Hi everyone! We’re excited to share the August edition of our Healthy Intersections Podcast with you. This month, we hosted Dr. Amanda Onwuka, a social epidemiologist and health services researcher at RTI International, as well as Jeremy Ney, author of American Inequality. We talk about the epidemic of drug overdose deaths in the US, mental health, and opioid prescribing rates, along with multi-level interventions aimed at preventing addiction and overdoses in the first place.
Below is the video. Keep scrolling to read the transcript. And don’t forget to subscribe! We’re on all the usual podcast streaming services, and you can also subscribe on Pod-o-Matic or here on the blog. Thanks!
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Transcript below
Lisa Lines (00:02):
Hello, everyone. Welcome to the Healthy Intersections podcast for August, 2023. My name is Lisa Lines. I’m a senior health services researcher at RTI International, and I’m also the host of this podcast. The podcast is sponsored by the American Public Health Association’s Medical Care section and the Medical Care Journal. We are also hosted on the Medical Care blog, and I hope that you will subscribe to the blog and subscribe to this podcast so that you’ll get notifications when we put out our next episode.
(00:32):
I’m really excited about today’s topics. We’re going to be talking about drug overdoses and the epidemic of drug overdoses in our country. We’ll be talking about opioids, in particular. We are joined today by two amazing researchers. I’m so thrilled to have them both here today. First is Amanda Onwuka. Amanda, please introduce yourself to the audience.
Amanda Onwuka (00:57):
Sure. Hi, all. My name is Amanda Onwuka. I am a health services researcher at RTI International. A social epidemiologist by training, which means that I study the effect of the social environment on health and vice versa. And I work on Meta, which is a really wonderful CMS demonstration, 1115 demonstration, whereby states are now using Medicaid dollars to pay for substance abuse disorder as well as mental health treatment for their patients. So, I’m happy to be here.
Lisa Lines (01:27):
Thanks, Amanda. What does that mean, 1115?
Amanda Onwuka (01:30):
So, there was an “Institutions for Mental Health Disease” exclusion for many years within the Center for Medicare and Medicaid Services whereby you could not use Medicaid dollars at all to pay for care that was occurring within an institution for mental disease. It’s what they called them, IMDs. And so now, with this waiver, this is a waiver that states can apply for, they can now use these dollars, these federal and state dollars, to pay for the services that we know residents of these states so desperately need.
Lisa Lines (02:05):
Thank you for that intro. And also, with us today, Jeremy Ney. Please introduce yourself to the audience.
Jeremy Ney (02:10):
Yes, of course, and I’m happy to be here. Hi, all. My name is Jeremy Ney. I am the author of American Inequality, which is a data project that looks at social issues and US regional divides to better understand the inequalities that are facing us and across different counties right now. I’m also an adjunct professor at Presidio Graduate School, where I teach a course on analytics for social impact. So how to use data for social change, and really trying to understand some of these quantitative measures to increase and improve outcomes and opportunities for Americans.
Lisa Lines (02:54):
Great. Jeremy, we are so grateful to have you here with us today and gracing our podcast. I want to share one of your maps, actually, with the podcast audience because I think it’s really relevant to today’s topic. Can you tell us a little bit about this map that we’re looking at now?
Jeremy Ney (03:12):
Yeah, so this is a map of mental health and inequality across regions in the US. And in particular, it looks at county by county level differences and how residents feel about their mental health. And what we can see quite clearly from this map of the US is that residents in West Virginia, Kentucky, and Tennessee in particular report having 18 out of the last 30 days as being mentally unhealthy for them. And this is one of these things that’s so important for us, and in American Inequality is really trying to focus on the issues that tend to get less attention, right?
(03:59):
Over the last three plus years, we’ve seen plenty of county level maps looking at COVID differences across regions, but there’s really much less of a spotlight on mental health issues. Right now, one in five Americans is actually struggling with mental health, and every year about 43,000 Americans with an underlying mental illness die by suicide. And so, these are not only really challenging social issues, but they’re also deeply tied up in many other inequalities, which is another second core tenet of American Inequality, is how interconnected so many of these social issues are, right? When you look at these regions that are bright red on this map, we tend to see those same regions also be struggling with many other social issues.
