America’s Opioid Crisis – Clinical Innovations and Controversies

In this final episode of our series on opioid abuse in America we talk with Stephanie Peglow, DO, MPH, about innovative clinical approaches, harm reduction and public health controversies such as the pros and cons of needle-exchange programs and widespread distribution of reversing agents like Naloxone. Dr. Peglow fills an impressive variety of roles including Assistant Professor, Department of Psychiatry at Eastern Virginia Medical School; Sentara Healthcare System Director for Addictions Treatment; and as a Substance Use Disorder Policy Advisor for Virginia Department of Behavioral Health and Disability Services. This combination of experiences gives her unique insight into the latest thinking on new approaches and will be of interest to patients, clinicians, and public policy experts.

Dave: Welcome to 4 x 4 health sponsored by Datica. Datica, bringing health care to the cloud. Check them out at www.Datica.com. I’m your host doctor Dave Levin. America is in the midst of an opioid abuse crisis. Consider some of the statistics reported by the US Department of Health and Human Services or HHS. It’s estimated that in 2017 more than 28000 deaths were attributed to overdosing on synthetic opioids which translates to more than one hundred and thirty deaths every day. Also of great concern is the steady rise in the number of people misusing opioids for the first time. In 2016 two million people misuse prescription opioids for the first time and reflecting the fact that patients often move on to street drugs when they can no longer get legitimate prescriptions, 81,000 people used heroin for the first time. This is a genuine crisis and an all hands-on deck moment for health care. In response HHS has proposed a five-point plan that’s designed to lead to better prevention, treatment and recovery services, enhance data collection and research, improve pain management and increased targeting of overdose reversing drugs like naloxone. In this special series of 4x4 Health our guests share their views on the crisis as we look at the current state of diagnosis and treatment as well as the role technology can play in enabling better care. Today I’m talking with Stephanie Peglow, assistant professor in the Department of Psychiatry at Eastern Virginia Medical School EVMS and the system director for addictions treatment for Sansoro health care. In addition to providing direct patient care Stephanie’s played a key role in the creation of new educational and clinical programs. She’s designed educational programs focused on the identification and treatment of addiction for health professions students at EVMS. She helped establish as an active volunteer at the Hope’s psychiatry clinic, a student run clinic that provides free care to needy members of the community. To help raise awareness and other medical specialties, she fosters inter professional education in substance use disorder treatment. Dr. Peglow research interests include health policy of addictions and disparities in opioid use disorder treatment. She also is involved in shaping public policy and serves as a substance use disorder policy adviser for the Virginia Department of Behavioral Health and Disability Services. Dr. Peglow’s triple board certified in adult psychiatry, addiction psychiatry and addiction medicine. As someone who had to work pretty hard to maintain one board of Certification, all I can say about that is wow! Which is what I expect our listeners will also be saying as she helps us explore current controversies in the diagnosis, treatment and prevention of opioid abuse and related disorders. Welcome to 4x4 Health Stephanie. 

Stephanie: Thank you very much. I really appreciate your time.

Dave: Before we get into the opioid discussion tell us about yourself and your organization.

Stephanie: Sure. I’m 37 now. Who just recently transitioned into an academic career two years ago after basically enjoying being in a professional student for many years in my life. I live in Norfolk; I have a wonderful dog. She’s a bully breed and my parents live in town. Really, I’m very happy transitioning back to Norfolk where I did my residency. The role I do it’s a mixture a little bit of everything. Here I am starting clinical works. And so what I’ve been doing since then it’s kind of been General Psychiatry, plus addictions on the inpatient unit. Now that I’ll be transitioning into outpatient work, I’ll be doing more of the primary addiction and substance use disorder treatment. I also teach residents and medical students. And do some mentoring with them as well as do research for a small amount of my time. And then the policy works are relatively new addition but really exciting to me. Because I always wanted to be part of policy, could never quite figure it out. When I went for my master’s in public health and health policy, I like I know I need to do this because policy informs so much of what we do. I just had no idea how to use it. And I guess it just so happens is you get the education and you just find the opportunities.

Dave: Well I have a feeling we’re going to dive deeper into both your educational activities and your policy work. Let’s continue now and tell us a little bit about your personal history of involvement with the opioid abuse crisis. When did this first get your attention and why did it become something central to your work?

