Bobby Mukkamala, MD: Welcome to the American Medical Association Physician Education Podcast on the Opioid Overdose Epidemic. Through expert discussions and insights, this podcast will feature information that can help physicians of all specialties address the epidemic of opioid overdoses. Free CME is available.
I'm Dr Bobby Mukkamala, board certified otolaryngologist and a member of the American Medical Association's Board of Trustees. It is also my privilege to chair the AMA Task Force on Substance Use and Pain Care. As North America is experiencing an unprecedented opioid overdose epidemic, there are steps we can take to prevent them.
In this episode, we'll discuss overdose prevention strategies, including the benefits of naloxone for overdose protection. We'll also take a look at ways to reduce stigma and bias related to overdose prevention. Joining me in this discussion is an innovator in pain management, opioid overdose prevention, and addiction treatment, Dr Nabarun Dasgupta. Dr Dasgupta is a senior scientist at the University of North Carolina at Chapel Hill. Welcome, Nabarun. Good to have you here.
Nabarun Dasgupta, PhD, MPH: Thank you, Bobby. It's an honor.
Mukkamala: So, can you share with our listeners a bit about yourself and your work, like, what's a day in your life like? What are you up to?
Dasgupta: So, what I've been doing for the last 20 years is really focused on overdose prevention.
Preventing overdose deaths is my life's work. Where I work now is the Opioid Data Lab, which is a cross-university collaboration with the University of Kentucky and the University of Florida, and we do studies on three different areas. So, we do theory, practice and lived experience. And so, theory studies are looking at pharmacology, looking at statistics, biostatistics. Practice is the practice of medicine, practice of pharmacy. And then lived experience are the most interesting studies where we work with pain patients, with people who use drugs, and community groups and public health to really understand what matters for them on the ground, letting them drive the research questions.
So, it's a combination of super nerdy stats and lab work all the way through community engagement.
Mukkamala: Very nice description and kind of encompasses medicine in general. So, I'd like to start our conversation about overdose prevention by asking you about Project Lazarus, which you co-founded. So, take us to the beginning of that story. Can you describe the circumstances that sort of compelled you to launch this project?
Dasgupta: There was a county in North Carolina, Wilkes County, that had the third highest drug overdose death rate in the country. And at that time, it was exclusively due to prescription opioids. There was no heroin to speak of in this county. And I met up with a local pastor there who was really engaged in trying to find solutions. I had just come off of working at the World Health Organization. I had kind of international and national experience, and wanted to help.
And we created something that was kind of a wraparound community engagement model where we, of course, worked with medical providers trying to find pain management providers who were really doing the right things and practicing pain management with the highest fidelity. But we also worked with the faith community, with schools, with law enforcement, as well as with methadone clinics and buprenorphine clinics to get addiction treatment.
One of the innovative pieces of that was to provide the overdose reversal antidote naloxone to people who are using drugs, but also to pain patients who had other risk factors. It was about eight different interventions kind of packaged together. And the overdose death rate dropped by 69% over two years and has remained kind of at a low level, and that county is no longer ranked in the national statistics in terms of overdose deaths.
One of the fascinating things that happened was increasing the engagement in pain management. When we first started, when I first started working with that team, we, there were all these like national guidelines on proper pain management, but the community really insisted on making their own. And it was this, it was this moment where I had to kind of step back and not impose my outsider vision on things.
And so, they took and read all the national guidelines from every professional society, but they made like a three ring binder of what they thought was the most important parts and kind of contextualized it into their own work product. And kind of making this into their own thing that really brought the community together and started them off on a path where they weren't looking at just pain management or addiction medicine or overdose as separate things, but as a continuum of things that befall that community and needing to augment, everything from support groups for pain patients all the way to harm reduction services for people who are just injecting drugs. So, that was my first lesson was as an outsider to kind of step back a little bit and let the process kind of wend its way through the local powers and local thought leaders to get them ownership on what they were doing.
Mukkamala: So, Project Lazarus has become a public health model hailed by former President Obama as a model for community-based overdose prevention. Can you describe the overdose prevention premise that the model is built on?