(04:50):
In particular, we see a really strong relationship between mental health and unemployment. And I know Amanda might talk a bit more about some of those relationships there that we tend to see, but it can be quite difficult to hold down a job if you are struggling with mental health, as well as the challenges of getting that job in the first place. And second, we also see a really strong relationship between mental health and incarceration. Right now, actually, the three largest mental health providers in America are jails. And as we dig in further on some of the opioid connections too on mental health, we’ll again see some of these interconnected social issues, and how many of these regions that struggle with one challenge struggle with many challenges.
Lisa Lines (05:36):
Absolutely. Yeah. Amanda, what are your thoughts on this map? There are, are the states that are getting waivers, are they the same states where we see really high percentages here? Can you share a little bit about that?
Amanda Onwuka (05:52):
Yeah. There are 32 states now that are participating in the substance abuse demonstration, and there are another 11 or so that are participating in the mental health demonstration. And a lot of them are those that struggle deeply with these issues. And so, we’re really excited to see the expansion of care in those states. And to Jeremy’s point, there’s absolutely a relationship between all of these conditions that we’re observing, mental health, drug use and overdose and death, incarceration. These are often bi-directional relationships whereby folks that are experiencing those social conditions, experiencing unemployment, experiencing incarceration, are more likely to use. And also, folks who are using are more likely to experience unemployment, incarceration, homelessness, et cetera. And a lot of that is due to the criminalization of these drugs.
Lisa Lines (06:53):
Yeah, absolutely. And I, and I think also, we talk about deaths of despair quite a bit in this country. Suicide is one of the causes of deaths of despair, as is drug overdose. So, we’re really, we’re thinking about mental health and the connections between these kind of really increasingly common causes of death. And Jeremy, you mentioned earlier, we were talking and you mentioned about life expectancy connections too. Do you want to share that real quick while we’re talking about that?
Jeremy Ney (07:32):
Yeah, sure. So, on an opioid in particular, there’s a very strong relationship right, between life expectancy, drug usage, and income in particular. So low income Americans are actually twice as likely to die from opioid deaths as their more affluent counterparts. And further along, when we get a bit further along in talking about some of these solutions too, we’ll end up seeing that some of these interventions to actually prevent drug overdose deaths can actually dramatically increase a state’s life expectancy. And as we look at, in particular on this map, we see some regions that are states where they are fully red, fully struggling with mental health issues. The same ones are often fully red struggling with the opioid issues. They’ll also be ones that are struggling with life expectancy. And some of these state by state differences can also be a product of state policies where states actually can pass laws, can enact contracts that actually improve life expectancies, and ensure that people have many more years to live with their loved ones and their families.
Lisa Lines (08:45):
Yeah, so looking at this map, it’s really interesting. For those of you who are able to see the video, you can see there’s a real strong concentration of mental health concerns in Alaska. Kusilvak, Alaska, that county there, nearly the average unhealthy mental days there is 24.5 out of a month, 24.5 days out of a month of just having mental illness or feeling down, blue. Just stress, depression, emotional problems. Also in the Four Corners area, it’s a lot of indigenous folks there, tribal land there, isolation, poverty, and also disinvestment, quite a lot of disinvestment. And yeah, Louisiana is another one that comes up. I think nearly the entire state is showing up in at least 15 days out of the past month on average having mental health issues.
(09:51):
So yeah, I really appreciate this map, although it is county level. So, let’s look at another map. I’m going to now move over to the RTI Rarity map, which is a census tract level map. This one is actually the local social inequity and drug overdose score that we’re plotting here. And you can see here the bright yellow is the top 20% of risk, and then the dark purple, or the darkest color there, is the bottom 20% of risk. And I’ve actually gone through and looked at across the US, what are the places that are at the top percentile and bottom percentile of risk, and what do those places look like? Can we understand, sort of by looking at these top percentile, bottom percentile counties, what might be happening there that might be driving such differences in outcomes? The difference between being absolutely on the bottom of the scale for drug overdose risk versus absolutely at the top of the scale.