Stephanie: Well in residency training in psychiatry you’re taught about substance use disorders, but they’re still put in a silo that’s somewhat separate and different unique from all of the rest of psychiatric treatment. And we do a fair job of fitting mental health and then referring someone to substance use treatment. But I find that we need to do both and I didn’t feel like my training really gave me both together in a helpful way which is why I felt like I needed extra training and fellowship and the fellowship really taught us to do both at the same time both mental health and addiction treatment. And I liken it to riding a bike. If we have a bike with just one pedal and we’re treating a mental health disorder and ignoring the opiates disorder, we are just pedaling on one side, kind of lean to the left and we’re just going to go in a circle on the left. We treat the substance use disorder and say things like well all of your mental health problems are because of your use of substances and once we get that taken care of your mental health will fall in line. That mean we’re just pedaling on the right-hand side and lean into the right and we’ll just go in circles to the right. We do both together may not be exactly the same time, maybe stepwise but concurrently to actually move the bike in a straight line and get somebody forward.

Dave: I like this bike analogy. What you made me think of was the general principle in health care of the holistic approach. And you know when we’re treating someone who has a physical illness looking at their psychological make up, their social situation all those things together I think increasingly we understand that’s the way to get the best result. When I was looking at your resumé I was struck that you had spent part of your time training in the Veterans Administration system and I was curious have you gained any special insights about addiction or the opiate abuse crisis in particular from that experience?

Stephanie: Well my fellowship was at a V.A. And then my residency was about half V.A. and half civilian training, which is not uncommon. I think the V.A. trained about 90 percent of residents. So we all get some training in the veteran’s population. But in terms of what’s unique about the veteran population with substance use disorders is both their exposure in terms of medications and the risk factors. So they usually get exposed more often to opiates than the civilian population because they are doing risky job and are subject to a lot of physical injuries. But like you said we have to think about the whole person, it’s not just a physical injury. Since we have a volunteer service now, we have a lot of people that come in with trauma prior to their service and then experience subsequent trauma during service. And we know that people that have recurrent trauma even dating back to the childhood will have a higher risk of misusing and later developing a substance use disorder if they’re exposed to substances that have a psychoactive component like opioids.

Dave: When you say trauma could you elaborate a little bit on what you mean by that. Because that could be many different things.

Stephanie: I was talking more about psychological trauma in terms of physical, sexual and emotional abuse. So there is this study called ACES. I don’t know if you’re familiar with it, adverse childhood experience survey that found that people that have repeated exposure to traumatic experiences in their childhood are much more likely to suffer a number of things in adulthood, obesity, substance use disorders, mental health disorders. And there’s something about both what type of trauma is and how much they’re exposed to. Plus we also know that people that experience trauma early in life are much more likely to continue to experience trauma later in life. So we have a veteran population or let’s just say enrolled population that has a lot more trauma in childhood. So we’re not quite sure what’s happened but they’re exposed in this very disorganized environment sometimes to both the people that are supposed to protect them traumatizing them or the people they’re supposed to be fighting against traumatizing them to. It’s not a clear picture of why, but we know that they have several more traumas and they’re much more likely to develop a substance use disorder.

Dave: Let’s pivot now and one of the things that I know that you’re involved in is “harm reduction.” could you begin by defining for us what is harm reduction and then we’ll get into some of the specific strategies directed at the opioid crisis. So Stephanie what is harm reduction?

Stephanie: Harm reduction encompasses a number of strategies and typically gets applied to the one that we find the most displeasing from society, but we try to accept them knowing that somebody that engages or uses these services has less risk of harm. So harm reduction can meet any number of things from let’s say somebody with diabetes instead of saying to them, no more sugar we say to them limit your sugar, that’s harm reduction. But we don’t necessarily call that harm reduction. We just call that realistic planning. But when it comes over to substance use disorders, a lot of people raise their eyebrows when we do the same thing. However when we think about it from a much larger picture, we know that reductions in risky behaviors and risky substances also lead to reduction in bad outcomes. That’s why we are willing to consider them and encourage them. 

