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A Conversation With Robert Pack

 “This is tragedy. This is misery. This is all kinds of pain, for families, for friends, for loved ones.”

“Good epidemiology is of paramount importance to our work and I’m so grateful for the work that epidemiologists do.”

                                                                                                                        Robert Pack

[Editor: Last month President Trump declared the opioid drug problem a national emergency and called for an all out effort to defeat this ongoing epidemic. To obtain a deeper understanding of the magnitude and causes of the problem, The Epidemiology Monitor interviewed Robert Pack, Associate Dean for Academic Affairs & Professor of Community and Behavioral Health at the East Tennessee State University (ETSU) College of Public Health. Dr Pack is chair of the Prescription Drug Abuse/Misuse Working Group at ETSU, Executive Director of the ETSU Center for Prescription Drug Abuse and Treatment and PI of an NIDA-funded five year research infrastructure grant that includes three research projects. The interview which follows makes compelling reading and provides epidemiologists with an in-depth understanding of the current crisis and how epidemiologists might further contribute to addressing the problem.]

EM: The President recently declared the opioid crisis a national public health emergency stating that 175 persons die each day from drug overdoses. What do you think best conveys the magnitude of the crisis?

Pack: Most commuter jets, such as those that take many of us from our hometowns to central air travel hubs, hold between 70-100 passengers.  Would Americans be OK with losing one or two commuter jets full of people each day?  Absolutely not.  Airlines would be grounded and all hands would be on deck to identify the problem, the very best engineers would be brought in to fix the problem and no resources would be spared.  Stricter safety policies would be enacted, and checklists made and completed at a scale heretofore unimaginable.  We simply would not allow the industry to continue.  The conditions that allowed such a tragic scale of events would be fundamentally altered and the problem would be corrected, such that air travel became safe again.  This is the type of national level commitment that we need to address the opioid problem.

EM: The President compared the problem of drug overdoses to gun homicides and motor vehicle deaths.  Help us to understand the toll being exacted by opioid drugs.

Pack: Unintentional poisonings, a category that includes overdose deaths, is the overall leading cause of injury death.  It surpassed motor vehicle accidents, falls, suicides and homicides in the US several years ago.  But the problem does not lie just in the numbers, though they are tragic.  It lies in the suffering of the family grieving for a son lost to overdose, or a daughter numbed for years by substance abuse, or the son or daughter that is confused and has no words to express the grief of losing their mom.  It lies in the stigma and shame of the broken relationships and trust that substance use disorder causes.  Suicide is similar in that it is shrouded by value judgements and whispers.  We can speak objectively about motor vehicle accidents and even homicides, to a large extent.  Until we can begin processing overdose and suicide objectively, and acknowledge the scale of the public health problem that we are facing, we will continue to accept fragmented, short-term solutions to the problem.

EM: What are the projections for the impact of this epidemic if current trends continue?

Pack: Dr. Don Burke, Dean of the University of Pittsburgh Graduate School of Public Health, leads a team of epidemiologists that has demonstrated that drug poisoning deaths have increased exponentially, far outpacing population growth, since at least 1979.  The exponential curve is striking when you see it, but is even more so when you see that, when transformed by logarithmic function it plots with an R^2 of .99,  i.e., that the next several years of the epidemic can be plotted with 99% accuracy.  They showed that the number increases about 9% each year, with a doubling rate of every eight years.  They have shown that it took about 15 years for our country to experience 300,000 overdose deaths, but that we will experience 300,000 more in the next five years unless we do something dramatically different.  His team has made similar plots for the data in each state, and for most major cities.  There are only a few examples of places that do not fit the same trend.

EM: The report from the Presidential Commission states that prescription opioids now affect a wide age range, both well-off and financially disadvantaged families, urban and rural populations, and all ethnic and racial groups. What should epidemiologists understand about the epidemiology of the opioid crisis?

Pack: The short answer is that it is complex and changing.  The overdose epidemic used to be one of older people and is now clearly moving into a younger demographic.  I have seen some bimodal plots of this wherein there are peaks currently emerging in the later 20s and the middle 40s.  Plots that break that data down over time show a transition from mid 40s to this bimodal shape.

The recent MMWR article that elaborated upon the distinctions between the epidemic in rural vs urban areas, as well as some of our team’s own work, has shown that the epidemic is very different along the urban-rural continuum.  Prescription drug abuse has been a more (but by no means exclusively) rural phenomenon, and heroin/fentanyl abuse more urban.

EM: How does risk perception influence the opioid crisis?

Pack: When many of us were young, our perception of risk about heroin was that it was extremely risky to even try it, and in most cases that perception, and a general lack of availability, at least when we were young, was likely protective. 

