Experts Discuss Harm Reduction and Substance Use Disorder Treatment

In the latest episode of the Public Health Matters podcast from Pharmacy Focus, host Christina Madison, PharmD, BCACP, AAHIVP, sat down with Jeffrey Bratberg, PharmD, FAPhA, a clinical professor in the college of pharmacy at the University of Rhode Island, to discuss harm reduction and substance use disorder treatment.

Christina Madison, PharmD, BCACP, AAHIVP: Hello, everyone and welcome to another episode of Pharmacy Times’ Pharmacy Focus podcast series with me, your host, Dr. Christina Madison, also known as the Public Health Pharmacist, for another incredible guest on the Public Health Matters podcast. So, I'm extremely excited to welcome today's guest, and this actually was very serendipitous, because one of my previous guests actually recommended this esteemed colleague of ours. And we're going to dive into some issues around substance use and decriminalization, and really just talk about how pharmacists can get more involved in harm reduction. So, without further ado, I'm going to let Dr. Jeff Bratberg introduce himself and we'll go ahead and get started with today's conversation. Thank you so much for joining us today.

Jeffrey Bratberg, PharmD, FAPhA: Hi, it's an honor and a pleasure. I'm a longtime viewer and first-time guest. I'm Jeff Bratberg. I'm a Clinical Professor of Pharmacy Practice and Clinical Research at the University of Rhode Island College of Pharmacy. Excited to be here.

Christina Madison, PharmD, BCACP, AAHIVP: Wonderful. Well, I feel like we can just dive right in. It's so funny, our pre-conversation before I hit record was quite lively and I think I want to dive back into one of the things we first started talking about, which is pharmacist involvement in the substance use space and sort of how you got involved in that process. Obviously, I'm involved to a small degree because of my work with individuals affected and infected with HIV, as well as being very much an advocate and provider for the LGBTQIA+ community. But I'm just curious what your journey was because you really are at the forefront of pharmacists providing [medication-assisted treatment] and substance use interventions.

Jeffrey Bratberg, PharmD, FAPhA: Yeah, thanks. So, I'll try to make it short here. Basically, I was trained as an infectious disease and critical care pharmacist and I worked on infectious disease services, got involved in advocacy, helped pass some policy related to immunization activity from pharmacists here in Rhode Island as part of our Rhode Island Pharmacists Association. And part of that, when I was president of our State Association, I had to find speakers for our conference and I met Tracy Green through an [infectious disease] colleague of mine, Jody Rich. They were both co-authors on the study that we published on buprenorphine access and pharmacies in the New England Journal of Medicine in January. And I met Tracy Green, and we started talking about naloxone. And basically, because I had known about laws and collaborative practice agreements and had a lot of connections by that point in the state, I said, “Hey, let's do this.” And we passed the first statewide collaborative practice agreement for naloxone in pharmacies and Walgreens pharmacies almost 10 years ago. Now, that translated to a whole big naloxone movement, studying its use in pharmacies, what patients thought of it, what pharmacists thought about it. Our state established a Governor's Task Force On Overdose Prevention. So, I was one of the first authors of our plan that is in process of continually being edited now. And so, yeah, I basically have been involved in research and service. And we got another grant to study buprenorphine, so moving out of the naloxone space, or I should say I’m still in that space, but moving into harm reduction, and really just realizing how pharmacists need to treat people, or how people need to treat people and that we have to meet them where they're at, which is the essence of harm reduction. Using all our skills of motivational interviewing for this vulnerable population. I tell my students, if you can treat people with substance use disorder, if you can treat them well and treat them, you can treat any chronic disease.