Dave: Well before we get into the controversial part of this and I’m sure we will, give us some specific examples of harm reduction possibilities anyway with regard to the opioid crisis. What are some of the things that could potentially be doing to reduce harm?

Stephanie: Sure. So telling people how you use opioids safer would be a harm reduction technique and it’s a huge part of education when we give people Narcan. So that would be things like snort rather than inject a new supply of opioids, use with your friends, don’t combine heroin with benzodiazepine for example or alcohol, try to limit the number of times you inject, use clean needles when you inject and they also can be more state or society structured interventions like needle exchanges where people either bring in dirty syringes or just present thing they use syringes and get clean syringes from this distribution program, so that they can inject with clean needles or Narcan is a harm reduction technique. We know that you may be using opioids and you may be someplace where the EMF connects you to right away and reverse your overdose. So I’m willing to give this to you or to your friends so that you can either spray this or inject this in the muscle of your friend to reverse the overdose. Also things like safe injection sites, where someone can bring their own opiates and their own syringes and inject in a place where they know that they’re not going to be subject to trauma, molestation, rape, victimization, those are all harm reduction techniques for opioids.

Dave: So these are all things that essentially start with the premise that a person is going to be using opioids that there’s risk involved in that and that there are things that they can do that can reduce at least the acute risk of severe overdose or death. Is that a fair way to sum all of that up?

Stephanie: Yeah. And long-term risk to so things like HIV or hepatitis.

Dave: Sure. In the case of needle exchanges and things like that that can reduce transmission of disease that we know is spread by sharing of needles.

Stephanie: Yeah absolutely.

Dave: Yeah let’s set Narcan aside for a minute, I do want to come back to that. But obviously these are things that are controversial in many communities and there are probably many reasons for that. I think it’s worth exploring it. But you’re the expert here. So tell me when you’re involved in discussions about these potential interventions and harm reduction at a policy level, what sorts of discussions occur? What are some of the issues pro and con and how do these conversations play out in these settings?

Stephanie: Well particularly in the policy realm people don’t necessarily want to endorse these options, because they feel like they’re endorsing the misuse of opiates. So for example if you were to involve attorney general’s office, the DEA, the FBI, they would not be able to at all say that they approve or endorse these. There are some studies that have been able to work with local police departments so as not to sit outside a syringe exchange and then arrest people as soon as they walk out for paraphernalia. So there are some potential relationships in that. Outside of that in the clinical world I hear a lot of physicians and other health care professionals resist the idea because they feel like they’re telling their patient it’s OK to misuse opioids. And I still hear it with Narcan. If I give them this or I offer them as an option, I’m not going to get any buy in for them to stop. So therefore I can’t say anything about it.

Dave: Yes. And I think that this also likely reflects a still widely pervasive attitude that addiction is some kind of character flaw or moral failing. This has come up previously in the podcast and I think this is still widespread in the public and sadly probably still prevalent in the medical professional community as well when the scientific evidence medical evidence is clear. This is a genuine disease just like diabetes or pneumonia or heart disease and increasingly an evidence-based approach to diagnosis and treatment supports that. So would you agree some of this is also just kind of the nature of how people perceive this particular problem?

Stephanie: Oh absolutely. I think the number one killer when it comes obese disorder is stigma. Stigma is an infection that has invaded every part of how we feel and think about substance use disorders in general and it’s a killer. Because it prevents people from getting the care that they need, it prevents policyholders from endorsing or promoting treatment. It’s even down to how we make laws about this one disease. We’ve decided that this one disease is a criminal action. And even having the disease and using something to make you feel better or having the equipment to make you feel better is a criminal activity. It’s the reason why people leave treatment early. It’s a reason why people don’t access treatment. We know that less than 15 percent around 12 percent of people are getting treatment for their use disorder. Its why people don’t feel like they can access the services. And also why those services aren’t offered. 

Dave: Yes and I was thinking about this in preparation for a discussion and I want to pose a kind of hypothetical for you. Setting aside the moral concerns if you will and just thinking about this purely from a medical evidence standpoint it’s a reasonable hypothesis on both sides. There’s the hypothesis that well if we do harm reduction overall that’s a benefit. And you know its sort of the least bad option among a series of bad options and then we have the other hypothesis which you mentioned earlier, which is well this may actually encourage people, it may actually make things worse. Fortunately there is data on this question isn’t there? I mean there are other countries that perhaps have implemented these in a more robust way. What does the evidence tell us about these two hypotheses?

