Part 1 of 2 — Lauren welcomes guest Dr. Josiah Rich for a discussion on addiction treatment and public health, particularly in relation to the HIV epidemic and injection drug use in Rhode Island. He highlights the impact of a law outlawing the possession of a single syringe, which led to a decrease in HIV transmission. He also mentions the routine testing program in the Rhode Island Department of Corrections, which identified a significant number of HIV cases. Dr. Rich explains the current state of opioid use in the United States and the restrictions on prescribing methadone for opioid use disorder. He emphasizes the need for health care providers to address the opioid epidemic and the importance of getting people into recovery.

Lauren Lavin:

Hello everybody and welcome to From the Front Row. This is Lauren Lavin, and today, we’ll be talking to Dr. Josiah Rich. Dr. Rich has both his medical degree and master’s in public health and is a professor of medicine and epidemiology at the Warren Alpert Medical School of Brown University, and a seasoned infectious disease specialist at the Miriam Hospital Immunology Center, where he has provided clinical care for over 29 years. He also works at the Rhode Island Department of Corrections focusing on the care of prisoners with HIV and other medical conditions.

Dr. Rich has authored over 250 peer-reviewed publications, primarily exploring the intersection of infectious diseases, addictions and incarceration. He’s the senior medical advisor and co-founder of the Center for Health and Justice Transformation at the Miriam Hospital. An advocate for public health policy reforms, Dr. Rich has played a pivotal role in improving legal access to sterile syringes and enhancing drug treatment for incarcerated individuals.

With continuous federal research funding since 1995, Dr. Rich is a principal or co-investigator on numerous ongoing grants. He has served as an expert for the National Academy of Sciences and the Institute of Medicine appointed by the former Rhode Island governor to the Overdose Prevention and Intervention Task Force. Dr. Rich has contributed significantly to strategies aimed at reducing opioid addiction and overdose deaths in Rhode Island, and the effects have contributed to reducing deaths across the country.

With that, we would like to welcome him to this episode, and also of note, this episode will be split into two parts because, honestly, there was just too much to fit in one episode and I think it’s easily digestible when you split it into two parts. So we’ve got about two 30-minute episodes that will space out across two weeks, so I hope you listen to both parts of that. And without further ado, welcome to the podcast, Dr. Josiah. Rich.

Can you share with us what initially drew you to focus on addiction treatment and public health in your career, and maybe a little bit of background on what your career is?

Josiah Rich:

Sure. Thank you, Lauren. I started out in medicine and internal medicine. While I was a resident at Grady Hospital, I was able to do a three-month rotation in Bangladesh.

Lauren Lavin:

Oh, wow.

Josiah Rich:

I went there expecting to see tropical diseases and interesting things, and I saw that, plenty of that, but what I really found was the critical importance of basic public health, clean air, clean water, simple nutrition, and those are life-saving in that environment, and that really clued me into public health. Of course as a physician, there’s only so many people that I can reach, that I can take care of myself, but with public health, if you make a difference, you can impact a much greater population. So that made public health interesting to me through serendipity and really the times.

I finished medical school in 1987 and the AIDS epidemic was just exploding. So I found myself, after residency, did a year of public health school and went into an AIDS and infectious disease fellowship. And then I went from that to the job I currently hold 30 years ago at the Brown University in Rhode Island. And at the time, Rhode Island’s HIV epidemic was predominantly injection drug use. More than half of the cases were related to injection drug use. So I was mystified as to why this would be, and it turns out there was a law that outlawed the possession of a single syringe. A single syringe was a felony offense punishable by five years in prison.

Lauren Lavin:

Really?

Josiah Rich:

That changed people’s behavior. So pretty soon, the police realized that, “Oh, if they find someone with a syringe, they got five years they can hold over their head,” and there’s a kind of cat and mouse game between the police and people using drugs, and that became the predominant tool because for a number of reasons, but if you catch somebody with drugs, you have to send the drugs to the lab, it takes time. You catch them with a syringe, you got them dead to rights, and you can squeeze them and go up the feeding chain, which is kind of what they do. So pretty quickly, the police learned to do that, and the people who were using drugs learned to not carry syringes with them. So that means they would go someplace to buy drugs.

