The Epidemic of Epidemics: Opioids, Part II

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: we continue our discussion of opioids and the growing concern over several related health epidemics facing Americans.

Last time, we heard from state health officials. Now, we explore the issue with those on the ground. Our focus, once again, is on West Virginia and Kentucky.

We explore the work to protect our youngest from the harms of addiction.

CHRISTINA MULLINS:
Since we’ve been tracking with improved data over the last year through our birth score instrument, we've not seen increases in the number of infants being born with intrauterine substance exposure or infants being born with neonatal abstinence syndrome.

JOHNSON:
The real impact on communities.

GREG CORBY-LEE:
It never fails, you know, when you ask the crowd in the room if they know of someone who's overdosed. They do—nearly everyone does.

JOHNSON:
How the local groups are working together.

JOE MARKIEWICZ:
There's a lot of merits and a lot of positive outcomes when we bring the right people to the table in the community, for whatever the problem would be.

JOHNSON:
And what one federal agency is doing to lead a coordinated response.

DR. AARON LOPATA:
This is very much a team effort. It's not only the federal government is saying, “Here, do this”—it's almost never that.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable population.

This episode is produced with support from the Health Resources and Services Administration, which oversees programs to improve health for those most in need, including pregnant women and people living with HIV.

SPEAKER 1:
Almost half a million Americans have died in the last 15 years from an overdose, and the majority of those involve opioids. On average, 91 Americans are still dying every single day.

In that same period, the rate of addiction to opioids has shot up by almost 500%.

JOHNSON:
The opioid epidemic has been called the worst public health crisis in America. It doesn't discriminate.

In fact, it affects the lives of people from all walks of life, including our youngest—unborn and newborn babies.

SPEAKER 2:
The footage may be tough to watch.

Baby Jaden, clearly suffering, is experiencing withdrawal, born dependent on opioids, meth, and other drugs.

JOHNSON:
About six years ago, physicians in West Virginia raised a red flag. Local hospitals were filling up with babies are experiencing the side effects of addiction, including drug withdrawal.

The state, working with its partners, developed a birth score intended to gather data and drive prevention efforts. It's a detailed survey that's completed as soon as possible once a doctor and a pregnant woman connect.

Christina Mullins is West Virginia's director of maternal and child health.

MULLINS:
So, we wanted to be able to improve pregnancy outcomes. That was the overarching goal.

But in about 2008, 2009, our physicians were really—had a very vocal voice through our perinatal partnership, saying that the neonatal intensive care units were full. They were running out of bed space, and it seemed to be because they were seeing more infants who were having withdrawal symptoms from substance abuse.

And we became—we started paying a lot more attention to what the physicians were saying, which is how that evolved, along with improving our infant mortality rates and a whole host of other things.

But that push towards understanding the substance use disorder and how it was impacting the infants was really being driven by our physicians and their overarching complaints about lack of bed space in the neonatal intensive care units.

JOHNSON:
So, once you implemented this plan, did you see immediate results?

MULLINS:
Actually, we didn't.

We were seeing—we were starting to monitor the data because we had done a core blood study in 2008, 2009, that had demonstrated that our substance use rates were actually in the high teens, and that our data on our prenatal risk screening instrument was very low—less than 5%, like 2-3% maybe. And we knew everything was too low.

So, there wasn't good agreement between what the physicians were reporting to us as their observations versus what we were getting on our screening instruments and what we were seeing in our NICU.

So, we knew that our data really wasn't where it needed to be for us to be able to do program planning and really understand what the issues were.

JOHNSON:
The birth score now carries this component with it, correct?

MULLINS:
Yes, it does.

JOHNSON:
And you've been at it for six years. No immediate results once you implemented the plan, but I am hoping that now you're seeing some benefit.

MULLINS:
We had a couple of different things that happened.

So, in 2014, our physicians got together and said, “You know our data really isn't defining our problem for us. It's not showing our problem.” So, we needed a way then to also screen the infants

And the physicians asked if we could have a meeting to determine what the diagnostic criteria was for infants being born with neonatal abstinence syndrome, and had a really rich discussion about identifying what was happening also in pregnancy at that first obstetrical visit. That was such a rich discussion that the physicians then developed some training programs.