Stephanie: Absolutely. We have evidence both from the US and internationally about harm reduction measures. So for example Narcan itself, we know that the more they are in a community the less overdose death they will have in that community. So much so that just 250 and about 10000 people will reduce a community’s overdose I think by 50 percent. So just having those in the community can be helpful and reduce deaths. The education that goes along with it on how to use opioid safer you know talking about snorting rather than injecting, people think well they’re going to have Narcan now to reverse it and they’re going to use in a riskier behavior. Well that education actually has been shown that people use it safer after this education. So it’s not endorsing the, I have a safety net mentality. Now that I have a safety net, I’m going to go hog wild. It’s the opposite. In terms of syringe exchanges, we know that people that access those clinics or those services are more likely to enter treatment and are much less likely to get infectious diseases. So if you look at those things from a societal standpoint even if you can put aside the moral thought on these are people and they don’t deserve to be marginalized and they don’t deserve to be a criminal because they have a disease. If you put that all aside just look at the cost, if we can prevent one case of HIV, we save couple hundred thousand dollars in a society in medical costs. So from a standpoint of financial only they actually works if we put money into them and then in Portugal who has decriminalized the disease of addiction and instead rather than policing the people that have the disease they’ve turned to policing more the trafficking and then offering, putting all that money that they were policing individuals into treatment. They’ve seen drastic reduction in number of substance use disorders. So people are offered the opportunity to go to treatment and it’s funded by the state, they go. And on top of it they’ve had the lowest rates of HIV in all of the developed countries. People are able to get treatment and they’re able to access safe injecting equipment without fear of being arrested for being criminal. 

Dave: I think this is fascinating. And my view is there’s a whole series of issues related to health care in this country that essentially follow this pattern of discussion. There’s a certain moral view of an issue or a legalistic view of an issue. There are reasonable hypotheses on all sides. But then there’s evidence and I think where we’ve struggled as a society is to follow the evidence. We don’t like it when the evidence doesn’t square with what our morality happens to tell us is the right thing to do, whatever position you I’m from and I think you’ve just given us a really excellent overview of that. So a series of interventions that probably none of us are wild about doing. But when you recognize that they can actually significantly reduce harm, that there’s substantial evidence that that is the case, it’s not just a hypothesis. There’s real data to back that up. Then we need to find ways to put that into policy to educate people and to pursue these things where they make sense. I’m sure you would agree with me.

Stephanie: Absolutely. And for most of us harm reduction things that I was talking about, like the syringe exchanges and the safe injection sites people will rally against them because they feel like it. It doesn’t go with their morality and from a policy standpoint will say, Well I don’t want my tax dollars going towards them. The reality is no federal tax dollars can go towards any of those things. In the state of Virginia if you have a syringe exchange program that just starting up you have to get it completely privately funded. So those folks can relax and knowing that not a single cent of their dollars is going towards them.

Dave: Yeah, I guess I would argue if they looked at what their tax dollars were being spent on as a result of us not aggressively going after these interventions, they might feel differently about it. Perhaps not. Again what I find fascinating about this whole area is that there is this sort of conflict between at least for some folks what their moral sense might tell them is the right thing to do. And again it’s understandable, it’s a reasonable hypothesis and what the actual evidence tells us about what happens in the real world when you do these things. I want to go extra deep on Narcan while we’re on this topic. Because it’s something that’s in the news. I think people hear about this frequently. So take a moment and tell us what Narcan it’s is how used and some of these opportunities to deploy it for further harm reduction.

