Principles for the Use of Funds from the Opioid Litigation | June 29, 2021

February 08, 2022

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Joshua M. Sharfstein, MD, is Vice Dean for Public Health Practice and Community Engagement, director of the Bloomberg American Health Initiative, and Professor of the Practice in Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. Previously, he served as the Secretary of the Maryland Department of Health and Mental Hygiene, the Principal Deputy Commissioner of the U.S. Food and Drug Administration, as Commissioner of Health for Baltimore City, and as health policy advisor for Congressman Henry A. Waxman. He is an elected member of the National Academy of Medicine and the National Academy of Public Administration.

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00:00Ready.
00:04So good afternoon I'm David Fiellin
00:06I'm I'm director of the Yale Program
00:08and Addiction medicine and I want to
00:11welcome you to the first talk in our
00:13finding solutions to the opioid crisis.
00:16This speaker series, in collaboration
00:18with the Sandgaard Foundation.
00:20We're joined today by Doctor Josh.
00:24Sharfstein, who will speak on principles
00:26for the use of funds from the opioid
00:29litigation before we get started,
00:30we just want to review a few housekeeping
00:33items on the following slides.
00:37First, we encourage you to stay
00:39up to date with the latest in the
00:41Finding Solutions series and the
00:43Yale Program in Addiction Medicine.
00:45By visiting our website.
00:47Following us on Twitter and
00:49joining our program listserv.
00:52Second, I'd like to invite Kyle Henderson,
00:55the executive director of
00:57the Sandgaard Foundation,
00:58to say a few words and share about the
01:00mission and work of the foundation.
01:03Thank you David and thank
01:04you everyone for joining us.
01:06It's an honor to be aligned with the
01:09health program in addiction medicine.
01:11The Sandgaard Foundation is exclusively
01:14focused on the opioid epidemic.
01:17The founder of our foundation actually
01:20started a publicly traded medical device
01:23company that helps reduce pain through
01:25electrotherapy and gets people off of opioid.
01:30Related pain killers and he's had some
01:32family members that also struggled with it.
01:35We've all lost so near and dear
01:37to us to this horrible crisis.
01:39Right now we're focused on Narcan,
01:42naloxone distribution around the country.
01:44So we've distributed over 400,000 units of
01:47naloxone and over 21 states thus far with
01:50direct relief in the Clinton Foundation.
01:52And we just launched our
01:55Colorado naloxone project.
01:56Which is one of the first
01:58in the nation where?
01:59We're making sure that all at
02:02risk patients that go to the ER.
02:04Come out with naloxone in their hand as
02:07opposed to having the fill prescription.
02:09Subsequent and overcome stigma and
02:11everything else that goes along with it.
02:14So we're rolling that out
02:16through the hospitals.
02:17We've got about 60% of the hospitals
02:20covered in Colorado so far.
02:21And now we're working on
02:23recovery homes as well.
02:24We're also funding movies in the
02:27space that focus on the cause.
02:29So not just films but documentaries
02:32and the recovery fest and recover
02:35Out loud concert in September,
02:37which we encourage you all to learn
02:39more about through the Voices project.
02:41But we're helping to fund that cause,
02:43and we just locked in Macklemore as
02:45one of our. Lead talents and artists.
02:49But we've got some more fun people
02:52getting aligned with that and iHeartRadio
02:54and Google are all coming alongside
02:56to help maximize just the reach there.
02:58But it's a free event so we'd love for
03:00everyone to attend virtually with us.
03:02But again.
03:03Doctor Shark Scene and thank you for your
03:06time today and your incredible work.
03:08We're all thrilled just to hear
03:11from you and your perspective.
03:13You know,
03:14this great great need in our nation,
03:15but thank you David for the
03:17opportunity to align with you guys
03:18on this great speaker series.
03:21My pleasure and thank you, Kyle.
03:23As a reminder for the
03:25speaker series coming up,
03:26we'll be welcoming welcoming Maritza Perez,
03:29who's the director of the Office
03:32of National Affairs at the Drug
03:34Policy Alliance on July 13th.
03:36Miss Perez will speak on decriminalization
03:39and public health approaches to drug policy.
03:41Registration is now open and
03:43we hope to see you there.
03:46Finally, CME credit is available for
03:48today's event and to receive credit,
03:51please text the code and
03:54read to the number in red.
03:56And then now I'd like to introduce
03:58you to our speaker for today,
03:59Doctor Joshua Sharfstein.
04:00Josh is a vice Dean for public health
04:03practice and community engagement and
04:05director of the Bloomberg American
04:07Health Initiative professor of the
04:09practice and health policy and management
04:11at John Hopkins School of Medicine,
04:13School of Public Health,
04:14and previously he served as
04:16Secretary of the Maryland Department
04:18of Health and Mental Hygiene,
04:20the Principal Deputy Commissioner
04:21of the United States Food and Drug
04:24Administration and as Commissioner
04:26of Health for Baltimore City.
04:27And a health policy adviser
04:30for Congressman Henry Waxman.
04:31He's an elected member of the National
04:34Academy of Medicine and National
04:35Academy of Public Administration and
04:37Josh work digit diligently over the
04:39past few years with a variety of states,
04:42including our own Connecticut,
04:44to develop strategic plans to
04:46address the opioid crisis.
04:47So it's a great pleasure to have Josh
04:49speak today on a national effort.
04:51He and others are involved in
04:52that relates to the principles for
04:54the use of funds from the opioid.
04:56Litigation, Josh. Please take it away.
05:00Thanks so much, David.
05:02Thanks for having me Kyle.
05:03It's great to meet you.
05:04Thanks so much for your support of
05:06this and so many other good projects.
05:09I am going to see if I can share
05:12my slides here and jump in.
05:15I really look forward to the
05:17discussion so I don't have
05:18an massive amount prepared,
05:20so we'll we'll walk through
05:22this topic and then I'm sure
05:24have a pretty great discussion.
05:26Hold on one second.
05:34The. If that working now.
05:40Yes. Yep, you can see the slide.
05:43OK, great. So what I'm going to do
05:47today is talk 1st about the overdose
05:50crisis very quickly just to set
05:52everyone at the same starting point.
05:55Then I'm going to talk about the
05:57politics of drug policy a little bit
06:00from my perspective and experience,
06:01and that's going to feed into a
06:04discussion of where the opioid
06:06litigation stands and hopefully
06:07add up to a strategy for the opioid
06:09settlements that we'll be talking about.
06:15So this is some of the most recent
06:17CDC data showing that the annual
06:20number of deaths that they calculated
06:22most recently is now crossed
06:2490,000 for all overdose deaths,
06:25and you can see the curve here on the
06:28right showing that it was pretty flat
06:30to increasing even before the pandemic.
06:33But really the pandemic has had a
06:36really negative effect on overdose,
06:38and you can also see that the map of which
06:42states are having improvements versus.
06:45Worsening is not looking like
06:46a good color generally.
06:52And there are many reasons which we
06:54won't probably get into for why overdose
06:56tests are climbing during the pandemic,
06:58the disruption in the drug supply.
07:02Hopelessness, loneliness,
07:03economic dislocation,
07:05and other things like that.
07:08So many people have talked
07:10about how people have, you know,
07:12relapse facing incredible
07:13stress in their lives,
07:14that the trauma of people dying from
07:18COVID can trigger substance use so.
07:22Where there are just so many stories,
07:24we have a Twitter account.
07:26I think it's at opioid updates.
07:28Maybe that cracks, you know,
07:31local stories and there's so many
07:33local stories about the worsening
07:34overdose crisis during the pandemic.
07:40So I want to transition from this.
07:42Here we are with one pandemic
07:44fading in the United States,
07:46but the opioid and the overdose
07:49epidemic continuing to worsen.
07:51Just ask the question, why hasn't
07:53the United States made more progress?
07:56And and I think that's a good question,
07:58because, you know,
07:59we faced a COVID pandemic,
08:01and while there were all kinds of
08:03challenges with the national response,
08:04it was a pretty impressive
08:07mobilization that you know,
08:09level of progress has not happened
08:11with the overdose epidemic.
08:14In fact, it's continued to get
08:16worse with as that curve showed,
08:18and one of the reasons for why
08:21the US hasn't made progress,
08:23I think I covered with Doctor.
08:26Can build Olson.
08:27Who is the real addiction
08:30expert in our household?
08:32We wrote about the role of evidence
08:35in the US response to the opioid
08:38crisis and a paper that I think
08:41came out during the pandemic.
08:45And we kind of summed it up like this.
08:47The steps that generate popular enthusiasm
08:50often or may have little evidence to
08:52support them while at the same time.
08:55And if she gives back by science
08:57as necessary to save lives,
08:58may be ignored or rejected altogether.
09:02In other words, what we want
09:04to do isn't what we need to do.
09:08What we need to do isn't what we want to do,
09:10and that is something that is pretty.
09:15Impressive for the drug crisis,
09:18more than other public health issues,
09:20and I've worked on a lot of different
09:23public health issues and oftentimes
09:24everybody agrees what needs to be done.
09:27But you can't. You know,
09:28maybe you can't get the money,
09:29or you can't.