There would often be a syringe there. They would use the drugs there, use the syringe there, but they didn’t want to be caught with the syringe, so they would leave it there and the next person would come and do the same thing. It almost seemed to be designed to transmit bloodborne infections, and that’s what it did. So we worked hard with a number of students and others and smoke and mirrors and convinced the legislature to change that law. In fact, it took a number of years, but it went from the worst law in the country to the best.

When I met with the legislature, I told them that this epidemic of injection drug use-related HIV would just disappear, would melt away and crashing down if they passed this law. They passed the law. Now, we had a wonderful team of pharmacy experts, pharmacists that really went out and educated every single pharmacist in the state that by giving someone a syringe, you’re not telling them to shoot up drugs. They already got that message. You’re telling them to be safe and protect themselves and the people around them, and that worked. That changed the behavior of the pharmacists and the people who are injecting drugs, and almost immediately, HIV transmission stops to injection drug use in the state. It was a real public health victory.

Now, at the same time, the Rhode Island Department of Corrections had set up a program of routine testing of everyone who was incarcerated that’s passed, basically related to a law that had been passed mandating HIV testing for sentenced individuals. That law identified 90% … It tested about 90% of the people coming through, and one in three people in the state in the 1990s diagnosed with HIV was diagnosed at the Department of Corrections. So that is a pretty big slice of the pie to ignore.

Lauren Lavin:

That is a high rate.

Josiah Rich:

So I’ve been working in corrections a half day a week for the past 30 years to address the HIV and addiction crisis. So I’ve kind of been involved from the very get-go in addiction and public health. That was a long-winded answer. Sorry.

Lauren Lavin:

No, that was a great background. I have a follow-up question regarding that syringe law.

Josiah Rich:

Syringe, yeah.

Lauren Lavin:

How has that changed? You were talking about the Rhode Island law. How has that affected the country as a whole? Has that spread across the states? Do you know what the federal status of a law like that is?

Josiah Rich:

Yeah. So there is no federal law outlawing syringes. For a while, there was federal restrictions on funding programs that provided syringes to people who were injecting drugs, and that was a problem because we’ve learned that syringe exchange programs, needle exchange programs are extremely effective at engaging people, getting them to come in, getting them to stop high-risk injection practices, and even getting them into drug treatment and certainly getting HIV tested. So it does all the things we want to do. So it’s this kind of unfounded but visceral anti-syringe attitude is really the problem.

Lauren Lavin:

Yeah. Okay. And so basically, you’re starting with the HIV epidemic is what wove you into the incarcerated population, and that’s where you stand today.

Josiah Rich:

Well, it’s only half day a week, but my career is focused on infectious diseases. I’ve trained in infectious disease, but also the overlap between infectious disease and addiction and incarceration. So that is really basically one ball of wax. It’s the same population getting the same problems in different venues and same collection of problems. There’s a term called syndemic. It’s synergistic epidemics. So there’s a syndemic of injection drug use, of poverty, of stigma, of HIV, of injection drug use, of overdose.

Lauren Lavin:

That’s a great idea.

Josiah Rich:

I’ve been in the same syndemic and stuck there, but it’s evolved over these years, decades.

Lauren Lavin:

It’s all woven together. Okay. Could you provide an overview, you gave us some backstory, but of the current state of opioid use in the United States and some of its causes of how we’ve gotten here today, which you kind of already answered?

Josiah Rich:

Opioid use has been around for millennia. It’s a natural occurring compound in poppy plants and they can make opium out of it, and morphine is a derivative, and heroin was initially a manufactured pharmaceutical compound manufactured by the Bayer company. So opioids have been around for a long time. In the Civil War, a lot of deaths from combat, from violent deaths, trauma, but even more deaths from these hospitals that were field hospitals that did not have antibiotics, and they were sawing people’s limbs off and doing barbaric things, and yet a whole generation of young men survives that, some [inaudible 00:10:56] but what they did have to offer people in that setting was morphine, even though they didn’t have antibiotics or really a concept of how to prevent infection.

So a lot of people came back from this war with soldier’s disease. Well, soldier’s disease we would now call opioid use disorder. It’s addiction to opioids. And then during the early 1900s, physicians had been prescribing morphine. It turns out if you give somebody with soldier’s disease, if you stop their opiates, they get very sick and unhappy, and if you give them enough to keep them safe and comfortable, they do okay. So physicians were prescribing opioids and cocaine, and then with the early 1900s, the intolerance in temperance movements really pushed, “Okay. Doctors, you can’t prescribe opioids anymore for addiction and could still prescribe it for pain.” So that took doctors out of the business.