Stephanie: Sure. Narcan is the brand name for naloxone. Naloxone is a new antagonist. So I say that the opioid receptor if we put a broken lightbulb in and we glued it in there so that it’s filling the receptor but there’s no action coming from it. What that means in terms of an overdose is if all of their receptors are full of heroin, methadone, Percocet whatever you either spray naloxone on in the nose or you inject it into the muscle and it goes into the bloodstream and into the brain and knocks all of those opiates off the receptors and kind of glues itself in there. So it brings people out of their overdose and it happens relatively quickly within a minute or two. The problem is its rather short acting, so it lasts about 30 minutes. So if someone’s on a long acting opiate they still need to go to the E.R. It isn’t meant to be used in these distribution ways with the opiate educational option distribution that the average civilian can do this intervention out in the street. We give people either the nasal spray or the auto injector which kind of talks people through how to use it in Virginia and train them how to use it. It’s about an hour and a half training in Virginia. But in many other places it’s just a few minutes because it’s very easy to use. And we also train people that if they come across someone who’s incapacitated and not responding. If there’s a chance, it’s an opiate overdose go ahead and give it because it’s not going to harm them if they’re in a diabetic coma If we give them Narcan. But it’s just as important to call 911 first in case there’s something else that the patient or the person you come across that they’re experiencing or just in case that you bring them out of their overdose and they’re on that long grafting opiate and they go back and overdose after the naloxone comes out of those light bulb receptors.

Dave: That’s a really good summary and so essentially what I heard was this is a drug that can be easily administered by essentially almost anyone with a little bit of training. Its immediate effect is to reverse the effect of the opioid and in overdose situations though the concern is people’s respirations are suppressed they stop breathing. And that brings imminent death. And this is a rescue, it’s really quite remarkable how quickly it works. So again I would ask you what does the data tell us about the use of Narcan and what are some of the more innovative ways that we’re looking at distributing again or making it available as part of a more robust approach to harm reduction? 

Stephanie: So there are a couple of questions in there.

Dave: Hey it’s my podcast. I got to ask as many questions. 

Stephanie: All right. So the data on naloxone for overdose.  It’s extremely effective. There are some anecdotal reports that it’s either not bringing people out of fentanyl overdose or that they’re having to use multiple injections or sprays to reverse the fentanyl overdose. Fentanyl in case you’re not aware is a synthetic opiate. That means it’s created in a lab. And we’re seeing more and more of it in our supply. And the reason being it’s much more potent. So just a tiny little bit of it can get the same action as a lot more heroin. So it’s easier to bring into the US in smaller amount. And they’re suggesting that most of it’s being made in China and coming over even in the US mail. In Virginia we’re seeing around 90 percent of our heroin supply tainted with fentanyl or other analogs of fentanyl. It is extremely effective though. It’s not to discount people from using it. It works for opiate overdose. And we use it in the hospital just in a different form in an I.V. form when people come in an opiate overdose. The only time it doesn’t work is when someone is already expired. It’s used in the medical field and like I said by civilians and civilians can be trained and learned how to use this and like I said just a few minutes. And their knowledge retains several months out. So it’s not something that we have to keep building skills for. The people that need it the most are people that are using illicit opiate and we’re finding a little bit of a gap in getting it to the right people. We have a lot more people accessing and asking for naloxone that are family members and loved ones with someone with an opiate disorder. And we really need to get it into the hands of the people that are using opiates because they are on the ground and with their friends and most likely to be the person there in the moment that is needed.

Dave: What about distribution to law enforcement, emergency services sort of other avenues of getting naloxone out there so what’s available at the point that it’s needed in a crisis.

Stephanie: Yeah absolutely. So a lot of cities and states have made a strong effort to make sure all of their police officers, EMT have naloxone on them. In cities where the police are more likely or even rural areas where the police are more likely to arrive on the scene, it’s absolutely important for police to have it on hand. The EMT, I don’t know why an EMT wouldn’t have it considering how often they’re getting called for opiate disorder overdoses now. In cities like Norfolk where the antes arrived just as quickly as the police officers it’s probably less than necessary that the police officers all have them, really like I was saying that people that need it the most are the users of opiates that misuse them. There are some cities that are creating other mechanisms to get it out in the community. I think it’s Boston that’s working on a remote-controlled box that contains naloxone and can be radio controlled so that someone goes to access it and remotely they can open it up, so someone can access it in public spaces like parks. And there’s also I don’t know which city is considering flying Narcan by drone to people that call in the EMT for no opiate disorder.

Dave: Well that’s another use of technology to combat this crisis I suppose. I want to wine down this part of the discussion about harm reduction by giving you the last word. So any other thoughts about this topic before we move on. 