09:30You know, there are political
09:32obstacles in the path here.
09:34There's a real fundamental political
09:37challenge that what generates the
09:39most political excitement in terms of
09:42response isn't necessarily what actually.
09:44Would make a difference in sometimes
09:46the things that get supported
09:49wind up making things worse.
09:51I'm sure many of you are
09:53familiar with these statistics.
09:54A couple papers that came out recently.
09:57That even addiction treatment facilities
10:00often do not provide the care that
10:04evidence indicates is life saving.
10:06In 2016,
10:08just 36% of substance use
10:11treatment facilities offered any
10:13form of medication treatment for
10:15opioid use disorder and in 2017.
10:17This is really just incredible.
10:18I mean, that is well into what
10:20people were calling the opioid.
10:22Epidemic medications were used in just 17.7%
10:26of admissions in residential treatment.
10:28Who are opioid use disorder and that was
10:30just in the states that expanded Medicaid.
10:32It was less than 2%.
10:34I mean,
10:35given that medications are particularly
10:37buprenorphine and methadone are associated
10:39with a staggering drop in the rate of death,
10:42and the rate of overdose death,
10:44it's just,
10:44you know,
10:45you just got to look at that
10:47statistic and realize few of the
10:48one in 50 people with this problem.
10:50We're getting treatment that
10:52could actually save their lives.
10:55So it really brings up the question
10:58of politics versus evidence.
11:00And interestingly,
11:01here I'm not at all talking
11:03about electoral politics.
11:04In fact, my experiences,
11:06these issues are pretty bipartisan that
11:09you have evidence of what can make a
11:13difference for overdose and addiction.
11:16But that's fighting up Hill
11:17against kind of small P politics,
11:20which includes the legacy of stigma,
11:23criminalization and racism, and drug policy.
11:26Difficulty accepting addiction
11:28as a chronic illness.
11:30And and local experts on drug
11:31policy may be the people who run
11:34a treatment program that doesn't
11:36provide evidence based care.
11:37You know, oftentimes with my students,
11:39I'll say,
11:39like you know who are the most powerful
11:41local voices on the addiction crisis,
11:43and in a sense,
11:45they've they've earned their authority.
11:46You know that includes family
11:48members of people who have died.
11:50You know law enforcement officials who've
11:52worked on the drug crisis for many years,
11:55from whatever perspective they
11:57bring and treatment providers
11:58and sometimes all three of those
12:01can be resistant to the idea of
12:03addiction being a chronic illness.
12:05Family members are looking for gonna
12:07be looking for kind of quick fixes.
12:09Sometimes you have the law
12:12enforcement view of this being
12:15kind of a moral failure or crime,
12:18and you have 28 day programs,
12:21or like you know, we can really.
12:23Passed you up and get somebody back.
12:24You don't need treatment for a long time
12:27with medicine so you have these local,
12:29often very powerful forces
12:32that mean that when
12:34people are looking for what to do,
12:37they're looking and what they're hearing is
12:41answers that aren't where the evidence is.
12:47So you know, for those of us
12:49who've worked in these issues at
12:51the local level state level at
12:53different places across the country,
12:54the issue of the opioid litigation
12:56kind of begs this question.
12:58Will the opioid settlements reflect
13:00the existing biases in drug policy?
13:02Are we going to get more
13:03of what doesn't work,
13:04or are we going to get more of what works?
13:06Or is this a shifting point to more
13:08effective strategy for this country?
13:10Or are we stuck with more of the same?
13:12A lot of money being spent
13:14but not real progress?
13:17So let's pause for a second,
13:19just review where we are with the major
13:21lawsuits, and I apologize in advance.
13:23I know that they're probably if there's
13:25anybody you know from the law school
13:27on you probably understand these suits
13:28a lot better than me and I learned a
13:30lot about this from Abby Gluck at Yale
13:33before she went to the White House, so.
13:38We have different places, suing many,
13:40many places all around the country,
13:42suing state cities, counties,
13:44territories, tribes.
13:45The defendants in these
13:47lawsuits are multiple.
13:49Also, you've got manufacturers of
13:51opioids and a number of companies,
13:54including some generic manufacturers
13:56from brand new manufacturers.
13:57Purdue Pharma is the maker of Oxycontin.
14:00You also have lawsuits
14:01against the distributors,
14:03including the Big Three Witcher,
14:05Cardinal Health, Amerisource,
14:07Bergen, and McKesson.
14:09Lawsuits against pharmacies
14:10saying that they were,
14:12you know,
14:13selling too many of good
14:14should've known better.
14:15And also Mackenzie there
14:17probably others getting sued.
14:18McKenzie is a management consulting
14:20firm getting sued for the advice
14:22that it gave opioid manufacturers,
14:24including Purdue.
14:29So some of these lawsuits have been resolved.
14:33Kentucky settled with Purdue
14:35Pharma for 24 million and 2015.
14:38West Virginia has done some settlements.
14:40New York just recently.
14:42I think last week settled for 230
14:45million with Johnson and Johnson,
14:47Oklahoma won a big lawsuit verdict
14:50against Johnson and Johnson
14:52settled with Purdue Pharma.
14:53Have an endo. We're seeing some
14:57suits with settlements by counties,
15:00including Cuyahoga and Summit County in Ohio,
15:03and the Mackenzie did a national settlement,
15:06so there are a number of these
15:09lawsuits are starting to resolve.
15:11Uhm?
15:14But we still have.
15:16Some really important lawsuits and
15:19litigation pending there's something
15:21called Multi District litigation
15:23where all the States and counties
15:26and all the the plaintiffs have come
15:29together to sue the distributors.
15:31Johnson, Johnson and Teva,
15:32and so that that's a very complex
15:35litigation that is pending.
15:37They're also continuing to be state
15:40trials and county trials happening.
15:43And separately from that you have Purdue.
15:46Pharma is now in bankruptcy,
15:48and so there's a lot of litigation
15:51about what it owes people through the
15:54bankruptcy and that I I'm again not
15:56going to be the legal expert in that.
15:58But there are billions of dollars at stake
16:00between the Purdue Pharma bankruptcy
16:01and the Multi district litigation.
16:07So, given that there may be billions
16:09or even more than $10 billion,
16:10that will flow to state cities and counties.
16:13With these cases over the next several years.
16:16The key question is like how decisions
16:19will get made and how to spend it.
16:21A lot of these decisions will be made at the
16:24local level from what we can best understand.
16:26The litigation itself will set set
16:28up some guide rules for the kinds of
16:31things that States and localities.
16:32The plaintiffs themselves will
16:33be able to spend the money on,
16:35but then there'll be a lot
16:37of discretion for states,
16:38localities, tribes,
16:39others to decide how to spend the money and.
16:43The concept of writing a big check
16:45to a state of locality and as part of
16:48this litigation is a little fraught
16:50because of what happened with tobacco.
16:52So you know, our key question is,
16:54you know,
16:55will this money be used to help reset drug
16:58policy and help actually bend that curve?
17:01Or will it be kind of more of the same,
17:03recapitulating the problems we've
17:05had before the tobacco settlement
17:07is not an inspiring example.
17:09In that case a very small amount
17:12of money actually went.
17:13To support tobacco control programming.
17:17A small fraction,
17:192.4% of what states actually received.
17:24And you know there are all
17:26these depressing followups.
17:2820 years after the tobacco settlement.
17:30Did you know that Niagara County
17:32spent money for sprinkler system
17:34on a golf course or that Wrangell,
17:36Alaska, you know was spent money
17:39to renovate shipping docks?
17:41North Carolina even spent money to market.
17:48So the question that I've kind of leading
17:50up to at this point is if you're with
17:52me so far that we have challenges in
17:54drug policy that these challenges are
17:56not just we don't have the evidence,
17:58but we can't effectively put
18:00that evidence into use,
18:02and we also have this unfortunate shadow
18:04from the tobacco litigation that people
18:06might use money for whatever they want.
18:09You know, what can we do so that opioid
18:12settlements are spent well and put
18:14the US on a path to save more lives?
18:20So out of that. We have been working
18:25with Doctor Falin and his colleagues
18:27and others who developed 5 principles to
18:31guide opioid spending and the idea was
18:34to really have a strong voice for smart
18:37spending of this funding that could make a
18:41difference and not just leave it to the,
18:44you know broad menu that States
18:46and localities might get as a
18:48result of the litigation.
18:49We also recognize that
18:51evidence is very important,
18:52but just providing evidence might not get us.
18:54Of where we want to go.
18:55It has never done that really.
18:57In the overdose crisis, our goal was.
19:01To have a bit of a map for
19:03navigating the politics,
19:04the process, the evidence,
19:05and the outcome of opioid settlements.
19:08And we wanted to make it simple.
19:12So we worked with the whole bunch of groups,
19:14so go through some of them in a minute.
19:16But we came up with five principles.
19:19Spend the money to save lives.
19:21Use evidence to guide spending.
19:24Invest in prevention with youth.
19:26Focus on racial equity.
19:27Sorry, not radical equity.
19:29Although it is fun,
19:30fun ways that racial equity develop
19:33a fair and transparent process for
19:35deciding where to spend the funding.
