02/06/19 Helena Hansen

This week, we hear portions of a public workshop on opioid substitution treatment that was held by the National Academies of Sciences, Engineering, and Medicine, featuring presentations by Professor Helena Hansen, MD, PhD; Professor Josiah Rich, MD, MPH; and Professor Eugenia Oviedo-Joekes, PhD.

Program: 
Century of Lies
Date: 
Tuesday, February 5, 2019
Guest: 
Helena Hansen
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CENTURY OF LIES

February 6, 2019

DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century of Lies. I'm your host Doug McVay, editor of DrugWarFacts.org.

On this edition of Century of Lies, we continue our look at opioids, addiction, treatment, and recovery.

The National Academy of Sciences, Engineering, and Medicine held a workshop not long ago on medication-assisted treatment for opioid dependence. We’re going to hear portions of that workshop now.

First, let’s hear from Doctor Helena Hansen. She has both an MD and a PhD, and is an associate professor in the department of psychiatry at the New York University School of Medicine.

PROFESSOR HELENA HANSEN, MD, PHD: So, I'm going to very briefly try to present some of my research as, first of all, a board certified addiction psychiatrist still working at Bellevue at their chemical -- outpatient chemical dependency program, where I've been for over a decade, also as a cultural anthropologist studying the social and cultural context of the current crisis and what led us here.

Three major points. The apparently universal nature of the current crisis is the product of specific ethnic marketing of opioids and targeting of drug regulation to white consumers.

Second, the impact of the opioid crisis on whites opens a window of opportunity to address the social determinants of health, but only if we directly address racial inequalities.

And then third, in order to see population benefits from addiction medications, we have to foster social and structural change, and that's where I think the panels from yesterday really anticipated this discussion.

So, my research -- let's see if I can change slides. Okeh. So, my research actually was prompted by my direct clinical observation of the pattern captured in this really early CSAT [Center for Substance Abuse Treatment] study, and that we continue to see today in most parts of the country.

According to the Congressional testimony leading to Data 2000, which legalized office based treatment of buprenorphine, buprenorphine was introduced to meet the needs of quote unquote "a new kind of addict," one that was quote "suburban" and quote "not typically associated with the term addiction." So implicitly white.

Deregulation of buprenorphine and the marketing and media surrounding it, which was coded as white, and these are just some images from the manufacturer's website. These were intended to destigmatize opioids and addiction treatment.

But addiction has long been enmeshed with race in our American policy. A century ago, racial imagery was used to build support for narcotic prohibition. And let me just ... okeh. There we go.

Later, racialized images of heroin justified the war on drugs under Nixon in 1971, and then racialized symbolism of crack cocaine reinvigorated the drug war in the 1980s to '90s in the midst of record unemployment in black and brown inner cities, prompting racially disparate law enforcement and mass incarceration instead of a public outcry over the tragedy of drug related deaths.

At the same time, as historian David Hershberg shows, there's been a separate track of legal, protected narcotics for use for middle class whites for over a century, and it has long been lethal.

Overdose among largely middle class white women from barbituates in post World War Two era rivaled opioid overdose deaths today. Later benzodiazepines like Valium were marketed as "mother's little helper" to suburban white middle class markets.

And our current opioid crisis was fueled by targeting marketing of Oxycontin and other newly patented opioids to predominantly white, rural and suburban areas for a large new market of moderate pain, people with moderate pain, like lower back pain, that traditionally had been -- where opioids had traditionally been restricted to post-surgical pain and cancer pain in their use.

So this -- they were marketed in populations whose race did not trigger regulatory surveillance due to their assumed lower risk of addiction.

And this led to non-medical opioid use in suburbs and small towns previously isolated from port city oriented heroin trade, and after restrictions on prescribed opioid supplies, prescription drug monitoring programs and other new opioid formulations that were difficult to inject or snort were introduced to the market, this brought heroin to suburban and small town markets.

And that's where these two images that I flashed earlier come into play, the new face of addiction.