Stephanie: We do harm reduction in everything we do in medicine. It’s just we only label it harm reduction and opiate disorders. It goes back to stigma. If you are willing to talk about diets that aren’t extreme and that are realistic if you’re willing to talk about how to take medication more often than not or create reminders if you’re at all willing to accept anything that’s less than 100 percent adherence to everything I say, then you’re practicing harm reduction. This is the same thing we do in opiates disorders.

Dave: That makes a great deal of sense to me. And again I’m a big believer in following the evidence and then the last thing I’ll just say is that sometimes people need time in their lives to figure things out and rather they’re trying to figure out what to do about their high blood pressure or their diabetes or they’re wrestling with mental illness or addiction. And I view these types of interventions as ways of buying time for people as well and particularly when the evidence suggests that it doesn’t increase utilization or have other untoward impacts. Again I’m sympathetic to the other arguments but show me the evidence at the end of the day and the evidence seems to be increasingly clear that the wise choice and wise public policy would reflect that evidence.

Stephanie: I agree. 

Dave: I knew you would. If you’ve just joining us, you’re listening to 4 x 4 health and we’re talking about the opioid abuse crisis with Stephanie Peglow, assistant professor in the Department of Psychiatry at Eastern Virginia Medical School and system director for [unclear] for Sansoro health care. I want to turn now to access to care and disparities in care. Because I know these are areas of interest for you as well. Let’s begin with access to care. What are some of the biggest challenges and how are they being addressed or how could they be addressed based on your experience?

Stephanie: Sure. So we know that access to treatment particularly for opiate use disorders saves people’s lives and reduces their risk of infectious disease and criminal behavior as well. The access to care issue comes from both stigmata, so people may not want to walk into the front door of a methadone clinic or ask their doctor for treatment for obese disorder because they might fear the repercussions that come from that. But looking at it from a larger perspective we’ve treated opiates disorders in methadone clinics since the 1960s and it requires a person to come every day for treatment at the beginning usually for several months. So someone who cannot get to a clinic every day for a couple months has access issues. We’ve since tried to open up access to treatment by using Suboxone and that’s the [unclear] naloxone combination that can be prescribed by doctors in their regular practice in a regular practice setting. The problem with this is it was largely marketed and intended for affluent insured working people and the majority of people that showed up to access the Suboxone 91% were Caucasian, insured working folks and mainly from what we call the suburbs. So that leaves access issues for people of color, people with low socioeconomic status, people who live in rural areas and people that experience stigma in their culture or in the places they live differently. I forget the rest of the question I was supposed to answer. 

Dave: Well. So we’re talking about access to care and the challenges which I think you outlined really well. What you’ve pointed out is that not unlike other kinds of medical care there’s a socioeconomic disparity when it comes to access to diagnosis and treatment. What’s being done or what could be done to address these kinds of disparities specifically around opioid abuse? 

Stephanie: So a large part of what cities and states that are trying to create access for everyone is to fund treatment centers both through increasing Medicaid reimbursement, expanding Medicaid or funding of these clinics. And most of them are doing it through Suboxone. I think that’s partially from stigma because they find Suboxone much more palatable than we do through expanding access to methadone. They’ve run into issues though where physicians are resistant to getting a special license that allows them to prescribe Suboxone for opiate disorder and they’re resistant for a number of reasons. But even people with the best of intentions who want to do this and are excited to do it feel restricted by their practice by lack of knowledge, by lack of training, by lack of mentors. And then there are people that get the training and get the special waiver and then don’t prescribe it to many folks. On the people that do get the waiver, the special training feel like they’re ready to do it and have a full clinic of people prescribing Suboxone for they have a federal limit on the number of patients they can treat. So for most physicians that’s one hundred patients and this was treated as a barrier so that we wouldn’t create extra pill mills. I think that is also probably more a reflection of stigma that someone that’s treating opiate use disorder would be a pill mill get someone that’s treating pain with opiates wouldn’t be. But anyways they’re also trying to increase access by getting more doctors trained through that eight hour of training to get Suboxone Labor, getting more mentorship through this program called echo. A lot of states have invested money into it where a doctor can consult with a group of experts, a whole team through telehealth and can bring cases to help as work as a group towards what would be helpful. And they’re also trying to get the physicians that do have the waiver that are prescribing to prescribe it to more patients. And in that case in Virginia for example they do that by increasing the reimbursement, the Medicaid care coordination costs for the number of patients you have in your clinic and then also the federal government has changed the limits recently so that someone who is specially trained can increase their limit up to two hundred seventy five patients.

