some of the licensing requirements were not as well thought out as they could be. Concerns about the effectiveness about some of the programs being done, things like that, what are your thoughts about that aspect?

I guess anywhere you go it’s variable, and there’s a whole cottage industry about treatment, and how that looks like. Right now, it’s kind of the Wild West in treatment, in what is a sober living home, or what is a recovery residence or what is a recovery support program, and there are some ethical players and there are some bad actors. Unfortunately, we have not developed a very good way of identifying what quality looks like. What regulatory frameworks should and could look like, and were really early in that process of this thing evolving, hospitals went through this many decades ago, what makes a good hospital, what’s a good doctor vs a bad doctor, how do you do quality ratings, and how do you get the joint commission to come through and survey these hospitals, and see who’s doing well and who isn’t, and accredit them and we are nowhere near the processes needed for the industry to mature and have accreditation, national standards, measurement standards, payment standards, regulatory standards, just like any other part of healthcare. You can’t open childcare center without going through a pretty elaborate process, to prove you can comply with state legislation to prove that you can open a childcare facility, appropriately so. But you don’t have to do that for opening a sober living home, just hang out a shingle and say here it is. Therefore, its very much just sort of the Wild Wild west, be careful what you’re doing, be careful where you put a loved one. Where you yourself wanna go, you may not be getting something evidence based, you might get a fly-by-night organization that just wants you take your money, or you might get a really good program, and we’re trying to find out how to identify those, and build standards, and try to sort of accelerate the maturation of this industry.

I know that there’s been, some of these programs you have family members who are desperate, so then they will pay 10s of thousands of dollars a month for some of these places, it works in some places and doesn’t in others, and I think it would be good, exactly what you were saying, how do we figure out what works and what doesn’t and have some sort of national standard, to protect people from some who may not be so ethical?

That’s exactly what we need.  It’s very difficult, the problem is so large, and so many people are in need of treatment, the treatment gap is so large, so I can totally understand why players would swoop in and try offering some sort of services, and now some are pretty good and it and some are not, and it’s hard to tell one from the other for a layperson or a health professional, you may not be able to tell, who’s doing well and who isn’t, until you find out later about some facility or some actor, and those being a bad actor are the ones who get the press, and not the ones who follow the rules and do a pretty good job, normally don’t get a whole lot of press, it’s not as sexy a story, I think it’s a good story, about hey there’s this group that does a good job and provides a whole lot of treatment, and of course that’s how people think that’s how it should work, so it’s not a whole lot of “new news,”  but it’s certainly news if someone isn’t doing their job and someone gets hurt and it’s a terrible scam and then it gets news.

For someone who has heard of things like OUD, like right now in the state of Colorado or some other state, and if they’re trying to look for a rehab center that hopefully will be effective, is there any kind of () or feedback system, review system, that can be helpful for them, or is that something we need to see emerge over time?

Its evolving.  The state of Colorado does offer regulation for the opioid treatment programs, methadone clinics, and voluntarily if someone wants to be certified by the Office of Behavioral Health, they can be certified as an affiliate, certification and try to jump through hoops and be certified as providers or buprenorphine prescribers or naloxone providers, organizations will voluntarily ask for, hey we want you to regulate us because we want to have legitimacy, and show people that we have gone through this process, and we are asking to be regulated so that we can prove it but of course not everybody does that, and these databases are not unified, and there’s a separate database for methadone clinics, there’s a  separate database for buprenorphine prescribers, there’s no state or federal database for Vivitrol prescribers, there’s a separate database for those who do behavioral health and counseling, so it’s a very disjointed thing. We’re trying in Colorado to work on one product right now to unify those databases and then have that available to people, like though an app or website, and then connect the same database to our crisis services line so they would be able to refer to the same single source, so that no matter if the person calls the crisis services or looks online, or uses the app, they would basically be accessing the same information, which would be arguable the most comprehensive database we can build, knowing that not everybody is regulated, so we’ll never have a complete database till we pass laws that everybody must be regulated, and report to the database, like we do with other things like getting a driver’s license, or whatever, you have to be in the database. You could do this, and I think eventually states will regulate them, and require them to register like pharmacies, you know where all the pharmacies are, and how they’re regulated, they’re inspected, they pay license fees, they’re fully legitimate. And those that don’t, an online pharmacy that doesn’t have that, you have to wonder, is this a fly-by-night organization that is solely on the internet, perhaps it’s not legitimate.

I remember reading something like that, some of these regulations they haven’t been put in place yet, because behavioral health was historically seen as being separate from physical health.