And then, as you know, fentanyl accelerated multiple overlapping opioid epidemics. Black middle aged men are now showing the fastest growth in overdose deaths. Native Americans show twice the overdose deaths as whites, but the epidemic is still seen as disproportionately affecting whites.

So I'm going to go forward to this. Okeh, this is probably a study that's very well known to all of you. So this -- this perception of the opioid crisis as affecting whites was made explicit when two economists sounded the alarm of population level decline in life expectancy, specifically white life expectancy, largely due to opioid overdose deaths.

And they coined the term "deaths of despair," referring to the post-industrial decline of the white working class in the Rust Belt. And it's blamed for opioid use, overdose deaths, and suicide, as the social fabric disintegrated in these areas through unemployment.

Because the focus is on whites, the logic of social determinants of addiction can finally be heard in drug policy, yet the same argument could have been made for the black working class that also progressed from industrial divestment and unemployment to opioid deaths decades earlier.

So in our era of neuroscientific understandings of addiction physiology, it's tempting to forego attention to social determinants in our longstanding search for magic bullets. In order for medications to have population effects, though, this is really my argument, the social and health systems in which they're used has to be foregrounded.

So let's take France, which is often held up as a success story of buprenorphine maintenance as overdose prevention. In France, the opioid overdose rate dropped 80 percent in the first seven years after buprenorphine's introduction into primary care. It was billed not as a stigma reducing agent for a white middle class market, but actually a public health intervention to stem overdose and HIV transmission in low income, largely immigrant heroin injecting communities.

In a country with universal health care and a robust social safety net, and I have to underscore that, universal health care, robust social safety net. Very different context. So contrast this with the US, where the overdose rates more than doubled in the first ten years after buprenorphine's approval for office based use.

The public health potential of buprenorphine is limited by our race and class segregated health care system, which orphans patients that have patchy insurance coverage and tenuous access to prescribers.

So the bottom line is that we have to intervene on social structures, race and class based inequalities, in order to see public health impact of medications for addiction. Thank you.

DOUG MCVAY: That was Professor Helena Hansen, MD, PhD, from the department of psychiatry at the New York University School of Medicine. She was speaking at a workshop on medication-assisted treatment that was held by the National Academy of Sciences, Engineering, and Medicine.

You are listening to Century of Lies. I’m your host Doug McVay, editor of DrugWarFacts.org.

Now, let’s hear from Doctor Josiah Rich. He has an MD and a Masters in Public Health, and he's Professor of Medicine and Epidemiology at The Warren Alpert Medical School of Brown University.

PROFESSOR JOSIAH RICH, MD, MPH: Doctor Kumar mentioned being part of the elephant. I always realize I'm holding onto the tail when I'm near the elephant. I'm going to talk about, tell the story of -- [laughter] -- I'm going to talk about, tell the story of MAT in corrections in Rhode Island, and hopefully that will translate into a larger discussion.

After completing my training in infectious disease and HIV, I moved to Rhode Island in 1994, in the throes of the AIDS epidemic. Rhode Island was unusual in that more than half of the AIDS cases were related to injection drug use, and that was related to a law outlawing syringes.

During the '90s, a third of the HIV cases in the state were diagnosed in the Department of Corrections, so, I started going out there on a weekly basis and I tell my students I've been behind bars every week for the last 24 years. But I've been released from behind bars every week for the last 24 years.

Went about setting up model programs, and I should mention that Rhode Island is both a combined, a prison and a jail, which is, few states have that.

But, a model program to diagnose the disease, start treatment, and link to treatment in the community, test to partners.

But, you know, HIV is less than one percent of the population out there, but as I'm out there I started looking and seeing well there's a lot more diseases. I mean, half the people or more have a mental illness, half have an addiction issue, and so, why not do the same thing for other diseases?

So I started working over a decade ago, almost two decades ago, on, well, hey, we have methadone, why not treat opioid use disorder in the same way, diagnose it, start treatment, link to treatment in the community.

Then I ran into a lot of resistance. And I figured the problem is not enough evidence, so I set about -- set about the, establishing the evidence base, applying for grants and writing papers, and moving forward.