(10:51):
So just to share some of the tracts that we looked at, they were located in five different states. So, the tracts that we looked at that were in the lowest percentile of risk were in Hidalgo County, Texas, which is down here in the very southern part. And then we also… I’m sorry, that’s Star County, but Hidalgo is right next door. And then we also looked at Dallas County, Iowa, which is up here. And then we looked at Madison County, Mississippi. So some of these places aren’t necessarily what you would think of as places that are doing well in general, but they are doing well in terms of drug overdose. And then at the opposite end of the scale, the two places that we looked at were Cabell County in West Virginia and Baltimore, Maryland over here. So, as we look at these maps, we think about what might be driving these huge differences in drug overdose rates. Can we talk a little bit about Cabell County in West Virginia? What’s going on there, Jeremy?
Jeremy Ney (11:57):
Yeah, Cabell is quite fascinating, actually, and has really been one of these epicenters of the opioid epidemic in America. So much so that there was actually a Netflix documentary about Cabell County and neighboring Huntington County called Heroin(e), where the documentary basically follows three women across these two counties as they try and help stop drug overdoses and deal with families that are reeling from overdoses, lost children and other heartbreaking issues. And what we sort of see from the data as well as from this fantastic journalism is that the fatal overdose rate in Cabell County has increased nearly 1300% since 2001, rising to about 200 deaths for every hundred thousand people there. And what’s also quite challenging for both Cabell and Huntington is that these were two counties, the only two counties in fact, who rejected a settlement offer from some of these drug manufacturers of about $21 billion that would be distributed over eight years, because these two counties really wanted to stop this core issue, which they really focused on, which was over prescription.
(13:26):
Over prescription of opioids was really what these two counties were wrestling with. In fact, we see much higher prescribing rates in these counties than nearly anywhere else. There were about 81 million pills that were distributed to about the hundred thousand residents over just an eight-year period. And this over-prescription killed so many people in the region. And these counties really were like, “We deserve more. We believe that there was more justice to be had.” And they rejected the settlement because this over-prescription robbed them, as you can see in the documentary, not only from children and fathers and CEOs, but also from just the community itself really gets ravished, not only in its healthcare buildings, but also employment, manufacturing. The whole region is really suffering as a result of this over-prescription.
Lisa Lines (14:23):
Prescribing rates are really one of the few things that really stood out to us as we looked at the characteristics of these highest percentile risk versus lowest percentile risk. We really were surprised there was only 3% difference in terms of mental health concerns. So, it was only 3% higher in these top percentile risk areas, but the prescribing rate was just off the charts.
(14:47):
When we think about prescribing rates, we have to remember at the other end of the prescription is a person with pain. Pain is difficult to treat without some of these opioid-based medications, and some people with cancer and other chronic illnesses are actually not getting opioids anymore because of this sort of issue with over-prescribing. So, it cuts both ways in a sense. Over-prescribing and under prescribing are equally issues, I would say, in terms of right now how we’re balancing the opioid epidemic in this country. We’re really just sort of across the board trying to cut back on all opioid prescriptions. Which, it’s a two-way street in terms of, these drugs can hurt, but they can also be very helpful to certain people with serious pain.
(15:33):
I have a relative, I’ve mentioned this before, who has had chronic pain for many, many years. I’ve written blog posts about her, so this is out there. You can read more about it. But it’s really challenging because she was recently forced by her pain doctor to go off of the medication that she’d been on for 30 years to treat her pain. And that forcing her to go off of her medication and then get onto Suboxone to manage the withdrawal, at this point now she has nothing for pain. Not a thing. And I think when you’ve got people who are in that situation, there’s a real issue with mental health and the chronic pain pathways, the sort of phenomenon that can happen when you’re on opioids for a long time. It actually works differently in your brain. But there’s not a lot of lifelines that we have for people with pain. Your insurance probably wouldn’t even cover acupuncture. Certainly, Medicaid certainly probably wouldn’t cover something like that. I don’t know, Amanda, do the waiver dollars go for acupuncture and yoga?
Amanda Onwuka (16:32):
Haven’t read anything about acupuncture.