I think that’s part of it, that’s part of the issue, we think that for whatever reason 25 to 20 years ago we decided to carve out mental health from medical benefits largely we did carve out separate benefits, we thought it a good idea to carve out the brain from the body, I never understood it, behavioral health is part of health, and the neurobiology is part of your body, and affects depression, how well you take care of your own diabetes or selfcare, they are very much comorbid with depression and anxiety and use disorder, are comorbid with everything. So it’s kinda nonsensical to carve it all out, but it’s how we’ve evolved over the last 30 years, as this separate behavioral health system over there, and we’re are trying our best to reintegrate behavioral health into medicine, where it belongs, and there is just a lot of work to be done, and systems of payment were built separately, to do those things separately, now we’re fighting that, the vestiges of this parallel system we created that I think was largely a terrible idea, and now we’re paying for that in trying to reintegrate things, and when reintegrating the brain into the body, why did you take it out in the first place. But it has created this problem, you pay for behavioral health people differently than you do for the doctor, you pay them differently from a facility for detox, they’re all paid differently, with different mechanisms, it makes it hard for people to want to get into this business, because how am I gonna try to figure that out, and hire people to do these different things, and the payments are low, and I have to build different systems for different parts of this, and it’s just very complicated.

I’ve noticed that for some patients, I know in general, MAT works, () works quite well, but I know that some patients with OUD for one reason for another, based on their particular biochemistry, buprenorphine doesn’t really work for them, for these kind of patients, is there any hope for them, is there any sort of other recourse that they have for some other options that they can go towards?

They can be managed, whether it be buprenorphine or methadone, or if somebody wants to completely detoxify and be opioid free, can use naltrexone and use that as a craving suppressor and a relapse preventer and be really opioid free, and do that that way.  Naltrexone is an opioid, but it is 100% an antagonist so people say its not an opioid, but I still say it is, it’s just a blocker. Buprenorphine is a partial antagonist, while methadone and others are full agonists. So it’s just kinda what you’re doing to the opioid receptors, still playing with these receptors, and that’s just what the doctor has to figure out, what is going to work and what is not going to work for that patient, and no matter what, they’re going to have to be engaged in some sort of counseling and work on the social supports and living situation and social circles and supports.  Twelve step recovery programs can be helpful for people, and other sorts of recovery supports can be helpful for people, and really to have the doctor have the ability to access any and all of those things needed to create a customized treatment plan for their patient, and figure out what works for them. We advocate for all doors being open, all possible pathways to recovery, we push the evidence based ones, but we realize that some do not have an evidence base yet, so we don’t know if they work or don’t work, but we just know the evidence-based ones we know of, and we really need to be studying all these others as we go, as we need to find out and continue to find out what works and what doesn’t.

I guess when it comes to the pharmaceutical companies like Purdue, like what role or responsibility do you think they should have in the effort to alleviate the crisis?

We tried for years and we try to get companies like that to partner and say hey how can you do a better job to promote rational use, and to some extent they helped keep some of the PDMP programs afloat in some of the states, continue to help saying why we really don’t want there to be abuse, but I don’t think they did very much, and now they have at least some responsibility if not a lot of responsibility, in doing this.  Now many states, including Colorado, are suing the pharmaceutical companies in federal court, many counties and municipalities are doing that, tribes, all sorts of folks are suing the pharmaceutical companies for their role in, as the allegation goes, in creating this mess and causing these damages from the crisis, our state is doing the same thing, our state is part of the multidistrict litigation, several counties in CO are suing individually as counties, as plaintiffs, so I’m interested to see what happens to consolidated cases in Northern Ohio, it will be interesting to see what happens with those cases, the judge seems to be pushing for settlement, rather than multiple years of litigation, like happened in tobacco, and it seems to be pressing both the plaintiffs and defendants to settle and come to an agreement, to try to get money to people who need it now for treatment, but who knows if that will happen or if it will just go to trial.  I heard just this morning that the trial date got pushed back to next spring to next fall, what was going to be in March, I believe now September or October which was the first of the consolidated cases in Northern Ohio. You’ll see what happens I think, it’s been a problem that a lot people, even if the companies are to blame, at least to some extent I would tell you I agree with, it’s hard to say where does the rest of the blame go, some of it might go to doctors, some of it might go to pharmacists or wholesalers, or even the patients for only demanding opioids and not being willing to accept anything else, not being willing to try something else for a long time, so there’s plenty of blame to go around. I don’t know if there’s a single bad actor kind of thing. I think there are contributory roles a lot of players across systems to have had some contributions and it is hard to apportion that, but a lot of people are pointing the finger at the pharmaceutical industry, and I think that a lot of that is well founded.

I know in law there is a concept called comparative negligence or contributory negligence, so there is a portion of blame among the parties. If someone gave you a magic wand that allowed you to change any policy whether at the state level or federal level in order to more effectively alleviate the crisis, which policy would you change?

