“Drug czar” steps up efforts against opioid crisis
By Lynn Sygiel, editor, Charitable Advisors
When Jim McClelland retired after 41 years at the helm of Goodwill of Central Indiana, he didn’t envision an encore career. He was looking forward to traveling with his wife and serving on several boards.
But when Gov. Eric Holcomb signed an executive order and tapped him for a cabinet position, McClelland relinquished his daily flexibility. Last January, he became Indiana’s first Executive Director for Drug Prevention, Treatment and Enforcement and reports directly to Holcomb. He also chairs the Indiana Commission to Combat Drug Abuse and coordinates the activities of nine Indiana agencies.
It’s a position that several other states have created.
While at Goodwill he supported the concept and developed programs around the idea that so many of our social problems are interrelated and tend to reinforce and compound each other, rather than treat them in isolation.
“What we were trying to do at Goodwill in efforts to reduce intergenerational poverty was to bring pieces together. And conceptually that’s at least in part what needs to be done here,” said McClelland.
Since then, McClelland has seen the opioid crisis up close and although he has a lengthy nonprofit working history, he had not realized the complexity of the epidemic. While it got its legs in Southern Indiana, it’s now everywhere.
“It is in small towns in rural areas, it’s in the cities, it’s in the suburbs, and it now cuts across all socio-economic groups. There are many pieces to this, and there are many steps that need to be taken simultaneously. You cannot do it sequentially and there are no quick or easy solutions,” McClelland said.
In 2016, the opiate scourge killed 785 Hoosiers, according to the Indiana State Department of Health, and the state’s emergency rooms handle more than 400 overdose visits weekly.
“This isn’t a recent problem. It’s been developing gradually over two decades,” McClelland said. “What is recent is the awareness of the magnitude and the complexity and how many lives and families it’s affecting. It’s almost as if it had to reach a certain, critical mass awareness before people started saying, ‘We have to do something about this.’”
“We use words like ‘epidemic crisis’ to describe it for two reasons. One of those is this one got started from the overuse of legally prescribed pain medications. People thought because the doctors were prescribing these medications that they were safe. It turned out they were much more addictive than a lot of people believed,” he said.
Doing something about it is just how McClelland spends his days.
The state now has three broad priorities to reverse the epidemic.
The first is keeping people alive. To support that effort, one change is that naloxone, the reversal agent, is not only available to first responders, but can be purchased over the counter. Another initiative is a pilot project at Eskenazi Health. When someone overdoses and is rushed to the hospital, peer recovery coaches encourage them to seek treatment. The state plans to use some 21st Century Cures Act grant money to replicate this program.
The second priority is to expand treatment capacity and access. Ultimately, McClelland hopes that no one is farther than a one-hour drive for treatment.
And the third is stopping the flow of fentanyl, a synthetic opioid, which is in part the reason for spikes in overdoses and deaths. Heroin’s cousin, fentanyl has many times heroin’s potency, but looks identical. Most fentanyl sold on the street is made in clandestine labs, is less pure, and its effect on the body can be more unpredictable.
McClelland said a lot of what he did in his first year was to put things in place that will really start paying off this year. He believes in a deliberate, strategic plan to attack the problem, and compiling and sharing data is critical. In the past year, he has worked to get state agencies that report to him to sign agreements to share data with each other, giving a more comprehensive picture.
“Now, they can start looking at this data in different ways and enable us to see things that we wouldn’t otherwise see. Hopefully, we will have data that is going to be converted into more useful, actionable and timely information,” he said.
Another is sharing this information with Pew Charitable Trust that is analyzing Indiana’s data and policies at no cost to the state. Pew will continue its work this year.
“They have just a wealth of talent and resources and a national perspective and a lot of national data. So they can look at policies across the country and they can say, ‘These really seem to be effective. Indiana, you ought to take a look at this.’ I will tell, what we’ve seen is we’re really on the right track in a lot of this,” McClelland said.
McClelland shared stories about two young men who were prescribed medications after surgery, one for a football injury and the other after an appendectomy. Both found themselves addicted and searching the Internet for more. Both had stable homes.
“A lot of people developed opioid disorder, which is the technical term. And regardless of how someone develops a substance-use disorder of that type, once you got it, you’ve got a chronic disease. It changes the structure of the brain. It’s treatable, but few people can recover without treatment,” he said.
Dr. Jennifer Walthall, secretary of Indiana’s Family and Social Services Administration, groups the people being treated into thirds. A third with treatment are on a maintenance dose of one of the FDA-approved drugs and taper off, another group needs to be on maintenance for life. For a third treatment doesn’t work. Compared to other addictive substances, treatment for an opioid-use disorder takes longer and the risk of relapse is higher, something that can take years even if in treatment.