19:38You can read these principles in a lot
19:39of materials we have about this at
19:43opioidprinciples.jhsph.edu.
19:47And we got more than 50 organizations
19:49to support it from the American
19:51Society of Addiction Medicine,
19:52the Legal Action Center of
19:54the Harm Reduction Coalition.
19:55Many, many groups across addiction,
19:58medicine, harm reduction prevention,
20:00advocacy recovery, and academia,
20:01including the Yale Program
20:03in Addiction Medicine.
20:07I'm going to just spend a little
20:09time on each principle because
20:11we tried to develop some specific
20:14items underneath these principles,
20:16so spend money to save lives is a
20:19way of saying spend the money on
20:22the overdose crisis like don't.
20:24Do the golf sprinkler stuff.
20:26You know you know,
20:28do something that it's entirely different.
20:31You know that that there's still so
20:33many lives to be saved with the crisis.
20:36At its peak, the moment.
20:38So we are recommending establishing a
20:41dedicated fund so the money doesn't get lost.
20:44In general spending supplement,
20:46rather than supplant existing funding.
20:49Don't spend it all at once.
20:51Spend some of it overtime.
20:52Make smart investments,
20:53and report to the public where the
20:56money is going so people can have
20:58some transparency about the fund.
21:02Item 2 is used evidence to guide
21:06spending given that we have evidence
21:08direct funds to program supported
21:10by evidence and at the same time
21:13not spend money on programs that
21:15are not supported by evidence.
21:17Remove policies that may block the
21:19adoption of programs that work.
21:21This is a good moment to say well
21:22if we want to spend for this,
21:23but we're not allowed 'cause we
21:25have some weird policy on it.
21:26Let's change that policy and at
21:28the same time build data collection
21:30capacity so you know how the pro.
21:32Problem is it's going.
21:33You know,
21:34one reason or the difference between
21:38how we have approached COVID and.
21:42The overdose crisis is that we get
21:43some pretty good data on COVID pretty
21:45quickly in this country and in a lot
21:47of places you can go online and see
21:48how many cases there were yesterday,
21:50what's going on?
21:51You know the the overdose crisis is much,
21:54much harder to get a handle
21:55on on a day to day basis,
21:58and for that reason you know the the
22:01responsiveness of like, well, did that work?
22:03Did that work?
22:04Did that work?
22:05You don't get that kind of
22:07feedback on drug policy,
22:09which opens up the opportunity for politics.
22:12They play a larger role.
22:15Third one was invest in
22:17prevention with youth.
22:19Particularly long term investments
22:20and effective programs and
22:22strategies for Community change,
22:24which of course the evidence
22:25indicates that generally,
22:26not like we're going to have
22:29an after school program to
22:30tell kids to not use drugs.
22:33It's these programs are really
22:35about supporting success of youth
22:39in school with careers and building
22:42resilience and coping mechanisms.
22:45Those sorts of things tend to
22:46have more evidence for them, but.
22:48We also suggest that there should
22:51be a strong evaluation component.
22:554th one is racial equity that there should
22:59be significant funds to communities
23:01affected by years of discriminatory
23:03policies and now experiencing
23:04substantial increases in overdoses.
23:06And you know, there is little bit of a
23:11risk that people will use the money from
23:14the opioid settlement since they are
23:16settlements that relate to prescription
23:18drugs and just take like the last
23:21year prescription drug overdoses and
23:23send the money to where there are a
23:25lot of prescription drug overdoses,
23:26not recognizing that.
23:27The epidemic has been different
23:29in different places and in like.
23:31For example, my city of Baltimore.
23:33It's very clear that the prescription
23:36drug problems very much caused a surge
23:40in the City of drug use and eventually
23:43that was translated into heroin and
23:46fentanyl because it's widely available here.
23:48But a lot of people who are dying of
23:50fentanyl and heroin overdoses started
23:52with prescription drugs because
23:53of some of the problems that the
23:56litigation speaks to you directly.
23:57If you just looked at what people are.
23:59Dying from eventually you
24:01might think Oh well,
24:02the prescription drug issue
24:03didn't really happen in Baltimore,
24:05and that would be wrong.
24:06And really putting out cities and
24:09places like Baltimore from funding
24:11and not really realizing the
24:13responsibility that society has to
24:15to places that have had all kinds
24:17of problems because of the way the.
24:21Policies on drugs have been implemented.
24:23You know,
24:24those mistakes shouldn't be repeated?
24:27So specific ideas are listed here.
24:30Investing communities affected by
24:32discriminatory policies support
24:34diversion from arrest and incarceration,
24:36fine anti stigma campaigns and involve
24:39community members in the solutions.
24:45And then our last principle has
24:47to do with the process itself.
24:49Decisions should be guided by public
24:51health leaders with the active engagement
24:54of people and families with lived
24:56experience as well as other key groups.
24:59And so it's not enough just to say you know,
25:03well, we decided to do this.
25:04You want a good process guided by
25:08public health principles and leaders.
25:10That really is inclusive in
25:12the way it is designed.
25:14And I'm going to show you something that
25:17might shock and offend some of you here,
25:21which is the title of an article that
25:23I wrote in the Milbank quarterly
25:26called Banishing Stakeholders.
25:28Now for you, click off your zoom here.
25:31I'm going to explain what I meant.
25:34I was trying.
25:35I read about the word stakeholders,
25:38not the people who are stakeholders.
25:41For the people who are referred
25:43to as stakeholders,
25:43I really detest the word stakeholders.
25:46It actually comes from people who have
25:48a financial interest in the outcome.
25:50Literally the state that is
25:52the derivation of that word.
25:54And oftentimes when you people
25:55think of a process,
25:57the immediate gut reaction is let's
25:59bring together the stakeholders
26:00and then they think of whoever
26:02is possibly involved in.
26:03Let's have like a 30 or 40 person committee
26:06and let's try to figure out what to do.
26:08The challenge I think particularly
26:09on this issue is when you do that.
26:12You wind up with the same types of challenges
26:16in letting evidence be an important guide.
26:20Then, as you do,
26:22just in general,
26:23your re capitulating the political
26:25challenges that you have on drug policy.
26:28And I've seen many of these committees really
26:31founder because people have fundamentally
26:33different ideas about what's going on,
26:35and there's not really
26:36a guide or an external,
26:38you know,
26:39evidence informed kind of.
26:42Gradient for reviewing different ideas
26:45so other approaches besides just saying
26:48anyone who has anything at stake in this,
26:51we should bring to the table
26:53and then that huge,
26:55unwieldy group is going to be vested
26:56with a certain type of authority.
26:58We're all just going to wait to see what
27:00happens that is not written in stone.
27:03There are other ways to do it,
27:04and another way to do it would be
27:05to have a much smaller group guided
27:07by public health with people who
27:10are trusted in in a community.
27:13And have that group do an enormous
27:16amount of outreach to to people
27:19who have absolutely essential
27:21perspectives to consider.
27:23And I like that phrasing maybe a
27:25little better than stakeholders,
27:27and you can really make sure
27:29you're hearing from, you know.
27:33People who use drugs, family members,
27:36the treatment community,
27:37the different kinds of the
27:38treatment community.
27:39You can bring all those things in and
27:41oftentimes when you have a process like this,
27:44that core group can be very engaging
27:47really explain its charge well.
27:50And when it actually has to disagree
27:53with someone then it can explain itself.
27:56And so we've been doing versions
27:58or supporting versions of
28:00this kind of process in different places.
28:03I'm from Rhode Island where this led to
28:05a big project to treat people in jail.
28:07So here there was a group
28:09at Brown that was convened.
28:11They were the public health side group.
28:12They did a lot of engagement activities.
28:14They also brought in speakers,
28:16including people who talked about the
28:18value of treatment in detention and
28:20they wound up being able to recommend
28:23that in the governor funded it.
28:25In other cases,
28:26we've had like assistant US attorneys
28:29come to the the public sessions
28:31and or the public comment periods.
28:33And say, you know,
28:35we cannot under any circumstances,
28:37you know, change the way we please,
28:39and the expert group or the
28:41the group that's been convened.
28:43its IT that public health guided
28:45will say we disagree with this and
28:47publicly explain why citing evidence.
28:49So you're kind of shifting the ground
28:52of the discussion to something to do
28:55an open but evidence informed process.
29:00Now. These processes don't make all of
29:03the challenges I talked about go away,
29:05but they do give an opportunity for
29:08really good ideas to come forward
29:10and some meaningful engagement with
29:12people from all types of perspectives.
29:15I hope you've forgiven me for trying to ban
29:18a stake holders at this point and understand,
29:21but I would soon find out.
29:23So we put these five principles out there,
29:27and we've gotten some.
29:29A little bit of news coverage on this.
29:32We've also been consulting with
29:34legislators who want to make sure that.
29:37These principles are put to good use.
29:42And the couple places I think have been
29:45introducing and maybe even passing
29:48legislation as they're setting up
29:50dedicated funds to try to do this.
29:52But the idea is that people should think.
29:57At every level are they following
30:00the five principles?
30:01Do they have a good process?
30:02Will there be transparency?