That’s good question.  If I had a magic want to change one policy, I would immediately tell the DEA, to immediately put a moratorium on all opioid prescribing. The DEA number that doctors have to prescribe opioids would now be re-issued, for all doctors, and if you want the DEA number, you’d have to complete 25 hours of training, and the training is 3 days, and it is about acute pain, chronic pain, and MAT, and opioid overdose reversal. So if you want to prescribe an opioid, you need to know how opioids work, for acute pain, chronic pain, overdose and MAT. So if you want the lighter, you have to know how to use the fire extinguisher. You have to have training in fires, and fire prevention, and in fighting fires, so if you want to be a fireman, you have to have the full training, you can’t just know how to start fires without putting them out. The new DEA number would be issued for anyone who wanted to prescribe an opioid, and I’d expect that many doctors would not apply for that, they would say I’m not gonna do it, I’m not gonna prescribe opioids anymore, which would technically be wonderful, it would force them to come up with other ways to treat pain. They would all say I would never treat pain anymore, I would just quit treating pain, and I would laugh because it’s the most common reason people go to the doctor, for pain. So doctors are not gonna stop treating pain, they’re just gonna have to come up with other ways to do it, and if we raise the bar on the prescribing side, fight at the lighters, and lower the bar on the MAT side, keep those 8 hours of training, but with 16 hours of therapeutic training for pain, and only 8 for MAT, which I’m fine with, make sure doctors are well trained, and the doctors that want to do this, are gonna be fewer number but it would really cut off the faucet for people prescribing  opioids, we would drop from not 250 million to 200 million, wed be down to 20 million prescriptions in about a year, we would immediately shut off the faucet which we really need to do, we really need to crank down on the faucet, were just giving out too many, and we are not making progress fast enough. The AMA says what wonderful progress were making, well I say, yeah its progress but like I said earlier, we stink less, which is not comforting to me. So that’s what I would do, I would level that, making it easier to prescribe MAT, and harder to prescribe opioids for acute or chronic pain, and level that playing field, and if you do that in one piece of legislation, and you can implement that in 6 weeks and change the problem in 3 months. It could be done, I’ve mentioned that to federal legislators, and continue to bang that drum, and it’s already in the purview of the DEA, these substances are inherently dangerous, and the DEA already has the authority in regulating the prescribing of them because they are dangerous and addictive, and what doctors do and don’t have to do in terms of regulations and what you have to do to get to jump through what hoops you have to get to prescribe them for what purposes. So I believe that the DEA has the authority to do it, but even if they don’t think they do, just pass a statute directing them to do it and giving them the authority and have them mandate to do that within 3 months, and it would literally be very simple to do, it’s not that complicated.

This is a very compelling proposal.  I think when it comes to news articles about the opioid crisis, they tend to have scores of statistics about overdose deaths and the economic cost of the crisis, what do you think is the best way to present a portrayal of the crisis that focuses less on the number, less abstract, and focuses more on the real actual humans being affected, something that the public can relate to more?

I think there’s various effective methods of storytelling, I won’t discount it, to share experiences and the common vectors that might be best the way to do it, sharing stories of people, or whether it was the first exposure was with wisdom tooth extraction or sports injury for whatever, and there were leftover 90 Vicodin or Percocet from this surgery, and I only used 6 of them, and there were 84 left, and my brother got ahold of the leftovers and started nonmedically using them, because he either had back pain or was just depressed and was whatever and had various reasons for trying them, and 70% of people started off with someone else’s leftovers, 17% start with their own leftovers, 6% of people get chronic opioid therapy, after a procedure, and they should never be taking them a year later, however 6% take them over a year later even after minor surgical procedures. So that 93% of the problem, and you can illustrate that with one or two cases, even with one family. Here’s this, Johnny got this for the tooth extraction, and Jane used the leftovers, and you can do this fairly straightforwardly, how this really does happen, most of the time. Make that compelling, like Oh geez, I wish I could have avoided the opioid withdrawal, could have had an alternative, if I got the opioids, I should have kept them under lock and key, and when I got done with the 6 that I needed, I should of gotten rid of them, and done safe disposal, and all these things get illustrated in a pretty simple cases of the most common vector.

That was really evocative, it was a very vivid picture, that people see that’s how it happens, and that’s how it could happen to me, and now I know how to prevent it.

Yeah, it’s so normal, oh my gosh. I had that headache that’s when I had my first one, oh my gosh I do have some of these left over, what do you mean that’s how 87% of the people start this, oh my gosh. I relate now that I could be the vector for someone like my friend or my daughter or my niece or whoever, might get into this, boy I gotta get rid of that stuff, or maybe I don’t even need to use this in the first place, 6% of the people get addicted to this and they just used it properly, maybe I shouldn’t even use this in the first place. Even if I could have, next time I’m gonna ask about alternatives. It really weaves in a lot of these angles into one simple story, about Johnny getting his wisdom teeth out, that’s about it.