And once they develop the training programs and trained themselves—as a health department, we didn't do that for them; we provided venues through the perinatal partnership for them to be able to have those conversations, but they trained themselves—and then we began to see data really improve.

JOHNSON:
How about the number of babies in the NICU after that? Has that started to come down?

MULLINS:
It has not, yet.

What we're actually cautiously optimistic about is a leveling off. That’s what we’ve been tracking.

With improved data over the last year through our birth score instrument, we've not seen increases in the number of infants being born with intrauterine substance exposure or infants being born with neonatal abstinence syndrome.

We're also seeing a similar leveling off in our birth to three program, which is our early intervention programs for infants and toddlers.

So, we're seeing a leveling off of data in the birth score instrument. The data isn't going up, but we're also seeing that steadying out in our early intervention. So, that is leading us to be cautiously optimistic that we are at least not, what—we might be leveling off and not continuing to see Increases.

JOHNSON:
We also spent some time with Dr. Gupta of West Virginia talking about some of the things going on in his state—your state. He mentioned data more than once, and you've already talked about that as relates to the universal screening program.

How does data translate into healthier babies?

MULLINS:
So, the data.

We use that to make the argument for the funding for programs for—we have one program that begins to be offered to pregnant women when they're first identified as having a substance use disorder in their first obstetrical visit, where they then work with their obstetrical provider and a mental health provider.

We've seen really encouraging results with that program, but we need more money, and we need that to—we need to expand it. And then, so that we can use that data to determine where we need to expand that program and to make the argument that we do need more of those types of programs.

The data also is helping us identify infants once they are born in need of treatment at neonatal abstinence centers here in West Virginia.

JOHNSON:
Let's talk a little bit more about that first doctor's visit for the pregnant woman.

What is that like as it relates to the screening? Is it just a questionnaire or is there more to it?

MULLINS:
Well, it is a questionnaire that is developed by a panel of physicians. But it should be a rich conversation with the obstetrician, it should not be just a form that's passed to the woman.

It should be a conversation starter so that the obstetrician gets to know the woman during that first obstetrical visit and can make those appropriate referrals to programs like the drug-free moms and babies program, or even our home visitation programs.

JOHNSON:
So, I am going to assume, not having been in one of those conversations, that it is not always obvious that there's something going on.

MULLINS:
It is not always obvious. It takes—you have to build trust with the woman because she is always, if she has a substance use disorder, she is always going to be afraid that she may lose custody of her child, or that there may be other really negative consequences to being identified, even just the stigma throughout the pregnancy.

JOHNSON:
But if you can get those things identified that early, you can make a difference, right?

MULLINS:
We can make a difference and we do have some treatment options available.

And even if a woman uses a medication-assisted treatment program and still has a baby born with some withdrawal symptoms, that woman is able to maintain a healthier life and better support for her infant, is much more likely to be able to maintain custody, and maintain just that stable home environment that's going to be best for her and her entire family as well as the infant.

JOHNSON:
So, if you're cautiously optimistic that the numbers of babies with issues when they're born might be about to level off, what is it that we're missing here?

We just don't have enough money to deliver the programs to the women when we figure out they've got an issue on that first visit? Or is it just a matter of them not telling the truth when they're asked?

MULLINS:
I think it's twofold.

I think what women have—I think that there is stigma associated with admitting that you have substance use disorder. So, we have to really work to develop trust and build and build programs that women believe that, if they admit that they need the help, that it's going to be a supportive environment that helps them get through the pregnancy and have a healthy pregnancy.

But we have—we also need money to be able to expand those types of programs. We have some very successful programs here in West Virginia, but we can only serve a certain amount of women. And it takes time for those programs to get established within their communities to build trust.

But what we know is after those programs have existed within their communities, the number of women self-referring and saying, “I want to go into this program,” dramatically increases. After about 12 to 18 months of that program being available in the community, that provider then earns the community’s trust, and the women then self-refer. So, we're able to help more women.

JOHNSON:
I wanted to ask you about that. Six years into this, are there any data points that are surprising or unexpected?

MULLINS:
So, for me, the rates in which the women who enroll in our drug-free moms and babies’ program, and the percentage of women who are negative for illicit substances at the end of their pregnancy is astounding—for many of the programs, it is above 90%.

