States of Despair: Understanding Declining Life Expectancy in the United States


Note: This is an unedited transcript. For direct quotes, please see video:


SARAH DASH:  Good afternoon, everyone.  Thank you so much for joining us here today for a briefing called States of Despair:  Understanding Declining Life Expectancy in the United States.  My name is Sarah Dash, I’m President and CEO of the Alliance for Health Policy.  And for those who aren’t familiar with the Alliance, we are a non-partisan organization that is dedicated to advancing knowledge and understanding of health policy issues.  So we thank you all for being here today to better understand this issue.  Hello as well if you are following on Twitter using the hashtag #allhealthlive, and folks can feel free to submit questions by Twitter, and they will be brought up here.

Before we get started, I would like to thank the Commonwealth Fund for its support of this briefing.

So the terms “Deaths of Despair”; deaths from suicide, alcohol and drug abuse, is a relatively new term. However, it’s a complex term with a lot of underlying issues.  And today we hope to help unpack this term, and the underlying trends, and understand better how deaths of despair relate to trends in declining life expectancy in the United States.  We are also going to highlight the development of state and federal policy solutions to address these trends.  You are going to hear from five excellent speakers and I know there are only four of them up here right now, we are waiting on the fifth who is — had a delayed flight, so if anyone does transportation policy as well, feel free to chime in. But he should be here momentarily. So that’s why we are going to get started.

Our speakers are each bringing a very different perspective to this issue, and we are really grateful to have them shed light on this critical topic. I’m not going to be able to do their background justice in the short time that I have, so please do check your packets for their bios with more extensive information. I will briefly introduce them, and then we will get started. So joining us today, to my left, we have David Radley.  David is a senior scientist for the Commonwealth Funds tracking health system performance program. He and his team develop analysis on healthcare system performance, and related insurance, and healthcare system market structure analysis. He co-authored the 2018 State Scorecard on Health System Performance, and we are grateful that he’s going to help us explain the methods behind that report and what it showed.  Next we’ll have Marvin Figueroa. Marvin is Deputy Secretary of Health and Human Resources for Governor Ralph Northam in Virginia.  Prior to his appointment, he served for seven years as senior policy advisor for Senator Mark Warner, and I understand was also a college counselor at some point in the past, so has perhaps helped people through some challenging times in their lives. Marvin is going to provide some on-the-ground perspective on these trends and what is going on in Virginia. Following Marvin, should he arrive in time, we are going to hear from Dr. Joe Thompson, who is going to provide another state perspective on deaths of despair. Joe is President and CEO of the Arkansas Center for Health Improvement, and he’s responsible for developing research activities, health policy, and collaborative programs that promote better health, and healthcare in Arkansas. Next, we will hear from Richard McKeon, who is Chief for the Suicide Prevention Branch, in the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, or SAMHSA.  Richard is going to provide insight into SAMHSA’s purview over issues related to deaths of despair, as well as their suicide prevention efforts. Finally, we will hear from Anand Parekh, who is the Chief Medical Advisor of the Bi-Partisan Policy Center. And prior to joining BPC, he completed over a decade of service at the Department of Health and Human Services.  We are thankful that he can use his expertise to provide some summary remarks and he will draw on some of his work form the article Towards the United States of Health, that looks at the global burden of disease across state healthcare systems.

So with that, I am going to turn it over to David Radley, to kick off the conversation. Thank you.


DAVID RADLEY:   Can you guys hear me okay?  Thanks, Sarah, and thank to the Alliance for putting this meeting together today. I think it’s an important topic, and I’m happy to sort of lay out some high level data just to sort of do some context setting for you, and then the experts on the panel that really sort of know the issues a little bit deeper than I do, will dig in.

But anyway, my name is David Radley; Sarah said I’m Senior Scientists at the Commonwealth Fund, and a Senior Study Director with West STAT. And I’m responsible for the Commonwealth Fund’s health systems score card reporting series.

Today, I’m going to be presenting data from our most recent state scorecard, which came out in May, and also from a blog post that we recently published on the Fund’s website just a couple of weeks ago, that takes a deeper look at Deaths from Despair.  Deaths from Despair is a measure that we included in our 2018 state scorecard, and the blog post just digs a little deeper on that particular measure. The data that I have, that I will be presenting today, don’t get too caught up if you don’t see all of the number — if you can’t keep up with the numbers on the screen. You have the data, it’s in your packet. The blog post has a table in the back, and all of the data that I’m going to be talking about, you have in front of you, so if you get lost, don’t worry, you have the material. So the Deaths from Despair measure is part of scorecard reporting series. We have been doing this series for about ten years, and the formula has really stayed about the same over those ten years. We look at 30 to 40 performance measures spread across five dimensions of care. We look at healthcare access, healthcare quality, efficiency, healthcare equity within states, and then population health outcomes. We started the series with a national report that basically looked at U.S. averages compared to international benchmarks, but we’ve grown the series to look at state and even local level data, and even a couple scorecards looked at special populations of interest.

Today, we are going to focus on just one measure, the Deaths From Despair. So Deaths from Despair isn’t a clinical term, per se. The term was actually coined by two economists from Princeton a few years ago, in some work they were doing to look at health outcomes associated with sort of broad economic and social trends. When we’re talking about deaths from despair, we are really talking about a composite of deaths from alcohol, suicide and drug overdose. So in suicide, these are basically any death that occurs of self-injury, and actually can include — our definition can include intentional drug overdoses; taking drugs with the intention of killing themselves, if there was some sign that that was the case. Alcohol related deaths are basically deaths that result from some sort of liver disease, alcohol use, and then I think what we are most interested in today is deaths from drug overdose. In this definition that we are going to be talking about today, we are talking about drug overdoses that include opioid deaths, but that aren’t limited to opioid deaths. This definition can also include deaths from adverse drug events, from prescription, or even over-the-counter drugs.

So just for a little bit of a context setting, if we look back over the last ten years or so, deaths from despair has been a leading cause of death to be sure, but still far few people in our country are killed each year from deaths from despair than are killed from heart failure or cancer. What is unique about this Deaths from Despair measure, is that it’s the only leading cause of death that has actually increased in the last ten years. So deaths from heart disease are down, deaths from cancer are down, stroke — everything is down. All of these major deaths, tied to a lot of these major chronic diseases, are all trending downwards, which is of course what we would hope from our healthcare system. But deaths from despair are going up, and they are actually going up a lot.

In this chart you can sort of see exactly — you sort of can see that increase a bit better. In 2005 to 2016, deaths from despair rose over 50 percent nationally. What’s really driving that is a huge increase in deaths from drug overdose. So drug-related deaths are up, they’ve more than doubled over the last decade. Deaths from drug overdose have far surpassed suicide and alcohol use as the leading contributor to sort of this composite of deaths from despair. We are going to focus on opioid deaths, and certainly that is the topic of the day, rightfully, it deserves a lot of attention. But don’t lose sight of the fact that suicides and alcohol deaths are still up, over 20 percent, in the last ten years. I mean, these are still big increases, and these are still important topics that deserve attention. Let’s take a look at what’s going on across states. These national trends are concerning, but it really doesn’t hit home until we are thinking about what’s going on across states. So if we go back to 2005, we are looking again at the composite measure of deaths from despair. If we go back to 2005, not a single state had an overall deaths from despair mortality rate higher than 50 deaths per 100,000 individuals, and 26 states, plus D.C., were all under 30 deaths per 100,000 population. By 2016, the map looks quite different. By 2016, only one state, which was Nebraska, was under 30 deaths per 100,000, and the whole country has shifted, and now by 2016, 18 states plus D.C., so 19 total, were up over 50 deaths per 100,000 individuals. West Virginia has fared far worst than the other state. Their deaths from despair rate is over 80 per 100,000 now. And here, we can sort of get a sense for just how sort of concerning the trend is West Virginia is. So what I’ve done here, each of the gray dots is the state rate, and overall deaths from despair for the year that is indicated across the bottom. So you can sort of see the full range as a distribution for the states. And if you go back to 2005, West Virginia was just a little bit higher than the national average in this overall composite of deaths from despair. Through 2009, through 2010, there was sort of a steady increase, a little bit of an anomaly in 2009. But then from 2012 through 2016, with a real inflection right around 2014, you can see just how steep that increase in West Virginia in deaths from despair is. And when we look at what’s causing it, it really is drug overdoses.

