Hello, my name is Josh Sharfstein. I'm the Associate Dean for Public Health Practice and Training here at the Johns Hopkins Bloomberg School of Public Health. It's my pleasure to have this conversation today with Dr. Nicole Alexander-Scott, the Commissioner of Health for the state of Rhode Island. We're going to be talking about Dr. Alexander-Scott's work on the opioid epidemic. Thank you for joining me. Thank you for having me. So, tell me a little bit about yourself. You are a physician. How did you get into public health? Yes, I'm an adult and pediatric infectious disease physician. Originally from New York, Brooklyn in particular, and went to Brown to do my adult and ped's infectious disease fellowship. During that time, really had the opportunity to get involved in legislative advocacy. We had a newborn infant who was born with HIV that I know would not have happened were we in New York, where I was for residency. So, changing the law there really drew me into public health and public health policy. What was your first exposure to the issue of opioids in Rhode Island? My first exposure was day one of taking on this role as Director of the Department of Health. When the governor appointed me, she very soon after that appointed me to be co-chair of the Governor's Overdose Prevention and Intervention Task Force. So, that's been an instrumental piece of this. Governor Gina Raimondo of Rhode Island has been a phenomenal leader regarding very decisive clear direction for helping Rhode Island as a state address this opioid epidemic. So, Rhode Island, would you say this is one of 1,000 problems, one of 100 problems, or the top 10. Where would you put the opioid epidemic? How serious an issue is it? It's number 1 public health crisis that Rhode Island has ever had to deal with. Certainly, I would say even nationwide. It requires multidisciplinary solutions coming together to really address it. I saw at one point that Rhode Island had more overdose deaths than homicides, suicides and motor vehicle accidents combined. That's it. How do you wrap your hands around a problem like that as the commissioner of health? We know, first of all, that it's a team effort. We're clear in the state about saying it's an all hands on deck approach. I mentioned that I'm a co-chair of the Governor's Overdose Prevention and Intervention Task Force. The co-chair who leads with me is Director Rebecca Boss of our Behavioral Health Department, and most recently we've had Mr Tom Coderre join and is on behalf of the governor and is going to take on one of the co-chair roles as well and add tremendous value to the approach that we're continuing. So, many states have recognized the opioid epidemic as one of the top crises facing the state. Many states have a lot of interest in seeing progress. Rhode Island has been noted to have made more progress than other states though. So, I think it would be helpful to take people through how you got from A to B. You're the co-chair of the Overdose Task Force, you've got this huge problem, you have all these interested people. But you didn't do everything, you picked certain things to do. How did you go about picking them and what were the most important things you think that Rhode Island has done? Well, we knew early on that we had to start with data and use that as a way to keep us focused. We also needed to make sure we didn't just stay with data, but use the data to drive us to action. With doing that, we developed a group of expert leaders, academicians in particular: Dr Josiah Rich, Dr Tracey Green, a person named Dr. Josh Sharfstein was also very instrumental. Combine that with local leaders. Mr. Jonathan Goyer is someone who is a true peer recovery advocate, Brandon Marshall is one of the epidemiologists at Brown University School of Public Health, as well as one of our pharmacists Jeffrey Bratberg. Together, that group developed our strategic plan, statewide strategic plan that was led by data and also engaged the public as well as our Overdose Task Force. So, it was informed. But we took all of that information, and what was critical about this group of experts was the guide us towards strategic simple strong strategy. So, by strategic, you mean at least 150 recommendations, or something fewer than that? A little bit fewer than that. So, one of the things Rhode Island plans to develop was really having some focus strategies, not just being a kitchen sink approach. What would you say the most important strategies were? What was extremely helpful and what I would recommend to anyone that looks at how to approach this, is being very clear on the four categories that really were the basis for the strategies: treatment, prevention, recovery, and reversal, or rescue, which is what references in the locks on. Our most important one was treatment, and the reason is because of the data. We had data from Baltimore, data from France, that showed when you scaled up access to medication assisted treatment, and you can certainly add to this, with Buprenorphine, you saw decreases in overdose death rates by upto 70%-80%. In order to really make a shift with this epidemic, our number one focus was to save lives. So, setting a target that was clear, we set out to decrease overdose death rates by a third within three years. Then, use evidence to develop clearly defined or major strategies and treatment as our primary one. Let's talk about treatment a little bit and then we'll go to the other ones. So, for treatment, what does that look like in practice? So, you have looked at treatment in unusual settings, you have expanded treatment in different places. Just give us a little bit of a sense of that. Absolutely. We know that scaling up access to treatment requires us to really involve the institutions around the state that the most people are going to come in contact with. So, one of them is our correctional institution, and I want to really credit our partners at the Department of Corrections in Rhode Island, Mr. A. T. Wall, as well as Dr. Jennifer Clark. With the governor's leadership and investment, we committed funding to offering medication assisted treatment to those while they are in correctional institution and supporting them after release, which was a complete shift from what it used to be. It used to be people withdrew from opioids when they were in detention and they came out having lost their tolerance at risk for overdose. You're saying actually that's an opportunity to treat people. Absolutely. Instead of removing someone who comes in from being on methadone. Yeah. Not only continue methadone if they come in on methadone, but screen, identify, and treat someone with any of the three options for medication