So, women who enter the program and complete the program have a high level of success. And for me, that was incredibly eye-opening and made me a believer that it really is worth the investment to get these projects and programs out there.

JOHNSON:
Public health professionals know data opens doors. It's been critical to building consensus in Kentucky.

Joe Markowitz is the program coordinator for the Kentucky Injury Prevention and Research Center’s statewide prescription drug overdose reduction initiative.

Greg Corby-Lee in Kentucky is HIV/AIDS continuing education program director. Greg begins our conversation about data.

CORBY-LEE:
You know, once we work at a local county's data—for hep C, in particular, and overdose deaths, and overdose emergency department visits, and a neonatal abstinence syndrome numbers—it can be very convincing to local folks that we have an issue here. And that's when they're more willing to listen to the multiple approaches that we have to help with this.

And, of course, the one that we are promoting here from the HIV branch with Kentucky public health is this syringe exchange program. We work closely with the Narcan distribution as well; but again, it all gets back to being data-driven to convince people of the need that they have.

JOHNSON:
Joe, can you make a dent in these problems? Can you fix these issues without data?

MARKIEWICZ:
Data-informed approaches is—I mean, if you look at SAMHSA, the Substance Abuse Mental Health Services Administration, with the federal government, CADCA, the Community Anti-Drug Coalitions of America, the CDC, they're all going to tell you the same thing; that, without data to drive why you're doing your prevention strategies, you really don't know if you're being effective or not.

JOHNSON:
Does the data make it easier to get what you need, as far as resources are concerned, to tackle these problems, or is that fight the same regardless?

MARKIEWICZ:
When I work with a lot of coalitions, especially in rural areas, you'll have law enforcement, emergency medical services, hospitals, and treatment and recovery centers are all at the table.

And when you can stand in front of them and say, “Let me just show you what the numbers look like.” And when you put the numbers up there in the wall and everybody's shaking their head in agreement, yes, this is something we definitely need to put some resources towards.

JOHNSON:
Greg, can you give me an example of how data has changed the trajectory of a debate or an issue where it's maybe helped you get support when you didn't have it before?

CORBY-LEE:
Absolutely. That's coming in many types of meetings.

I've been at quite a few town hall meetings, and, you know, this is where the public health department is opening it up to the community to have that community discussion. And, you know, there's always going to be folks in the crowd that are just dead set against having the needle exchange program.

But once you look at the data, it can really be overwhelming. And it never fails, you know, when you ask the crowd in the room if they know of someone who's overdosed. They do—nearly everyone does. And you know, when you couple that with the data that we provide, it's difficult to not change your mind and realizing that we've got to do something because we're losing Kentucky.

JOHNSON:
So, let's talk a little bit about syringes. That's a topic that gets people going sometimes—at least it used to, maybe it still does in some places.

Dr. White from Kentucky talked quite a bit with us earlier in this podcast about the safe communities program. Tell us about that. Tell us how it came to be and how it's working today.

MARKIEWICZ:
It's actually an international initiative of bringing local stakeholders together in whatever the defined community is, whether it's the large urban setting or a smaller rural setting. And it's a matter of looking at the data and doing the community needs assessment and coming up with the priorities that need to be addressed.

And, in many times, substance abuse is one of the priorities, and obesity can be one of the priorities, and mental health issues, and suicide can be another popular area that gets addressed by safe communities. But there's a lot of merits and a lot of positive outcomes when we bring the right people to the table in the community for whatever the problem would be, let alone the opioid crisis.

There's a lot of merit in just who's sitting around the table. One of the key aspects of this is not necessarily having lower or middle management people sitting around the table. The communities need to engage the key holders, the people who can unlock the funds through the organizations that are going to support the prevention strategies in the long haul.

JOHNSON:
So, is it more than syringes, then, in Kentucky, or is that one of the leading success stories as it relates to safe communities?

MARKIEWICZ:
I would have to say that it is. One of the leading success stories about safe communities is dealing with the opioid crisis and the implementation of the needle exchange program through people collaborating together.

But they are focusing on other areas as well, and within the last three to five years, the opioid crisis has kind of taken center stage.

JOHNSON:
Greg, what's your thought on that process as it relates to the syringe issue?