So in this chart, we are looking — I’m comparing Nebraska and West Virginia. These are the states with the lowest and highest rates of deaths from despair in 2016. When we look at Nebraska, there was sort of a modest increase between 2005 and 2016 for each of the components of deaths from despair, but for West Virginia we see a modest increase in alcohol deaths, a modest increase in suicide deaths, but an absolutely staggering increase in drug overdose deaths, which of course is driving the overall composite.

Just a quick summary: Deaths from despair are up in every state, they are up nationally, the trends are concerning. Deaths associated with drug overdose are the primary contributor to that, and even though ten years back they were the smallest contributor to the overall composite in deaths from despair, by 2016, now they are by far the leading contributor. State experiences are very different. There is much different things going on, and it’s a problem everywhere, but different states are being impacted much differently by this. And so the other panelists will talk a lot about the policy implications, but at a very high level, I think we sort of an opportunity to be thinking about improving access to opioid reversal medications. I think there is an opportunity to be more proactive with opioid prescribing guidelines, and in fact, limiting opioid prescribing rates. And there is of course opportunities to enhance people’s access to mental healthcare services, and to encourage care delivery models that integrate behavioral and medical care into one model.

That’s it for me. Just a real quick shout-out to Susan Hayes who is in the audience, who is actually the lead author on the blog post you have, and to Doug McCarthy, another one of our fun colleagues, who’s done a lot of work on this topic with us. Thank you.

MARVIN FIGUEROA:   That was a pretty segue.  Good afternoon everyone, my name is Marvin Figueroa, I’m the Deputy Secretary of Health and Human Resources for the Commonwealth of Virginia. Before I became secretary, I spent seven years working for Senator Mark Warner. So in large part, this feels like somewhat of a homecoming. So I really want to thank the Alliance Health Policy team for welcoming me, and Sarah in particular for inviting me.

I’m going to start off my segment by showing you this Health Opportunity Index. It was put together by the Department of Health in Virginia, and it’s a composite of about 13 indices, that takes into account about 13 social determinants of health. So it’s everything from education, food insecurity, job participation, income, and equality. And the case that I want to make today, is that when you think of — these are more death of disparity. I will show you maps later on where you can see how they track each other, but in large part, what has resulted in these deaths of despair, is exactly the disparity that we see across the Commonwealth. I want to particularly bring your attention to the blue and the pink.

None the less, understanding the factors responsible for recent mortality trends, is important for us to address the possible health crisis, and also think through what are the underlying causes. So just a slightly different definition. When we think about death of despair in the Commonwealth of Virginia, we are looking at a particular population. That is what I will focus on today. It tends to be white, non-Hispanic. 25 to 50 years old, and the stressful conditions that Dr. Radley mentioned are the same — so unintentional drug overdoses, suicides, alcoholic liver disease, and alcohol poisonings.

So we take, say, 1992 through 1995, and we take 2010 through 2014, and look at the percent increase in mortality rates, there are a couple of things that we will observe. The death rates from unintentional drug overdoses increased by 331 percent. Death rates from alcoholic liver diseases increased by 37 percent, and the suicide rate increased by 29 percent. And not on the graph, but worth noting, is that a condition responsible for the increase in mortality rates have to do with organ diseases. So everything from bio hepatitis to heart diseases, many of which have a potential link to substance abuse and other trauma. But these deaths are not evenly distributed in the Commonwealth of Virginia. Remember that health opportunity index? The higher stress rates of mortality rates are in Southwest, are at West Central, which borders Kentucky and West Virginia on our south side. These populations have the lowest and second lowest median household income, highest unemployment rate, and more than one in four children live in poverty. Taking a deeper view of things, the sharp increase happened in — is 262 percent, 245 percent, 215 percent at Wise County, [name] County, and Dickenson County. Thinking about social determinants of health, in Wise County, 49 percent of adults graduate from high school, and Buchanan, only 9 percent of the population has a bachelor degree. 31 percent of the children there live in poverty. If you look at Eastern Virginia, they had the largest proportional increase in these type of deaths. Lowest percent of high school graduates, largest shortage of mental health professionals, and the second highest unemployment rate in the Commonwealth And what do you know? What do you see? The rates of the fatal prescription opioid overdoses tend to happen in those locations as well. This is excluding Fentanyl, this is including Fentanyl.

What we see from the federal government these days is a reaction to this. So we have a number of different grants that have been awarded to the states. I apologize for all the text, but the biggest takeaway here is that because of the opioid crisis, we are receiving more financial resources to be able to combat this issue. But the challenge for states is how do you look at opioids and look at substance abuse, and try to create a system or infrastructure that responds to addiction, regardless of the substance. For us, the way ahead means that we have to move away from the immediate response to a crisis, which is often to just react. And more look at the systematic approaches to be able to address this issue.

In the time that I have remaining, I’m going to focus on four topics in particular. One is, Virginia has what we call community service boards, and its in the code of Virginia, and the responsibility is provide intellectual disability, mental health, substance use disorder services either directly or through contract with private providers. We have about 40 CSBs scattered across the Commonwealth, and what you will found is that depending on what CSB you are in, you will see different quality, and different types of services. So if you’ve seen one CSB, we say, you have seen one CSB. Part of our strategy to transform a mental health system, is to integrate behavioral health, and primary care, emphasize population health and awareness, excellence in behavioral healthcare, and also sustained strategic investment in community service, and supports. What we call STEP Virginia.

So what you will see on the right hand column is kind of what we are building towards. So we are making strategic investments to make sure that regardless of where you are in the Commonwealth, you will be able to receive these services. Secondly, we are taking a closer view on our Medicaid population and working with the American Society of Addiction Medicine, have created a benefit that we call ARTS. And ARTS encompasses evidence based services that we know are useful for individuals who have SUDs. So that is a full spectrum of addiction and treatment services that include residential treatment, case management, peer recovery counseling, and most importantly, demonstrating the commitment that the general assembly and the governor had made, that we also increase reimbursement rates for behavioral health and mental health services. The result is that we have seen treatment rates increase, we have seen the number of members receiving pharmacotherapy for opioid use disorder increase by 34 percent, and we also have more practitioners able to provide services.

Here is a graphic of the impact that we’ve seen. So this is before ARTs, this is after. Finally, trying to bridge the gap between our public safety secretary and our health and human resources secretary, we formed an executive leadership team that brings together the secretaries to kind of combat substance abuse writ large. Here are some of the initiatives that we have going on, so everything from how do you get justice involved interventions, the treatment, to prevention, to supply prevention and harm reduction. And we can talk about that a little bit later during the Q&A.

Then finally, we are focusing on average childhood experiences. One, most of the time, when we serve these individuals, we acknowledge that there are different issues that they’ve gone through, that have caused traumatic stress. They have manifested themselves in some form of abuse, and the governor’s goal at this point, is to try to figure out how do you include trauma informed counseling in education, and also in healthcare? We also have to think through the fact that a lot of these individuals, in particular those regions where we’ve seen these higher mortality rates, that they have children sometimes. And what do we do to ensure that the children also don’t become substance use abusers.

We have Medicaid expansion in Virginia, and so more people have access to the ARTS program. I’m just including that to talk a little bit about — to put that as a post we can talk about later. And then these are the challenges. And it all has to do about funding most of the time, but also, what are the changes that we can make because of this increased funding, to allow us to better serve these individuals, where they present, and provide the right care at the right time.

Finally, this is a note that we received from one of our constituents:  So, less addictive drugs — we need less addictive drugs, people are committing suicide because of drugs, and they are getting diseases because of drugs. Our children are watching. Thank you.

SARAH DASH:  Thank you.  Marvin, before we go on, I just want to ask:  Could you talk a little bit more about the impacts of Fentanyl on the death rates you showed slides with, and without, and just wondering, you know, there’s been some talk about that being the driver of some of the deaths, and of course if anyone else wants to chime in, but just wanted to ask you what’s going on there.

MARVIN FIGUEROA:   Well, what we observe is that it all depends on where — what locality you are in.  So depending on the locality, you will see either the biggest drive being Fentanyl, you have other little places where it’s heroin, and other places where it’s Methamphetamines.  So again, the biggest takeaway is a drug will always find some — will always be different depending — well, let’s start over.  If you are a substance abuser, you will find a drug to abuse. And so we have to figure out, not necessarily how to react to the drug itself, but reacting to the underlining causes that are causing that individual seeking that drug.