And, I had this epiphany in about 2015, and I just realized, you know, in spite of all this work that I had done, I hadn't really budged the dial. You know, in Rhode Island, if you are on methadone, you would be continued on methadone for a few days, when I first got there. It was a five day detox, fifty, forty, thirty, twenty, ten, and done, which is inhumane.

But that -- that is much better than neighboring Massachusetts, where you get zero.

And over the years, that evolved. We were able to start people on the dose they came in on, and then we were able to push that out a week, and then we -- we were able to push it out even further.

But, anyhow. In 2015, under the advice of a colleague and friend, Josh Sharfstein, the governor set up a task force to address the opioid epidemic, overdose epidemic, and I was fortunate enough to be one of the expert advisers, along with Traci Green and others.

We were given ninety days to develop a plan. We developed a four point plan. The key point was treatment, and we basically said, you know, Rhode Island has about a million population. We have about twenty thousand people that we think would benefit from getting onto MAT, and we should see where those people touch the systems, identify them, and get them onto treatment.

And at the same time, expand treatment capacity. And of course they touch in the entire medical system, in hospitals and clinics and emergency rooms, but also in the criminal justice system, and police and courts, prison and jail. And after jail, in community corrections, probation and parole.

So, the governor said, well, that's -- that's great. That's a great plan. Where should I put my resources? And we said, you should put them into corrections, because that's where the people with most advanced disease, you know, people become desperate, they resort to stealing, they resort to getting involved in the drug trade, in the sex trade, and all of those activities get them caught up in the criminal justice system.

There's also this situation where they're taken off of opiates, or reduced their use dramatically, and their tolerance goes down, and so they're released at a time when their tolerance is low, and at a time of maximal stress and triggers, and they relapse, and they're set up to overdose and die.

So, the governor allocated two million dollars. I spoke to the director of the Department of Corrections around that time, and he said, Jody, you know, you've worked long and hard in our system, and you've really, you know, my staff is starting to come around about this methadone stuff. You've done some really good work.

But, they're not ready for this suboxone, buprenorphine, you know, they're not ready for that. And I said, well, director, with all due respect, it doesn't matter, because the governor's going to tell you to do this, and you're going to tell your staff to do that, and if your staff wants to keep their job, and you want to keep your job, you're going to do it.

And he was sort of taken aback, but really, that was critical, because it set the tone, hierarchical tone to make it happen.

So, we began in mid-2016. A year later -- and Jennifer Clarke is the medical director, she said, we're going to screen everybody, we're going to start the most effective treatment that we have, and we're going to make sure they connect to treatment on the outside.

She did that, and within a year, we showed a sixty percent drop in overdose deaths in people being released from incarceration.

And I'm just going to end with a few things that jumped out at me, that I was not -- I was a bit surprised.

First, most people say yes, I want that treatment, when offered.

Second, most people have a preference. They know what they want. They want either methadone or buprenorphine. Very few chose deponaltrexone.

And I would say the most critical thing is connecting people to treatment in the community. If you don't have treatment to connect people to, you're not -- you're not doing any favors by starting a treatment program in corrections.

So, I think we've shown that this is doable, that -- but our major investment in this problem of opioid use disorder remains in the criminal justice system, and we really need to change that, and invest in treatment, and get people out of the criminal justice system.

And I would finally just say that we should really examine closely the Portugal model, where they diverted people from the criminal justice system into treatment. Thank you.

DOUG MCVAY: That was Professor Josiah Rich, MD, MPH. He's a Professor of Medicine and Epidemiology at The Warren Alpert Medical School of Brown University, and he was speaking at a public workshop on opioid treatment that was held by the National Academies of Science, Engineering, and Medicine.

You’re listening to Century of Lies. I’m your host Doug McVay, editor of DrugWarFacts.org.

You know, it's semantics. This was a workshop on medication-assisted treatment. Now, a quite convincing argument can be made that any medical treatment that involves the use of medication is, by definition, medication-assisted treatment. It’s odd that we’ve chosen to only use that phrase to describe the use of opioid agonists like methadone or buprenorphine in treating substance use disorders.