Christina Madison, PharmD, BCACP, AAHIVP: Wow, that's so funny. And so, sort of the godfather of motivational interviewing within pharmacy is Bruce Berger, and I just interviewed him, and we were just talking about how motivational interviewing could really be revolutionary when it comes to vaccine hesitancy and even just vaccine confidence. And I think, you know, I love communications, it's kind of my love language. And when I think about how we communicate, it really is about language. And…you know, when we were chatting, we were talking about just the evolution of harm reduction language as it relates to people with substance use disorders and talking about out it less as addiction medicine, right? Because the word ‘addiction’ has such a negative connotation. And more around that space of disease state management because it truly is a disease. It's not this social experiment or decision that people make. And that if we give people clean needles that we're not going to enable them to inject, we're just going to help them to do it safely. And having these access points really goes back to something that I'm truly passionate about, which is health equity. And when we think about being able to provide care in an equitable way, that's being able to provide access to people who wouldn't ordinarily have it. And pharmacies are literally the gateway for everyone to access primary care, right? If it was up to me, and if I could change the world, right, I would want us to be able to offer more of these points of care services that really allows for the expansion of our primary care services, as we know that we have shortages of primary care providers and individuals who want to work in this space. So, with that being said, and I know that you talked a little bit about legislation, do you want to talk about how you guys were able to do this since there was a X-waiver requirement that did limit the ability to provide things like buprenorphine to patients in the past.

Jeffrey Bratberg, PharmD, FAPhA: Yeah, so I took my knowledge [and] our team took our knowledge of collaborative practice and what's necessary there, we allow testing, [and] our law was silent on whether we could do controlled substances or not. So, some states again, remember, pharmacy laws are only good in one state. So you go to a different state, it's going to be a different thing. So, while I'm working hard with lots of national organizations and leaders to try to translate our study into other states, some can do it already because they are providers, they can have a DEA license, they can prescribe controlled substances, they can maybe even get paid for it, maybe from public and sometimes even private payers in Rhode Island. This was in the era of the DATA-waiver, which just ended in December. But our collaborative practice really has the DATA-waivered physician delegating all the tasks of the management and the choice of the regimen, and then their name went on the prescription. So, it was a legal buprenorphine DEA X-waiver that was filled there. The pharmacist would do that, and the only way that we were able to do induction—which is the really revolutionary thing, as many of your listeners may know, that medications for opioid use disorder are much more widely available in pharmacies in the UK and Norway and Switzerland and Canada and Australia. It's just a normal thing where people get their methadone, their buprenorphine, their naloxone over the counter in Canada, et cetera, et cetera. So, in our study, basically, we paid our pharmacy partner to have their pharmacist trained as part of the grant, and I did the training. So, we had a CPA to allow them to manage it, but then when the COVID-19 pandemic occurred and the DEA and SAMSA regulations were relieved, we can actually have audio-only initiation of buprenorphine through the CPA, through our DATA-waiver providers who would call in on each induction. And then the pharmacists could do the management of that patient. For our 3-month study, our New England Journal of Medicine letter only reports on the data from 30 days, but it's incredibly positive, right? Patients who came to the pharmacy got started there, they wanted to stay there, and they did stay there versus usual care.

So, you know, this is an incredibly vulnerable and marginalized population. Three-quarters were unhappy or didn't have transportation, were unhoused; we had double the number of people who identified as Black as compared to our Rhode Island census. So, we were serving a population that clearly needed to be served. And these people weren't naive to buprenorphine, and a lot of them had gotten treatment before. And we gave them a chance to say today's the day coming to the pharmacy, we had outreach workers help, and they got started that day, which is not something that usual care often does and has lots of limitations. We provided medication first. Again, the legal structure was there, approved by our health department, Board of Pharmacy, Board of Medicine, all of that came through. The agreement is actually in the supplement in the New England Journal of Medicine so you can read what we put together.