Lisa Lines (16:35):
Yeah, I mean, so what are people supposed to do, basically, if they do have pain at this point? I think a lot of people are using street sources to treat their actual, legitimate pain. I can’t say how many, what percent is that? But there’s a real difference between opioid use, overuse, and addiction, opioid use, misuse, and addiction. So anyway, I’ll stop there about my relative and pain, but do others have thoughts about that particular issue?
Amanda Onwuka (17:07):
Yeah, I mean, there’s just so many known and unknown structural determinants to the opioid epidemic that we’re observing, and a lot of the interventions can have these unintended side effects. But yeah, absolutely, chronic pain is a great source and disability are a great source of opioid prescriptions. But also, there are other structural determinants, like we’ve talked about homelessness and joblessness. Also, mental health, workplace injuries, just the income inequality. There’s just so many of these structural determinants that we know are increasing both on drug use as well as overdoses and deaths. And so it’s important to be attentive to all of those determinants, and to really consider some of the unintended consequences that may come about as a result of our policy interventions.
Lisa Lines (17:59):
Yeah, thanks for that, Amanda. I also wanted to mention the HEALing Communities Study, which is something that NIDA and SAMHSA have invested many millions of dollars in to try and reduce opioid overdoses in four states. And those are Kentucky, Ohio, Massachusetts, and New York. And so this work was actually developed in part for that project. And so we’ve done a lot of work with the communities around stigma and trying to understand how to really, at the community level, address the social determinants that drive addiction and misuse. And then also the structural issues around getting more providers up to speed with prescribing medication that’s assisted treatment, having mobile clinics go out, doing more outreach, getting people to carry naloxone.
(18:44):
And actually, we should talk about naloxone a little bit, right? So that’s one of those things that has recently, sort of, been developed. It’s a nasal spray that you can administer to someone who has had a suspected opioid overdose, and it will reverse the overdose and hopefully save someone’s life. I actually read this really interesting interview with the person who invented the nasal spray, naloxone nasal spray. And he talked about actually being in Los Angeles, which is where I live, and being in a cab on a way on his way to a meeting and saw someone laying on the sidewalk, and actually had the cab pull over and administered naloxone to that person, and saved that person’s life. And he said, basically, if you are in one of these cities like Baltimore or New York, San Francisco, Los Angeles, Portland, Seattle, if you’re in one of those cities and you’re out and about, carry naloxone, because you personally could actually save someone’s life.
Amanda Onwuka (19:38):
Yeah, absolutely. Naloxone is a great example of what we would call a tertiary prevention strategy where we’re trying to prevent death. So, after an overdose, we’re trying to prevent death. So that’s one potential strategy at the tertiary level. And another is just reducing stigma. We know that a lot of times, the populations that are misusing these drugs often have a stigma and do not want to engage with local law enforcement or with medical institutions. And so, reducing stigma is another potential opportunity to intervene at that level. But there are also strategies to intervene more upstream, right? To prevent someone from having an overdose. And so that would include a lot of the interventions that you’re suggesting from HEALing Communities as well as some of the strategies that are being implemented as a part of the Meta program through CMS. And so, really trying to reduce the barriers for providers to be able to prescribe buprenorphine, increasing the access to different locations of care so that folks are able to get inpatient medical mental health care, as well as inpatient substance abuse treatment, improving care coordination.
(20:50):
There are so many strategies to prevent the progression of the disease. And then ultimately, though, we want to invest in primary prevention strategies. And so those are going to prevent drug use in the first place. And so, a lot of those sorts of investments are things that are just investments in the general infrastructure of the health of the community. And so investing in public education systems, investing in housing opportunities, and investment in reentry programs for folks who have been incarcerated, all of those sorts of strategies are going to prevent use in the first place. And so it’s really a comprehensive strategy that we need to really be able to face this crisis.
Lisa Lines (21:32):
Thanks, Amanda. Jeremy, can you talk more about the path forward for drug overdoses from your perspective?