I imagine the people whom the narrative is for are traditional physicians prescribing unexpected sources like dentists, others along that line, that results in a lot of these prescriptions.

The most common first opioid prescriptions are for third molar extractions (wisdom teeth), and sports injuries, between 16-24, that is the most common first exposure, basically everybody has had that as their first exposure, or knows somebody that this was true. So this really resonates with people when you tell them that, like oh geez, and this isn’t the weird thing, people have had a bizarre procedure, its really not. It’s really everyday regular life for everybody, and 10 billion tablets going out into medicine cabinets, 10 billion tablets a year go into medicine cabinets. That’s the source of it, that’s why this is a sort of created epidemic, it’s in our medicine cabinets, not on the street corners, with a drug pusher with this.   Yes, heroin dealers are there, meth dealers are there, but that’s not where most people start, most people start with the stuff in the medicine cabinets. So we all have to stop that, and it’s a very much easier thing to understand like oh geez, I should go look into my own medicine cabinet.

When it comes to Illicit drugs, recently many overdoses are due to fentanyl and now there’s carfentanil, what can be done to protect against this newest threat to public health?

This is a very difficult one, because now we’re dealing with the black market, and it’s a very very strong market, most of the fentanyl comes in illicitly from China, most of the black tar heroin comes now increasing from the Western half of the US, meth comes from Mexico, most of the White China heroin comes from India and Pakistan, to the East coast through trade routes, its very hard to disrupt global trade in illicit substances, this isn’t oxycontin, this is illicits, and it’s a very hard thing to try to break. The Opium Wars brought down Imperial China, opioids are a centuries old problem now, to try to figure it out with international shipping of illicit substances and the black market for those illicit substances I don’t know what the answer is to that, other than to do really good prevention, and work with people so they don’t feel they need to turn to a substance to address their problems, whatever they might be experiencing, to build resiliency and build protective factors and reduce risk factors and try to build more resilient communities, and so people don’t feel the need to use them because I don’t know how you eradicate on the supply side, we’ve never been able to do it in recorded history, to eradicate the supply side. We’ve tried, but we’ve never successfully done it, we shut down alcohol, no we didn’t. We shut down opium, no we didn’t. Meth, we did largely in the US, but the cartels figured out how to do it in mass, we just don’t have individual meth labs in people’s basements very much anymore. Now everybody’s doing individual cannabis grows, and high potency THC concentrated cannabis that were starting to see cannabis use disorders, and this isn’t like the cannabis that existed when I was 20 years old, this is a whole different ballgame now, were gonna see what happens with it being largely unregulated and decide if we need to regulate things like that, but it’s just a difficult one, especially in things that have a black market presence, and that’s just a different animal.

What have you thought about claims that medical marijuana can help reduce opioid cravings, what are your thoughts another those claims?

It’s an interesting claim, and I’m eager to see the data that prove it, and I’m very eager to see any evidence to that in that direction and would get on board. I hold the same standard for a Tylenol capsule that whether you want to reduce your fever with Tylenol, or you wanna lower your blood pressure with a beta blocker, or you treat your pain with an opioid, or treat your cravings with cannabis, I just wanna see the same level of medical evidence to prove that that works. Right now we’ve got an awful lot of people claiming that cannabis works for everything and is completely effective and is completely safe, neither of which are true, so we need to be able to do the studies to prove what works and what doesn’t and what is the safety profile, what is the benefit profile and then if its evidence based, we need to regulate it like any other drug, and have the FDA do that.  Finally if we can get to a federal level where we don’t prohibit it and make it schedule I, make it schedule II or II or whatever, and regulate and study just like any other medication, and find out if it works, and if it does, let people sell it for those indications, and let people market it to those indications and if it doesn’t have evidence, we’re back to the year 1902 where anyone could sell anything, and did not have to prove it. You got a lot of snakeoil, there was a whole era of snake oil, and traveling medical shows, and that sort of stuff. You could do that because anyone could claim whatever they wanted, and some of it was useful and some of it was probably true, and a lot of it probably wasn’t, and you can’t tell the chaff from the wheat. When you’re doing that, and you don’t have an FDA-type process to prove what they’re claiming is true, and that’s what I advocate for, is proof and science, so I’m not pro-cannabis or anti-cannabis, I’m pro-science.

Well, in terms of my planned questions, that’s pretty much all I have, did you have any additional thoughts or ideas that you would like to share?

I don’t think so, it was really really good. You asked a lot of good questions, front to back on this kind of thing, and I thought that was a really well crafted set of questions, that kinda threaded it pretty well. I’ve nothing to add, which is remarkable, I usually have plenty to add.