Now, doctors are notoriously difficult to herd to change their behavior, but it turns out if you arrest a bunch of them and lock them up, it does change their behavior pretty quickly, which is exactly what happened.

Lauren Lavin:

Good signal.

Josiah Rich:

So unfortunately, doctors had been out of the game of treating addiction with opiates, and that lasted until the 1960s when methadone came out. Now, methadone is an opiate just like any other opiate like Oxycontin or [inaudible 00:12:30] Percocet or Vicodin, but it has a very long half-life. It stays in the body a long time, so you can dose it once a day. And it turns out from some elegant experiments in the 1960s that if you give people one dose a day, that they change their behavior dramatically. They stop doing all the crazy things they do, desperate things they do to get opiates and they become normal, and more importantly, they stop dying because this is ultimately a deadly disease, the opioid use disorder.

Now, the government had to allow this. The studies were so clear that it was effective, and yet it was almost begrudgingly because there was very tight government to control. So it can only be prescribed in certain doctors in certain programs, and it really has continued through to today. Most doctors are not allowed to prescribe methadone to treat opioid use disorder outside of the opioid treatment program setting.

People have to go every single day initially, and there’s a maximum amount that you can prescribe, the so-called take-home doses. So it’s the only medicine that’s treated like this. In the face of the current crisis, there’s interest in trying to expand that, open up those restrictions because even though it’s true, there are some dangers associated with methadone, people can overdose on it. It’s far safer than what is in this illicit drug market right now, which is extremely dangerous.

Lauren Lavin:

Can you explain a little bit more what methadone is because I don’t think I was aware that methadone itself was an opioid and how it’s used and how it’s different than one that someone buys?

Josiah Rich:

Okay. So opioid use disorder is a significant disease. There’s a few things you need to understand. First is that opioids are different than other drugs of abuse with two fundamental properties. One is the development of tolerance. So if you take a dose on a daily basis, pretty soon you develop tolerance, which means that you’re not getting as strong an effect from it, that you need a higher dose in order to get the same effect. So over time, the natural history of this disease is that people they use at a certain dose for a while, and then they increase the dose, and then that works for a while, and then they increase the dose. Then that works for a while, and then they increase the dose. So the natural history is that people go up and up and up and up.

The second property of opioids is the more diabolical one, which is when you try and stop using it, you go into withdrawal. Now, withdrawal, if you ever have an opportunity to ask someone who’s been through it, you should ask them what it’s about, but people feel like they are dying. They feel absolutely miserable. Imagine the worst flu you ever had. Your head is pounding, your body is aching, you just feel awful. Imagine the worst stomach bug you ever had. You’re nauseated, you’re vomiting, you’re having diarrhea, having the runs, and put those two together and then multiply it by 100 or 1,000. That’s what withdrawal will get to. It is a terribly noxious, just a horrible feeling.

And when people feel like they’re dying, the primitive part of their brain takes over. If you or I were in a room and a terrorist ran in and started shooting and we thought we were going to die, we would jump out the window and then we’d look around and say, “What floor are we on again?” You can do desperate things if you’re … In fact, your cerebral cortex, our thinking brain-

Lauren Lavin:

Fight or flight.

Josiah Rich:

Yeah, but our primitive brain takes over. Our cerebral cortex is pushed to the side, and you just do what you have to do. And if you look at the way people behave to either avoid or get out of withdrawal, it is a primitive behavior. They will do whatever they … Now, it doesn’t come on all at once typically. It comes on gradually and gets worse and worse and worse minute by minute, hour by hour. And that whole time, you know that all you need is to get one fingernail full of opioid into your body somehow and it’ll just melt away. You’ll feel normal.

So a typical course of somebody who has opioid use disorder and starts getting worse is they will use more and then they’ll use more, and then they’ll use more, and then they’ll kind of run out of resources and they’ll use enough to just get out of withdrawal, but not enough to get high, and then it starts to wear off and they go back into withdrawal, and then they’re just stuck trying to just desperately do whatever they can.

The patients tell me all the time, “Doc, I don’t even get high anymore. I just want to feel normal,” and they can’t feel normal. This disease is like a boa constrictor. It just wraps around and around and around you and it squeezes down tight, and every time you take a breath out, it squeezes tighter and you try and breathe in and you can’t. So tolerance can develop in days to weeks of daily use. It can happen fairly quickly.