Possibly it’s because the medication is seen only as part of the overall treatment, which also would involve possibly counseling and lifestyle changes, maybe even acupuncture. But that still wouldn’t really make sense. I mean, there are a number of health conditions for which counseling is a part of treatment. And as to lifestyle changes, well, exercise and diet are essential for treating a number of conditions.

Type Two diabetes is a great example. According to the Mayo Clinic, quote, “Management of type 2 diabetes includes:

“Weight loss
“Healthy eating
“Regular exercise
“Possibly, diabetes medication or insulin therapy
“Blood sugar monitoring”

End quote. Yet when someone who has diabetes is using insulin to treat it, we don’t refer to it as medication-assisted treatment. I mean, the phrase makes little sense. I think it’s just a figleaf for people who are afraid of offending any drug warriors out there who are opposed to substitution treatment.

Well, here’s a hint: those people don’t care about the name you use. They're opposed to the treatment, not to the label. Trying to hide behind semantics doesn’t work, and it can even backfire.

I prefer the term “opioid substitution treatment” because, well, that’s what it is, that's what distinguishes this type of substance use disorder treatment from others. People who have a substance use disorder involving an opioid are regularly given an opioid of known purity and potency within a healthcare setting. The goal is for the person to be able to maintain so that they can integrate into the broader society, and the underlying factors that drive their substance use can be addressed.

In the US, this opioid substitution treatment involves the use of methadone or buprenorphine. In some countries, for example Switzerland, and to a lesser extent Canada, substitution treatment may involve the use of injectable diacetylmorphine – otherwise known as heroin.

Heroin maintenance treatment, heroin assisted treatment – again, several euphemisms to refer to the practice of helping people who have an opioid addiction and who inject heroin, to be able to maintain and live a normal life, and not involve themselves in criminal activity.

Rather than have me explain this, let’s hear from another of the presenters at this National Academies workshop, and I’ll apologize ahead of time for mispronouncing her name. Apparently no one at that workshop could pronounce her name correctly.

Doctor Eugenia Oviedo-Joekes obtained her degree in Clinical Psychology at the University of Cordoba in Argentina, a PhD in Social Psychology and Behavioural Sciences Methodology in Spain, and did postdoctoral studies at the Andalusian School of Public Health.

In addition to her affiliation with the Centre for Health Evaluation and Outcome Sciences in Vancouver, British Columbia, she's an Associate Professor in the University of British Columbia School of Population and Public Health and a Michael Smith Foundation for Health Research Scholar.

PROFESSOR EUGENIA OVIEDO-JOEKES, PHD: Good afternoo. My name is Eugenia Oviedo-Joekes, and I think I'm the only one that can pronounce it, so I'm going to say it myself.

Thank you very much for inviting me -- can I? Am I reaching? Oh no, that's okeh. I guess I'm too tall, or too low, for this?

Thank you so much for inviting me, or us, everywhere I go, I present the research of the team, so if I say I, or, at least remember that it's a huge team of fifteen years of doing research in Vancouver, University of British Columbia.

In the 1980s, a huge epidemic of HIV flooded Europe. One of the responses they had was to be able to reach almost eighty percent of the people that were using drugs by injection with long-acting oral opioids. Mostly methadone, but in countries like France, was buprenorphine.

Then, in the '90s, rich countries like Switzerland were still being hit by another heroin epidemic, and even when they are having safe injection sites, methadone, and many resources available to them, there were still very beautiful and lovable young people injecting in the streets.

And they decided that if that was the medication that they were using in the street, they would open sites for them, to provide them safe, medically prescribed, pharmaceutical grade, heroin.

It's called diacetylmorphine. So that was in the nineties. Since then, many countries, including the US, have been trying to prescribe diacetylmorphine, and some countries followed, including Canada, and today, in Canada, we are able to prescribe pharmaceutical grade heroin, diacetylmorphine, and in a second clinical trial, we are prescribing another injectable, short-acting opioid, that is, you may know it as diluadid, that is hydromorphone.