In order to provide better access to treatment, the lawmakers approved five additional FSSA-approved, licensed and monitored opioid treatment programs that will open this year. The additional five are in Greenwood, Terre Haute, Fort Wayne, Lafayette and Bloomington and, through the federal 21st Century Cures grant, FSSA is working with addiction services providers across the state to create other new residential treatment programs or expand their existing programs.
Currently lawmakers are considering whether to add nine new treatment centers around the state in H.B. 1007. If the bill passes, the new treatment centers would be operated by hospitals.
In October, the state launched its Next Level Recovery website, www.in.gov/recovery. The site includes a geo-location feature designed to help Hoosiers find Division of Mental Health and Addiction-certified addiction treatment providers throughout the state.
Additionally, two improvements to treatment access are on the horizon. Next month, the state will launch an open-beds platform linked to the 2-1-1 system. It will enable someone looking for a residential treatment to find an empty bed. Until now, calling sites individually was the primary method.
“This is really innovative, and it’s going to enable us to make more efficient use of existing capacity. We know how many beds are out there but at any given point in time, we haven’t known where an empty one was without calling. So this is going to change that,” McClelland said.
Another change is approval of a federal waiver from the Centers for Medicare & Medicaid Services (CMS) to use Medicaid dollars for residential treatment and recovery support services. Approximately $80 million in annual funding was recently approved.
But one of McClelland’s continuing concerns is that those who get arrested have to be treated, and unfortunately with a lack of treatment access, the jails are the de facto detox centers.
“In most counties in the state, jails don’t want to be in that position, but they are. We need some better solutions to dealing with that situation. DOC is the largest treatment provider in the state of Indiana,” McClelland said. They are working together to offer more comprehensive services.
This month, the state will launch Project Echo, a training developed in New Mexico. It is a medication-assisted treatment training that is available to providers. Primary doctors can apply for and receive a Drug Enforcement Administration (DEA) waiver to allow them to dispense methadone and buprenorphine for opioid use disorder.
In January, the state announced with the state Department of Health and the Indiana State Medical Association for the management of acute pain to include post-surgical pain. Over the next couple of months, six webinars dealing with various aspects of the opioid situation and pain management will be available.
McClelland said that another significant change is a way to integrate the prescription drug-monitoring program with electronic-medical records and pharmacy management system statewide.
“This will give prescribers and dispensers of prescriptions a tool that’s fast and very user-friendly and enable them to see a controlled substance history of a patient. They will also know if someone is doctor shopping. They will know if somebody is taking something in combination with an opioid that would be really dangerous. Up until now, the system has been clunky but the state’s paying to fix that,” he said.
There is a bill in this year’s General Assembly requiring prescribers to check INSPECT before issuing a first prescription for an opioid. It passed 47-1 in the Senate, and in February moved to a House committee. If it passes, practitioners will be phased in, but by 2021 will be mandatory.
Other innovations include locations on where to dispose of unused opioids, which are listed on the state’s Next Level Recovery website. Walmart has taken a step to help with disposal. When a prescription for a controlled substance is filled, the customer also receives a DisposeRx packet. When disposing of unused pills, the customer adds warm water and the powder, and it is converted into a non-divertible and biodegradable gel.
There is some positive news. In January, Clark County had overdose deaths drop by a third, from 90 to 60.
“Any good news is welcome, believe me,” McClelland said. “There hasn’t been very much to this point. Here’s the problem, if you could magically prevent anyone else from becoming addicted, we still have tens of thousands of people, maybe even hundreds of thousands who need treatment. And we have to deal with that. They will not recover without treatment, and abstinence-only treatment only has about a 10 percent success rate. We are focused on expanding the availability of medication-assisted treatment and the recovery support systems or services that people are going to need, and we’re going to be doing it for a long time.”
McClelland also talked about the Fairbanks Foundation’s prevention initiative — $12 million over three years.
“Fairbanks has been interested in this for a long time. We have had a lot of conversations with them over the last year, but this is their initiative and they really stepped up to the plate here. They are focused on evidenced-based prevention programs and there are some programs that have been around a while that have shown through randomized control trials, real solid evidence, significant long-term impact, introduced in substance use and misuse among young people.
“And that’s what we want to see more of. I’m always been interested in innovation and trying new things, but here with the problem that we’ve got now and the limited resources to deal with it, we need to focus our resources on what we know work,” he said.
“When it comes to preventing substance abuse and helping those who have a substance use disorder achieve and maintain recovery, there’s a quote from ‘Dreamland,’ by Sam Quinones that I particularly like: ‘Nobody can do it on their own. But no drug dealer nor cartel can stand against families, schools, churches, and communities united together.’”