Dasgupta: So, I think in a simple way, it takes community. The overdose problem that we were facing then wasn't just because of physicians, it wasn't just because of pharmacists, it wasn't just because of decisions people made to use drugs or not.
It was kind of the holistic environment. And the impetus to do it was, even at that time, a frustration that the traditional things of a purely law enforcement response wasn't doing enough. It was not working to reduce the overdose death rates. And one of the ways that we know that this, that what we did worked was, before we did the intervention, most people who were dying of an overdose had been prescribed the opioid analgesic that they had died from by a physician in that county. After the intervention, there were no deaths linked to the prescriptions of physicians in the county.
It wasn't like a one-sided thing where it was just cutting out opioids, but the amount of opioids kind of stayed more or less the same. But the way that opioids were being prescribed was much safer, and it was kind of taking a lot of pieces of conversations that were happening nationally and blending them together in this rural Appalachian context. And that Appalachian context is really fascinating too, because why would this like particular location have such a problem? Well, this is the birthplace of NASCAR, where NASCAR was inaugurated as a sport at the Wilkes Motor Speedway.
Now, the reason why NASCAR comes into this is that the origins of NASCAR are intimately linked with substance use. So, if you had a car that was stripped down, looked like a normal car, could go really fast and had a lot of room for storage, that kind of vehicle was used to run moonshine from the rural areas down to the cities starting in the Prohibition era.
And so, you have a community that has been dealing with substance use at the margins of the law for generations. So, changing the mindset and the response in those communities was in some ways difficult. Because there was only one solution, which was law enforcement. But at the same time in this particular place, because in the words of someone who was from that community said, we know we can't lock up all our sons for providing for their families. And so, they were ready for something that was broader and addressed their economic and other issues that were going on at the same time.
Mukkamala: Even the Office of National Drug Control Policy, which used to be sort of a law enforcement presence there at its head, now has a physician there for the first time.
And so, looking at these issues, not as something that needs to have more law enforcement, but instead treating underlying medical conditions, really sort of changed the way we approach it.
Dasgupta: That's right. And even in addition to the medical conditions, also the societal conditions too. There's so much stigma, there's a lot of denial that there is even a problem in many places.
There's this disconnect that I find in doing this work where publicly people will have kind of entrenched ideas about this, but those same people are also having conversations around their kitchen tables about the folks they've lost in their families or in their communities. And so, there's kind of a, almost a disconnect between the human kind of around the kitchen table conversations and the policy dialogue. Where people kind of know that we need better solutions.
And I think in some ways, doing this work for 20 years, I've come to appreciate a level of humility that I didn't have when I started. The problem has tripled since I started doing this work 20 years ago, in terms of number of overdose deaths. So, in some ways it feels like either I'm not very effective in my job or more likely that we're dealing with forces that are so far outside of our control that we need to have an open mind in how to bend the arc of some of these broader forces.
Mukkamala: Yeah, exactly. It almost seems a little bit like the whack a mole analogy and that with physician prescriptions going down by more than 40% since you started the work that you're doing and bringing awareness to our prescribing habits. And yet, the number of deaths has gone up because the target has moved not, it's no longer in our offices as much, but it's out in our communities.
Dasgupta: Sure, so if we're talking specifically about physicians, let me tell you about one study we did. We did a survey of 400 something physicians in one state, and what we found was that across medical specialties, there was a big difference in how physicians viewed the origins of the opioid overdose problem.
Some specialties, especially emergency medicine and addiction medicine, kind of had more of a finger to point at their own profession. Whereas other specialties thought that this was something that was more a broader societal problem, not driven by the medical community. And the reason why I bring that up, regardless of how true it is or not, what's really important is that if physicians or anybody working in this field has a mindset that the origins of the problem were external, they're going to feel less empowered to make changes that can address the problem. And so, this is a kind of well-known Nobel Prize winning psychological theory called attribution theory.
It's really easy to think back to events that happened 20 years ago and say, “that's what caused the problem we're in now.” And yes, it might've catalyzed it, but the problem we have now is something that we should feel more empowered to change. And I think hearkening back to what happened decades ago and just blaming pharma is counterproductive in actually getting people to feel like they're empowered to make changes, physicians included, from our data.
