On this episode, Founder and CEO Lynn Madden speaks with Dr Rick Altice.

Dr Altice is a Professor of Medicine and Public Health at Yale University School of Medicine. His research interests are focused on infectious diseases, including HIV, tuberculosis and viral hepatitis, and substance use disorders. He is specifically interested in implementation science including prevention, treatment, and behavioral intervention research activities. As a clinical epidemiologist and implementation science researcher, he has created novel programs for the treatment of HIV, viral hepatitis, tuberculosis, and substance use disorders in vulnerable populations around the world.

Join us as we talk about Dr Altice's incredible career to date and about the Open Access model that The APT Foundation has been pioneering.

Find out more about his life changing and life saving work.

The APT Foundation has been committed to the promotion of health and recovery since 1970.

www.aptfoundation.org

Connect with Dr Lynn Madden: https://www.linkedin.com/in/lynn-madden-9b2aa18/

Connect with Dr Rick Altice: https://www.linkedin.com/in/rick-altice-56b44954/

Get in touch with us to find out more at aptfoundation. org. On this episode of Open Access Open Mic, I'm joined by the APT Foundation President and CEO, Dr. Lynn Madden, and our special guest today is Dr. Rick Altice. Now Dr. Altice is a professor of medicine and public health at [00:01:00] Yale University School of Medicine.

Dr. Madden, His research interests are focused on infectious diseases, including HIV, tuberculosis and viral hepatitis and substance use disorders. He is specifically interested in implementation science, including prevention, treatment. Treatment and behavioral intervention research activities as a clinical epidemiologist and implementation science researcher.

He has created novel programs for the treatment of HIV, viral hepatitis, tuberculosis, and substance use disorders in vulnerable populations. He is currently the principal investigator on numerous clinical investigations and training grants around the world, including studies in Ukraine, Central Asia, Malaysia, Peru, and the country of Georgia, and of course, the United States.

Lynn: So I'm Lynn Madden, as Claire said, and it is my great pleasure to welcome Dr. Altice here today, who is both a colleague and a friend. I've had the good fortune of being able to work with Dr. Altice in many parts of the world over the last decade or so. And I'm very excited to, uh, ask him today to, to kick off our, our conversation by telling us a little more about himself, his career to date, and, um, how you really got interested in this work, Rick?

So, that has sort of. resulted in a 40 year career of sort of thinking about those two things together and creating innovative ways to scale up both HIV treatment, hepatitis C, TB, and at the interface of substance use disorders.

Lynn: So thank you for that. Um, Rick, you know, you're well aware of the open access model that App Foundation has been pioneering.

Rick: Absolutely. You know, one of the things that has been a struggle is that I've had the good fortune and perhaps the, the challenge of, Even introducing substance use disorder treatment in several countries in Ukraine, 2004, methadone in Malaysia in 2005, and in a number of other settings.

And one of the things that has always been a challenge is that many of these programs remain somewhat limited. They look like pilot studies for many years. And so the question is, is how can you open up those doors and increase access to treatment so That it's not just treating the individual, but really sort of thinking about population health.

S., but the challenges in so many ways are the same.

Lynn: Absolutely. I, I too find that fascinating. Each location believes that its issues and problems are of access and stigma are so very unique. When in fact, if you have the opportunity as we both have to kind of travel a bit and listen to people, what we, what we learn over and over again is that many of the difficulties are quite across the world are quite common.

I know most of your work Rick is focused on the intersection or much of your work is focused on the intersection of HIV and drug use. As you mentioned, have you seen or are there healthcare delivery models that you've seen in Europe, Asia, elsewhere? Yeah. that make it easier or easier to treat opioid addiction and other substance use disorders?

Some of the work that we've been doing more recently is thinking about how to deliver it in settings that, where there might be reduced stigma, such as primary care settings. You know, we've even done work here in Connecticut and elsewhere where we link addiction treatment to sort of reduce opportunities to reinforce stigma by using telehealth and doing it at syringe services programs.