But other states need to think about how is their CPA setup? How is autonomous prescribing put up? And our big limitation for sustainability is what we were just talking about before provider status. That's it. We’ve got to get paid to do this care. But as you sort of mentioned earlier, too, is we lacked not only primary care, but I think you'd agree behavioral health care is even more in short supply, and so pharmacists, to be able to get that first prescription for opioid use disorder, to get that first prescription for alcohol use disorder. We're already doing smoking cessation, where we are so well positioned in communities to provide sort of all of that health and maybe even provide behavioral health with prescriber-controlled substances, provide all that care, as long as it's reimbursed. And if your law needs to be changed, hey, everybody listening, do it now.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, I couldn't agree with you more. And I will definitely make sure that we include that information in the show notes so that people can go back and take a look at that New England Journal of Medicine article, which was pretty groundbreaking. And thank you so much for what you did, as far as bringing that to print, because here's the thing, we do the work every day, but there's not a lot of people who are publishing that data and, you know, working in public health and working in population health. Data is king, or queen, depending on the way you look at it. And I feel like there's a lot within the epidemiologic space and the population health space that we can take from the lessons that they've learned and how they've been able to get funding for things. And it's because they document, document, document. And when they document, they take that data, and they can use data to tell a story. And when you tell a story, you can make such a big impact, and it's so much easier to ask for funding when you can show results. And I think that that's really what you guys did, and I applaud you for those efforts. And again, you know, I've said it before, every pharmacist is a public health pharmacist, they just don't call themselves that. And so, I would hope that they see that this is an outlet and a potential way that we can be paid for our services, paid for what we're worth, and in the process help people that wouldn't ordinarily get access to care. A question that I did have for you, and I know this might be slightly out of the topic that we had previously said that we were going to discuss, but…because you were talking about mental health services, have you thought about implementation of use of community health workers as part of this program, in order to help get people in for the addiction induction process? But then how to keep them in the program post-implementation?

Jeffrey Bratberg, PharmD, FAPhA: Yeah, absolutely. And I just want to be very clear, we all paid for the study, by the way, this is sponsored by [the National Institute on Drug Abuse]. And so again, to my colleagues Tracy Green and Jody Rich, and our team who, you know, applied for the grant, they gave us a chance to do this. We proved it in a pilot study, we did the randomized control trial. And we'll have 3-month data coming out soon, showing what we hope to be exciting results. And to Genoa Healthcare, which is a pharmacy chain that is in most states and embedded in behavioral health care. They were a phenomenal partner [and] continue to be a great partner today. And it's unusual to sort of see these studies done with a federal partner and a chain pharmacy, so we you know, we kind of hit the jackpot that we had such positive results and we're able to publish that. Can you ask the question again? Sorry, I just wanted to thank folks again.

Christina Madison, PharmD, BCACP, AAHIVP: No problem. So, my question was in regard to community health worker utilization as part of the program.

Jeffrey Bratberg, PharmD, FAPhA: Yeah, since we've done the program, and when we started looking at how marginalized the population was, how many social determinants of health, how many cell phones we gave people to stay in contact with the study, how many transportation Uber health rides that people utilized to get to the pharmacy to make their visits, you know, we realized, wow, there's much more at stake here. We need social workers. We need community health workers. There's already an emerging body of evidence of the usefulness of community health workers in pharmacies, maybe training technicians to do it. I think that's where there's sort of 2 pathways to accomplishing this. You can have pharmacists be independent prescribers and manage people and start people on SUD drugs like buprenorphine, a very safe and effective mortality reducing drug, or we kind of really push the collaborative care aspect to, say, team-based care is where it's at. I know you work in a team-based care environment; we were talking about that. But let's not only include community health workers, let's include peers. Peer recovery specialists is what we call it here in Rhode Island. All of those things can be part of a bundled payment or some kind of way we're…you know, why should pharmacists enter a system that is skewed payments to different people, and say, let's just create a whole new behavioral health scheme made up of the people we know that improve outcomes, which is retention and care, referral to housing, making sure people eat, making sure people get the tests that they need to identify other health problems. And really, that's primary care, right? Start with behavioral health, primary care can come next, but all part of that team. So, I definitely think that's a great idea and something that we're pursuing.