SARAH DASH: I think next we have Dr. Joe Thompson.

  1. JOE THOMPSON: Great. Thank you for the invitation, to the Alliance, and support from the Commonwealth Fund, and fellow presenters, I’m honored to be here on the platform with you, and to all of you for being here today.

By way of background, just for information, I’m a physician, I lead the state’s unofficial health policy center. For ten years I served as the lead cabinet advisor to former Republican Governor, Huckabee, and Democratic Governor Beebe. So these issues have emerged over the last decade, and I have had upfront and important kind of opportunities to see the death and despair that we are talking about today.

I will start by just one of the fundamental outcomes that I’m going to share with you:  zip code matters. The deaths of despair are concentrated in areas of our nation, and areas within our states, which despair is not just about mental health depression, it’s other opportunities, it’s the erosion of the community fabric, it is the out migration of individuals from small cities in rural America that is leading a fabric of despair, that can subject individuals to turning to drugs or alcohol, or other escape mechanisms that we’re talking about here today.

So let me give you a state specific perspective, and I have to start — Arkansas is always — or has always been in the bottom two or three of state’s health rankings. We compete with Mississippi — anybody here from Mississippi and Louisiana?  We are there with you. We were one of the few states that in 2014 took the Affordable Care Act opportunity, and expanded Medicaid. The only southern state that expanded Medicaid. And to just share with you, it does make a difference. It’s not often that within a year you can see graphical displays that are state’s boundaries for the dramatic reduction in uninsured that we have. Specific to this topic, importantly, it forced our insurance carriers to cover mental health and substance abuse, which most of them did not do prior to 2014. As a point of advertising again, our rates, because of the way that we did it, through Medicaid, large purchase in a small individual marketplace, had been lower than other state’s experiences.  And our competition has increased. We’ve gone from one carrier statewide, to now we have three carriers statewide, and the increase in choice. And so we had the financial mechanism in place, but we still had the challenges of the topic that’s on the table today for our deaths of despair. This is for the Institute for Healthcare — Health Metrics and Evaluation, from the University of Washington. These are mortality statistics.  The darker red color are where mortality rates per 100,000 all cause, are greater. And you can see in areas of our nation that had economic depression in rural areas, and areas that had not benefited from some of the expansion and some of the technology advances of the coast, or of our larger cities, you have significantly higher mortality rates. Along the lower Mississippi River Delta, Arkansas, Louisiana, Mississippi, we have statistics that rival third world countries for the entire state, on virtually every health statistic, and unfortunately, in the federal government, when you look at health statistics, the Mississippi River is used to divide the Eastern Region and the Western Region, so that you never really see how bad it is on either side of the Mississippi River, because those health statistics are diluted by higher functioning cities to the east and west.

It’s focused in poverty. The median household income, if you line all the households in Arkansas up, is $44,000 a year. That includes the Walton’s, who are some of the richest individuals in the country, so you can get an idea, here in Maryland, it’s about $87,000 a year. If you go out into those rural areas of the state, and it’s not just Arkansas that has these rural challenges, it’s the entire nation. You have a significant economic depression, and many of those families lost much of their net worth during the recession a decade ago, and they have not regained it. So these are stimulus for individuals turning to substances of abuse, and the drugs that we are talking about.

You already saw this:  We are one that is experiencing a higher death rate, although not yet to the extent of Kentucky. However, we are the second highest prescribing state in the nation with more than one prescription per individual each year, of opioids. We have attacked this, and I will share with you what we are doing well, what we are trying to do better, and what I believe we have yet to do, and I think this is a nationwide call. We have established and had one of the more robust prescription drug monitoring programs, that we have required physicians to access the PDNP prior to prescribing a schedule 2 or a schedule 3 narcotic. We have active surveillance of the PDNP, the Health Department has mailed out letters to providers that are outside of the norm for their practice characteristics. We have statewide and local drug takeback programs. We have a significant level of effort under Public Outreach in Education. We have payer engagement strategies on both the public and the private side. Our state and public school employee’s plan, the largest health insurance plan in the state, limited nascent, or first time narcotic prescriptions to 7 days in an attempt to try to avoid a longer term exposure that leads to addiction. Our College of Pharmacies, one of the leading investigatory units in the nation, supplying the CDC with much of their “how long it takes you to get addicted”, which is between three and five days of consumption. Our Medicaid program has limited the Morphine milligram equivalents, there are prescribed on nascent prescriptions, and also required lock-in to a single pharmacy for Medicaid paid drugs. So I think we are moving on the public and the private side. This is an example. On your right are the Medicaid bill rates for beneficiaries. On the left, where the commercial sector is lagging, you can see far higher consumption of opioids on the commercial sector, some four to five fold higher on the adult commercial, compared to the adult Medicaid program. We’ve got new and promising interventions underway with physician engagement; our medical board has actually now put a requirement that if you are over the CDC recommended Morphine milli equivalents, you must have in the patient’s chart a rationale for that, and a treatment strategy to try to lower that level of prescribing. As well as other review activities at the Medical Board. The Employee Assistant programs, I think every employer — large and moderate size employer — has an employee assistance program. I think this is an area we are not actively utilizing. We have tens of thousands of individuals currently addicted, and dependent upon narcotics. We have a number of efforts going to turn off the supply. But if we don’t have the mental health treatment, and the addiction recovery efforts in place, we are going to drive people to more elicit drug use, which we have yet to experience in a significant way as have other states, I think, on either coast.

A new effort, a crisis stabilization units, these are efforts at four counties within our state to put a medical three day way station between individuals who are picked up by the police, and on their way to jail, to try to stabilize them for a mental health perspective, or potential substance abuse issue, rather than incarcerating them and taking them down a path that we know leads to recidivism and poor health outcomes.

So these are efforts going forward. I think we have some gaps, and some policy interventions that are still needed. We need coordination within the state across payers. I mentioned the commercial side, and the Medicaid side, but they need to get together to reinforce the consistent messaging to providers. We need coordination between states — Missouri does not participate with the PDMP, and so our residents that go across, we lose line of sight. When individuals on the northern border of Arkansas go into the southern border of Mississippi. Medicaid, although the expansion is required to cover substance abuse, traditional Medicaid in our state, and in many other states does not cover substance abuse as a covered benefit. That’s why I think that is a challenge. And Buprenorphine availability is limited. I think there are waivers under my DEA card that we have too few physicians that have sought to be able to do substance abuse treatment. And the barriers to the number of individuals, even if I had a waiver, that I’m able to care for, it’s not going to match up with the demand that we have in our population.

So with that, let me close. I look forward to questions and answers. There are good things going on, there are challenges going on. Zip code matters, and I think we need to go upstream; not just think about the supply line, but also think about the treatment line for individuals that are addicted. Thank you.

SARAH DASH: Thank you. Dr. McKeon?

  1. McKEON: It’s a pleasure and an honor to be here with you to talk about this important issue of deaths of despair, which SAMHSA has really tried to focus on. In fact we invited (indiscernible) to SAMHSA and arranged involvement with MIH and IAAA, (indiscernible) HERSA, VADOD, so that we could all talk together about this important issue, because of the increases. And while SAMHSA has been heavily engaged in the response to the opioid crisis under the leadership of our assistant secretary Elenore [names], who is an addiction psychiatrist. I’m going to focus with you on the issue of suicide. It’s only in the last couple of years that the deaths from opioids have overtaken the deaths by suicide, but suicide is also increasing in an alarming manner.

So there are nearly 45,000 people lost to suicide in the United States in 2016, the last year for which we had data. And of equal concern, suicide has increased in 49 of the 50 states, only Nevada has not seen an increase, and Nevada had one of the highest rates of suicide beforehand, and has not really gone down. More than half of all states have seen more than a 30% increase in suicide. So that is really important. And while mental health conditions play a very important role, those with serious mental illness, youth with serious emotional disturbance, have much higher rates of suicide than others. Suicide is complex, and there are multiple factors that are involved, including certainly substance abuse and economic stresses, legal, et cetera, or a wide range. Anything that causes stress and destress and human misery, may play a role in suicide.