30:04Are they going to use this money
30:07and and use this as an opportunity
30:09to learn about and pivot a bit in
30:11addiction and overdose policy in
30:13order to have a bigger impact than
30:16people have been having today?
30:17And in this way the funding can be a
30:22spark to change not just extra funding
30:25that comes in and then goes out the door.
30:31I should point out that there's
30:33some great companion documents
30:34that we also have on the website,
30:36including from Harvard walking through a
30:39bunch of good recommendations for places,
30:42and another part of Harvard which has
30:44like a huge compendium of the evidence
30:47for each different type of intervention.
30:50And so we're trying to encourage States
30:52and localities to use resources like
30:54that as they think about you know,
30:56embracing these principles supported
30:58by so many different organizations.
31:01And so you know what's next?
31:05Obviously we're in the process
31:07of advocating for people to admit
31:09to these principles,
31:11and we're also worried working on
31:12developing an assessment tool to see
31:14whether they're being followed and then
31:16monitoring the implementation of the of
31:18the for the in the spending of the funding.
31:20Advocacy this is called
31:22the advocacy sandwich.
31:23We're constantly trying to figure
31:25out how to add support at the
31:27principals in different ways.
31:30We are working to develop a set of metrics,
31:32align with the principles that will
31:34post on the website that people can
31:37use to see if states, counties,
31:38others are spending the litigation
31:40funds in accordance with them.
31:42For example, does the state have
31:44or the county have a dedicated
31:46fund for the litigation dollars?
31:53So to conclude.
31:58It's not probably right.
31:59Think of the upper litigation
32:01as the knight in shining armor.
32:04That's going to save the day
32:05from the overdose crisis.
32:06It's not changing the underlying
32:07challenges of opioid and drug policy,
32:09it's just adding more money so,
32:12but it does create an opportunity,
32:15and it creates the opportunity for a
32:18strategy that is is engaged with politics,
32:23science and advocacy.
32:24And so the five principles
32:26are what we are working on.
32:28With many partners to try to.
32:32I create a push in in the right direction.
32:34Of course at the local level,
32:37you know when they're particular budgets.
32:38We hope that people in.
32:42I'm all backgrounds,
32:43including schools of public health,
32:45schools of medicine.
32:47Community members are really engaged
32:49with how their locality is going to
32:51spend the money and that you know
32:54there are a lot of local opportunities
32:56and in the end of our peace,
32:59doctor Olson and I wrote that,
33:02you know,
33:02we can write a lot of papers
33:04about what needs to be done,
33:06but this is really a moment when
33:08people have to come out from
33:10behind their computers and really
33:12speak to the policy world because.
33:14There is money coming not just from this,
33:16but also from the federal
33:18government more coherently,
33:19and people really need to hear
33:21what would make a difference and
33:23what wouldn't it if they really
33:25hard political challenge.
33:27But it's necessary for everybody to
33:29think about how they can best engage.
33:34And I'd just like to thank
33:36Sarah Whaley and Josh Rising.
33:38They're leading this effort on the
33:40principles and all the principals
33:42partners and Bloomberg plan fees
33:44for their financials for this.
33:55Thank you Josh. That was wonderful.
33:57We do have some questions
33:59in the Q&A and I'll.
34:01Try to read those to you.
34:06Next, Abros asks is there anything
34:08that can happen at the national
34:10level to hold states accountable
34:12on how the funds are being used?
34:17Uhm? So. That's a good question.
34:20I think there are a number of groups working
34:23kind of across the country that you know we
34:25have some very strong partner shatterproof.
34:27Once it created a National
34:29accountability project around this.
34:31But if you're asking the federal government,
34:33there's nothing, there's no.
34:35Direct legal hook.
34:37There are some somewhat indirect legal hooks,
34:39and I'll give you an example of 1.
34:42There are some clawback rules meaning
34:48the federal government gets to keep
34:50some money under some circumstances.
34:53If the federal government is
34:55spent money in federal programs,
34:57and so the federal government
34:58might be able to say we will.
35:01If if you're spending money,
35:03well, we won't.
35:04Clawback money for Medicaid,
35:07but if you are not,
35:09if you're spending money on
35:11things that don't make sense.
35:13And maybe we will try to take some of the
35:16back so that we can use it some other way.
35:18That is,
35:19I think a heavy lift for the federal
35:22government to do at that level of detail,
35:24but it's possible that there
35:27are some federal aspects of this
35:30that still have to be explored.
35:32I think most likely it's going to
35:34be very hard for the programmer
35:36to have two strong hand in this,
35:39because this was litigation brought
35:40by States and they're getting
35:42the money directly. In counties.
35:45Let let me I I thought about this recently.
35:48The issue of linking various
35:52datasets at across the state.
35:58Within a state has seemingly
36:00been a useful tool that some
36:02states have been able to achieve,
36:04but not very many, so I'm wondering
36:08if there is an opportunity for.
36:12And entities such as the CDC
36:15to either create incentives or.
36:20You know requirement that the
36:22outcomes that are can only be
36:25achieved by linking datasets be
36:28reported on a on a regular basis.
36:31Well, I don't think there's there's
36:33really a built-in reporting requirement
36:35for the federal government to set
36:37for the litigation, but the issues
36:39that you raised are really good ones.
36:41And it could relate.
36:42I mean, look, the federal government is
36:44giving States and localities a lot of
36:46money and and over the last few years
36:49has not really asked that much in terms of,
36:52you know, standards from them.
36:53So I think probably the federal
36:55government could get at some of these
36:57same issues through the money the
36:58federal government is distributing.
37:00And that's going to be a big
37:02challenge for particularly Samsung.
37:03But also the CDC this year,
37:05I think the CDC has invested
37:07in some great programs,
37:08but what are really the minimum expectations
37:10for this level of federal funding?
37:12That's going to be a really important area
37:14to watch separate from the litigation.
37:15Although I agree it.
37:17I.
37:19Yeah, so thank you.
37:22Doctor Wesley Clark has a
37:24few questions for night.
37:25Neither open up his mic so you can ask them,
37:28but I will start reading.
37:30Public health usually uses the
37:33construction of stakeholders.
37:35And I think he's wondering whether
37:37substance use disorders should move
37:39away from this traditional paradigm.
37:42So you know I,
37:44it just makes my skin crawl every
37:46time I see the word stakeholders.
37:49I'll just be totally honest because
37:51I'm I come from you know,
37:53all these discussions,
37:56oftentimes involving, you know,
37:58commercial interests which are
38:00literally stakeholders and sometimes,
38:02and I'm going far afield from
38:05from this particular.
38:07This particular issue and the
38:09stakeholder construction puts
38:10everyone on exactly the same footing.
38:13I think it's very important to hear
38:14from people with commercial interests,
38:15but I think we should think of them
38:17as people with commercial interests
38:19or businesses that are involved in
38:21the particular issue as opposed to
38:23everyone has the same title like I
38:25think of like patients affected by a
38:27situation very differently than the
38:30companies affected by a situation,
38:31and both of them you know should
38:33be listened to and appreciated.
38:35But a single term that just
38:37sort of lumps everyone together.
38:38I just I just don't like that
38:40much and I think we should be more
38:43specific about who we mean when we
38:45say stakeholders who's you know whose
38:47perspectives we really need to get people.
38:50Another way to think about this?
38:51There's a lot of discussion
38:52about involving people,
38:53for example, who have used drugs,
38:55or use drugs and in thinking
38:56about some of these challenges,
38:58you know, then we should do that.
38:59We should say that we shouldn't
39:01say stakeholders and people say
39:02like we had a lot of stakeholders,
39:04you know and feel like they've checked
39:05the box for something that really isn't what.
39:08We might want to have included,
39:10so I'm I'm basically making a
39:12call for more specifics,
39:13but I'm not saying that people who
39:15are involved or have a perspective
39:17on something shouldn't be engaged
39:19or listen to at all, and so I would,
39:21you know,
39:22refer you to the Milbank quarterly for
39:24my full top fund on stake holders.
39:26I think I said something like.
39:29The only legitimate stakeholder
39:31is Van Helsing,
39:32who I think was the person
39:34who killed Dracula.
39:38I get it.
39:41So Wes has another question,
39:44wondering whether the governors
39:45and the attorney generals have
39:46agreed to the five principles,
39:48great, great.
39:49Another great question from Doctor Clark.
39:51It's great to know that you're here.
39:52Doctor Clark. The answer is no
39:56governors or attorney generals as yet.
39:58I think we are getting
39:59interest in state legislators.
40:00I think there's a lot of interest
40:02in the principles as we've
40:03talked to different places,
40:05but they don't really know yet.
40:07For a lot of these settlements,
40:08how they're going to pan out
40:10so they don't want to commit,
40:11you know, kind of in advance of
40:13doing what the settlement is,
40:14but I think there will be a moment
40:16where hopefully people will
40:18have to answer on this question
40:20in to become possible.
40:25Robert Kerns says I haven't heard
40:27you mentioned a third public health
40:29crisis, namely poor management of.
40:34Poorly managed pain and especially
40:37high impact chronic pain.
40:39Other countries have invested in large
40:41public health campaigns to promote.