CORBY-LEE:
Well, the communities that have the safe communities going were very quick to approve syringe exchange for the most part. And for those communities that don't have a safe communities going, we're kind of having to reinvent that wheel with each of these counties.

JOHNSON:
What is it that causes a community in Kentucky to say yes to the idea. Joe?

MARKIEWICZ:
Half of it is just educating the public about the facts surrounding hepatitis C and HIV infections. And a lot of the times when you just educate the community about what the data actually says is half of it.

The other part is if you approach a community from a public health standpoint, with the idea that we have these treatment centers and re-entry programs and substance use disorder facilities. If we cannot keep the person alive from the infections that they can get from their disorder, we can't treat them.

So, if you approach it from a public health standpoint—that we need to keep them alive before we can treat them—it makes a lot more sense to a lot of folks.

JOHNSON:
Can you talk about the work that the two of you have been doing on models for training local coalitions to hit these problems head-on?

MARKIEWICZ:
What I have done is I've been interacting with SAMHSA and CADCA, these large federal agencies. They all produce community toolkits for coalitions to address the opioid crisis. What I've done is I've taken a lot of that information and made it user-friendly to local community prevention coalitions.

For example, there are six focus areas that every community should be working on. And if I had to pick an area, Robert, that I thought we could really expand upon and do a better job? Communities being to pick and choose which prevention strategies they want it to utilize—for example, a syringe exchange program or a naloxone training strategy—but they're leaving out a lot of other pieces of the puzzle—primary prevention and treatment, and re-entry back into the community—and what do we have for that?

And so, the coalition trainings that we've been providing at KIPRC are more comprehensive. We need to address all of these focus areas, not just one or two.

JOHNSON:
Do either of you have any closing thoughts about this conversation as it relates to what the audience might take away from it?

MARKIEWICZ:
You know that they say that a coalition is not collaborative until somebody gives something up. Otherwise, it’s just a meeting.

But a lot of times when I conduct coalition trainings, I talk about not just getting together and talking about what you did last month, like process outcomes. But you know, you can't drive down a highway looking in your rear-view mirror. You have to be forward-thinking and forward-acting.

And we have to look out, you know, five, 10 years from now, on how we can keep from getting any worse and not reoccurring again.

JOHNSON:
Nothing about data can prepare you for the first time you see a newborn suffering from withdrawal symptoms.

Aaron Lopata is the chief medical officer for the Maternal and Child Health Bureau, a division within the Health Resources and Services Administration.

Long before he came to Washington D.C., he was a resident pediatrician at Children's Hospital in Los Angeles where he saw more than his fair share of babies suffering the consequences of addiction.

LOPATA:
It's very frustrating, of course. It's sad to see a child who is in distress. You know, as soon as they are born, to take their first breath, they're already experiencing distress.

There’s physical signs of withdrawal—increased heart rate, crying, excessive crying, sweating—it is what you would see if anybody had withdrawals, except these kids are experienced it as soon as they're born.

And honestly, it's not their fault—they have, of course, haven't done anything. So, to see a baby who's just born experiencing withdrawal symptoms from exposure to drug in utero it, you know, it's heartbreaking.

JOHNSON:
Now, Lopata and his team of doctors, nurses, and social workers use their experiences to hit the epidemic head-on with programs and grants directed toward people suffering the most.

LOPATA:
The opioid epidemic is obviously something that’s caused a lot of devastation, but I think we have reason to believe that we can help.

We have a critical role to play in preventing further tragedies down that down the road, and I think there's a lot we can do to help that.

JOHNSON:
In recent months, the agency has granted $200 million to help more than 1100 health centers and rural health organizations increase access to substance abuse and mental health services.

Another two and a half million dollars was granted to several states, including Kentucky, for a new rural health opioid program.

LOPATA:

It's definitely very challenging, and sometimes you have to be aware of the limitations of what you're able to do.

And I think that can be very frustrating because everybody here wants to do more. We constantly want to do more.

JOHNSON:
Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear them. Email us pr@astho.org—that's PR at ASTHO dot org. Also, if you liked the podcast, please share it on your social media channels.

Finally, you can find links to information about HRSA’s grant programs in the show notes for this episode.

For Public Health Review, I'm Robert Johnson. Be well.