Christina Madison, PharmD, BCACP, AAHIVP: I also want to just point out, you know, the reproductive health side, as well. So, when we look at individuals who are having challenges with substance use, often they are within that reproductive age range, so talking with them about ways that they can get into care in order to make sure that they have healthy pregnancies, that those pregnancies can go to term. Also, you know, just looking at it from a legal standpoint, a lot of times they are hesitant to seek care, because they think that their existing children may be taken away by CPS. And so, I do want to just make sure that individuals that are maybe thinking about working in this space understand that it's not just the medication, that there's so many other like layers to this. And, you know, not that I'm telling pharmacists that they need to become social workers or counselors, but I do think that having that understanding of why people choose to come in and get care, maybe from a variety of different reasons, and then also that depending on the state that you live in, the criminalization or decriminalization of substance use disorders really can impact those people's ability and desire to want to get help. And so, I know we talked about decriminalization and what that may mean, and also just looking at who's more likely to have challenges with substance use. And I think about the sex worker community, in particular, because I have individuals that I work with, that are part of the adult film industry. You know, it's kind of a hierarchy, you know, there's people who are doing like, Only Fans and the cam girls or cam guys, and then, you know, people who are on the streets and are seeking payment from an encounter. You know, those individuals will often be on a substance, or multiple substances, or their pimp is who got them on the substance. And then that's how they end up being trafficked. And so, do you want to talk a little bit about some of the work that you're trying to do with the decriminalization space? And, you know, I know I've talked a lot about it here in Vegas, because, you know, even though in Las Vegas proper, we don't have legal brothels, we do have legal brothels and other places in our state.

Jeffrey Bratberg, PharmD, FAPhA: Yeah, I mean, I think I'm maybe brought it in a couple of ways. When I give talks about treating substance use disorder, you can't tell people to forget about the society they're in that believes criminalization is actually helpful when it's not. The drug war has failed. The drug war is discriminatory. And so, ending the criminalization of the use and possession of drugs is a helpful harm reduction effect. Sometimes we're not even using harm reduction. We want to say risk reduction—which we got from the HIV researchers—some people say, you know. And so, you have to think about the person in front of you. Is the person in front of you, right? Think about when you talk to somebody, when somebody shows interest in you, you're like, I think that maybe I trust you and I could get care from you. When most health care has been detrimental to anyone immediately when they say they've used drugs, or they are using drugs, or they're in those communities, stigma and discrimination happen just like that. So, it's important for pharmacists, and really any health care provider to say, look at the person in front of you. They have a story, it's worthy, they're a person. Try to think about how you'd want care provided to you and that that person deserves equal care, right? It's about the health equity lens, all those things. So, all of these highly stigmatized things—drug use, and having a criminal record, and being a sex worker—all intersect being HIV-positive. What if you're all of those things, which you probably are because we've criminalized these things? And again, I know that people think that that's actually going to help them. But incarceration increases mortality. Having a conviction decreases your chance of good employment or safe housing. We really have to think about the intersectionality of our carceral system. I don't really like to call it a criminal justice system; it's a carceral system, that it has massive detriments.

And so, you know, for example, on my study in Rhode Island, it’s 1 of 2 states that actually decriminalized the possession of buprenorphine. Which then people say, “Well, here's this drug that's helping me, I can possess this, if I know the law that has been decriminalized. And maybe if I encounter law enforcement, I'll be able to possess that to treat my withdrawal and treat my disorder, or maybe I'll get referred to care from law enforcement.” We still need to partner with them, we still need to be advocates for our patients, and realize that the systems—as you said, it's very, very complex. And, you know, the work that's being done in Oregon, in other places, I think, is really exciting. And we really need to follow it for a long time to see what the outcome is to shift from a criminalized system that we know doesn't work and taking all of that money, an incredible amount of money, and shifting it into a treatment system or referral system and a true care system for our most vulnerable people.

Christina Madison, PharmD, BCACP, AAHIVP: So, with that being said, I just wanted to reiterate again, you know, when we think about decriminalization, this is not us, or you or I, looking at ways to allow people to commit crimes or do things that are against societal norms. This is really just wanting to make sure that someone who is suffering from a disease, right, so like if you were suffering from diabetes, and I said I want you to go home and think about your choices and why you're diabetic, and then maybe I might give you some medicine, you would be suing that doctor for malpractice. But in the HIV space, in the addiction medicine space or substance use disorder space, that is so common, right? Like we almost re-victimize and re-traumatize these people when they choose to get help, because we have not been taught how to deal with our own implicit biases around something that we could never understand the impetus for, why these things are going on with them. And a lot of substance use and mental health research has shown that it doesn't take much for someone to become dependent, and that it really is our existing brain chemistry. That is what the challenge is. And I think, you know, as we see things like the FDA looking at putting Narcan OTC, which I have a little bit of misgivings about just because of price, and that potentially pricing out people from the system that really truly need it. But I do think it's a step in the right direction because it is showing that this is a life-saving reversal agent that should be widely available. I just hope that price doesn’t become a barrier to care.