40:43Adaptive pain, self management and
40:45other investments in prevention
40:47and care for persons with pain.
40:49Do you believe that such an
40:51investment fits within your framing
40:52of how opioid litigation funds
40:54should be appropriately spent?
40:58That's a terrific question,
40:59and I do think it it can fit in,
41:03particularly as you realize,
41:05as the point that you're making about
41:08the importance of evidence based
41:11care for people with pain and just
41:13the gaps that exist in that system,
41:15I think that is relevant to
41:17the principle of using evidence
41:18to guide policy in this area.
41:20It's certainly relevant to.
41:23Using evidence and and using
41:25these funds to save lives.
41:26So I I certainly would think it
41:28would be a reasonable thing for
41:31a location to use a portion of
41:34these funds to to expand access
41:36to really a great care for pain.
41:42OK, Sidney Fox is wondering for
41:44states where public health is already
41:47indoctrinated in doctrine and belief
41:49of large multidisciplinary stakeholder
41:52committees to generate policy.
41:54How you approaching and educating
41:55public health at the highest
41:57levels to consider this approach?
42:01So. It's a great question,
42:04you know generally,
42:05what we say is, you know,
42:08let's say you've got like a unwieldy
42:11you know stakeholder committee,
42:13and most likely are frustrated with it.
42:16Like if it's going well and then you
42:18know there's nothing you're going to say.
42:19But a lot of times I'll talk to
42:21people and they're frustrated.
42:22And frankly, oftentimes the people
42:24on those committees are frustrated.
42:26They feel like they're not getting anywhere.
42:28I believe in Rhode Island there
42:30was a committee that like the.
42:32Avidan's Journal was editorializing
42:34about being notoriously inefficient,
42:36and it was frustrating so many people.
42:38And so you don't have to disband
42:41that committee.
42:42You can just create a,
42:44you know a much smaller nimbler group
42:46with a specific charge and one of
42:49the things you say is they've got to
42:51go really listen to this committee.
42:53They they can then structure a discussion
42:56with the bigger group and listen to
42:58what they're saying and respond to them.
43:00To me, the response is incredibly important.
43:03It's really a principle of administrative law
43:05that you can't be arbitrary and capricious,
43:07but and as a result that leads agencies
43:10to have to explain what they're doing.
43:12I think in these kinds of things we
43:14you can adapt our principle and say,
43:16and let's have a smaller group
43:18and let's have that smaller group,
43:20you know, make actual recommendations
43:22and try to explain them.
43:23So, for example, in Rhode Island Dr.
43:25Jody Rich,
43:26who was one of the leaders of
43:28the smaller group,
43:30got up in front of this bigger group
43:32and said and was quoted saying I
43:34can't wait to hear all your ideas,
43:37but we can't do everything all at once.
43:39I'm I'm paraphrasing,
43:40and he said something like, you know.
43:42My job here is to find what's going
43:44to matter the most to save lives,
43:46and I'm going to be honest with
43:47you about what I think that is.
43:48I'm going to respond to all
43:50these different ideas,
43:51but I want you to know why
43:52I'm here and what I'm doing.
43:53And and people, didn't, you know,
43:55respond by throwing him out of the room?
43:56They he was a credible person
43:57in Rhode Island.
43:58They listened to him and he,
44:00you know,
44:00mixed it up with people and and
44:01had conversations with people.
44:02And so you create a smaller group
44:04with a charge that gets you more
44:06forward momentum and then they
44:08can work with those other groups.
44:10And frankly those other groups
44:12suddenly are excited.
44:13A lot of them that something
44:14is actually moving forward.
44:15Now,
44:15obviously if they're investing
44:17in something that some of those
44:19people don't like,
44:20you know you're going to have you're
44:20going to have to deal with that,
44:21but the majority of that group is
44:24quite likely going to be excited
44:26to see things going forward.
44:30So I'll take my proactive and say you know
44:32to your point about you can't do everything.
44:34There are just so many things to be done.
44:38In other areas of medicine and public
44:41health we often use modeling or other
44:44techniques to help us determine what will
44:46give us the greatest return on investment.
44:50Quote UN quote, the biggest bang for our
44:52buck, and to your first point about,
44:54you know the first principle is to
44:56save lives and I would add to that.
44:57Save lives now, not a generation from now.
45:02Should we be using more sophisticated
45:05modeling strategies to dictate which
45:08of the 100 things we could do,
45:11or the three or four that will make the
45:13biggest difference in the short term?
45:15Yes, I'm I'm not an expert in these studies.
45:17There have been some published.
45:19I think there was one out of Hopkins
45:21by Caleb Alexander and Jeremy Barrett,
45:23and I think there's some out of Stanford.
45:26That have been published that go through
45:27a bunch of different options I did.
45:29I do think that that that that's helpful.
45:31I think the trick here is look,
45:33there's a way of thinking about this.
45:35It's saying here's what every
45:36place needs to invest in.
45:38Here's exactly the budget you know,
45:40for if you've got sort of like if you only
45:43have a few days and you know neuro Shell,
45:46what do you do in New Rochelle?
45:47If you have five days in Neuro Shell,
45:49what do you do in New Rochelle?
45:50You know, you know,
45:51if you only if you're going to
45:53get $200,000 from the settlement,
45:54what do you do if you get 500,000
45:56you get 2,000,000 what?
45:57You know how you spend it?
45:58Spend it exactly on this.
46:00I think the concept behind the principles is,
46:02you know, that's not how it's going to work.
46:05It's not going to be realistic
46:07that we want to that we're dealing
46:09with some pretty fierce obstacles.
46:11And if you come in with something
46:12that is not realistic,
46:14it'll just get brushed brushed
46:15aside so you have to balance.
46:18You know some degree of understanding
46:20that look, these people brought lawsuits.
46:23They're entitled to some,
46:24you know,
46:25discretion how to spend the money
46:27recognizing there are.
46:27Unique local situations,
46:29but trying to create a process
46:32and a mandate for you.
46:34Know evidence to be very influential in this,
46:37and you know,
46:38I I just given just how poorly funds
46:40are often spent in this area to expect
46:42it all to turn on a dime just because
46:45it happens to be coming from the
46:47litigation I think is unrealistic,
46:48but let's let's start to create
46:50that momentum and absolutely in that
46:52discussion you know you can do that.
46:54One of the things that is worked really
46:56well in all these places that we've worked.
46:58Is when you have a public meeting,
47:00you know the general default
47:02is like open mic night.
47:04You know people can come
47:05and say whatever they want,
47:06and that's really important.
47:07I like to stop and structure that
47:09so that people who are you know
47:11talking on similar themes maybe
47:13so you can hear it I'll I'll happy
47:16to share all my advice here.
47:18Well, another thing is,
47:19I think that when people what I
47:21don't like about open night Mic
47:22night is people feel like they're
47:24just screaming into the abyss.
47:25You know you get people together
47:26and like you got 100 people.
47:28They're all standing behind the microphone,
47:29they're all aggravated.
47:30They they yell at.
47:31They don't think anybody is
47:32listening much better to have people.
47:34Often I recommend bringing people
47:36up on stage and having them seated
47:38four or five at a time.
47:40They give their testimony and
47:41then you've got a group
47:43that's reacting to that.
47:44That's your you know, public health group.
47:46They ask them questions so people
47:48have to think about what they're
47:50saying and and and they respond and.
47:54You know, if you if you have something
47:56like that and you got everybody there,
47:58the other thing you can do is you
47:59can bring in external experts.
48:01So let's say we were in,
48:03you know County X and County X has
48:05got to decide how to spend the money.
48:08You know you could have as a zoom in
48:10with somebody who's done a great,
48:12you know, a computer model that
48:14explains what would be the most
48:16important thing in that county,
48:17and then everybody who's there
48:19has to listen to that.
48:20And that becomes part of the discussion.
48:22That is kind of the approach that
48:24Rhode Island took to being able to
48:26treat everyone you know in jail in
48:28prison with medications is they
48:29brought in an outside expert and at
48:31a big public meeting before people
48:33got up to say what was on their
48:35mind and haven't back and forth.
48:37They had an whole expert discussion
48:39about that,
48:39so I think that they're sort of
48:41like these administrative tools in
48:43a way that can help shape people's
48:44understanding of the issue.
48:45And again,
48:46get evidence into the process
48:48a little more effectively.
48:53So Melanie Racine says the principal
48:57focused on racial equity highlights
48:59investments in communities affected by
49:02discriminatory discriminatory policies and
49:04tackling root causes of health disparities.
49:07I'm wondering how broadly this principle
49:09is conceptualizing and will later be
49:12measuring such community investment.
49:14Can you give some examples and thank
49:17you for your presentation. Sure,
49:20well, I think we're at least conceptualizing
49:24at very high level that the process
49:27that gets set up will be recognizing
49:29this history and asking itself.
49:32Are we spending the money
49:33in a way that counters it,
49:35and being able to point to specific
49:38investments that the counter it?
49:40It may be, you know,
49:41in one place that that looks
49:44like investments in housing for
49:46people who are in drug treatment.
49:49Or are you know using drugs
49:53that because of the.