From the Monitoring the Future data, which is specific to youth (taken from a random sample of high school students each year) we know that for some drugs, like marijuana, risk perception and use are negatively correlated.  For the most part, opioid use disorder has historically been a condition of older users that graduated to opioids after other drugs in their teens.  Because of this, the same annual cross sectional data for opioid use disorder and risk perception are less clear mostly because the numbers were historically so small for high school student use of heroin (the survey did not ask about prescribed opioids until a few years ago).  But I believe that a lot of people slipped into this condition because the risk perception of prescribed opioids was so low for so long.  The risk perception for heroin use was likely very high, but for prescribed opioids, quite low.  I think people went over the ‘risk threshold’ into heroin when it became known that heroin was more cheaply and readily available to satisfy the craving for opiates.

EM: What are the main drivers of the overdose problem?

Pack: The current overdose problem is a result of several different drivers, a few of which I will describe here.   First, there has been tremendous growth in the amount of prescribed and dispensed milligrams of morphine equivalent (MME; a standardized unit of measurement for opioids of different strength) which started in the late 1990’s and has grown into a large scale of individuals that are physically dependent on opioids.  Beginning around 2010, the medical and policy community began to see the risks of over-prescribing and subsequently clamped down both on over-prescribing and the phenomenon that became known as doctor-shopping, or individuals going to several different prescribers to get prescriptions for opioids, for consumption or sale.  I believe this contributed to a larger demand for illicitly traded opioids, including heroin.   Fentanyl is, I am told, easily synthesized and trafficked from China and Mexico to sites in Canada and the US, and then cut into both heroin and other street drugs, including counterfeit prescription drugs.  Fentanyl-laced heroin is largely responsible for the current spate of overdose deaths.  The 2017 National Drug Threat Assessment from the Drug Enforcement Administration is very informative on this topic.

EM: Can you describe how you see risk perception changing?

Pack: I believe that, at some point, there will be a large enough awareness about the topic, that it is going to cause people to fear the outcome of a drug overdose and we will begin to see population level declines in the initiation of opioid misuse.  I believe this will cause a slowing in the rate of new people with opioid use disorder, over a long period of time.  However, there are a lot of people with opioid use disorder already, and some with massive tolerance for opioids.  Depending on how long and how severe their disorder many will not have volitional control over their behavior and won’t follow rational decision making processes that you may expect from most.  A large number of them are immersed in this new reality of their supply being more deadly than ever.  Hence, between now and then (when the population level perception of risk is extremely high and new initiates to opioids have greatly decreased) there will be a lot of misery.

EM: What other drivers are you aware of?

Pack: There are other drivers of this problem, to be sure.  For example, a lot of money has been made by profiteering all along the legitimate supply-side, such as by pharmaceutical companies, poorly run pain clinics, overprescribing physicians (both willing and unwitting), and even by some people in the business of treating those with opioid use disorder such as with medication-assisted treatment or in-patient treatment.  However, these are difficult things to prove and our team is trying to stay focused on the larger picture, which is that a lot of people are suffering and need help urgently and that excellent primary prevention programs need to be put into place quickly.  

EM: You have said in another venue that we need to think about the opioid problem as a “chronic relapsing disease” and treat it accordingly.  Is this the most beneficial way to think about the opioid crisis?  What other conceptual approaches have been put forth?

Pack: I am certainly not the first to frame it as such.  In fact, I’m not sure who said it first, but I think framing it as a chronic relapsing disease, such as diabetes, helps to frame opioid use disorder as a medical problem, with all the inherent physical complexities of a medical problem, rather than a moral failing or a behavioral problem.  The analogy is particularly apt because type-2 diabetes can be controlled by diet and exercise in some while others may need insulin for life.  Yet we should not and would not judge people for having type 2 diabetes and we certainly would not restrict their access to insulin.  We would also endorse social support, cooking classes, other tertiary prevention opportunities for them.  Stigma about mental illness and substance use disorder prevents us from being so objective about overdose and even suicide.

EM: Do we know enough to control this epidemic or is there a scientific or technical breakthrough that is needed to effectively end the epidemic?

Pack: Much is made of personalized medicine and the potential for an addiction vaccine.  I support the type of science that is leading to such breakthroughs.  While I am hopeful for the utility of such amazing tools, I know that they are many years away from being applicable in my community, state and region.  Hence, our team has been focused on identifying the tools that we already know to be effective, and we’re systematically trying to implement them in multiple different places, to have the greatest effect. 

We are presently doing original scientific work on communication between prescribers, dispensers and patients with the aim of creating interventions to improve accurate risk and help-seeking communication between each part of the triad.  This work is being led by my colleague Nick Hagemeier, Associate Professor of Pharmacy Practice and our Center Research Director, and my senior doctoral student (who just defended her dissertation!) Stephanie Mathis.  Most of the rest of our work is guided by principles of dissemination and implementation science, or the science of getting people to use evidence-based tools that we already know are effective.