Now, most people, I mean, everybody who takes an opioid on a daily basis is going to develop tolerance. Not everybody’s going to develop opioid use disorder, which is really defined as an addiction. It’s defined as ongoing use despite adverse consequences. So you know that bad things are going to happen if you use and yet you still use. So the biggest risk factor for who’s going to develop opioid use disorder is people who have a genetic predisposition to addiction, so we can kind of predict that.

The other is people who’ve had traumas because opioids are very good at relieving pain, both physical pain and psychological pain. So imagine if you had been molested as a kid and you went to try and tell somebody and they said, “Oh, no, he would never do that. You’re lying.” And then they say, “Well, if he did do that, it must be your fault because you must have tempted him. By the way, we don’t talk about that in our family,” and then you grow up with this psychological trauma burden on your shoulders occupying every waking and sleeping moment of your life, and then somehow you get an opioid and all of a sudden that weight comes off your shoulders and you feel, “It’s okay. It happened. It’s over there.” You’re not in denial about it. You know it happened, but it’s not crushing you down. It’s not crushing your soul. You can just breathe and you can get on with life, and isn’t that wonderful? “Now I can move forward.” And then the opioid wears off and it comes crushing back down on you more than ever.

So who wouldn’t want to go back to that happy [inaudible 00:20:29] So people who have traumas are vulnerable, and because of the nature of this disease and how we treat it in our society, people who get this disease, if they didn’t have trauma before they got into it, they get traumatized over and over again afterwards.

Lauren Lavin:

That was all really good information. And then methadone can be used to ease that transition that was solved.

Josiah Rich:

You’re reminding me, I gave you a long story and I didn’t answer your question.

Lauren Lavin:

No, that was all really good backstory.

Josiah Rich:

I must be a politician. So there are three approved medications to treat opioid use disorder. Methadone has been around the longest. It’s the most studied and most proven. It’s highly effective. It reduces risk of overdose by over 50% and is life-saving for so many people. Now, as I mentioned, it’s an opioid just like heroin and morphine and opium and Oxycontin and Vicodin and Oxycodone and Percocet. So it is an opiate, but the difference is it has a long half-life, meaning it stays in the body, so it has a long time before it gets up to speed and has a long time to wear off. So because of that, you can give a single dose every day, and the methadone molecule itself will bind onto the opioid receptor. And then if somebody tries to use another opioid like heroin or even fentanyl, it won’t work because the methadone is on the receptor. So it essentially blocks the receptor.

In fact, the other two medications do the same way. The second most proven and effective one and much safer one is a medicine called buprenorphine. It’s commonly referred to by the trade name Suboxone. That is typically given as a sublingual, either strip or tablet, but can be given in a patch and an injection or an implant, and is also highly effective at reducing overdose deaths and is desperately needed. It is a partial agonist. It turns on the receptor, but only partly. That’s why it’s safer than methadone or other opioids because it has somewhat of a sealing effect. It initially turns on the receptor at a low dose, and the higher dose, the higher it turns it on until it reaches a certain level and then it levels off. You can give a higher dose, but it won’t turn it on any higher.

So it is possible to overdose on it, but much more difficult and usually only in conjunction with another sedating medication like a benzodiazepine or alcohol or some other sedative. So anyhow, buprenorphine, much more safer and consequently is not treated like methadone in that you have to go to a program every single day. It’s treated like a normal medication almost. It does have a few more restrictions. Physicians had to do an eight-hour training to prescribe it. Fortunately, recently, that’s been let go, so any physician with a DEA license can prescribe it now.

And then the third one, naltrexone is a medicine that blocks. It’s a complete blocker. It doesn’t turn on the receptor at all, and that helps some people, but does not seem to be as effective as the other two mostly because people stop taking it because they’re not getting any beneficial effect. If you take buprenorphine or methadone, you tend to feel a little bit better. You’re not high, and if it’s adjusted to the proper dose, you’re not high, but you’re feeling a little better. People seem to drop off of naltrexone faster than others. So in the long run, it’s not as good.

Lauren Lavin:

Great.

Josiah Rich:

But I’m glad to have it in my toolbox of things I can offer patients.

Lauren Lavin:

There’s a variety of tools that you can use to kind of customize the solution to fit the patient.

Josiah Rich:

Three different medications, yeah.