Dave: So to summarize all of this there’s a general problem of access to care in the United States. Some of that tracks with socioeconomic status with rural versus urban, those sorts of things. In this particular case we know that medication assisted therapy has a much higher rate of success and so use of drugs like Suboxone are extremely important. You’ve given us a really good flyover of the challenges with that and also some of the potential solutions in terms of training more generalists in this, providing telehealth and other kinds of consultations to provide backup so that a broader group of clinicians could participate in this. And you’ve also pointed out some of the other challenges. Let’s continue in this theme. What other kinds of disparities in care have you seen and what are your thoughts about how those are or could be addressed? 

Stephanie: There’s racial disparities in treatment for substance use disorders that’s seen both in who access care, what type of care they access, like I said the methadone versus Suboxone versus religious based organizations or abstinence only organizations. But also, we see it very strongly in the legal system. African Americans and people of color are four times more likely to get arrested for substance related charges and when they get sentence generally get much larger sentences. The judges generally have the option of referring people to drug courts which are limited by the number of people they can take in, so that’s not the solution for everyone. So they have to pick out the most likely for success to go to drug court and drug court is an alternative to getting prison time where your freedom is stipulated on continued absence from substances and engagement in substance use disorder treatment. And it’s very effective. The problem is most of the people getting referred to drug courts are Caucasian people. So we see the disparities in who access and care, what level of efficacy is it the care that they’re accessing and also very very very large racial disparities in our penal system when it comes to substance use disorders. 

Dave: And what kinds of hope can you give us around these issues? Are you seeing any activity either in delivery of services or in policy that makes you hopeful? 

Stephanie: Well I’ve seen a whole flurry of papers come out in the last several months that is shedding light on this very thing. I think from the very beginning what we need to do is show that there is a racial disparity and make it unacceptable to people. We just had a paper come out that said that African Americans are less likely to get Suboxone than white Americans. And recently a paper that showed that African American, the rate of dying of fentanyl overdose has doubled and it’s significantly higher than white Americans. So we’re beginning to shed light on these racial disparities. I’m seeing more and more interest from the policy side and I can’t speak for all the different states, but I’m involved in Virginia and was just in a meeting that wanted to discuss specifically disparities and racial disparities with Department of Corrections and Department of Juvenile Justice and how we can address those related to substance use disorders. And for note for later let me make sure that I can talk about that. If they don’t mind me promoting that.

Dave: OK. Well so noted. Part of what this aspect of the crisis is really fascinating to me because we’ve discussed with some other guests the one of the big differences in the opioid crisis at least in this wave is that there seems to have been less respect if you will for socioeconomic boundaries, that this is a disease that’s striking at all levels of society. And at least one of our guests hypothesizes that this is also why, one of the reasons why it’s gotten so much more attention and it is getting perhaps more traction and public policy in other areas because the face of the epidemic looks more like me, looks more like my neighborhood. It’s not those people over there if you will. So it’s very interesting to hear from you how these dynamics are playing out in different settings. Am I making any sense here?

Stephanie: Yes absolutely. There is this undercurrent in my field that talks about how we’ve had epidemics of substance use disorder every decade. But this one has come to light unique in its past probably because of who’s affected, the face of the person that’s affected. Like you said maybe racially or someone you know from your high school or on your soccer team and then it cuts across socioeconomic pattern and groups and so maybe that’s why we’ve gotten a lot more media attention and a lot more talk about treatment than we ever did in the past. So at the same time while it’s probably creating some disparities in care, it’s also been a good thing in effect that it’s brought attention from a national level that’s not all about making this criminal and jailing people and not all pejorative. We’re able to see people as quote victims of a substance use disorder. Maybe that’s partially because they look like us. 

Dave: Well I think that’s true and I think it’s hard to find someone in this country who hasn’t been touched by this in some way. Maybe not directly, maybe indirectly. Maybe it’s a family member or a member of an extended family or friend. But it’s so widespread, so deep and wide. I think this is the other aspect of it so many of us have been touched by this whereas in the past we might not have been, or it might not have been as obvious to us.