So, in terms of what physicians can do, I mean, I think the emergency response of providing naloxone. And so, naloxone is the antagonist that reverses an opioid overdose. Providing that to people who are at risk for overdose is really powerful. We've heard of hundreds of thousands of reversals. There's tens and tens and maybe even hundreds of thousands of people alive today because of this intervention that was started in 1996.
At the same time, there's also smaller things that we hear about why people who are looking for help don't get the help they need. So, if people are ready for addiction treatment and your practice provides that, making that as low barrier as possible is something that takes active, it's an active thing that must be done and thought through. Everything from literacy to the font on the size of forms, all the way through to what does aftercare look like, where do they store their medicines.
There's a lot that could be done to reduce the burden on the patient so that once they come to you, you're ready to meet them where they're at and really make it easy for them to stay engaged in care.
Mukkamala: Another thing that a lot of communities are working on is related to medication disposal, right? So not so much what happens in the offices, how much we're prescribing, checking the PDMPs, but after that prescription, there is sometimes an excess of medication.
So, so tell me about the project that you were working on. I think Project Pill Drop, a community-based medication disposal program?
Dasgupta: Sure. So, the disposal of unused medications was part of Project Lazarus. It was one of the outreach strategies. And it was really fascinating because we were thinking of it initially as like a way to get excess supply off the streets.
What it turned out being, it's like, of the medications that were being returned in these drops, a relatively small fraction were prescription opioids. A lot of them were old antibiotics that people didn't finish the course of or other medications. So, it turned out to be kind of this moment of educating about medication safety more broadly and even going through the same discussions of why you should finish a course of antibiotics and kind of it was a more holistic response.
In some ways, pill drops became, it was the choir. It was the choir that we were already preaching to who were interested in bringing those in. When we did a statistical analysis looking at how much impact those pill take-back events had, it didn't show up in the overdose mortality data as having a statistically significant impact. But what it did do from talking to and being at those take-back events is that it engaged the community. It was something that law enforcement could say they were doing and allowed for those events to have not just law enforcement there, but social workers, public health folks.
And to be able to be a venue for education and providing resources, including distributing naloxone to folks who were prepared and ready to listen to, and look for new solutions. Once people dropped off the pills that they weren't using, they wanted to know more. What was the next thing they could do? And I think that's where the real power of that was.
Mukkamala: So, it's an interesting point that dropping off the prescription for amoxicillin actually could stimulate a conversation or a thought in somebody's mind when they see somebody else dropping off some opioid pills that they might have at home, that then starts that conversation that say, “oh, I didn't think to bring that in.”
So, not necessarily counting the number of opioids that were dropped off, but the conversation that starts in the community.
Dasgupta: That's right. Not to play the stereotype too much, but one person told us that we don't even throw away our old, unfunctioning cars. Like, why do you expect us to throw away the medications that work?
And in places that have low access [to] health insurance, whether private or government funded, it's hard to sometimes see a doctor, sometimes see a specialist, especially in rural areas. And so, addressing some of those fundamental needs and knowing who, which physicians or clinics in the community have capacity, have a more tidy practice and better referrals, like those things are all kind of part of what a comprehensive program involves.
Mukkamala: You mentioned word comprehensive. So, as far as the Segments of the community that are present in those coalitions law enforcement is a logical one. Medical folks physicians and other health care providers. You mentioned social work. What are any other categories that you would say if you're going to build a coalition, these are the people that should be in it.
Dasgupta: A champion, someone who feels like this is their mission and helps drive things forward. In one community, it was a retired physician. And another, it was a pastor. In another place, it was someone from the harm reduction world. And so it's really, it was fascinating. After I had done a lot of international work, that kind of local champion model is something that international public health development uses, and is kind of just a known thing that works. And to see that kind of on the ground in rural Appalachia was also like, “oh yeah, duh, of course it works here too,” right? We're not special in that way. So, the champion, I think, was often really like the person who made things happen.
Mukkamala: And you mentioned several examples of people that could be a champion. I've seen champions be the family, the survivors of somebody that they lost to a substance use disorder. Have you seen that in your work?