So this shows you the data on the increases in suicide across the states, and within those states as a dimension, there is a clustering of where the increases have been most stark in many of our rural communities that are seeing increases both in opioids, as well as in suicide. And I should mention that sometimes it is hard to know whether a death was a suicide or accidental overdose. I have now been to three different states where I have been told anecdotally about encountering people who upon being resuscitated with Narcan said, “I wish you hadn’t brought me back.”  Whether that was a suicide attempt, or whether it was a person so despairing, they didn’t care if they lived or died, it may be impossible to know.

Suicide is the leading cause of death — the second leading cause of death among all Americans from age 10 until age 39. Then from the — as you see, it goes to fourth, and from age 40 to 49, and then to seventh for 50 to 59. It’s not because suicide has gone down, in fact the numbers and the rates go up then, but other causes of death accelerate during those age groups at a greater rate. But the U.S. has been working hard on this issue. We do have a national strategy for suicide prevention that was released by the Action Alliance and the Surgeon General several years ago. SAMHSA released a report earlier this year that said, “We weren’t able to identify a single state that was implementing everything that we know about effective suicide prevention.” We know more than we’ve ever known before about suicide prevention. We are doing more than we’ve ever done before, but there is a lot more we need to do.

This is a slide from NIMH, you can’t fix what you can’t measure, and most U.S. healthcare systems don’t track suicide related outcomes. We think that this is an important thing to be encouraging, because within the healthcare system is one, but not the only important way that we can reach people to prevent their suicide. But there are healthcare systems that are doing this. One that has attracted a lot of attention is the Henry Ford Healthcare System, and their Perfect Depression Care, which had a zero suicide goal as part of it. They showed it was possible in a healthcare system, by taking a systematic approach to drive down the number of deaths by suicide, of people under their care. That data has been published, this has been submitted for publication. This is Centerstone, one of the nation’s largest private non-profit community mental health centers. They also have found similarly that they have been able to decrease this. So for this reason, SAMHSA, as well as several other federal agencies, have been supporting the zero suicide initiative. Congress has expanded the funding for that. We just made 14 awards, including to five new states just about a month ago. SAMHSA has had a large youth suicide prevention effort going back a number of years. The Garrett Lee Smith Youth Suicide initiative, all 50 states have received one of these grants, since they were initiated in 2005. What we found is that counties that were implementing GLS funded activities, had lower suicide rates than matched for youth, then matched counties that were not. But the effect faded after a year, which speaks to the importance of finding ways to sustain and build into the foundation of states, communities, drives suicide prevention efforts if we want to be able to combat suicide effectively. That shows you that. You can see there is a dip for a year, and then it goes back up. We’ve been able to extend it for a second year, and data was currently submitting for publication, before it fades, but we need to find ways embed it.

We lose people in the United States pretty much every day when they leave in-patient units and emergency departments. We simply must do a better job of handling those care transitions. The science is absolutely sound. Two major studies have come out in the last two years:  one is called ED Safe, and other is called Safe Vet, but what it’s shown is that telephonic follow-up, after these discharges, is associated with reduced suicidal behavior. The issue here is that there is diffusion of responsibility between healthcare systems, and the lack of financing mechanisms to have these very inexpensive but effective interventions implemented. And safety planning is an intervention that also now has randomized control trial evidence. These are just some of the resources that SAMHSA has available for free around suicide risk assessment.

Let me just speak really briefly about the National Suicide Prevention Lifeline, we answered over two million calls last year. Call volume continues to go up. But as call volume goes up, capacity is not going up, we rely on community crisis centers who need additional support in order to answer these really important calls. Most communities in America, it’s the only thing available other than the Emergency Room in the middle of the night, or even on a Sunday afternoon. SAMHSA has also been supporting enhanced crisis services, this is something called the Crisis Now Model. I won’t go into detail, but think of it this way:  We live in the era where you can track a package halfway around the world, but we routinely lose people within the lethal gaps of our crisis and emergency systems. Just last week, the President signed into the law the National Suicide Prevention Hotline Improvement Act, which calls on SAMHSA, the VA, and the FCC to look at the potential for an N11 three digit national mental health and emergency number, and we will be working on that over the next six months.  So thank you very much.

SARAH DASH:   Thanks. And last but not least, Anand Parekh.

ANAND PAREKH:   Sarah, thanks so much, I’m Anand Parekh, and Chief Medical Advisor at the bipartisan policy center, it’s terrific to be here, and I want to again thank the Alliance, and Commonwealth Fund, all of the terrific panelists, and all of you for being here.

I want to just spend a couple of minutes echoing, I think probably summarizing some of the key points, and then helping us transition to the discussion. I’m going to probably take a step back, talk about life expectancy, come back to deaths of despair, and then really hone in on the opioid epidemic.  I think there are a lot of terrific points that have already been made, hopefully I can underscore some of them. So I think as David mentioned, we are in a stretch, as the CDC tells us, of declining life expectancy in this country. It’s been two years that we’ve been tracking — 2015 and 2016. It may be that 2017 follows that stretch. This is pretty unprecedented, the last time there was declining life expectancy in the United States, it was 1993, the last time you had two years in a row was 1962 and 1963. The last time you had three years in a row was 100 years ago, with the Spanish flu in 1918.  And so these are unprecedented times. There has been a lot of literature in the academic community trying to understand why life expectancy in this country is going down. And if I can just synthesize in 30 seconds all of that literature; if you were asked sort of a public health multiple choice question here:  Is declining life expectancy in the United States due to A) Deaths of despair, B) Obesity, or 3) what we call the leveling off in the decreasing mortality from heart disease and cancer, some of the leading causes of death in this country. The answer is actually “D”, it is all of the above.  A, so as David has explained to us, deaths of despair is the one category that is going up in terms of mortality in this country. That is being driven by drug overdose deaths, which are being driven by the opioid use disorder, and opioid overdose deaths, which is being driven by the illicit flow of opioids currently — particularly synthetics, and Fentanyl, and precursors coming in from China, and its really — if you look at much of the mortality figures, it’s really Fentanyl waste, with heroin, being sold as heroin, and many other drugs or components of that right now. So unfortunately, the opioid epidemic in this country is going to get worse before it gets better. We are seeing overall reductions in prescribing, but until we see a commiserate decrease in the illicit flow, as well as treatment, which is absolutely critical, we are not going to see the decreases in overdose deaths that we’d like to see.

Certainly alcohol has been talked about here. 88,000 Americans, by the CDC, dying from excessive use every year, costing a quarter of a trillion dollars in economic costs. This is an issue where there is evidence-based clinical and community services, and practices that if we just employ, that we be able to reduce debt. So here there is a certainly a way. We need to find a will.

Suicide — Richard has already covered suicide, 45,000 Americans dying from suicide deaths, the importance of focusing on youth, focusing on early intervention, is absolutely critical. There are an array of risk factors we know about that we need to focus on — firearm access is critical as well. Half of deaths involve firearms. So all of these areas, deaths of despair, are critical.

Obesity. Now 40% of Americans in this country are obese. Latest studies from January 2018 show that obesity reduces life expectancy by about a year at the age of 40. So I often say, in a lot of talks, that while the opioid epidemic is the public health crisis of the decade, certainly the obesity epidemic is the public health crisis of the century for us. So we need to think about all of these epidemics.

And thirdly, the leveling off in decreased mortality from heart disease and cancer is critical, because if it was just deaths of despair increasing, then those would compensated by decreasing levels of heart disease and cancer. But we are seeing in many sub populations actually a plateauing of deaths from heart disease and cancer, and that is also a critical reason for reductions in U.S. life expectancy. And I think the other point to make is that all of these issues are interconnected. So for example, some of the risk factors driving obesity are the same risk factors driving heart disease and cancer, and maybe organizations like the Well Being Trust, a really influential philanthropy and non-profit organization, remind us that even diseases of despair make it more difficult to prevent chronic diseases and manage chronic diseases. So all of these items are interconnected.