So, today, in Canada, we have several options for people that cannot stop, or do not want to stop, using street opiates. We have methadone, we have buprenorphine plus suboxone, and we have slow release oral morphine, and we have hydromorphone, and in certain places, you can access -- with a bit of help from Health Canada -- diacetylmorphine.

So, I have been involved in too many clinical trials, trying to bring these medications, and bring evidence. We have been well published, and I say that just to make sure you know we have the evidence to back this up, and what we have learned is, once we see the patients in our clinics, because of the nature of the medications we provide, we see the patients at the very far end of the continuum of care.

It means those patients that, by the time we see them, they have been injecting in the streets for twenty years. If there is something we see, it's the patients have failed nothing, it's the system that's failed the patients.

We see many training opportunities for the system on how we should care of the patients. We learned to listen to the patients. Thirty percent of our population that reach this treatment are from an indigenous community, when actually only five percent of our population is indigenous. So we learned that we are over-stigmatizing our indigenous folks.

We learned how the cultural genocide translates to the people that are using street drugs. So we learned that we need to include in our curriculum culturally safe ways to treat, and culturally safe means that we need to look at who we are, the ones who provide treatment, not so much the people that are coming, because people don't feel safe when they come to our offices, because we are very different, and we don't treat them in the way that they would like to be treated.

Because fifty years ago, we used to lock them when they had tuberculosis, and take them away from their families for years. So yeah, there is a precedent for why they, probably they don't come to treatment.

We learned that probably between thirty and ninety percent of the people we reach, they have childhood traumas. Physical, and sexual abuse, and neglect. We know that emotional neglect causes almost the same amount of damage in long term and how you build relationships with people, and how you care about yourself, as physical abuse, and we have ninety percent of our folks present to treatment with childhood abuse and neglect.

So we learned that we have to include trauma informed care, because we need to learn how we are, and how we relate to our folks. And as we learn to share patient decision making, when we allow physicians to have five medications they can choose from, and the patients feel less stigma.

We have talked about stigma, how stigma looks like for our folks. When they come to our clinic they have five medications they can discuss with a physician.

We're talking about ideal training, because we have a very small island of luxury today, in a few clinics in Canada, where we can practice how this will look like if you were able to have more options and all of them evidence based, with several randomized clinical trials, double blinds, published, New England, JAMA Psychiatry, British Medical Journal.

It will look like, when you come, the patients feel like they're not judged on what medication a physician will, as we heard today, very wise and compassionate people, saying we will want the patients to take the medication that we were trained and know might be the best for them, but we don't want them to leave without medications taken, because we know that if there's no medications, most likely they're not going to do well.

People come because of the injectable short acting medication, but nothing else will do. It's about the medications. It's about caring for people. So when we're trying to talk about training, we talk about training a full spectrum of patients' needs, and meeting people where they're at.

Sometimes from the health care system, we're really, really, really far to understand what people need, because we have not been trained for it. And I heard very interesting, and beautiful ideas. Yes, students are now, today, in a very social justice mind, and they want to know, they want to be, they want to be part of this.

So, if there is something we can share from the very wild idea of providing injectable short acting medications to patients is, it allows an idea of ideal way of negotiating better care for our patients.

DOUG MCVAY: That was Professor Eugenia Oviedo-Joekes, PhD, with the University of British Columbia School of Population and Public Health and the Centre for Health Evaluation and Outcome Sciences. She was speaking at a public workshop on opioid substitution treatment held by the National Academy of Sciences, Engineering, and Medicine.

And that’s all the time we have for this week. I want to thank you for joining us. You have been listening to Century of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.

The executive producer of the Drug Truth Network is Dean Becker. Drug Truth Network programs, including this show, Century of Lies, as well as the flagship show of the Drug Truth Network, Cultural Baggage, and of course our daily 420 Drug War News segments, are all available by podcast. The URLs to subscribe are on the network home page at DrugTruth.net.

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We'll be back in a week with thirty more minutes of news and information about drug policy reform and the failed war on drugs. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.