Dasgupta: Absolutely. Yes. And I think when you're thinking about these coalitions, it's a really good time to have this conversation because in each of the 3,000 or so counties in the US with, who are getting settlement funds, they're all kind of mandated to put together these types of coalitions. And the obvious players have already been talking to each other in a lot of ways and aren't necessarily going to get something new or bigger done.
And so having people who use drugs at the table is an absolute core, just as important as anybody else. And also, I think having pain patients at the table is really important because the collateral damage that is being done to communities of people with chronic pain, and acute pain for that matter, is tangible.
I mean, the suicides are real and they can't be an afterthought at this point, given what we know. And so, I think even within like people who use drugs, there's a, it's really fascinating to have this conversation with the folks who are on these different county advisory boards. And there's a difference between someone who's a stimulant user versus predominantly an opioid user or someone who injected versus is a smoker.
And those kinds of differences really matter in terms of whose voice is represented at the table. A lot of times we make the mistake of trying to, of thinking of people who use drugs when, at the worst point in their lives, right? As medical providers, you see people when they come to you for help and they're at a low point.
But a lot of people who have a drug use history also maintain very normal lives and you'd never know. And kind of, getting people into those coalitions, who have a breadth of drug use experience, but also have some sort of standing in their communities to represent their communities with fidelity, I think is really important.
Mukkamala: Yes, absolutely. So, I'm shifting a little bit and we mentioned it a little bit earlier. So, Project Lazarus was one of the first programs in the world to provide the antidote naloxone to patients with pain and people who use drugs to reverse this overdose epidemic. So, what is naloxone and what role does it play in overdose prevention? And what motivated you to provide the naloxone rescue kits as a cornerstone effort of the Project Lazarus?
Dasgupta: So up until that point, this is again, like the mid-2000s and the naloxone had been used as an intervention to prevent heroin overdoses, mostly in urban areas, started in Chicago with Dan Bigg and the Chicago Recovery Alliance.
And then it was in Baltimore and Boston, San Francisco, places that looked very different to rural Appalachian North Carolina. But the pharmacology of what we were trying to prevent was exactly the same, right? We're still talking about a mu opioid agonist, right? Something that can cause respiratory depression like heroin or oxycodone, hydrocodone, fentanyl, morphine, whatever.
And the naloxone is the antagonist. It's the antidote that reverses the opioid overdose and allows breathing to be resumed so that there's enough oxygen going into the brain and people's respiratory rates are up again. And so, what had been kind of an urban heroin injector intervention, we retooled it and with the blessing of our state medical board, were able to kind of roll this out specifically in that county where, like I said, at that time, it was all prescription opioids that were causing the fatalities.
And so, we knew from the PDMP data that a lot of those folks had been seen in medical care, and so we rolled it out there. What was really fascinating is how the theory versus practice diverged really quickly. So, we, at first, were thinking like, okay, look at the risk factors of the patient, look at kind of what other medications are they on, thinking of very like biomedical perspective.
Once we gave them the naloxone kits, those naloxone kits often did not stay with that patient, but the patient gave it to people in their circles that were actually using opioids illicitly, without a prescription or were not under medical care. And so, they would come back for refills and we would ask, “Oh, what happened? Did you use it?” And it was, “no, we gave it away to so and so.” And it quickly became not just that the pain patients who we were prescribing the naloxone to were the, were not necessarily the ones who we ended up influencing, but there was this kind of diffusion of benefit throughout the community.
That model kind of surprised us at first because we started with such a biomedical approach to this. But then when we brought the naloxone kits into the opioid treatment facility, a buprenorphine and methadone clinic, they saw that kind of behavior of giving it out, of what we call secondary distribution, really powerfully. And they were seeing, they were giving out more kits, naloxone kits, than the number of patients that they had at any given time. And that was actually when we started getting reversal reports, wasn't necessarily from the people who had been prescribed it, but people who they had given it to within their social networks. And that kind of made us really change how we think about it from just a purely pharmacology and risk factor-based thing to, okay, this is something that really needs to be out in the community.
But there's only going to be certain folks in the community who feel empowered enough to come get it. And so how do we create a model where we encourage that secondary distribution? And this is all still when it's a prescription drug. So, there's a lot of legal issues, ethical issues, third party administration of medication.