assisted treatment. So, methadone, buprenorphine, or naltrexone. So that any of those options are possible, that's key and being able to continue them on afterwards. So, the second element to that that has been so transformative is, instead of waiting until they are released from incarceration to get them engaged with treatment afterwards. We partnered with our treatment provider Codac in Rhode Island, to begin engaging with people while they are incarcerated. So, they get screened, diagnosed and started on treatment, any of the three options, and then Codac comes and meets with them and starts them as a client then and there. Got it. Now, what about in the hospitals and emergency departments and other treatment setting? In the hospitals, we've created levels of care. Four EDs in hospitals throughout Rhode Island. I want to really credit our hospital systems throughout the state. They've been excellent partners in becoming the first state to put this in place. With the three levels, we expect that every hospital in Rhode Island, fulfills level three at least as a baseline. That includes making sure that naloxone is offered to patients, making sure that fentanyl testing is included in the drug screen that's done. That people are screened for any type of substance they use. That they referred to peer recovery coaches as well as treatment and recovery services that are needed, and that the data that's collected in the hospitals is reported to us at the Rhode Island Department of Health. That's the baseline level and baseline requirements so that across the board, there's a standard level of treatment for anyone that comes in with substance use disorder. Level two, means that you do all of those things plus partner with an addiction specialist. Who is able to provide support upon consultation, to get someone started on medication assisted treatment and connected further to referral and recovery services. As well as, in addition to a baseline screen, doing a more comprehensive assessment to see what other services are needed. Level one, makes a hospital equivalent to our statewide centers of excellence. That's a model that says, "A patient can be started on medication assisted treatment as well as receive behavioral health and recovery services that are needed to continue a life in recovery successfully." They can then be referred out to a primary care provider, or Codac, or one of the other behavioral health agencies. But have the opportunity to come back if they need further surfaces stabilization, or to be weaned from medication assisted treatment. That's great. I just think it's important to get a sense of how seriously Rhode Island has taken this job of expanding access to treatment, particularly achievement that includes highly effective medications. Absolutely. We know that that's everything. So, let's move on to the other three major areas, prevention. I am aware that one of the focuses has been to improve prescribing for pain and particularly prescribing that combines benzodiazepines and opioids. What are the other major prevention activities? Well, we've worked closely with prescribers and providers to raise awareness, about ways to limit opioid prescribing particularly upon initiation for acute pain. Ways to distinguish that and have a different approach for those who are experiencing chronic pain. So that we know that people who have cancer or palliative care or sickle-cell disease, could be potentially harmed by being just cut-off completely from opioid prescription, but would benefit from tailored transition to what's needed to maintain their long-term pain concerns, because pain is real. With acute pain though, that's where your risk of going into long-term therapy is highest, and where there's the greatest opportunity to limit opioids by either not even starting it to begin with or decreasing the amount. So, what we did as an approach for Rhode Island is instead of giving an automatic day cutoff, we'll have limit the pain based on morphine milligram equivalents. Okay. And set a mark that, for acute pain initiation of opioids if needed preferably not, would require that someone is not prescribed more than 30 morphine milligram equivalents per day, for a total of 20 doses. That allows for the prescriber and the patient to develop the relationship that they think is best for either three days, five days, or seven days, as long as they fall within that limit. Then, thanks to partnerships with our pharmacy benefit managers, we've been able to insert mechanism for alerts to occur at the pharmacy level, so that if a pharmacist receives a prescription for acute pain in someone that is beyond what our regulations say of the 30 morphine milligram equivalents, an alert goes up so that pharmacists can call the provider. We've seen that that's been working well, to help decrease prescribing of opioids. Great. As for now, you've been convening communities to talk about a little bit more upstream interventions on prevention. Absolutely. We are developing a campaign for youth to be able to prevent and that's in partnerships with truth initiative, which we're excited about. We've also activated a family task force to talk to parents and families impacted by the overdose epidemic, so they could help inform the message that we need to get out to youth and to parents. Another early mark that we're doing is, our Medical School at Brown University has become the first one in the state, to incorporate data waiver training into the medical school curriculum. Not just the first one in the state, is it? First in the country. Okay. I don't know how many medical schools you have in Rhode Island. Okay. Thank you for that clarification. Excellent. So, let's talk about reversal for a minute. Narcan, people are familiar with. What's been the approach that you've taken on Narcan? Addressing stigma and getting Narcan everywhere. Our goal is for naloxone to be available in supermarkets, in movie theaters, in schools, in churches. So that, it's not just based on whether or not someone have substance use disorder, but it's equivalent to the defibrillator that exist. We've actually created naloxbox, so that they are available in public settings. The other thing we've done, is worked with pharmacies so that anyone with insurance can walk into a pharmacy and ask for naloxone and receive it. Let's just pause for a second and talk about stigma since you mentioned that. How important is kind of addressing stigma to the general strategy on the opioid epidemic? With each passing day, I see more and more how critical stigma is. We as a state have done all the right things. We had an evidence-based strategic plan, put that in place last year. We really focused