49:55Enormous gaps that are there and and
49:57the fact that that location feels like
49:59that's a real high priority I'm, I'm just,
50:01you know, throwing that out there.
50:03But like it,
50:04it may not look exactly the
50:07same in every place we do have.
50:09We're working on the indicators to see
50:12how well that's being taken into account,
50:15but it might look like you know,
50:18is there a clear commitment initially
50:21so we think of the indicators
50:24as upfront and afterwards so.
50:26Up front is this part of the construction
50:28of the plan for how to spend the money.
50:31Is this explicit?
50:32And then on the back end,
50:34how is it manifested?
50:36Is there?
50:37Sending that can be tide
50:39to those those priorities,
50:40and is there evidence that communities
50:43of color were really engaged and and
50:46involved in the decision making?
50:50But we'll have specifics on that,
50:51as as we get it sorted out, hopefully
50:53on our website and people can react.
50:57Thank you Josh Sygnal is
50:59wondering whether areas with
51:01schools of public health,
51:03medical schools, etc.
51:04Probably have the personnel and
51:06will to implement these principles.
51:09What about rural areas where
51:10the expertise doesn't exist?
51:14Yeah, well obligate relationship
51:17between sort of experts and
51:19expertise and the implementation.
51:23I think that's where some of these
51:25other resources come into play.
51:27I mean, we are so you know,
51:29we have a whole page of different resources.
51:32If people are interested in following it,
51:33they can, you know,
51:34get ahold of all these compendiums
51:36of evidence based practices models.
51:38Other things we've we're trying
51:41to actually set up ways for.
51:45Uh. People to reach out if they
51:48want help like look if there's
51:49somebody in a rural area who's
51:51interested like we're interested,
51:52we'll figure you know we'll
51:54we'll match them someplace and.
51:58But but I do think that this is.
52:03A factor in,
52:04particularly because so many non states
52:06are going to be getting direct funding.
52:10A obvious concern is going to
52:12be whether or not there is.
52:17And.
52:20You know whether there's sufficient
52:23public health options to guide
52:26is this is really something that
52:27the field of public health also
52:28has to be prepared to take on.
52:33And Sanjeev Kumar, what lessons have
52:34we learned from the use of tobacco
52:37settlement money that can be deployed
52:38for more efficient use of the settlement
52:40money for opioid use disorders?
52:45I mean, I think the big lesson
52:46is don't do what we did for
52:47the tobacco settlement money.
52:48I mean, it was just.
52:50Really unhelpful, you know.
52:52I mean, I think some of these
52:54lessons are being learned.
52:55I mean, I think the attorney generals
52:57would say the attorneys general would say.
53:00That they are.
53:03Not hoping that places you know
53:07that that they're putting in some
53:09bounds on how the money can be used,
53:11so you just can't use it to pave
53:12roads or put sprinklers in golf
53:14courses or character mask or
53:16whatever it was being used before.
53:17It's not just general fund.
53:19But within the lists of provable
53:23spending are a bunch of things that
53:26are kind of vague and in some cases
53:28it might be like reimbursements
53:30for you know policing activities
53:33or reimbursements for the county's
53:35expenses at the jail, or reimbursements,
53:37and that just winds up all going
53:39back to the same place.
53:40So you know, I, I think that.
53:44You know,
53:45I think you've got the biggest
53:47lesson from the tobacco settlement
53:49is to be very suspicious and
53:52to try to build in as a strong.
53:54Of the framework as possible for
53:56how the funds could be spent
53:58spent and really develop people.
53:59Understanding that this really
54:01matters to save lives.
54:02And in this community now and isn't just,
54:05you know, a free pool of money.
54:10OK, and one anonymous
54:11attendee is wondering what?
54:13What is the role of supply reduction
54:15control and addressing this problem?
54:16How do you approach that community?
54:23I wish I could ask the anonymous
54:25attendee a little bit more about
54:26what they're thinking, you know?
54:29I think that. The traditional law
54:34enforcement approach to overdose
54:37has not been particularly helpful.
54:38In some cases.
54:39It's made things worse and that is
54:42the conclusion the National Research
54:44Council and others who have looked
54:46at all the evidence. So in general,
54:49I think at the local level there may be.
54:54I mean I I would.
54:56Be a little bit.
54:59Concerned about, you know?
55:00Rushing to spend a lot of
55:01money on supply control.
55:03I think the supply issues that
55:05are probably most salient have to
55:08do with the synthetic opioids,
55:10which you know are coming in from
55:13different places and are uniquely deadly.
55:16And you know getting a better
55:18handle on what the drug supply is.
55:21If there are ways to do that,
55:24and I'm not, I think diplomacy may.
55:28Turned out to be one of the
55:29most effective ways to do that,
55:31but you know,
55:32I I don't rule out like all supply
55:34issues when you have these just
55:37incredibly dangerous compounds around.
55:39But I think we have to be pretty
55:42deliberate about investing in
55:43a local supply kind of strategy
55:46given the very poor track record.
55:51Couple more questions when Carolyn
55:53Missouri asks when resources are allotted,
55:56it seems essential to recognize
55:57that women and men have different
55:59routes to addiction and have
56:01very different treatment needs.
56:03Can you speak to whether this
56:04has been part of the discussion
56:06and developing the principles?
56:10I think that's a great question.
56:12It has not been a big part of the discussion.
56:15I think. Be interested in.
56:18Thinking about the.
56:21You know how that might be referenced
56:23in the principles and we could put
56:25it up in the resources section,
56:27and I think the principles are
56:30sufficiently flexible to incorporate that.
56:32We certainly don't have a one size fits all
56:35approach I've been reading recently about.
56:39This is not exactly on point,
56:41but the idea that in in many
56:44places reimbursement does not cover
56:46different types of family therapy.
56:48For addiction treatment and that may
56:50be very helpful to certain people.
56:53But you know if there are particular
56:56particular ways to categorize spending
56:59and make sure that populations
57:02are not overlooked,
57:04I think that we we could certainly
57:06make those kinds of resources
57:08available through the website.
57:09And emphasize that.
57:12I think you're hiding something
57:13I I don't know as well.
57:14I bet I met Doctor Olson here,
57:16knows a lot better than me.
57:21Back to West Clark. Doctor Clark.
57:24How do you reconcile the federal
57:26billions devoted to the opioid epidemic?
57:29In the MDL settlement dollars,
57:32when is there too much money in the
57:34pot and and to that point you know
57:37we look and talk a lot about these
57:39settlement dollars as if they're
57:41functionally different and you know.
57:44I guess the big picture question is you
57:47know what is their size in relation
57:50to the overall you know pot of money
57:53to be spent and should the principles
57:56that you've developed guide all of
57:58the spending for for those funds but
58:01to to doctor Clark Clark's point,
58:02when is there too much money in the pot?
58:06Are all good and related questions.
58:09I think that given.
58:13It's not just about the
58:14amount of money, right?
58:16It's about whether or not the kinds of
58:18investments we're making are good ones,
58:20and that's why we're, you know,
58:22trying to use the momentum of
58:24the settlements to get people to
58:27really pause and think about it.
58:29And I think that in theory the federal
58:32government could do doing something
58:34quite similar in parallel for its
58:37money that it's giving out the federal
58:40government could require different
58:42kinds of planning documents that.
58:45Might be inclusive of some of this
58:47additional spending that that there
58:49being a very clear priorities that are
58:51guiding the spending and in different places.
58:53And I think we're again we're
58:55trying to hit a sweet spot of
58:58keeping something that's really,
59:00you know,
59:01focused enough and able to take advantage
59:03of this opportunity without trying
59:05to swallow everything all at once.
59:07Our hope would be that if people.
59:11Have the principle that we want to
59:13spend this money as wisely as possible,
59:15that they're then able to, you know,
59:18use prophecies that exist.
59:20If there's some good ones or generate
59:23new processes that can be used for
59:25spending some of this other money,
59:27but I think it might be a lot to try
59:31to force that right at the beginning.
59:34I do think one of the biggest
59:37questions is going to be how the
59:39federal government goes about,
59:40you know, spending the money that
59:43is continuing to be allocated.
59:45I don't think it's too much.
59:46I mean, this is a 90,000 live a year problem.
59:50I'm not worried about that.
59:52I'm more worried about where
59:53the money is going and is it,
59:55you know being spent wisely?
59:57Are we making good long term investments
60:00and that I'm very worried about
01:00:02and and I think this is sort of the
01:00:06a spark that can be used locally
01:00:08to rethink you know the approach.
01:00:11But you know,
01:00:12we it's it's very easy for us to,
01:00:16you know,
01:00:16be on the zoom and say they should do this.
01:00:18They should do that.
01:00:19I mean in out out there it is
01:00:21very difficult for people to.
01:00:27Run away from some of the most
01:00:28credible voices that they have
01:00:29in their community that are
01:00:30telling them to do something else,
01:00:31and so you know we're trying to
01:00:34position this as a as a least a
01:00:36one lever of change in in in that
01:00:39and hopefully inform some of those
01:00:41voices so that they get more.
01:00:45You know more more aligned
01:00:46with where the evidence is.