There's a lot of complicated things in there. But at the end of the day, we made the case for why this was important and it worked. And we've heard repeatedly that there's people walking around, people who are alive because of that work that we did.
Mukkamala: As we're in this next chapter from the chapter you just described that you went through, we're now the prescription barrier to get it is gone, and it will soon be showing up on the shelves of our pharmacies over the counter. I imagine that dynamic will change. What sort of resistance did you run into then, and what do you anticipate sort of the problems may continue to be, even though now it's gone from behind the counter to over the counter?
Dasgupta: So, I think from the beginning, cost has been the biggest issue. There's a few nasal spray versions of naloxone at different dosage strengths, but there's also liquid injectable. The price difference between those is something like 30-fold different. When we think back to like how naloxone actually gets into the hands of people who are in a position to reverse overdoses, if we think of naloxone as this precious commodity that is expensive, we're going to hesitate to give it out everywhere it needs to go.
And so, for me, like the OTC designation I think is a great step in the right direction. But if that still costs like $50 for a box of two applicators of naloxone, that's still a lot of money compared to $2 or $3 that the liquid injectable could cost. And so, in order to scale this to where it needs to go, we take our eyes off the cost.
Unfortunately, the Food and Drug Administration only allowed for the nasal spray to be OTC and not the liquid injectable. So, now we're in this kind of limbo period where the states have all passed laws and had standing orders and all sorts of other, tied themselves in knots trying to get naloxone out. But now we have kind of this two tier system.
There's a cheap, expensive over the counter product, a cheaper one that remains prescription only and I can understand needle phobia. I think COVID vaccines reminded us all about how much some of us hate needles, but a lot of the people who are dying are people who are already injecting drugs and having a liquid injectable that they are comfortable with using our biases as maybe needle phobic or just not in the drug game, like that shouldn't inhibit us from advocating for the cheaper, more accessible forms of naloxone that really get to the population who's actually dying from overdose deaths.
Mukkamala: Tell me about some of the lessons you've learned from the community outreach when naloxone is used for overdose prevention and when it's been implemented. What's been the response of the community? What lessons have you learned from the community's acceptance of this as an available treatment?
Dasgupta: So, about a year ago, we started a non-profit. called Remedy Alliance / For The People that negotiates prices with pharmaceutical companies to get very low-cost naloxone.
And as part of that, the Food and Drug Administration acknowledged an exemption in federal law that allows us to provide that in bulk for harm reduction programs that, without having to have a prescription for the liquid injectable. And what has been really fascinating in being able to open up naloxone distribution in this way is that the community groups that are coming to us asking for naloxone has really changed. From traditional public health departments, they're still in the mix. But a lot of you know, a lot of groups that we wouldn't think of, whether they're street buskers or Buddhist communities doing outreach to homeless folks. I mean, there's this amazing array of folks who have come and asked for either free or low-cost naloxone who had been left behind by traditional public health systems.
There's one group that was doing voter registration in a inner city community and they said that this was the number one topic that when they were canvassing that people wanted to talk about is why can't I get naloxone at my local pharmacy and how can I get it? And when you hear that kind of response for groups that have been stigmatized or are on the margins for any given reason, the kind of grassroots demand for an antidote to help their own family members is really powerful. That's, like, what keeps me going every day is to hear about these oftentimes small groups that would not have access otherwise to naloxone.
Mukkamala: So, we've just described groups that are coming to these groups to obtain naloxone. But just like that, there are segments in the community that because of stigma, because of bias, because it's a, it's not insulin for a diabetic crisis. It's naloxone for an overdose. There's stigma associated with it. And so, there's lessons probably learned there about how to overcome the stigma and bias. How have you overcome these challenges related to stigma and bias, which is really powerful inertia that slows progress in this area?
Dasgupta: Yeah, I think there's kind of the direct approach of trying to address stigma. But honestly, that is such a, that's such a big mountain to move that it's something that's going to be slower. It's going to take a long time. Our solution was to make things easier and really focus on the logistics of actually getting the naloxone.