EM:  What key interventions exist to counter this epidemic?

Pack: The epidemic of opioid use disorder is fundamentally interprofessional in its origin.  Hence, solutions to the problem should also be interprofessional.  No one entity is responsible for the epidemic and efforts to address it need to include all stakeholders.  In 2012 we established the ETSU Prescription Drug Abuse/Misuse Working Group, a volunteer group that meets monthly.  The group is intentionally highly interprofessional and engaged with the community. The group actually has over 240 people on the email list but between 30-50 people show up to our meetings each month.  Its open to anyone, and we listen to and discuss all ideas. 

EM: What happens at these meetings?

Pack: We alternate on-campus and off-campus meetings to learn more about programs in the community.  Of all the things we've done, the Working Group is by far the one that is most rewarding and the place where the best ideas originate. 

I view it as a very fertile ground for new ideas and a place where informal connections can lead to powerful new partnerships.  Members are from many different organizations and sometimes have very different views on a topic, but what they all have in common is great interest in finding solutions, high engagement and tremendous expertise.  I wish I could list them all here, because they are such valuable colleagues, but one person in particular facilitates these relationships with such skill that I need to mention her by name.  Ms. Angie Hagaman is our NIDA grant project director, our Center Operations Director, a Masters prepared counselor and part time DrPH student that has tremendous instincts for relationships and community engagement. 

EM: How does the Working Group think about the opioid situation?

Pack: To frame our Working Group efforts, we use a conceptual model based on a simplified “life course” or “continuum” of addiction to demonstrate the complexity of the problem and to highlight the fact that there are many evidence-based interventions that can be implemented at different points along the continuum. The figure is provided below. By focusing on the continuum of addiction, it is possible for both university and community partners, who might normally only work at different points along the continuum, to coordinate and collaborate towards the common goal of having a measurable impact on the problem in the region.

EM: In talking about the complexity of the crisis, you have said that different groups are seeing only one part of one elephant in what is actually a herd of elephants!

What more holistic approach do you see to bending the curve downward?

Pack: Heretofore, public health efforts to address the problem have been fragmented, or focused on only one or two of the interventions on the continuum.  For example, just this week, we learned of a well-resourced team that met for several days to plan healthcare-focused solutions to the problem centered around the prescribing of pain medication.  I feel like that was truly missing the point.  That will control some of the supply, but the healthcare industry has multiple points of concern all along the continuum.

As another example, national level efforts to educate and train many stakeholders about naloxone have been a recent focus of the public health systems in many states.  While our Center is also devoted to naloxone distribution, and Dr. Sarah Melton, Center-affiliated Professor of Pharmacy Practice in our Gatton College of Pharmacy, worked with our partners to create a training programs for naloxone administration that have been completed by more than 38,000 people, it is an unfortunate reality that naloxone alone will not be the answer to the problem.  In fact, though essential, a focus on naloxone to reverse overdose should be viewed as a loud and clanging alarm of how urgently primary and secondary prevention efforts should be brought to bear against the problem.  That's what I mean when I say that this is like a large group of people with blindfolds on describing an elephant.  It's a well known analogy.  You describe the part of the elephant that is in front of you.  I have also said it is more like a herd of elephants because there are so many different perspectives on the right thing to do at different points along the continuum.

All of the interventions listed along the continuum have the potential to be scaled up, implemented with high fidelity and evaluated for local performance.  Many even have different points of intervention at each level of the social-ecological framework.  For example, a primary prevention program for school children may have modules for the child and also a parent component, a school level plan, a system level plan and perhaps even a community information component. 

With respect to the figure shared above, ultimately, the effectiveness of each intervention is interdependent with the scale of implementation of each of the others.  We can’t focus on just one point along the continuum.  We must have a concerted effort at all points across the social-ecological framework as they target individuals, families, healthcare initiatives, communities and systems that all play a role in the epidemic. 

EM: The President stated it will take many years and even decades to address this scourge in our society. Given that we are in an emergency situation, is there a reasonable prospect that we can achieve a significant decrease in deaths more quickly? What would have to happen to rapidly achieve this desired outcome?

Pack: One thing that must happen quickly is to create high quality access to care for everyone that needs it.  And we need to reduce payment and waitlist barriers for people to get engaged in treatment.  Payers, such as Medicaid and insurance providers would be smart to scale up the treatment side of this as quickly as possible, because the problem will be even bigger the longer they wait.  

EM:  What are the main obstacles to a rapid and effective end to the epidemic?

Pack: Stigma and denial.  And the drug cartels trafficking in heroin and fentanyl.