on implementation of that plan and this year, our focus is going to be on addressing stigma and making sure that at the community level, social, economic and environmental determinants of health are addressed for individuals. Because we've seen you can have the models in place and have it be evidenced-based. There needs to be an understanding of empathy for people regardless of drug use history, regardless of the color of their skin, regardless of where they live, what their background is, who they pray to. An understanding of meeting people where they are and not treating this as a criminal issue, or law enforcement issue, but treating this as a public health needing to get to treatment issue, because it is a disease where recovery is possible. Making it similar to someone who has diabetes or someone who has cancer, we don't blame them for it or stigmatize them. Making some of those changes are critical to have seen any turnaround in these numbers. How do you as a leader, address stigma? If somebody comes up and maybe they use a term that you wouldn't use to refer to someone or they ask you why you're spending all this time on this issue or something that you can tell that there are some stigma behind that, how do you handle that? We all have to do it by example, we all learn as well, the humility that's necessary there, so learning from you and other colleagues about how powerful words are and avoiding words like addict, or junkie, or even drug user, but we we are people and some people have different challenges, everyone has a challenge of sorts. So that's one, and the other and really focusing on the environment and making sure that the resources that people need to have a job, to go to school, to live, to have access to transportation are in place regardless of your background, regardless of drug use history, regardless of cancer or diabetes. So, that gets into the fourth area which is recovery, and that's really pioneered the use appears to help people in recovery. I don't know if there's like a story or two you can share related to peers, how do you try to explain the value of a program like that. The peer recovery coach leadership in Rhode Island are my heroes. It's really where the true expertise and guidance comes from for the state. I mentioned earlier one of our expert advisers Jonathan Goyer, has taught me a tremendous amount. Things like the fact that we are in an addiction epidemic and we are focusing on opioids but it's really a reflection of so many of the elements of despair and other things that are out there that we have to be sensitive to. Also, the opposite of addiction is something that Jonathan says is not sobriety but is connectedness, and community and coming together and that's so poignant in this day and age where there's so much social media, and people are next to each other, and texting as opposed to engaging with each other and our seniors and the isolation that so many of our baby boomers are experiencing, really focusing on community and coming together as a key part to this epidemic while we adjust stigma so that we can do that effectively. Our only lessons that we would learn from our peer recovery community and there's nothing as powerful as being able to say, "I've been there, I know what it's like and I need it you're going to be able to make it too.". So, I'm not know one of the things that I've noticed is people look at the scale of the Opioid overdose epidemic particularly are the overdose epidemic overall 63,000 or so Americans lost their lives in 2016 and I think they're pretty hopeless. They may see people around them who are suffering, they may also just be frustrated with the state of politics or whatever it is, I've heard people just express a tremendous amount of hopelessness and they'll say things like, "Well, we should try. We should try we shouldn't expect to be successful but we should try and maybe once we'll be successful." You've been doing this for how many years have you been health commissioner now? Since April of 2015. So, it's almost three years? So, what's it been like for you as it had been a gradual sopping up your level of competence on this or how do you get up in the morning to take on a battle like this. Do you agree with the idea that this is an overwhelming challenge? No. I agree fully with the notion that we've said that the overdose deaths that we've experienced has been over 1,200 unfortunately in Rhode Island over the last five years, each one of them could have been prevented, and it's with that understanding that we're motivated for going forward. We know that this is not going to just happen like that in terms of overcoming it. We delivered about using the term an all hands on deck approach, and in particular this year, we want to really focus on what each individual can do. There's something that each of us can do. Whether it's at the dinner table with our family, and what the conversations are like, and how we can generate being judgment free, and being a demonstrating empathy, and understanding or meeting people where they are. That's something that can spread at the dinner table with children, with parents, and other family members, to what someone can do at work whether that's their job focus or whether it's not, because people in recovery need to be able to work in whatever job they're in. So, creating an atmosphere that embraces each other whether we're dealing with addiction or some other challenge or not, and really doing it in a way that's different from what we did 20 years ago. What do you say to people who say there's no way to be successful on this? We're demonstrating that it is possible to be successful. We, in Rhode Island, have seen a leveling off and even a decrease of some of the overdose deaths. We're clear that it's of so much of what we described today. It's having evidence-based plan being strong and simple about it and making sure that there's an all hands on deck approach that the pharmacist to the peer recovery coach so the provider to the insurer to the public are all a part of helping us make this shift. So it's not mission accomplished on the other hand? Not at all. You are seeing the progress? We are seeing progress. You have through your work, I can feel the energy and enthusiasm that you have engaging people, engaging institutions, or even jails to do things they've never done before at the hospitals involving peers and others thinking about these underlying causes, you feel some momentum. Absolutely. Strong leadership in place like our governor and people recognizing that we each play a role in making a difference. Great. Well, thank you so much for joining me this been a great discussion. Pleasure are mine.