01:00:51So we have a couple of questions,
01:00:53ones on stigma ones on prevention.
01:00:57Sidney Schnoll says we more frequently
01:01:00talk about evidence based treatment,
01:01:02but what about evidence based prevention?
01:01:06And that's obviously one of the principles.
01:01:09I guess it it does raise the question and
01:01:13I think you alluded to this in your talk
01:01:15is that we specific to opioid initiation
01:01:18and the development of opioid use disorder.
01:01:22We have less evidence about the efficacy.
01:01:28Or effectiveness of prevention interventions.
01:01:30And so how do we?
01:01:32How do we reconcile that?
01:01:36Yeah, I think it says the challenge.
01:01:38This is another one where.
01:01:40The politics and the evidence
01:01:42can be a little bit off.
01:01:44People like to announce that they've
01:01:46got a special program in schools,
01:01:48for example, and a lot of those
01:01:50special programs that get set up.
01:01:52May not have a lot of
01:01:54evidence behind them at all,
01:01:55and so then you've spent money for
01:01:58something that doesn't really work.
01:02:00It may not be quite as bad as
01:02:01some of the other investments
01:02:02which actually backfire,
01:02:03but it's just not a very
01:02:07efficient investment.
01:02:08I, I think that my understanding
01:02:10the evidence and doctor putting
01:02:12you should obviously jump in here,
01:02:14but that particularly with
01:02:16respect to prevention,
01:02:17that it's often more general kinds of.
01:02:23Programs, resources,
01:02:26other other things that are going to be
01:02:30helpful to people and to communities.
01:02:34I remember when I was health
01:02:36Commissioner Baltimore and we had a.
01:02:41$1,000,000 a year came to us
01:02:43in Samsa prevention grants.
01:02:45And the question was,
01:02:46well, how do we spend it?
01:02:47And we're like, well,
01:02:48how are we spending it?
01:02:48And we're spending it on like 2 after
01:02:51school programs for like 15 kids each.
01:02:54You know, and they were getting just
01:02:56a tremendous amount of like don't
01:02:58use drugs training and it would.
01:02:59I think these programs were considered like
01:03:01evidence based in the sense that like they,
01:03:03kids were reporting slightly
01:03:05less interest in using drugs.
01:03:06At the end, I don't remember exactly,
01:03:10but we wound up taking that money
01:03:11and doing something very different.
01:03:13We wound up saying, like, look big picture.
01:03:15Most kids who start using drugs
01:03:18have had trouble in school.
01:03:21First, it's rarely it is possible,
01:03:23certainly, but it's rarely the
01:03:25straight a kid who gets into drugs.
01:03:27Who winds up, you know,
01:03:29really in trouble.
01:03:30It's more often kids who are frustrated
01:03:33and failing in school and dropping out
01:03:35of school that wind up turning to drugs.
01:03:38And there's some good evidence from that
01:03:40from some longitudinal research in Baltimore,
01:03:43so we said, well, you know.
01:03:44And and that research pointed to 6th grade.
01:03:47Is like a big key point in middle school
01:03:48like her kids going to stay on the
01:03:50track or they going to fall off back.
01:03:52And if you're falling off track in 6th grade,
01:03:547th grade, 8th grade.
01:03:55You're in real trouble from,
01:03:57uh, you know,
01:03:58a lot of public health
01:03:59challenges coming your way,
01:04:00including drug use.
01:04:03Another not all kinds of terrible things.
01:04:05So if we can help more kids
01:04:07succeed in 6th grade.
01:04:08So it turned out that there was a
01:04:10big 6th grade attendance initiative
01:04:12getting started in Baltimore,
01:04:14so we used that $1,000,000 to put.
01:04:18Mental health providers on
01:04:20all of the school teams.
01:04:23That they could be part of an
01:04:25interdisciplinary approach to helping
01:04:26the kids who are at greatest risk
01:04:29for having trouble in 6th grade.
01:04:30Now there was an evaluation found some
01:04:33beneficial things, some challenges.
01:04:35I don't know whether that was,
01:04:37you know, perfect program,
01:04:38but I would say that's was the principal
01:04:41around prevention that we want to
01:04:43help people stay on track with what
01:04:45they want to do in their lives and
01:04:47the opportunities available to them.
01:04:48That kind of you know,
01:04:52investment.
01:04:52In different ways can maybe
01:04:55better than the very targeted,
01:04:57targeted and you know messaging
01:04:59type interventions I I don't know
01:05:01doctor feeling if that comports
01:05:03with your sense of the evidence,
01:05:05and I think I think you raise an
01:05:08important caution when we think
01:05:10about allocating funds to to be
01:05:12sure we're clear on what targets
01:05:14we think were impacting that.
01:05:16Yes, we know that there are some
01:05:19modestly effective prevention
01:05:20strategies as it relate to tobacco.
01:05:23In alcohol and probably cannabis and youth,
01:05:27but we shouldn't assume that because those
01:05:30programs impact those that substance
01:05:33initiation that it's also going to
01:05:37impact opioid initiation and so you know,
01:05:40quite frankly,
01:05:41I think we need to double down and
01:05:43invest in better strategies that are
01:05:46targeted towards this major public
01:05:48health crisis as well as youth targeted
01:05:51programs to address smoking vaping.
01:05:54And and other in alcohol initiation.
01:05:59So there's a question about stigma.
01:06:01I just want to let folks know
01:06:03that in this series we're going to
01:06:05have Gary Mendell come and talk
01:06:07about stigma and the the work that
01:06:09shatterproof is doing to address that.
01:06:12But Judith Stoner,
01:06:14just at Judith Stangor asks.
01:06:16You mentioned anti stigma campaigns
01:06:18as a strategy and we've been working
01:06:20on these for years and I'm not
01:06:22sure how far the needle has moved.
01:06:24Do you have any strategies for best
01:06:27practices? Let's take my reduction.
01:06:31That is a great question and actually
01:06:34we have some great at Johns Hopkins.
01:06:37We have a place called the Stigma Lab,
01:06:40which is not where you,
01:06:42you know they bring in medical
01:06:45students to get stigmatized.
01:06:46But it's not the signal at the stigma
01:06:49lab is where they ustads different
01:06:54messages for Sigma and they try to really
01:06:58understand how people think about Sigma.
01:07:01Halle Berry and Beth McGinty
01:07:02run that Beth McGinty.
01:07:04It's actually been advising some states on
01:07:06how to think about smart stigma strategies,
01:07:10and Colleen has a wicked presentation
01:07:12which at some point you may want to
01:07:15invite her to give where she shows
01:07:17all these different campaigns and
01:07:19how they wind up actually testing.
01:07:21One of the things I've noticed in
01:07:23my experiences in public health is
01:07:24that you know people don't wake
01:07:26up in the morning and then go.
01:07:28I've got an idea for the new
01:07:29design of a spaceship.
01:07:30You know not that many people.
01:07:32Or, you know,
01:07:33I know I have a new technique to do
01:07:35some weird neurosurgical repair.
01:07:36I I just.
01:07:37It just came to me,
01:07:38but literally everybody in this
01:07:40was very clear during the pandemic
01:07:42as an opinion about public health
01:07:44and knows what it is and often
01:07:46times when it comes to messaging,
01:07:48people pick messages that.
01:07:50You know,
01:07:51resonate with them personally and
01:07:53not really thinking about the
01:07:55audience that you really want
01:07:56the message to resonate with,
01:07:58and you have to do good research to be
01:08:01able to to find that resonating message.
01:08:04And I think Beth has and we could
01:08:08pull it up pretty easily and a
01:08:10couple great blog posts where she
01:08:12talks about what she recommends
01:08:15for states for campaigns around
01:08:17stigma and how to think about that.
01:08:19So I would probably.
01:08:21Defer to that,
01:08:22but you know a lot of it is really
01:08:25doing your research ahead of time.
01:08:28Monitoring the impact of it.
01:08:30She really likes language based
01:08:33interventions that can be done
01:08:35relatively quickly so that people are,
01:08:37you know,
01:08:38not discussing stigma programs
01:08:40with stigmatizing language and.
01:08:44So you know I, I do think that there
01:08:45is at least an evidence base out
01:08:47there that that can guide guide us.
01:08:49One of the projects we're doing at
01:08:52Johns Hopkins is who understands stigma
01:08:54better within healthcare institutions
01:08:55because there's a lot of stigma about
01:08:57people who use drugs and drug use
01:08:59within and the treatments for drug
01:09:01use within health care institutions.
01:09:03And we're really trying to follow
01:09:05those those basic principles which.
01:09:10R. To be very thoughtful about how
01:09:14to put together the campaign and to
01:09:17study it very carefully before really
01:09:19deciding that it's it's ready to go.
01:09:21Because this is an area where you
01:09:23think you're telling people not to
01:09:24use drugs and what you're actually
01:09:26doing is demoralizing people more.
01:09:27And you know having something
01:09:29that's actually?
01:09:36OK, two more questions.
01:09:38One issue with this is from Melissa Baney,
01:09:40who says one issue with tobacco
01:09:43settlements was that many mandated
01:09:45state taxes on tobacco sales,
01:09:47which rendered states dependent on the
01:09:49continued sale of harmful products
01:09:51for their budgets in the long term,
01:09:53and even less willing to spend on smoking
01:09:56prevention and cessation initiatives.