EM:  Unlike other public health problems such as lack of physical activity, you mentioned that there is a layer of physical dependence that underlies the drug addiction problem and consequently a deficit in volitional control that impedes safer and healthier behaviors. In that way this problem may be similar to sexual risk behavior. Can you expand a bit further on why this opioid crisis is different from other public health problems.

Pack: I mention this because I think many people misunderstand substance use disorder to be a moral failing and just evidence of bad character, and that if someone suffering from opioid use disorder just really wanted to, they could get better.  In fact, many of the theories that we learn about in our public health training are based on a rational decision making process, that behavior can be changed if we just value health more than the reward that we get from some risk behavior, or that behavior is influenced in a predictable fashion when considering social influences and peer norms.  That is simply not true when you are talking about opioid use disorder.  Habitual use of opioids results in a physical craving for the drug, when the body is in withdrawal from opioids, that can overwhelm even the best predictors and models for behavior change.   

EM: What single underused intervention or interventions might we employ now to ameliorate the epidemic?

I truly wish there was a single intervention that was that effective for the problem.  But there is not.

Pack: If you were named the Opioid Czar and given $100 million dollars to control this epidemic, how would you invest it to produce the best results? Is there agreement among the professionals in your field about how to invest this money?

I was recently asked this question at a national meeting.  My response reflected the answer I gave above, which is to accept the complexity of the problem and implement, with high fidelity, the interventions all along the continuum that have the greatest potential for return on investment.  But on further reflection, a $100 million investment would represent a unique opportunity to create a sustainable infrastructure for clinical treatment that would produce revenues for re-investment into other primary, secondary and tertiary prevention strategies that I outlined above.  It would create a flywheel effect, to adapt an idea from Jim Collins’ Good to Great.  If done carefully, leveraging partnerships with health systems, mental health care organizations and networks of community coalitions, that scale of investment would be transformative for our region and several others. It would require the establishment of public-private partnerships with much greater creativity and flexibility than we have seen to this point.  I would use it to establish non-profit, but revenue-generating medical, pharmaceutical and other treatment entities that would then reinvest most revenue, above costs, into other non-revenue generating activities. 

For example, health systems with a focus on population health metrics could establish non-profit medication assisted treatment clinics, non-profit methadone clinics, and non-profit pharmacies that could all leverage revenues into programs that are generally non-revenue generating, such as, but not limited to, school based primary prevention, harm reduction outreach, clinical education, naloxone distribution and drug courts.  Most of the latter are typically funded by grants which are usually time limited, limited in scope and simply not sustainable. In the model I describe, as the problem shrinks in magnitude, the available revenues would also shrink.  As it grows, revenue for prevention would also grow.  Our Center has entered into such a partnership with our regional health system, Mountain States Health Alliance, and our regional mental healthcare system, FrontierHealth and we have opened a non-profit treatment center wherein revenues will support prevention, outreach, research and evaluation efforts of our ETSU Center for Prescription Drug Abuse Prevention and Treatment.  It is brand new, having just opened in late September, but our goal is to deliver state of the art care to our region, and to reinvest any revenues back into the same community for population health improvement, evaluation of those programs and research.

However, if I was actually named the Opioid Czar the first thing I would do would be to use that massive power to step down and replace myself with my colleague Stephen Loyd, MD, a true hero both for the tireless and creative work he is doing every day as the Medical Director for the Tennessee Department of Mental Health and Substance Abuse Services, but also for the life of purpose and impact that he is living while in long-standing recovery from this very problem.

EM: What do you think our epidemiologist readers can do to help address this opioid crisis? Is there a role for them to assume easily and readily at work or in their communities?

Pack: This is a great question. Epidemiologists have a tremendous role to play in the epidemic.  A couple of epidemiology highlights, if you will, are the role that epidemiologists played in halting the spread of HIV in the rural Indiana countryside in 2015.  If your readers don't know, which is unlikely, Scott County Indiana had an HIV spike around 2014-2016 where around 200 new cases of HIV were found that were mostly attributable to sharing needles for injection of opioids.   Some needles were used dozens of times a day and shared between multiple people.  The CDC acted quickly and mitigated the threat. They did so with great epidemiologists using tried and true shoe-leather epi methods, network modeling, and the establishment of systematic harm reduction including one-stop shops for HIV testing, counseling, safe syringe programs and other preventive services. 

Another highlight is the advent and promotion of use of creative sampling techniques like Respondent Driven Sampling, which can help investigators learn how to access representative samples of hidden populations to learn about and assist with their health needs.  Another is the maintenance and reporting of our behavioral and health statistics that are so important for understanding these complex issues and how they change over time.  I could go on and on.  Good epidemiology is of paramount importance to our work and I’m so grateful for the work that epidemiologists do.


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