By Taylor Knopf
During Josh Stein’s first year as the North Carolina Attorney General, he has spent a lot of time focusing on the problem of opioid addiction across the state. NC Health News sat down with Stein last week to talk about what he’s learned fighting this deadly epidemic.
NCHN: How did the opioid crisis become your number one policy issue?
Stein: The opioid crisis has been my top policy priority because it is having a devastating effect on individuals, families and communities. When I travel the state and meet with law enforcement — which is an important part of my job — I would ask, “What issues are you confronting?”
Chiefs and sheriffs would tell me that the opioid crisis is clogging up the entire criminal justice system. Three-quarters of people in county jail or in our state prisons have some form of substance use disorder, and a growing percentage of those are people with opioid addiction.
NCHN: You are traveling the state and meeting with different folks. What have those meetings entailed? And have you come across something surprising or memorable?
Stein: I’ve learned a great deal. Over the past year, we have held 23 community roundtables all across the state from the mountains to the coast, Piedmont, urban and rural. What we do in those meetings is bring together all the relevant stakeholders: law enforcement, the medical community, policymakers, substance use and (sic) treatment community, the business community, the faith community, and just individuals in the community that care about this issue. It’s touched so many. There are a lot of those kind of people.
We ask, “What are you doing to confront the crisis? What are you experimenting with? What initiatives are you undertaking? What’s working? And what do you need from the state to help you in this battle?”
I think these meetings have been incredibly informative for me. One of my goals is to compile all of these good ideas going on around North Carolina into a resource that other people can use. So we’ve got a page on our website where we’ve listed 50 good ideas we’ve learned traveling the state. If you work for EMS or are a health care provider or you’re a sheriff or a city councilor, there are going to be ideas on that page that can work for you. We put contact information so you can call the person actually doing that work. Ask how is it working? What would you do differently if you could start over again? Hopefully, we can empower people to take action.
The other thing we hope to accomplish is bring together communities that don’t always talk to each other.
And the third thing is just by talking about this issue, the issue of substance use disorder, we’re trying to help dissipate the stigma that surrounds the disease. We have to change the way everyone looks at this issue. To recognize it is an illness and we need to have a health care focus on treating the illness if we are ever going to be successful.
NCHN: Could you give an example of one of those interesting partnerships that you’ve seen?
There are initiatives dealing with pregnant women with addiction. There are initiatives dealing with people after they overdosed to try to connect them with treatment. There are initiatives to reach out to people with addiction to let them know that there is a way forward and you can achieve a sober life. There are a lot of initiatives to train doctors on prescribing and how to treat pain without first relying on opioids which is often an ineffective way of treating pain, as well as having an incredible side effect of fostering addiction. There are some groups out there training doctors on the nuts and bolts of how to access the CSRS, the Controlled Substance Reporting System. There are just a lot of really exciting things going on at the local level.
NCHN: You’ve been going after a lot of drug manufacturers and announcing those investigations and giving updates. Should we expect more of that? Are there more companies you want to get under compliance?
We’ve filed a lawsuit against one company, Insys, over the marketing the sale of its opioid product Subsys, which is a fentanyl product. It’s incredibly addictive. It’s 100 times more powerful than morphine. We alleged that they engaged in deceptive marketing where they were promoting this product for sales and not for the ultimate health of the consumer. As a result, people became addicted and I’m sure some people died.
Simultaneously, I’m part of a multi-state, about 40 states’ other attorneys general, [a] bipartisan group from across the country and we are are looking at the major manufacturers and the three distributors that take the drugs from the manufacturers to the pharmacies. We’re in negotiations with them at the same time that we are collecting information that we need to analyze for a potential lawsuit. Hopefully, we can reach a resolution. But if we can’t, I will do everything in my power to protect the people of North Carolina if I conclude that these companies engaged in unlawful business practices.
NCHN: With Insys, you’ve said before that they offered incentives and kickbacks to doctors. What did those look like?
Stein: It was money. They were paying money to doctors in the form of speaker fees based on how much they were prescribing. The question wasn’t, “Who is a good speaker?” The question was, “Who’s getting more of our product out to the marketplace?” And that’s unlawful. We are holding them accountable.
They would target speakers programs where they were treating headaches or back pain when this was a product designed for cancer. It’s incredibly potent stuff.
NCHN: You say you want to hold these folks accountable, but we all know that these companies make so much money that any sort of settlement or sanction that you could put on them would be a drop in the bucket. What sort of institutional changes could you make to prevent this from happening again in the future?[sponsor]
Stein: As we engage these companies, we are looking at two primary things. One is to get money to help deal with the consequences of the overprescribing that’s occurred in the United States. And the second thing is to change their business practices so it never happens again. That means for the manufacturers, not marketing these drugs to the medical community and to the general public. And in terms of the distributors, it means having rigorous systems to determine when there are too many drugs flowing into a particular part of the country. We know where the sales are occurring. What we are concerned about is the distributors didn’t do enough when they should have.