01:09:58Are there any similar risks of incentivizing
01:10:01potentially harmful practices?
01:10:03In the opioid settlements.
01:10:07This is a great question as I'm answering
01:10:10that I'm going to put where would I put?
01:10:16Open authentic hears.
01:10:18These are the best mic indeed.
01:10:21Principles and stigma.
01:10:23I think that the biggest.
01:10:26Concern here has to do with
01:10:28what happens to Purdue Pharma.
01:10:31And most of the other stuff
01:10:33I think is is largely,
01:10:35and I'm not a total expert on this,
01:10:37but largely transfers of funds,
01:10:40but there's a very interesting
01:10:41question which I did not get
01:10:43into in the presentation about
01:10:45what happens to Purdue Pharma.
01:10:46And there's a concept that's floated
01:10:49that it could become a public
01:10:52corporation of some kind and basically
01:10:54would continue to sell opioids
01:10:56with the proceeds going to the.
01:11:00Plaintiffs but suddenly the plaintiffs
01:11:02are now in the opioid business.
01:11:05I think it does raise some of
01:11:08those questions in some cases.
01:11:10Some of the ideas of actually involved
01:11:12the plaintiffs literally running the
01:11:14company like appointing the board
01:11:16and stuff like that other places.
01:11:18Other iterations of the idea had been
01:11:21that it's basically some external third
01:11:23party running it on behalf of the plaintiffs,
01:11:26and they're sort of saying here turn it over.
01:11:28But what's interesting is when they.
01:11:32Are saying how big this settlement is like,
01:11:34oh, this is a $15 billion
01:11:36settlement or whatever it is.
01:11:37It could be that like 12 of the $15
01:11:40billion are from selling opioids overtime.
01:11:44And so that is that's raises some very,
01:11:47very serious issues,
01:11:50and I think that.
01:11:53We're going to have to.
01:11:56You know, be very, very cautious about that,
01:11:59and I think some of the state attorney
01:12:01generals are being very cautious about that.
01:12:04And it's it's really uncharted territory.
01:12:06I mean it, it's it.
01:12:08It's one thing to say for tobacco that like
01:12:10we're dependent on the tobacco industry,
01:12:12is, you know, continuing to sell.
01:12:14It's another.
01:12:14It's like you're the tobacco industry.
01:12:16That's kind of what?
01:12:17What is contemplated here?
01:12:18So I I don't have a have not
01:12:20thought this through entirely
01:12:22other than to say like boy,
01:12:24that's really a minefield and you really
01:12:26have to think about how that's done.
01:12:28Well, it may not make sense
01:12:30to constructive alone.
01:12:34One more question.
01:12:36This is from Sanjeev Kumar.
01:12:38It seems one of the stumbling
01:12:39blocks when it comes to stemming
01:12:41opioid use disorder is deeply
01:12:43moral and contradictory.
01:12:45Nature of the treatment.
01:12:46Quote UN quote use of drugs or I
01:12:49would say medication to fight drugs.
01:12:52Is this issue salient in the
01:12:54allocation of the money?
01:12:57Sure, I mean this, particularly
01:12:59as we get to medication goes
01:13:00back over 100 years in this country,
01:13:02are ambivalent about using
01:13:05medication to treat addiction,
01:13:07particularly when those medications
01:13:09are opioids themselves, and.
01:13:12I think it's it's going to be selling its
01:13:15selling in every aspect of opioid policy.
01:13:18It's stallion at the community level.
01:13:20It's talian its state policy.
01:13:22It's salient.
01:13:24You know everywhere,
01:13:25so I would expect it to be pretty
01:13:28salient now I have had the experience
01:13:30you know of speaking to judges
01:13:33about treatment and big rooms back
01:13:36when we could meet in big rooms.
01:13:40And I gave one very aggressive talk
01:13:43to a bunch of judges who work in drug
01:13:47courts or associated with drug courts.
01:13:49And I talked about how important it
01:13:51was that if you were going to treat
01:13:54people in the criminal justice system
01:13:56that they get care that actually can
01:13:57save their lives and not get care.
01:13:59That actually puts them at
01:14:00risk for greater risk.
01:14:01For that, you know, just takes away their.
01:14:06Their tolerance and then puts
01:14:08them at risk for overdose.
01:14:09Like don't do that, you know,
01:14:10and I just couldn't tell you like for
01:14:12some some of these presentations I
01:14:14challenge myself to be is absolutely
01:14:16patient with the evidence, but in the end,
01:14:18just land with some very very strong
01:14:20statements so that there was just
01:14:21they could be on their phones the
01:14:23whole time they were looking up at me.
01:14:25At the end.
01:14:25You know, I was saying, like you know,
01:14:27this is the difference between
01:14:29people whether people will live or
01:14:31die that are before you in court.
01:14:33You know, like I was just as
01:14:35clear they possibly could.
01:14:36And what I would say is it.
01:14:37That part of the biggest one
01:14:38of these that I did I had.
01:14:41Some people,
01:14:42like literally cheering me on some
01:14:44people looking at me with these puzzled
01:14:47expressions and some people giving
01:14:49like every negative vibe known to man.
01:14:52You know, as they were looking at me,
01:14:54you know. And.
01:14:56There's just a huge mix,
01:14:59it's just part of our national discussion.
01:15:01I do think it's getting a little bit better,
01:15:03but it really hasn't moved a huge amount.
01:15:04What would it take?
01:15:06Maybe you know to.
01:15:08To move that,
01:15:09I will tell you when I give that talk.
01:15:10And like there's one judge who comes up
01:15:12to me like tackles me afterwards and so
01:15:13it's like I never thought about it this way.
01:15:15This is incredibly helpful.
01:15:16I feel like the whole trip
01:15:18you know was was worth it,
01:15:20and that has definitely happened.
01:15:23It's worth asking what we think about Sigma.
01:15:25What would it take?
01:15:26And I don't think it's just anti
01:15:28stigma campaign that tackle stigma,
01:15:30and I'll leave.
01:15:30Maybe with this last thought if it's
01:15:32OK and I I'm I'm going to guess that
01:15:34you're with me on this here at Yale,
01:15:36but I think that the medical.
01:15:39Community,
01:15:40truly embracing addiction treatment is not
01:15:43just a strategy to increase access to care,
01:15:46it's an anti stigma strategy.
01:15:49And if you think a lot about
01:15:51how Sigma came down for HIV,
01:15:53it was because it became an
01:15:54illness that doctors treated.
01:15:55It was part of the medical,
01:15:58you know,
01:15:59experience addiction in many parts of
01:16:02this country is still not the case.
01:16:06We I've just seen some recent data
01:16:08among some of the top scoring hospitals
01:16:10in the country will hopefully
01:16:13eventually be able to publish soon.
01:16:15And you know,
01:16:16we we asked all these great
01:16:17things for hospitals to be doing
01:16:19and one of the things that.
01:16:21With the least popular among
01:16:23the top scoring hospitals,
01:16:24was being able to provide buprenorphine
01:16:26in the emergency department in an
01:16:28area where he has been a huge leader.
01:16:29And you know,
01:16:30I think that that may matter
01:16:32as much as anything,
01:16:34whether the medical profession
01:16:35which could embrace this,
01:16:37whether it does embrace this,
01:16:39and I think.
01:16:41You know there there are
01:16:42all kinds of things that
01:16:43we can do in our own world
01:16:45to to help with this shift,
01:16:46and I think the idea of this
01:16:49talk is that the purpose of the.
01:16:52Of the settlement is not going to.
01:16:55The settlement is not going to rescue us all,
01:16:56but it is another leverage point to try that.
01:16:59You know, work with all the tools that
01:17:02we have to to shift the focus of of
01:17:05where we're headed on over to separate.
01:17:08Josh, I absolutely agree with your point.
01:17:11We will be having a talk later on
01:17:14in this series from Doctor Edward
01:17:16Coupe and Don State are talking
01:17:18about Ed based interventions.
01:17:21I agree that to the extent that
01:17:23we can normalize in mainstream,
01:17:25it will only go to address issues
01:17:27around stigma and and understanding.
01:17:30I want to thank you for your time and all
01:17:34of this great work you're doing, Kyle.
01:17:37I didn't know if you wanted to
01:17:40say a few words or.
01:17:41If we should just sign off.
01:17:43No, just a massive thanks to everyone,
01:17:46especially you Josh.
01:17:48Terrific presentation, very informative.
01:17:50I really enjoyed all the questions as well.
01:17:53So thank you for.
01:17:54Allowing us to be a part of
01:17:56this great speaker series.
01:17:58We've got some wonderful
01:17:59speakers coming up and.
01:18:00Josh, we'd love to have you
01:18:02join for some of those and
01:18:03ask some tough questions.
01:18:06And I'm going to have the final slides.
01:18:10Will include information you all
01:18:13will receive an email with access
01:18:15to this and we look forward to
01:18:17seeing you on our future talks.
01:18:19Thank you everybody and take care.
01:18:22Thank you.