And I think the second point on the slide is this last bullet here:  “When it comes to health, United States is far from being united.” And this is a quote from an editorial that co-authored in JAMA back in April, looking at a recent study — Joe mentioned this organization from the University of Washington, the Institute of Health Metrics and Evaluation. And they really focused on geographic disparities in the United States, an area that we need to, I think, focus a lot more about. And for example, life expectancy in this country — if you live in Hawaii, life expectancy is 81 years old. If you live in Mississippi, it’s 74 years old. So if you live in Hawaii, you are right behind Ireland, if Hawaii were a country, you’d be about 20th in the world. Mississippi, if it were a country, it would be about 76th in the world, right after Kuwait.  So there is dramatic — as Joe said — zip code matters quite a bit. The study also showed that Americans aged 20 to 55, their mortality reversals over the last two decades in 21 states across the country, and they are driven by deaths of despair.  So psoriasis, so alcohol is there. Drug overdose, and self-harm. So all of these issues, I think we are seeing these issues play out. The research is demonstrating all of this. So all of these state-level analysis are so important. To reiterate some of the score card data, the data alluded that all of these issues are important in every state, but certainly for Montana, it still might be suicide as a key public health issue. For New Mexico, it could be alcohol. And for West Virginia and New Hampshire, it could be opioid overdose. So I think looking at individual states are so critical.

The last sort of two slides are really sort of place holders for I think the discussion and this is sort of wearing my former health and human services hat. I think they are tremendous opportunities at the federal level to better support state and localities will all of these deaths of despair. Take the example of opioids. The tremendous work coming out of CDC and SAMHSA right now, grants the State Health Departments — Marvin mentioned the STR and the SOR grants. These are critical investments to states to help them curb these epidemics, but I think we need to think even more about mandatory spending, and how to take Medicare and Medicaid — Joe talked about Medicaid in the State of Arkansas. How we make sure that our mandatory dollars go to tackle some of these important public health challenges.  I remember my time in health and human services, I would often say that CMS was actually our most important public health agency, because while many of our agencies are absolutely important, their budget runs into several billion dollars, whether its CDC or SAMHSA.  Well, CMS has a trillion dollar budget, so we need to figure out, how do you leverage our mandatory dollars, the unique levers that CMS has, whether it’s payment policy, delivery models, waivers, state plan options, quality metrics, quality improvement organizations, coverage? There are a lot of unique levers that CMS has, that Medicaid has at the state level to really tackle some of our critical public health challenges.

And the final slide is just a reminder, I think from the state perspective, so many opportunities, November 2018 there will be 36 gubernatorial elections. It doesn’t mean 36 new governors, but 36 elections that will lead to either new agendas, new state health leaders, or updated agendas, and I think it’s a critical time to have our state leaders focus on what I call the 3 P’s of population health, which are:  Prevention, public health, and primary care.

Just a quick note, I think on primary care, and why it’s so important, this has been alluded to in terms of treatment. So France, in the 1990s had a significant opioid epidemic, it was really driven by heroin.  Within four years, they were able to reduce opioid overdose deaths by 79%. How did they do it? They completely unleashed the entire primary care health system in that country. So all providers, all could prescribe Buprenorphine, and so dramatic reductions in opioid overdose deaths. So there are public policies that we have right now that don’t really allow our primary care providers, for example, to prescribe medication assisted treatment as easily as needed.  There are caps, there are training requirements. So there are a lot of things that we can do in terms of learning from other countries. And the last point to make is just simply the importance of promoting bi-directional flow between the federal government and states in terms of what we can learn on how to tackle these diseases of despair. So one of the things at the Bipartisan Policy Center we are trying to do, is track in the FY18 omnibus over four billion dollars are going to states to tackle the opioid epidemic.  Where are these dollars going? Where are they flowing, for what purposes, how can we evaluate that? I mean, states have a tremendous opportunity to take all of these resources and evaluate what’s working, what’s not, through a feedback loop, inform the federal government, congress, and the executive branch as all of these challenges are going to be with us for some time. So I think that feedback loop is absolutely critical.

Hopefully a couple of points just to highlight, and Sarah, I will turn it back to you for the start of the discussion.

SARAH DASH:  Thank you all so much. So it’s time to ask questions. You can come up to either mic on either side of the room, write a question on a green card, and someone from the Alliance will bring it up, and you can also submit a question by Twitter at #allhealthlive.

Let me kick it off really quickly, and then we’ll turn to the mic. A number of you mentioned the need for multidisciplinary efforts to address these so-called deaths of despair, including in areas outside of the health systems. I want to ask, just from a real-life perspective, what does it really take to make these successful?  And are they sustainable?  Perhaps I will just open it up to anyone who wants to jump in.  Joe?

JOE THOMPSON:  I will start off. Yeah, I think recognizing it, and this is in the role that I played for both governors, starting a conversation, but recognizing as you start that conversation, you may be using very different language. Our criminal justice system, our health care system, our public health system, our school system, our foster care system, they may be talking about the impact of opioids on a family, in a community, but they will use very different language in the discussion. So I think having an honest table that you can start the discussion, because if you can get the discussion going, if you can define the words that people use, the threat is real for all of the different perspectives, and that will naturally draw people together to look for opportunities that have an impact.

RICHARD McKEON:   Yeah, so what I would say, is that a really critical issue in terms of suicide prevention, is that suicide prevention requires a coordinated, multisectoral response in order to be effective. That’s part of what makes it challenging, because it can’t just live in the mental health, or the Department of Health, somewhere else. So it needs to have a strong focus. Colorado, for example, has established a state suicide prevention commission that has brought together various parts of state government, because you need to have involved — you need mental health, you need the Department of Health, you need substance abuse, you need Veteran’s Affairs, you need education, you need the justice system. All of these need to play their roles, and someone has to convene them, right? And they need to use the national strategy for suicide prevention as a blueprint for doing that. But it doesn’t come easily.  If you are not structured to do that — Tennessee for example has a six person office of suicide prevention and crisis intervention, but in some states you have one state suicide prevention coordinator, who may have one part of a full time equivalent devoted to this issue. It’s not enough to get it done.

MARVIN FIGUEROA:   I will just add that it’s also difficult. I mean, the ability to collaborate across secretariats is usually a challenge, and it requires a level of intentionality that is sometimes not there. So the governor has to establish it as a priority. I think additionally, when you look at a place like Virginia, there is a lot of — counties have a lot of power, and counties, depending on where you are, have different resources to bear. And so you also have those disparities for say, Wise County versus Arlington County. And so how do you create a level playing field where everyone can bring their resources, while at the same time, the state supports those local efforts?




SARAH DASH:  Thank you.  Okay, we have people lined up at the mics. So if you could just introduce yourself, and ask your question. I will start over here.

AUDIENCE MEMBER:  My name is Mary Karuk, I was looking over the states, and all these regions are rural people with not very high education levels, and except for probably some of the states in the Southwest that have Indian reservations on them, that have historically had a big probably with substance and alcohol abuse. They are overwhelmingly white. Has any of these studies made a connection to American manufacturing jobs being sent overseas, usually to third world, or close to third world countries?  And also the 11 plus million illegal aliens that are currently in this country, and get hired to do the few jobs that are left, you know, without having to have minimum wage laws, OSHA requirements?  And the other question I’ve had is the term “opioid”.  What percentage of these opioids are illegal street drugs, and what percentage are being prescribed by doctors?  And is there any pushback from the pharmaceutical industry in the case of the legal opioids? Because they are making a lot of money off of this.

SARAH DASH:   Alright, so two kind of different questions. One is kind of, are any of the studies looking at some of the causes of economic distress that may be driving some of these trends.

JOE THOMPSON:   So I’m not aware of studies that specifically look at manufacturing exits, but I think you will see a correlation. Again, I think we need to be careful of causation, but there is, I think, going to be a correlation in many of these areas that are economically challenged and distressed. You are also going to see, those are the areas each census report that have out migration of their population, because they have fewer opportunities, and whether it’s Kentucky, whether it’s Arkansas, Mississippi, the upper mountainous regions, I think you are going to see a correlation of opportunity go right with some of the issues around the addictions and the death of despair that we are talking about.

SARAH DASH:  David, did you want to –?

DAVID RADLEY:  You know, it’s interesting, again, just to echo what Joe said, the original work on deaths of despair by the two economists, Agnes Encase, and Agnes Deaton, they were looking at deaths of despair as sort of a health outcome that was sort of happening as sort of economic and social trends were changing. If you read some of their work, they are actually careful not to tie it too closely to sort of the level of income that you have, so much as it’s the amount of opportunity that you have. It’s not necessarily that these deaths of despair are always high in low income areas, but as sort of that social fabric starts to break down, as your sense of opportunity starts to go away, that’s where (indiscernible) the deaths of despair start to really, really shoot up.

SARAH DASH:  Anand and Marvin?