NCHN: There are a lot of programs out there that divert people with substance abuse problems away from jail or prison and into treatment. How effective have those been?
There are programs that exist pre-arrest, like the Hope Initiative in Nashville. There is a similar program in Oakboro and in Brunswick and Orange counties. There is the LEAD (Law Enforcement Assisted Diversion) program, happening in Fayetteville, Statesville, and Waynesville. Hundreds of people are being served by these programs.
I think we need more of this work. We also need substance use diversion at trial with drug courts. Unfortunately, the legislature cut funding for drug courts and there has been a reduction in the number of them. I think drug courts play a really critical role with this problem.
Then there are people who need treatment while they are in jail or prison. The Department of Public Safety has some substance use treatment programs. I think they recognize that they need more of them. In Rutherford County, the sheriff has instituted a program in their county jail in partnership with a treatment facility and funded by a foundation. They provide treatment to people in jail before they get out. And they have a deal where they provide them a year’s worth of medication assisted treatment (MAT). So that when they get out they are not immediately looking for their next fix. Because that’s what drives crime.
NCHN: There has been a shift in the way law enforcement approaches drugs. How have you seen that change and what are you doing to affect that?
I’ve seen it everywhere. I’ve talked to a number of sheriffs that say, “I would apply the same drug-fighting strategies that I always did where I’m arresting people and putting them in jail. Then I would find that I’m arresting the same person when they get out and put them in jail again.”
I’ve heard this from a countless number of law enforcement officials. It really doesn’t matter if they are urban or rural. It doesn’t matter if they are a Democrat or Republican. I’ve heard this from some very conservative rural sheriffs. They say we are not going to arrest ourselves out of this crisis. We need to have new approaches or else we are going to keep doing the same thing. That’s something I’ve learned from these roundtables, and I share it as I travel the state. It resonated with law enforcement.
NCHN: This is not the first drug epidemic in this country, and law enforcement has dealt with various drugs for a long time. What is it about this drug that made many in law enforcement change their mindset?
Stein: I think that it’s partly a recognition that the approach that was taken in the ’80s, ’90s or 2000s didn’t work. So I think part of it is learning over time. I think that fact that epidemic is distributed all across the state, urban and rural. And it affects everybody, old and young. The fact that racial composition of people is more white than black: I think we can’t ignore the racial element of this. And the other thing is this epidemic is the deadliest. It’s killing substantially more people than the meth problem or the crack and cocaine of the ’80s. As a country, our life expectancy has declined in two consecutive years directly attributable to this epidemic. So it’s just incredibly devastating.
NCHN: How is your office balancing the fight against opioid abuse with the legitimate needs of chronic pain patients and their doctors? Some people say they now feel criminalized for needing continuous heavy pain medication.
Stein: Opioids are a lawful product that have a medical use. Our effort is not directed at trying to curtail that. In fact, the STOP Act which we helped push, clearly delineates between people with acute pain, such as a broken arm, and chronic pain. The limitations on prescribing only apply in acute pain circumstances. If people with chronic pain still need that, they have the right to do it. Of course, the CDC has recommended that opioids are not ideal for treating chronic pain for most people. Which doesn’t mean all people, it just that opioids are not an effective pain treatment drug. We’ve worked closely with the medical society and the medical board. We heard loud and clear that folks didn’t want this kind of restriction placed on chronic pain patients. So we didn’t.
NCHN: How have the Trump Administration’s actions affected the opioid efforts in North Carolina? Either helped or hurt?
Stein: They haven’t done much of anything, unfortunately. The declaration of a public health emergency was probably a good thing in it helped to shine some light on this issue. We need to raise the profile for people to understand how serious this is. But it came without a single dollar. The Trump Administration hasn’t put any money into fighting this crisis. In fact, their biggest objective is to try to curtail Medicaid and take away people’s health insurance when Medicaid provides 40 percent of all treatment dollars. So what I fear is if they are successful in cutting Medicaid by the trillion dollars they want, it will actually be a devastating step backward. We’ve been in written communication with Congress about how critical this issue is and their need to step up to the plate.
NCHN: Are we doing anything in N.C. to help employers deal with the issue of addiction with their employees?
Stein: Workforce issues are a real concern in this crisis. We hear from employers about their challenge in filling positions. There was a manufacturer who said for every vacancy they will get five applicants. And they have to eliminate two because of a drug screen and two more because of a criminal record, usually drug related. So they are having a challenge filling their workforce at a time when we want good manufacturing jobs in our state. Employers need to be creative, and we’ve met with business groups to urge them to take a new approach to this issue, not to be so quick to screen out people with a history of addiction but instead to develop system of support so they can thrive in recovery and be productive employees.