Jeffrey Bratberg, PharmD, FAPhA: Yeah. 100%. I mean, the cost of things is part of barriers to care. We talk to anyone who does what you do in free clinics, like, why do we need free clinics? You know, we're the only country that doesn't have health care as a human right, you know, the US did not sign that. And so, that is just the difference between us and many, many other countries, both, you know, up and down the socioeconomic ladder. In terms of is this the primary thing we want to do? Provide care? And I am sure you've talked about this, but 80% to 90% of care is housing and education and health care. And in this country, the color of your skin and how you identify, all those facilitators are barriers to your baseline health, and also whether you get the care is in that 10% or 20%. And so, when I talk about buprenorphine or Naloxone, I go, “This is keeping the person alive, so they can try to address all that other stuff.” And people I've talked to say that.

You mentioned selling syringes. I just want to mention, we did a focus group, and I'll never forget that one of the pharmacists said, we said, “Okay, you know, what's your feelings on selling over the counter syringes?” And he said, “I had a person that I sold syringes to,” and he made a motion of like selling the syringe or selling the syringes. And he said, “I feel like I kept her alive, so that the next time I saw her she had a buprenorphine prescription and I felt like that was success.” That is the essence of risk reduction, you know? Yeah, we decriminalized syringes. We basically eliminated HIV transmission, through sort of massive community- and pharmacy-based syringe access, so that it's just normalized here. But it's not everywhere. And so, we still have a lot to do in getting people educated. We've come far in substance use disorder and risk reduction, harm reduction, but we've got a long way to go. And so, I've got a lot of work to do, or we have a lot of work to do, I should say.

Christina Madison, PharmD, BCACP, AAHIVP: Well, I hope that this conversation has brought, you know, these things up and openly and honestly discussing them, and talking about people's lived experience. And, you know, you telling that story about that pharmacist that was able to make an impact. I always say when we help one, we're able to help many. And that's the difference between public health and population health versus, you know, when we think about disease state management for chronic medical conditions. You know, you may be able to help that one person, but when we think about these kinds of things, you may help an entire community, because now someone who wouldn't ordinarily be a productive member of society and be able to be gainfully employed or outside of the carceral system is now able to because you've helped them, and then that therefore goes towards their family. And then they're able to have someone else in their family go on and be a productive member of society, go on to college. You know, it just a cycle. And the more you lift people out of poverty, and you give them opportunity, and you give them education, and you give them access to health care, and God forbid basic needs, like housing, food, and transportation, they can actually do good things. And so, again, I thank you for the work that you're doing. I will absolutely make sure that all of those links in the references that you stated during our conversation are added to the show notes. And I would encourage people to continue to follow you. So, if people want to know where to find you or to ask you more questions about the work that you're doing, what would be the best way for them to get a hold of you?

Jeffrey Bratberg, PharmD, FAPhA: Well, I'm still on Elon Musk's Twitter @jefbratberg, and then we have our own podcast called The Regimen and we advertise that on my students’ social media feeds. It's @PharmDPubHealth, and find us online. Only @PharmDPubHealth is on the Insta, I'm too old for Instagram so I don't do that, but my students do for me. So that's where you find it.

Christina Madison, PharmD, BCACP, AAHIVP: Wonderful. Well, thank you so much again. I so appreciate this. And I'm grateful to Dr. Kathy Pham for introducing us. And if you haven't had a chance to check out my episode with Dr. Pham, please make sure that you check out that previous episode that aired earlier this year. And again, my name is Dr. Christina Madison. I am your host for the Public Health Matters podcast, which is part of the Pharmacy Times Pharmacy Focus podcast series. And remember, public health matters.