So, you know, I sort of say, you know, when my kids say that they're hungry and they want something to eat, I need to feed them now and it should be the same way for treatment as far as I'm concerned. That's fascinating. And I think that those models, you know, there are creative models that have really emerged because of necessity and They have happened in many different places, and I don't think that there's an exact formula.

I think all of those things combined together to create a patchwork quilt of, of treatment options is really the way to go.

Lynn: So the COVID epidemic, the COVID pandemic showed us that the international epidemics can show up at our doorstep. here in the U. S. at any time. A lot of your work is funded by the United States government and NIH and National Institutes of Drug Abuse, etc.

Rick: Well, I think, you know, being able to have the 30, 000 foot view of the globe rather than just the U.

S. really helps you think about things, but. One of the unifying themes around COVID was that it was a major disruption. It changed the way that we had to do things. And so, you know, on one hand, as an infectious disease physician, I was really recommending that we reduce opportunities to transmit HIV. I'm sorry, reduce opportunities to reduce.

They were somewhat different, but they used those same sort of principles around sort of reducing in or mitigating community transmission. And it created opportunities to take a look at, you know, how you might think about organizing treatment. And I think it was true in the U. S. where, you know, addiction treatment programs were asked to sort of relax.

But one of the things that was force majeure during COVID was that we had to give patients take home dosing and we had to come up with creative ways to support them during that stressful time period for them as well, which we could do through, you know, telehealth and through conversations and take home dosing.

And screening them for ways that we thought that they were safe. And, you know, even in published data, so, you know, it's your real world observations. But in real published data, it really shows that in places that did that, they reduced the demands on patients. They reduced the demands on their time. If you're not seeing a patient for, you know, five minutes every single day, seven days a week, you know, throughout the entire year, you're able to spend time doing other things such as counsel them, or to talk to them on the phone, or to keep in touch with them.

And so if you're really thinking about a public health benefit, this is the way to do that. Fortunately, you know, even in the U. S., we've been able to sort of maintain some of that COVID guidance around keeping those patients on take home dosing, which is really sort of a, a, a sea change in terms of way as of thinking about patients.

And I think that You know, while I wish that we would have gotten there quicker and that we didn't have to have the COVID pandemic, you know, to learn that, we did learn from that. And we learned that we could do other things faster, better, and cheaper. And we really need to think about that.

And as you and I talk about all the time, the policies that governments design and adopt Don't always promote wellness or public health goals, although it may look like that is the intention on the surface. How has this paradox really played out in your career?

Rick: Well, you know, the most recent thing that comes to mind, and I've been doing a lot of thinking about this is, is the war in Ukraine.

And you know, one of the things that happened is that, you know, 9 million people were displaced. They became refugees in Europe and. You know, many of those patients were patients who were on addiction treatment and unlike Let's say for HIV where, well, you still don't want to miss medications for a few days, but if you miss your medications for opioid use disorder, you, you go into withdrawal and you feel sick and you feel awful.

One of the things that was very clear is that certainly some people were getting out of the country, they were going to other sorts of settings. And in the case of HIV, many of them lost access to their medications and they, we found that they developed viral resistance in their treatment options.

And let me just give you a couple of examples. First of all, if you have to navigate a healthcare system, and even if you're doing it in your own country, it's not always so easy. But if you go and you're in another country and all of a sudden you're looking at a different alphabet, the Cyrillic alphabet doesn't look anything like You know, the Latin alphabet.

So you've got a different language, you've got a different alphabet so that you can't even really distinguish that from a healthcare perspective, you're trying to go through policies and even the restrictive policies, many places in Europe had even more restrictive policies. Then they had in Ukraine.

You have to spend time. every single day, and if you're having to care for your family or for anyone else, that's not really compatible with that. And so these borders, you know, we have them there, I suppose, for, you know, governmental reasons. But when it comes to treatment, it's really sort of a challenge and things like war, you know, really transcend that.

I have colleagues who were on, let's say methadone treatment and they want to go to conferences. They're professionals. They're working in, in doing their work. And the real challenges they have is, you know, they can't take a vacation in another country. They can't present at another conference. Unless they go through sort of special regulations or they get to the other countries and the other countries can't absorb them because of their own sort of policies and, and structures.

