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We sat down with Jay Butler, MD, president of the Association of State and Territorial Health Officials (ASTHO), to talk about the 2017 President’s Challenge: Public Health Approaches to Preventing Substance Misuse and Addiction, which appears in the September 2017 issue of the Journal of Public Health Management and Practice. Read more about ASTHO in our special section commemorating the organization’s 75th anniversary. 

Read the special section celebrating the 75th anniversary of ASTHO

JPHMP Direct: In your article “2017 ASTHO President’s Challenge: Public Health Approaches to Preventing Substance Misuse and Addiction,” you explore a potential model that could minimize substance misuse and addiction. Can you start by telling us about the ASTHO President’s Challenge?

Jay Butler, MD: The ASTHO President’s Challenge was first launched in 2009 by ASTHO President Dr. Judy Monroe. The Challenge provides a timely topical focus for public health policy and practice. Each ASTHO president since 2009 has selected a challenge on topics such as health equity, injury prevention, infant health, healthy aging, and integration of public health and primary care.

JPHMP Direct: Why the focus this year on substance misuse and addiction over other ongoing public health issues?

Jay Butler, MD: Three reasons—the first and most obvious is the ongoing opioid epidemic. I generally avoid the term “epidemic” because it is overused and sensationalized in the media. However, a four-fold increase in a single cause of deaths over a 20-year period, as is the case for opioid overdose deaths, meets even a conservative definition of “epidemic.” Second, the opioid epidemic has developed on the background of the long-standing health challenges from misuse of other drugs and alcohol. The approach to addressing these issues has too often been centered in either the criminal justice system or connecting individuals with clinical services—which are not necessarily bad things, but there needs to also be a population-based approach to what is a health issue, not only a criminal justice issue or a mental health issue. We need to rethink our approach, incorporating population-based health improvement principles. Third, as we consider the public health issues of the 21^st century—suicide, interpersonal violence, social isolation, low educational attainment, homelessness, imprisonment and recidivism, to name only a few–they are interconnected. A critical cause and effect in these issues is substance misuse and addictions.

JPHMP Direct: You discuss several barriers that need to be overcome to improve substance misuse management. What would you say is the greatest barrier we face?

Jay Butler, MD: Stigma. Addiction is too often viewed as only a personality fault or a moral failing. This view fails to recognize two important issues: the multiple and diverse factors that increase the risk of substance misuse (eg, adverse childhood experiences, use during adolescence, stress, genetics) and the emerging neurobiological understanding of addiction as a chronic health condition primarily involving the brain. Additionally, while the comparison of addiction to chronic diseases such as hypertension or diabetes has some merit, there are unique society effects of addiction, such as associated crime, which understandably creates anger and adds to the stigma of “the addict is a criminal.” We need to reframe the conversation about addiction to bring it out of the shadows and into the light. I believe that this can best be done by recognizing addiction is a health condition that merits compassion and requires treatment and that can be prevented by a multi-tiered, multi-sectoral approach, while acknowledging that there are those who have been victims of personal property and violent crimes associated with substance misuse and the illicit drug trade.

JPHMP Direct: What is the rationale behind the three-level approach to preventing substance misuse?

Jay Butler, MD: The three-tiers of prevention recognizes that there is a continuum from first exposure to an addictive substance to death from overdose or an associated condition (such as HIV, endocarditis, or cirrhosis) and that at the population level, there are people at various places in this continuum. Prevention strategies differ at various points along this continuum. For example, if all we do is provide naloxone, the number of persons who could enter recovery through screening and treatment will not decline, and we will only continue to give more naloxone. If we could institute all of the measures that are part of primary prevention, we would not address the needs of those who are currently addicted and those at high risk of a life-threatening event, and it could be years or decades before we could see real progress. Additionally, the three-level model acknowledges that complex problems may require a complex response. I am frequently asked, “What is the solution to the opioid crisis?” The answer starts with recognition that there is no one solution in public health to the challenge of addictions. We must also recognize that the health care of the individual must address the physical, emotional, and spiritual needs of the person living with addiction as well as those who are around them. As a physician, I find that I often talk about care of the whole patient, but at the end of the day, it is the biological aspects of disease that really captures my attention and that I address. To adequately treat addiction, providers need to think more broadly than just the biochemical make-up of the patient and also seriously consider whether there are other disciplines that need to come alongside in the care of the patient. Finally, I would like to point out the levels are not mutually exclusive. While I label treatment as “secondary prevention,” treatment can also be primary prevention. For example, a young mother who is in recovery is less likely to be incarcerated and her child will be at lower risk of adverse childhood experiences and subsequent substance misuse.

JPHMP Direct: Under tertiary prevention, you mention naloxone, an opioid antagonist that reverses the respiratory depression that causes death in opioid overdose. As a drug that can cause life-changing results, why are there such barriers to obtaining it, given the number of overdoses is on the rise?

Jay Butler, MD: First, let me affirm that naloxone can indeed be life-changing. Dead people are never recovery-ready. But I think of naloxone as being like a tourniquet—it can be a life-saving measure in a desperate situation, but it is not definitive care, and it does little or nothing to address the underlying cause. The barriers are multiple: access to naloxone is one where there has been significant progress as states have taken measures such as statewide standing orders, providing training in administration and immediate care, and supporting coverage under Medicaid or other third party payers. Cost has been a concern, particularly as manufacturers of some formulations and products have increased the price of these life-saving drugs several-fold. And stigma is a barrier at all levels, including tertiary prevention—I still hear people say that those who have overdosed are only getting their just reward or that they brought it on themselves. While I would like to think that we can change that view through evidence-based education, too often, it seems that it is only when a loved one dies that people begin to rethink this position.