Stephanie: It may not have just been as obvious to us. Look at alcohol for example, alcohol use disorder cuts across all socioeconomic groups. It affects people of all races some more than others. I imagine there’s a whole different set of socio-cultural beliefs about alcohol that have created the environment where we’re willing to see that everywhere and we’re willing to deal with it. 

Dave: Well it’s a great contrast. You make a really really good point there.

Stephanie: Alcohol kills more people when you think about all of the long-term effects of alcohol use disorder kills more people than opioid disorder.

Dave: Yeah, I don’t think this is a fact that’s well understood in the United States in particular. We have so normalized the use of alcohol and we get so exercised about other substances when the evidence is very clear about how dangerous and destructive the alcohol is. So again it’s so much of this conversation I think has been a fascinating window into culture, philosophy, morality and how these things overlap with what the medical evidence what science tells us about what’s actually happening with the possibilities are and in a free society we have to kind of struggle to balance those thing, at least that’s my point of view. I’m curious if you see it in a similar fashion.

Stephanie: Oh absolutely. Because of substance use disorders unique thread throughout our history and its association with immigrant groups or groups that we felt for taking our jobs or didn’t like. It’s not just the disease, It’s a cultural phenomenon. It’s hard to make the argument for access to treatment and put it purely in a medical standpoint like I like to do because it’s much more than that. It’s hard to ignore. Like you said the philosophical, the ethical, the legal things that come from it. And a lot of it’s based around how our culture defines addiction.

Dave: I think that’s right. I mean I think the other thing that it’s been really striking as I’ve read more about the crisis in conversations with our guests on the podcast is you know the vast majority of people who have serious substance abuse disorders have mental health issues as well. And to state the obvious we still have a terrible snakebite in this country about mental health issues, about access to care, about the quality of that care. All of those things and so it’s almost like it’s a double whammy in this situation. You have these two combined stigmas that create an enormous barrier to people seeking treatment. And to us as the society being thoughtful about what we can do about it. 

Stephanie: Very true. 

Dave: Well I’m kind of depressed at this point. I’m hoping that you can give us a little hope here at the end Stephanie. You’re really at ground zero in this and you’ve waded into some of the most controversial aspects of it. What is your most sage advice when it comes to a crisis? 

Stephanie: That’s a good question. In both the light of being more hopeful and giving advice the best thing we can do for our patients is give them hope. The worst thing we can do is destroy it. The evidence points to treatment works and treatment is effective. And as long as I reinforce that with my patients and their families it gives them something to hold on to, even when they’re feeling like there’s nothing else to hold on to. The idea that there’s hope for the future and I can access it. It’s attainable for me, I deserve it is empowering and I think helps my patients and my clients through those moments where I feel like nobody else is supporting them and society is against them. And in terms of being more hopeful for the future I also teach, like I said I teach medical students and spent a fair amount of time with them in their first through fourth years. And each generation has felt opioid disorder crisis differently and how they felt it is different even than how I felt it. [unclear] classmates that they had in math class in high school, English class and middle school died from opioid disorders. It’s around them and they see it almost every day and what they do. And I don’t know if it’s social media. It creates a different frame for them, but they are so excited by all of these harm reduction techniques and getting people into treatment and talking about substance use disorders rather than hiding under the pillow away from it. They are the hope for the future for medicine, they inspire me daily.

Dave: Well I’m sure that flows both ways. And good on you for taking up the mantle of education out on them for recognizing this is one of the issues of the day. This is what has been if you will fate has served up to them in their careers and their willingness to look at the evidence and look for new ways to intervene and support their patients. And I imagine support each other as well. So truly sage advice from someone who’s at ground zero in this.  We’ve been discussing the opioid abuse crisis with Dr. Stephanie Peglow. Stephanie thanks for joining us today.

Stephanie: Thank you very much.

Dave: You’ve been listening to 4 x 4 health sponsored by Datica. Datica, bringing health care to the cloud. Check them out at www.Datica.com. I hope you’ll join us next time for another 4 x 4 discussion with health care innovators. Until then I’m your host Dr. Dave Levin. Thanks for listening.