And so I, I think that we've got this, this sort of system that is designed to not help people succeed in their recovery.

How would you say the war in Ukraine has affected the clinical care being provided there, including people's ability to access methadone treatment?

Rick: Well, it's a, it's a mixed story and it depends on, on where you are in the setting, uh, within the country that is, you know, if you happen to be in a conflict area, you may have major disruptions to medications and you know, your doctors may do the best that they possibly can and give you 30 days supply and say, please go find a safe space.

S. But people were getting coaching and they were getting support and they were getting, they were creating a collaborative community where they [00:18:00] could communicate. And one of the things that happened. Um, as a consequence of the war and many displaced patients and having patients who weren't previously on treatment who, you know, really were very stressed out and they all of a sudden wanted treatment is really required them to create different ways to do their work so that they could absorb those patients, not restrict access to treatment.

And I will say parenthetically that while they, there was a sort of a disruption and a decrease in patients for. A very short time, they actually ended up scaling up extremely fast. And the other thing that they had to do is there were several thousand patients who were getting private, private treatment, and they were getting their medication through pharmacies.

And, you know, one of the things that happens in war is many people retreat and they go back to, let's say, protecting their patients and their sorts of own careers. But many of them, through coaching, decided to open up their doors. They. They massively scaled up and took new patients in ways that they did not think that they would be able to do.

I know that they were really grateful and I think they should be really proud of the work that they, they did under, you know, heroic circumstances. The other point that I think that's really important for those physicians to be able to do that work with, you know, supportive coaching was that they had a government that was intact.

So they did a really heroic job of not only the government supporting it, our coaching them, supporting them through the process. And them creating a community, they were networked through WhatsApp and Viber, they communicated, they were able to create new systems and models of care, whereas, you know, we're oftentimes restricted to, you know, multiple, you know, sort of releases of information and paperwork.

And they just did the right thing. And I think that that's an important testament to what people can do whenever they're faced with such hardship.

aspect of the every region of of Ukraine. One observation I would throw in there is just the absolute dedication that you refer to Dr. Altice, the absolute dedication of these physicians and other care team members to their patients. And let's say what's important about that from my point of view is a illustration of the, the regard in which they hold each other as citizens, despite the fact that these are persons labeled as substance users and diagnosed as people.

One of the things I admire about you and your work is that you have taken the long view in many of the settings that you work in internationally. And what I mean by that is that you work with people on the ground over years. Comment then on that a little bit about your approach and, and, and why you look at it that way.

Thank you.

Rick: Yeah, I'll, I'll definitely do that, but I want to just reflect back on what you just said about some of those commitments and, and, and, and an anecdote about that. So one of the things that has been so impressive is that, you know, if you sort of think about the people who do addiction treatment, they're, they're marginalized within their own community, right?

And, you know, that was the landscape and this sort of speaks to the long arc that you're talking about. But, but that's where much of the community was when we first got started and they developed a community. They created their expertise and because of the really extraordinary work, they elevated themselves.

We didn't do that. And so that sort of long arc, you know, was there. And as an example of that. One of the things that happened during the war is there was a physician who headed up the program in Mariupol, which you know was completely decimated. And this is a guy who almost no time whatsoever, you know, rallied his family.

And so that kind of resilience sort of speaks to that because they had created a constituency within that setting and they were supportive of each other, which I thought was really, you know, very sort of striking. You know, while they don't have sort of a professional sort of, you know, sort of, uh, a group to, you know, like the American Society of Addiction Medicine or Addiction Psychiatrists, they don't have that sort of thing there, but they created that, which was you know, really important.

They drop into these settings, they, they do their studies and they parachute out or they helicopter out. And what I find is that one is that doesn't result in a sustainable change. It doesn't result in, in people who actually will think kindly about the way that, that, uh, people come in and, and do work.

And it really does not allow you to culturally understand what these things mean in these settings. And so even though I would say that the brain and addiction is the same in every single one of these settings in terms of the way you treat it, the cultural competencies of understanding what your constituents and your colleagues are thinking about is so absolutely important.