JPHMP Direct: Secondary preventative measures include removing the stigma surrounding addiction, especially since it creates disincentives for providers to improve training to treat the condition. Given current perceptions of addiction and substance misuse in health care, how do we change the dialogue with and among providers?

Jay Butler, MD: As an infectious disease physician, I have seen a lot of complications of self-injection. What I, and many of my colleagues, may not see is the large community of people living in recovery. We don’t see them because they do not interact with the health care system as often and because, when they do, they may be hesitant to discuss their substance use history because of stigma. This is where recognition of addiction as a chronic health condition primarily involving the brain can help reframe the clinical view of the addiction and address the frustration that providers can feel in caring for patients who can, quite frankly, be difficult to care for. It was only after learning more about the neurobiology of addiction that I really began to understand that patients are not lying when they say “Doc, I’m never going to do that again” only to return to the emergency department in two days because they “did it again.” At the moment of our conversation, the honest desire and intent was to never do it again. But addiction highjacks cognition and executive function, particularly when there is an overlay of physical dependence, and behaviors that were not intended are realized. This can lead to fatalism for both the provider and patient.

JPHMP Direct: You mention a survey of patients discharged after surgery that shows 72% of pain management pills given to those patients were never used. To what do you attribute the main reasons for this overprescribing?

Jay Butler, MD: The recurring answer to that question that I hear from my surgical colleagues is simply that is how they were trained. All providers want patients to be comfortable and, to be honest, not calling in the middle of the night, but our approach to pain management with opioids has not adequately addressed the risk to the patient or the risk for the population as a whole caused by the societal burden of addiction and drug diversion.

JPHMP Direct: On the topic of overprescribing within substance misuse, are there any additional important steps physicians can take to preventing overdoses?

Jay Butler, MD: There are several actions that can be taken: for patients on high doses of opioids or who are currently misusing opioids, discuss options for access to naloxone. An increasing number of insurance carriers and Medicaid programs cover it. Discuss appropriate drug disposal with the patient. Use your state’s prescription drug monitoring program (PDMP). It can be a useful clinical tool for promoting patient safety, but like any tool, in only works when it is appropriately used. One comment that I frequently hear from new users is “I had no idea.” Providers like to think that they know their patients well enough to discern who may be at risk of overdose, but that is often not the case. Also, patients may not be aware that they are at risk—a provider told me of an elderly patient who had received oxycodone from a dentist and hydromorphone from an orthopedic surgeon during the same week. This was before Alaska had mandatory registration and a pre-new prescription look-up requirement—neither provider knew what the other had prescribed and the patient did not recognize that both were opioid medications. And most importantly, remember what you said about your desire to help people when you interviewed for medical school admission. “Firing” of a patient who is misusing opioids should occur rarely, if ever. Talk with the patient, and if needed, make a referral for help.

JPHMP Direct: You discuss bridging bureaucratic divides as foundational to progress in preventing substance misuse and addiction. How can states and cities improve collaboration to address this issue?

Jay Butler, MD: I have often heard it said that the opioid crisis is a health issue and not a criminal justice issue. Actually, it is a health AND a criminal justice issue. It is also an education issue, an economic issue, a transportation issue—engagement with all sectors of government, as well as health care, businesses, the faith community, and most importantly the people in recovery is required. While I don’t think that there is only one way to improve cross-sectoral collaboration and coordination, there are a number of options. At the state level in Alaska, we have used a unified command structure for the opioid response, and because recovery will take longer than anticipated during the unified command, we have also established a coordinating office (Office of Substance Misuse and Addiction Prevention) within the Department of Health and Social Services. But there is only so much that can be done at the state level—much of the effective work occurs through community coalitions that can establish ongoing communication and collaboration among local organization and citizens.

JPHMP Direct: Do you have any final thoughts you would like to share on the topic of substance misuse and addictions?

Jay Butler, MD: The opioid issue is the crisis of the year. But we will not be effective with molecules-specific approaches. We are also seeing increasing numbers of overdoses from methamphetamine that has mirrored increased use facilitated through new modes of trafficking. Alcohol continues to kill more people than opioids in my state. The overall approach must be comprehensive or we will not make a difference—untoward health effects from one substance will simply be replaced by those of another if we do not take a broad, multisector approach that includes addressing primary prevention to reduce the demand for addictive substances.

For more about Dr. Butler’s 2017 President’s Challenge, visit ASTHO.org or click here.

Jay C. Butler, MD

Jay Butler, MD, was appointed chief medical officer for the Alaska Department of Health and Social Services and director of the Division of Public Health by Governor Bill Walker in December 2014. From 2010 to 2014, Butler served as senior director for community health services at the Alaska Native Tribal Health Consortium in Anchorage, where he was also a clinical infectious diseases consultant and medical director for infection control and employee health. His earlier work includes serving as chief medical officer of the Alaska Department of Health Social Services from 2007 to 2009, Alaska state epidemiologist, 2005-07, director of CDC’s Arctic Investigations Program, 1998-2005, and medical epidemiologist in CDC’s National Center for Infectious Diseases in Atlanta, 1991-98.

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