ANAND PAREKH:   I will just echo sort of Joe and David. I think case indeed, when they initially came up with deaths of despair, they were looking at a specific population. So white non-Hispanic Americans, age 45 to 54 with less than a college education. So a high school diploma or less. And I think the opportunity frame is sort of a better frame, the need to increase opportunity for those vulnerable Americans. So they don’t really fall into addiction or are not predisposed to some of these diseases of despair, I think is critical. And to your second question, we are seeing sort of prescribing slowly start to nationally come down. We are under 200 million prescriptions for the first time in a long time, which is still absolutely a strong — astronomical, but it is really the illicit flow that is driving the epidemic right now, and you mentioned pharmaceutical companies, in fact there are a number of states and local jurisdictions that are now suing pharmaceutical companies. In fact, President Trump asked his Attorney General just earlier this week about doing something similar. So there is a lot of, right now, focus on prescription drug companies, and also sort of what they can do to curb the epidemic as well.

SARAH DASH:  Marvin, did you want to…?

MARVIN FIGUEROA:  Well, only that when you look at the data, the African-American mortality rate in Virginia continues to be stubbornly high, and while we have to — you know, we are focusing on the death of despair, you have to think about what those deaths are telling us.  They cannot be to the detriment of other populations. So that’s why I think the opportunity, and the health opportunity index kind of framed the conversation well.

SARAH DASH:  Okay, you’ve been waiting patiently, can you introduce yourself and ask your question?

AUDIENCE MEMBER:   Yes, I’m Bob Rosenblatt with the website.  I have been following this on Twitter, and have seen an increasing number of comments from people who say, “I have a chronic health condition, I have been taking opioids for a long time, and my doctor just cut me off because he’s afraid of getting in trouble with the state and federal government.” And I’ve also seen similar comments by a number of physicians saying exactly the same thing. “We have these patients, they need this, but we are not sure what to do now.” So what, if any, advice, suggestions, can be given to these doctors and patients?

SARAH DASH:  And before you answer — thank you for your question — before you answer, there is a related question on a green card, so I just want to try to combine them.  And it relates to this question of chronic pain.  And to your question, there is — the questioner asks, “Is the CMS rule on limiting opioid prescriptions to 90 milligrams per day the correct policy to work towards lowering opioid substance abuse?”  So getting towards the question around prescribing patterns, and then how to manage chronic pain and perhaps, are there alternative chronic pain treatment options that might work?

JOE THOMPSON:  Well, let me start, and I think is where I think it is important for us to evolve the discussion.  We have nascent first time users for which we have overprescribed, and for which we now know that if you’re using between three and five days, that’s when you become addicted.  We have a decade and a half ago, in emergency rooms, and hospitals and clinics across the nation, we had a pain scale, that if you had any pain, there was a marketing effort to try to treat.  So we have a number of people who I would say are dependent.  To get through the day, they have to have a narcotic of some type.  The effort to squeeze the supply on physicians needs to anticipate reactions by both of those two groups. The first group, the nascent group, will not have much of an effect other than not becoming addicted because of seven day, five day limits, and limits on the amount of morphine milli equivalents.  The second group, the addictive group, if we don’t ramp up the treatment, if we don’t have more physicians that are actively engaged in assisting people to withdrawal from their dependency, those individuals are at risk to turning to the elicit market, and I think that’s where we do have the potential to drive individual — by only focusing on the supply, and not on the treatment, to potentially, as Anand said, we may have higher death rates in the coming year.

ANAND PAREKH:  I’ll just add that there are millions of Americans suffering from chronic pain in this country, and some absolutely need opioids and we have to make sure that any — our policies don’t have the unintended consequences of increasing more chronic pain.  That being said, many of the policies, even the prescribing guidelines at CDC put out, have not been interpreted correctly, so there is a lot more education that we need to do to ensure that individuals who need these medications have the ability to stay on these medications that physicians and healthcare professionals aren’t scared off, for example, of being able to prescribe these medications. So I think we need to examine sort of state policies, correct them where there is an overreach, ensure that there is more education about the important prescribing guidelines, which I think are very important.  Just a quick note to Sarah’s questions and to a question to Sarah about what CMS is doing. So starting in 2019, a Part D plan for CMS beneficiaries, whenever somebody is on a regime with more than sort of 90 milli equivalents, it’s not that they can get anymore, it’s simply — so it’s sort of that the pharmacist has to call the healthcare professional to verify the dosage. There will be a new seven day limit for first time acute chronic pain episodes, and many states have already done that. So I think we just have to make sure that our policies are evidence based, but then communicated very well, and I don’t think we’ve done a really good job on communicating these, and educating healthcare professionals and patients.

SARAH DASH:   Thank you, and speaking of communication, was that in Part B or Part D that you said?

ANAND PAREKH:  Sorry, Part D.

SARAH DASH:  D as in — David.


SARAH DASH:   All right, you’ve been very patient.  Introduce yourself and ask your question.

AUDIENCE MEMBER:  I’m [name], I’m a policy fellow with the Association of Asian Pacific Community Health Organizations, and also a physician in training.  My question is regarding addressing the infectious disease consequences of the opioid epidemic. My focus right now has been on viral hepatitis, particularly Hepatitis B, as well as C. I think when we are looking at the opioid epidemic, it’s important to address the immediate health consequences, like ensuring a Naloxone availability, ensuring patients have access to support programs to help address their addiction. But I think we need to make sure that we don’t get so short sighted and forget to address preventable infectious diseases like Hepatitis B, which has a vaccine that is very effective, but only a quarter of adults are currently vaccinated against Hepatitis B, and we’ve seen rises of up to 400% of Hepatitis B cases in certain states, and then Hepatitis C, where there is no vaccine, but there is a cure where we can completely treat and cure people of Hepatitis C, and there have been significant rises into Hepatitis C across the country. And so what is being done at the state and federal levels to address this and ensure that we are looking at this from a public health perspective more broadly to prevent something like the HIV epidemic in the 1980’s has exploded into what it is today, from happening in Hepatitis B and Hepatitis C.

ANAND PAREKH:  One state that I would refer you to is Delaware, and they piloted a syringe exchange programs, for example, and then they expanded that statewide, and saw reductions essentially in infectious disease transmission HIV and Hepatitis C. Vice President Pence and Surgeon General Adams saw the same thing in Scott County, Indiana when they were previously in Indiana and had to essentially install an evidenced-based syringe exchange program. So then you are getting at sort of harm reduction, and how do we make sure that through the lens of the opioid epidemic, we’re also able to tackle some of these co-morbidities, and certainly with injectable opioids, the risk of transmission of infectious diseases like HIV and Hepatitis are there, and we need to look at evidenced-based harm reduction programs, like syringe exchange programs, to see how they work, if — when they work, and when they do implement them.

AUDIENCE MEMBER:  And I think another part of this is, how we do bridge the siloes that exist?  For example, at CDC, there is a division of viral hepatitis, then there is immunization services, and those divisions often have separate streams of funding, and this goes across the board when you’re looking at issues of addiction, and then how do you transfer some of that money so that you’re looking at things comprehensively?

JOE THOMPSON:   So I think your question is spot on, and I just want to expand it a little bit, building off of Marvin’s comments a few minutes ago.  It is rare that you have the focus, the energy, the new money, going into the health system and in part it is because this is the sexy topic right now. We need to make sure that our focus in this topic doesn’t fail to recognize the disparities that are still present, and some places growing, or the other conditions. You are saying there is — it’s almost like throwing a pebble in the pool — we are focused on where the pebble landed, that’s the opioids, but outside ring are infectious disease, your interests, adverse childhood events when a parent is incapacitated by drugs. And the rings go out from that. As a nation, and hopefully in your every day opportunities, there will be a way to say, let’s look at the whole pond of health, not just where the opioid’s landing — or where the pebble is landing, because of the opioid focus today.

RICHARD McKEON:  If I can just make one comment regarding the issue of that kind of ripple effect. When we had Case and Deaton come to visit us, we also had Robert Bussard, who was the VA’s main data guy on suicide. And he told us that there are counties in West Virginia where 40% of the kids are either in foster care or under the protection of Child Protective Services. And then I was further told by the West Virginia State Suicide Prevention Coordinator that there is one county where that number is 60%, and she expressed concern about, in years to come, you know, what will happen to those kids?  What will happen in terms of their suicide rates? What will happen in terms of a range of other really negative outcomes? So I think it’s very, very important that we’re aware of those ripple effects, and each death, whether it’s suicide or accidental opioid overdose, affects many other individuals, and brings its own intense pain with it that has a ripple effect that we need to pay attention to.