There's a lot more power we have over the pricing, even like the shipping of the naloxone in the boxes, right? Like, there's like lots of little things that you can change to make it really easy. And when we think about technology in terms of like smartphones and apps and all these things, right? As you lower the barrier for people to use those tools, they're going to use them if you put them out there. Their stigma can be overcome by making it easier for them to do the right thing.
So, that's like one form of stigma, kind of on a societal level. The other form of stigma that a lot of our patients and our participants face is that they have experienced mistreatment in the medical system. Whether you're a pain patient who has been turned away and been told that their pain is not real or doesn't have a biological etiology and so they can't be treated. As well as patients who are injecting opioids and fentanyl who are coming in with really terrible skin wounds. There's a common level of stigma that a lot of folks have experienced within the healthcare system. And that's not something that we can undo, for those experiences of those individuals.
We still want them to get them into care, right? We still want to take care of those abscesses. We still want to get them into drug treatment and have their pain resolved, right? We share the same goal. What oftentimes, it is providing warm referrals saying like here's a specific physician or specific clinic or hospital who we have a relationship with and they have, you know, experience working with people like you.
You have to acknowledge that those experiences are real and have happened. There's a lot of very practical things we can do as public health practitioners to build, that has been slowly eroded over the years through these experiences. But it also takes a lot of work to work with the physicians and identify physicians and nurses and clinicians more broadly to be people that we can feel comfortable making those referrals to.
And I think what's been super cool is especially watching the younger generation of physicians, when I go to some of these conferences, come up through the ranks like their mentality is markedly different and more open and there's a level of compassion that gives me a lot of hope.
Mukkamala: Because they've gotten the education, you know, they went through school in a culture that looks at substance use disorder the way that we're encouraging it to be looked at, not as something that is a negative, but just as a health condition that needs treatment and they are there to treat that patient. And I think that's a cultural change that's been welcome in medical education.
Dasgupta: That's right. Yeah. I mean, it was fascinating. I had taken someone, a participant who we knew, to the UNC hospital, like this is the institution I work at. And we knew exactly which physician we wanted to hook them up with. We had a care plan going in.
It was gonna be great. But the triage person in the front, when we brought her in with us was like, and said like, “okay, she needs, she's on methadone. This is what the care plan is, blah, blah, blah.” And the triage nurse was like, whispering to us like, “do you know she uses drugs? Like, do you know that she's a drug user?”
And it was kind of this moment and it's like, yes, this is why we're here. And this isn't something that we're whispering about. We're addressing it and have a plan for, and she has these other biological problems that need to be fixed. So, let's get on with it. So, it's not just one part of the system. It's something that needs to change throughout.
Mukkamala: Yeah, it's a great point. I mean, between the time that patient leaves their home and enters our exam room, there are multiple interactions with the healthcare system, like this person that whispered in your ear, that we need to change the culture around if we're going to take care of these patients better, I think.
Yep. So that's a really powerful place to wrap up our discussion on overdose prevention. It seems to be at the heart of your work in public health and community-based interventions. So, thank you for that. Any closing comments, Dr Dasgupta?
Dasgupta: I think we need to have hope. I think this is a time where it's easy to look at statistics and feel like this is a problem that's bigger than us.
There's some of us who are working on policy at a national level. And what I think really is going to matter to keep each of us engaged in this task, not at a policy level, but really focusing on helping individuals going and helping, figuring out solutions for small groups of people in our communities.
And I think it's that incremental, if we all did that little by little, instead of trying to solve the big problem all at once, I think that's where I find the most satisfaction, that's where I find the motivation to keep going, and that's where I see the most hope emerging from.
Mukkamala: Well, thank you for being here.
More importantly, your work has been ahead of the curve, both educational and inspirational at the same time. So, and thank you all for listening and thank you for your work to address our country's issues with substance use and pain care.
Dasgupta: Thank you so much. It was an honor.
Mukkamala: Thank you for listening to the American Medical Association Physician Education Podcast on the Opioid Overdose Epidemic. Make sure you tune into other episodes in this series to learn more about opioid use, opioid use disorder and harm reduction. Visit the Resources tab to learn more and don't forget to complete the quiz to earn CME.
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