Lauren Lavin:

All great information. I diverted off of the question list, but I want to turn now to the idea that, especially during an election cycle, there’s a lot of political rhetoric around an opioid epidemic and that there’s a lot of concern around it. So then my question is, what role do you think that healthcare providers and the healthcare arena has played in this perpetuation of the opioid epidemic? How concerned should we be as a society about an opioid epidemic as a whole?

Josiah Rich:

Well, this current crisis, overdose crisis has killed as many people as were killed in the COVID pandemic, as many Americans. The last time, other than COVID, that this number of Americans died from an infectious disease was 100 years ago, at the 1918 flu pandemic. This is a once in a century disaster, and this last year, there’s been slight advances, but Ireland is celebrating dropping down 7%, but we are a teeny lowest. We’re the smallest state. We only have a million people, and we’re losing one person every day to overdose still at this lowest rate, more than a person a day.

So this is unprecedented. It’s uniquely American, and it’s a very complicated, complex situation. I listened to that really disappointing presidential debate, and both the candidates were asked about what should we do to treat people with opiate addiction.

Lauren Lavin:

I listened to that one too, that question.

Josiah Rich:

Biden said something about, “Well, we need these expensive machines to screen for fentanyl at the border,” and Donald Trump said something about the immigrants or bringing [inaudible 00:26:47]

Lauren Lavin:

It was going external.

Josiah Rich:

They completely missed the question. They completely ignored the question, and they echoed the common … This is the approach. This is the approach we’ve taken is a punishment that this is a crime, that this is a bad thing, and that we need to stop and lock people up and arrest people who are creating it and shut down the markets. Some of that is necessary, but to have that be like that is the thrust of our approach is extremely ineffective. It has led to the war on drugs. It’s filled up. Our incarceration rate is higher than any country ever in the history of mankind. We’re locking a greater proportion of our citizenry up, and we have what to show for it? Nothing. In the face of this locking people up, we have this exploding epidemic of overdose deaths of our young people. So what do we do about it?

I mean, I think the very basic problem is the stigma. The stigma about people who use drugs is like, it’s okay to lock them up. It’s okay to treat them poorly, it’s okay to destroy them and their families and their communities, it’s okay because they’re those people, they’re not us, and so, “Oh, okay, Well, actually, maybe it’s a disease now, so maybe we should try offering some treatment. Okay. We’ll treat you, but we’d just as soon lock you up. In fact, we’d rather lock you up. In fact, if you’re trying to get treatment and you don’t get it, then we’re going to lock you up anyhow.”

You can’t say, “Come here. Come in and get some treatment. Oh, by the way, oops, sorry, you broke the law. Go to jail.” It doesn’t work that way. We have to decide. Are we going to treat people or are we going to lock them up, and I’m talking about people who use this. So we haven’t figured that out.

But the other thing is, since physicians were kicked out 100 years ago from the treatment of this, for the most part, I mean, addiction has not been taught in medical schools. Addiction treatment has not been taught. With this big a crisis affecting this many Americans, there is no excuse. No one should graduate medical school or residency program training or be a doc without understanding the ins and outs of this disease, how to diagnose it, how to prevent it, how to treat it, and actually have real experience treating it, writing a prescription, talking to a patient, going over the risks of the treatment, the risk of not doing the treatment. That’s how we learn as physicians.

So we are getting a D minus, if not an F, in that this country right now. And this far into the epidemic, it’s inexcusable. So we have to get our house in order on the medical treatment side. There’s some movement, but it’s far too slow given the magnitude and the gravity of this issue. We got distracted. We took our eyes off the ball with COVID, and that’s okay, but COVID, of course, made things so much worse because people got disconnected from their support systems and from their employment and other things that keep people in recovery because, really, what we want to do is get people into recovery, and it’s hard to do that when people are struggling to just get by.

Lauren Lavin:

Okay. This is a great space to pause for the first half of this episode with Dr. Rich. We covered a lot of good topics from opioid use disorder and its treatment to some of the history with the opioid epidemic. And then next week, we’re going to dive further into the history of the opioid epidemic. He’s going to take us through the four waves of it, as well as ways that we can reduce opioid use in the future and improve the treatment for those individuals who have opioid use disorder. So I hope you’ll tune in next week to hear the second half of this episode with Dr. Jody Rich.

This episode was hosted and written by Lauren Lavin and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassar@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious and take care.