MARVIN FIGUEROA:  In Virginia, we are working to establish harm reduction sits.  One thing to recognize, and I don’t think sometimes this is truly appreciated, is how difficult they are to set up, and how much local buy-in you need in order to be able to not only stand it up, but also maintain those sites. So even a locality where you have a high prevalence of infectious diseases as a result of substance abuse, will say, we don’t want that here. So part of it is kind of making sure that the state prioritizes it, but working with those localities to set them up, and also sustain them.

SARAH DASH:  Can you say just a little bit more about a harm reduction site? What does that entail?

MARVIN FIGUEROA:   I mean, the one that folks most often cite is (indiscernible), so in some places, especially where we see, again, a high prevalence of these infectious diseases, tend to be more conservative. And so, how do you work with the Health Department in that locality? How do you work with the sheriff? How do you work with the local electives to set up this program? Usually what you will get — you will get some pushback from law enforcement. We are seeing more collaboration between law enforcement and health and human resources, in large part because of those working groups that we’ve established, but none the less, these things are hard to set up.

SARAH DASH:  Okay, we’ll get to your question now, thank you.

AUDIENCE MEMBER:  Thank you. My name is Jonathan Duff, I’m from Congressional Research Service. So I’ve heard some conversation about hypothesis as to why such an increase over the past decade. And it seems like economic opportunity has been cited, and certainly the influx of opioids has been well-documented, although I don’t know that that explains all of it. But I’m curious about hypothesis in the context of prevention. So even if you were to prevent some of these deaths of despair, you are still talking about potentially a lifetime of care for some of these people, whether its substance abuse treatment, or mental health treatment. So I’m curious about examples, either ideas that you have, or specific examples where you are actually addressing the underlying positives of some of the symptoms, or some of the issues that result in these deaths.

SARAH DASH:   While you are thinking about that, I’m going to throw another one at you, which is a related question that someone asked:  What are some of the most burdensome laws and regulations preventing more providers from being waivered to dispense Buprenorphine?  So I don’t want to necessarily target the answers just on Buprenorphine, but it’s a related questions. Thanks.

JOE THOMPSON:   So if I can try to tackle — I don’t want it to be represented that opportunity and the presence of opioids are the primary causes. I think, and this is the basis for many — much of the litigation against the pharmaceutical companies. I think there was some false advertising practices that occurred over the last decade and a half. I think that as physicians we didn’t recognize the addiction potential of some of the prescriptions that — or many of the prescriptions that went forth. I think our understanding of that is growing, so that it is now known, and fairly solidly shown that it’s the three to five day window, that if you are using a narcotic for three to five days, that your addiction potential doubles and at seven, even goes higher. So think there are practices on the medical side as well as the supply side, and that have to be directly affected. Now that’s not getting over into the illicit drug issues, or some of the more non-healthcare activities, but I think this is a whole package. It’s susceptibility of individuals, it’s exposure with lack of knowledge about medical personal, and then it’s some of the lack of understanding of how dangerous these drugs are at initiation.

RICHARD McKEON:  Let me mention this from the perspective of suicide prevention. I think the suicide prevention field, and I would count myself among them, has really done an inadequate job of providing coherent explanations for the increase in suicide in the United States. We know it’s not only about the Great Recession, because it was already going up before that. The Great Recession may have exacerbated some of those trends. You know, so there is a real need to understand better these trajectories over time. Case and Deaton talk about the cumulative disadvantage, and the notion is that these things may come together. So you lose your job, but thankfully, most people who lose their job don’t kill themselves. So what is it that’s going on? Well, it may be something like, you lose your job, but you are living in an area where there are not a lot of other jobs to get to. And here is the key point that Case and Deaton make:  You’re not college educated, you are not mobile, and you don’t have the wherewithal to go to other places to pursue economic opportunity, so you are staying in your community that has fewer opportunities.  You start to get depressed, you start to drink, maybe if you — you’re doing hard labor and you’re injured, and you got prescribed an opioid, and that these things come together and build on each other, and begin to put people at increased risk. But we need to understand these trajectories better, including among youth, and being able to intervene earlier to try to alter these trajectories over time. Now, while most of the suicides take place among adults, so it’s really important to pay attention to them. on the other hand, if we can alter these trajectories earlier on, then we may — there may be many years of life saved, for many people, if we can learn to intervene more effectively.

ANAND PAREKH:  Very briefly, just build upon what Richard said and sort of echo his comments. I think this really speaks to the importance of improving children’s health policy in this country, and adverse child experiences, and a lot of the diseases of despair start at an early age whether it’s alcohol access and binge drinking, in high school and college, whether — Richard showed you for suicide, leading — the second leading cause of death, particularly for young persons.  Opioid epidemic for those who are on heroin laced with Fentanyl and other opioids. So I think we need to do a much better job focusing on policies from a prevention perspective, since that’s what the question was about. Starting early in life, and making sure we’ve got the policies right, get people on the right trajectory, so later in life, they are not actually dying from these diseases of despair.

SARAH DASH:  Marvin?

MARVIN FIGUEROA:   And I think that we fully don’t understand the issue. I think up until recently, you started to see even addiction being called a disease. And from the state level, before we dealt with these kind of situations, through the justice system, and now you’re starting to see treatment. And so we are at a critical time where we are evolving as to how we react to this situation, but are we fully there?  I would say that we are not.

SARAH DASH:  Thank you. So there was a specific question actually: “I’m following on the point about children, and children in foster care, can you expand on the impact of opioid use disorder, or substance use disorder on children in the child welfare system, specifically in foster care, and do you think that the recent rise of children in the foster care system can be completely attributed to the rise of drug related deaths, or use of drugs, or is there some other cause?  And then talk more about what can be done to make sure that these kids can have some more resources to live a more — a healthier life, and be in more of a state of well-being.

JOE THOMPSON:  So briefly, and others may — I will try to be targeted in the response here. You know, the state or the county, or the municipality has got legal obligations to safeguard the children in those geopolitical areas, and when the parents are addicted, and potentially incapacitated because of drug use or other issues, the state, or the political entity has to step in. I don’t think there is any way that foster care has been taken over by substance abuse. We have had long term issues of parental challenges with children, but clearly in certain areas where we have high drug use, you see a correlation with much higher requirements, and those requirements then spill over to drain the personnel, the parents, the other families that are willing to serve as caretakers for children that are under protective custody, or that need a safe environment, and financial resources. And so it really does end up — the ripple effect is a negative ripple effect, if you will, across the state, or municipalities ability to respond and safeguard those that are most vulnerable.

AUDIENCE MEMBER:   Tate [name] with the American Academy of Physician Assistants.  I want to bring up a recent quote form Dr. [name]. “Imagine a cure for cancer deaths that, (indiscernible) but not using it, and that that is opioid addiction.” MAT, including Buprenorphine is 80% effective in reducing deaths for those who are addicted. There has been a major effort to increase waivered providers, although it has had limited success. In 2006, Congress created a five year program for nurse practitioners and PA’s that are increasingly primary care providers in the country to be able to provide MAT services, Buprenorphine, and it was limited to a five year program because there is a cost to — about 40% of people who are addicted are on Medicaid, so there is a mandatory healthcare cost to making a policy like that permanent. We have made free training available to PA’s across the country to get a waiver, and we have really heard heart-warming stories from our providers who have earned a waiver, and are providing those services. However, it’s a slower take up than we would like to see, and my question is, both Joe Thompson and Marvin mentioned increasing waivered providers in states, and I just think we know that this works, and what can we do to coordinate federal and state efforts to have more waivered providers out there? We are working to make the waiver permanent, the House opioid legislation that recently passed would have done that. The Senate bills that went through committee currently do not do it, and it has to do with a (indiscernible). Interested in your thoughts on that.