Jeremy Ney (21:39):
Yeah, absolutely. I think Amanda really hit the nail on the head here. It’ll require looking across many of these issues to address this really sweeping challenge. But on the path forward and trying to think about these solutions, it really comes down to try and ensure that people don’t get addicted. And if they do get addicted, make sure that they don’t die. And what we’ve seen is that states have actually introduced several policies that have been quite effective at these two measures. And so on that first part of let’s not get people addicted in the first place, over the last nearly half decade or so, the number of states that have introduced opioid limitation laws has nearly quadrupled. These are largely referred to as these prescription drug monitoring programs. And these have been incredibly helpful at reducing the addiction rates.
(22:38):
In places like Florida, New York, Rhode Island, you’ve seen opioid addiction rates plummet by 25% in some cases, almost one month after introducing these programs. They’ve been very effective on the state level. So that’s on the side of let’s not get people addicted in the first place. But then if people do get addicted, let’s make sure that we’re actually addressing that and making sure that they really don’t die, because this has really become this epidemic.
(23:10):
One of the fascinating things that we’ve seen here for naloxone, as we’ve been discussing, is that Massachusetts, when they introduced a naloxone distribution program, they actually saw life expectancies increase by 11% in the communities that had distributed naloxone, in those areas. And so, it can be incredibly helpful for actually saving lives, particularly as we saw in that powerful story, Lisa, that you shared. And now that the FDA recently said that this can be sold over the counter, this can actually perhaps close some of these huge state by state gaps that we actually see here. But it’ll require more than that, right? Again, it’s tied up in so many of these social factors. So, we’ll have to keep pushing on many of these parts, but trying to be both upstream and downstream of the challenge will help us improve opportunity across the US.
Lisa Lines (24:02):
Yeah. Thanks for that, Jeremy. And I think one other thing just to add onto that is, from a health services perspective, we think about just the distribution of resources across space and time. Right here on the map, we’re showing right now the Local Social Inequity in Drug Overdose score along with the locations of substance use service providers in West Virginia. And in particular, I’m showing the little yellow dots that you see here, everywhere in West Virginia does not have equal access to substance use treatment in terms of service providers. And one thing that we really want to try to encourage people to do is look at this map for your state and your area and think about how you could potentially be part of the solution in addressing drug overdoses in your community.
(24:50):
And I think with that, we have pretty much run out of time. So, is there anything else, final thoughts that you all want to share before we close?
Amanda Onwuka (24:59):
Yeah, I’ll just say, so we’re not all Debbie Downers, that there has been a tremendous amount of progress in this area. We’ve gone from a public narrative of a war on drugs and users are criminals to a narrative of, really about structural determinants, right? What’s happening at the pharma level, what’s happening at more of a community and institutional and policy level that is increasing use and misuse in disadvantaged communities? And so, it is refreshing to see that realignment because even an individual’s choices are going to be shaped by the choices that they have. And so, all of these things are critically important to interrupting the cycle of this epidemic. So thanks a ton, Lisa.
Lisa Lines (25:51):
Absolutely. Thank you, Amanda. Jeremy?
Jeremy Ney (25:54):
Yeah. This point in time is such a really critical juncture for us to be having this conversation, as we are really experiencing such high opioid overdoses as well as addiction rates. I think as we were doing research at American Equality on some of this, one of the heartbreaking things that we found is that children with parents who are addicted are much more likely to get addicted themselves to opioids, as well as experiencing many other downstream issues like mental health as we talked about, but also issues of physical abuse and physical development too. And so, if we don’t address this challenge now, we stand at risk of having a generation of children further down the line in 25, 30, 50 years as well, who continue to battle with the injustices that we kind of wrought on so many of these counties now. And so if we can actually start implementing some of these path forward solutions and trying to address several of these underlying causes, we can ensure that, for generations to come, they’re not continuing to battle with many of the challenges that we’re talking about today.
Lisa Lines (27:01):
I really appreciate both of you for coming on today. I can’t say enough good things about American Inequality. I really love the work there. And just so great to talk with you, Amanda, and looking forward to hearing from you listeners and viewers. If you have thoughts on, your thoughts on the opioid overdose and drug overdose epidemic and treatment of pain and that kind of thing, please comment. You can leave a comment right in the comments on the blog. And we look forward to seeing you next month here on the Healthy Intersections Podcast.
Lisa M. Lines