JOE THOMPSON:   So for the broader group, some of that might have sounded a little bit mumbo jumbo, and Tate has been on the health efforts for decades. As a physician, I have a DEA number that allows me to prescribe. However, there are restrictions on my DEA number for certain substances — Methadone, and Buprenorphine specifically.  The waiver allows me to be able to prescribe those, and the DEA puts a cap on the number of individuals — 30, I think it is, in my first year that I had a waiver. And so it is an effort by either physicians, nurse practitioners, or physician assistants, to go through to be able to medically assist individuals to withdrawal from their narcotic addiction. I think the earlier question, too many physicians just say, well, I just won’t prescribe them anymore, as opposed to going through this effort to try to be able to be supportive of their patients who have an addiction. So I think Tate, to your question, we’ve got to figure out how, on the education side, to our clinical providers, we emphasize the importance of their willingness to treat individuals that have addiction, and then on the regulatory side, that we put systems in place that allow a more rapid expansion of support, given the threat that we have across the nation.

MARVIN FIGUEROA:  Well, you have a lot of individuals who are waivered that are not prescribing. And so part of the STR grant that we’re applying for includes a hotline, so if a prescriber has a question about, can I prescribe in this situation or that situation, they will be able to have that question answered. The second piece of that is that the MAT is really important, but also the treatment piece. The reason why our ARS program has been particularly successful is because you have to create the conditions by which you have treatment services, and reimbursement usually drives what treatment services are available and what’s not. And so those reimbursements are really important as conversation.

SPEAKER:  If I can just add, I think, and also the states practice laws, particularly for NPs and PA’s, and whether they can prescribe Buprenorphine, is important, but I don’t think our federal public policy — and I think the legislation in Congress right now does a lot of good things, but it doesn’t address these fundamental issues. There are still barriers. Why do we need waivers? Why are there caps? Can you imagine if we said, healthcare professional, you can only take care of 30 diabetics in your practice. You can only take care of 100 patients with heart disease. We don’t do that with any other chronic disease. We further stigmatize this issue, and reduce the capacity we need to treat individuals with opioid addiction. A waiver. Why should an NP or a PA have to go through 24 hours of training? This is not more complicated then many other things that healthcare professionals do. We treat complex diabetics, we manage insulin regiments, this is not that complicated. There is no reason there ought to be an 8 hour training requirement for physicians, and a 24 training requirement for NPs and PA’s. Until — and it’s really Congress. Until we can fundamentally tackle some of these public policy issues, and expand capacity, caps and waivers and all sort of — we are not going to see the commiserate increase in treatment, and so that’s one thing I hope Congress takes a look at before the ultimate package moves forward.

SARAH DASH:  So we have one more person at the mic, so I think we have time for one more live question, and then we’ll close. Go ahead.

AUDIENCE MEMBER:   Good afternoon, my name is Garrett Moran, I’m a vice president at Westat and direct the Arch Academy for Integrating Behavior Health in Primary Care. We have been doing a lot of work on opioid issues. I was going to make a couple of statements that the panel has already — there are many more doctors who have the waivers, then who are actively prescribing. 30% of docs get the waiver and never do anything with it. The median number of patients treated is something like five. It’s very small. And a key issue here is the stigma. And the patients have stigma and shame about this disease. Our communities have stigma, our providers have stigma. They don’t want to deal with this population, and a fundamental thing we’ve got to address is the stigma around this disorder. The other thing, I’ve been doing a study where I visited a number of programs around the country over the past few months, and going beyond the prescribers, we are finding a real shortage of behavioral health professionals to work with these patients. Probably 80 or 90% of them have trauma. Half of them have serious depression, the rate of opioid prescription to people with mental disorders is just sky high, about half of all opioid prescriptions are going to people with mental health disorders. And it’s not enough.  Medication assisted treatment is absolutely essential, but it does take solid behavioral health services to do that. We’ve been looking around the programs around the country, there is no clear standard of what that should look like now, and there is some really good programs, but it’s an area that many programs are struggling with, and they are struggling finding professionals with the willingness and the training to work with this population. Like your reaction to those observations.

JOE THOMPSON:  I think your observations are on target, and probably exacerbated in areas that we have healthcare provider shortages, even — I mean, mental health is usually the one that has the most shortage, when you start looking at shortage areas.  I would say, and I think this is on this opportunity in some of the value-based purchasing.  When we put in pretty assertive patient-centered medical home and told the primary care providers, we will share 50% of the savings with you. One of the first things they turn to, is bring a mental health provider into the primary care space. The alignment of financial incentives in the primary care space to reinforce and reward integration of mental and physical health, works. We need to do more of that so that we can accelerate the transitions.

SARAH DASH:  Thank you. Okay, we’ve got a few minutes left, and we’re going to wrap up. I’m going to ask each of you a final question and these are difficult topics and “despair” is a really strong word, and I think we have examined some of the reasons why this is going on. But what I want to ask is, and we are gonna just go down the line, so I’m going to put each of you on the spot. What gives each of you hope for progress on this issue going forward? I will give you a minute to think about it.

While they are thinking about it, you all have blue evaluation forms in your folders, if you could fill one out before you leave, that would be appreciated. Thank you. All right, so what gives you hope, David?

DAVID RADLEY:  So I think what gives me hope is, like we’ve said, zip code matters, and we’ve — there are places in the country where the problem isn’t as bad as in other places in the country. That tells me a couple of things. It tells me that there is an opportunity to learn from those places, and so I think what gives me hope is the fact that when we look around, that no everybody has the same experience. There is different experiences, and let’s try to figure out how to take some lessons from those places where the more positive, or the less bad experiences at least, and translate that into new care models, new payment models, whatever. So that we can sort of float the boat, rise to the level for everybody else.

MARVIN FIGUEROA:   I think what gives me hope is that I think Virginia is taking this opportunity to examine the inequalities that exist within our commonwealth. And for the first time, you have individuals that otherwise wouldn’t talk to one another at the same table, trying to discuss the issue, because it impacts every population across the board. And so public safety is talking to health, labor is taking to employers, to figure out how we move forward together. And for me, the way ahead is the fact that at this point in time, we are all in the same situation, and we have to figure out how to work together.

RICHARD McKEON:  What I would say, first off, is that “despair” is a strong word, but it’s an important word, and I think it’s what units all of these kinds of deaths. And in America, no one should have to die alone and in despair. So what we can do — what gives me hope, is that we are continuing to ramp up our efforts. We are not there yet, but we know more about suicide prevention than ever before. We know a lot about what works. We have examples of programs and approaches that have demonstrated reductions in suicide attempts and deaths, and the challenge is in many ways is to bring what we already know to scale. So the fact that we know that it can be done, is what gives me hope.

ANAND PAREKH:  I will say similarly, there are evidence-based interventions in the clinical setting, and the community setting to tackle each and every one of these conditions of despair. We don’t know everything, we need to learn more, but there are evidenced-based interventions. We need to have the will to implement these interventions, and I think the best way also to tackle stigma, is to educate, and communicate and talk about these issues and I want to again thank Commonwealth and the Alliance for actually — these aren’t uplifting topics, but they absolutely need to be the focus of discussion, because if we don’t, that further stigmatizes these conditions.

JOE THOMPSON:   So I would say “despair” is a strong, but appropriate word. The synonym that you could put there is “loss”.  States of loss. Because people are losing family members, community members, each and every day from these several specific causes. What gives me hope, and it’s the second part of the title, is that I think there is motivation and awareness that we have statistics now showing our life expectancy is decreasing. It is unlikely we are going to have a magic pill, or a surgical procedure, or some healthcare intervention that’s going to solve this. And so we are moving upstream to try to figure out how. We have our communities be a healthy place to raise our children and to experience our lives, and I think that’s a new paradigm. Some call it the “social determinants of health”, I can’t make that work with my policy makers. They glaze over. That’s why I went to “zip code risk”. I can get there with “zip code risk”. In my community, two miles makes a difference in terms of what you’re offered in the grocery store, in terms of what you have available to you in terms of safety. In terms of what you have available to you in terms of transportation. In terms of what you have available to you for jobs, or educational outcomes. And I think we’re going to recognize that that life expectancy number is going to continue to go in the wrong direction until we pull together, as this full room indicates, and we start addressing what’s causing those states of despair and states of loss.

SARAH DASH:   Thank you all so much, and on that note, I want to thank everybody for being here to learn with us and hope that perhaps you’ll take a moment to think about what gives you hope and what is something you would like to work on related to these very, very important issues for our fellow Americans. So thank you to our panel, thank you to the Commonwealth Fund for their support. And I hope everyone has a great afternoon.