And that was 40 years ago, but it was. at a time when, you know, we didn't really think about the ideas of task shifting. And that idea is things that I've brought back to my own work here. And it's been things that we've been able to do in other settings. And as long as you give people sufficient training and they know where that, you know, the guidelines are for them and when they need to sort of reach out to, you know, someone else who is licensed has been sort of a game changer in being able to do this kind of work, especially in low and middle income settings.

Absolutely. That's spot on.

Claire: It really is.

So we're to you, I think, Claire. Okey dokey. Incredible. Absolutely incredible. Sorry. Is substance use getting in the way of your ability to partake in activities you once enjoyed or maintain any aspect of daily life? Opioid or other substance use disorders can be treated safely and effectively. Reach out to your local treatment network through a M h.gov/find treatment.

Spoiler

Rick: alert, spoiler alert. Yeah, there's, there's, there's a lot of really good stuff that, you know, I think. is, is really exciting. You know, I think that the, the, the disruptors that we've seen from COVID applied to war and we're finding that we expanded and we're able to sort of take advantage of those disruptors even with war to really sort of think and reframe how we, you know, can do this work.

And a lot of this work, we're doing some work in Central Asia, we're working in three countries and each of them is really different. And the types of things that, you know, that come your way during the process of your work has been really important. It's being adaptive. Many researchers work from a protocol perspective, protocols don't work in implementation and they don't necessarily work in real world.

And, you know, even if I shift back to something that my mom said to me, even before I went to college, she said, the most important thing you can do is make a difference. And I think that the work that we're doing in all of these places, is truly making a difference whether we're shifting the way that the delivery of HIV care is happening.

We're using lessons from addiction treatment to shift the way that HIV care is being done in Peru. Or with how do we reorganize the services. For HIV in a way to reduce stigma by reducing interactions that can reinforce stigma. So all of it's interrelated and, you know, whether your area is addiction treatment or HIV or any of these other sorts of things.

Lynn: Some of the things that I would tease out that we have been talking about lately, um, really play off what Rick was just saying.

And that is that. You know, the idea that the government shapes healthcare is a really fundamentally important one that we brought up earlier in this conversation. But I also think that, that people, once they understand what their healthcare needs are, have the opportunity to influence the development of the system.

et cetera, et cetera. And, you know, necessity really is the mother of invention. They will rise if in fact they're not available to people who don't want to be sick and who don't want to die. And we undertook a small study to have a look at quality in these programs and just who is entering them, right?

And very preliminarily, what we can say is that The people who enter these private programs are endorsing fairly high symptoms of substance use. They are paying out of pocket, so you can assume that they have sources of income of one kind or another. And that they're getting about as well as their counterparts in the public system in about the same amount of time.

So it's just been very, and I think, and Rick and I have been talking about this, I think you'll see this develop in other parts of the region that we've been working in. So we're pretty excited about that kind of idea and, and many ideas that have come out of this work.

Rick: You know, and if I could build on that, you know, one of the things that even if the benefits did not look as good as they did in the private clinics, you know, that basically is an opportunity, right?

And so rather than shut down these things that are scaling up on a population health basis. If you can show that it's not, you know, working quite as well as you'd like, but it's working, that becomes an opportunity to intervene, whether it's through coaching or through process change or, you know, any of these other sorts of things that you can do.

And you know, my sort of observation is, has been that when people get the type of thing that they think about and that they want, they just do much better with that. So I think that I would sort of see this as an opportunity as. You know, rather than a concern that many people have had that these private systems just won't deliver quality care.

I think that they are. I think that if there is room for improvement, it becomes an opportunity and people need preferences.

How does some private treatment, if you like, in somewhere like Ukraine compare to other countries that, you know, you've, you've researched in?

Rick: Well, you know, the, the, the private treatments require that a person, you know, does have resources. It's not going to be for everyone. So you've got to start out with some money, but let's just say you're an employed person, you're a professor at Yale and you have a substance use disorder and you can afford to go out and buy your buprenorphine.

That becomes an option where you can go get treatment, you can get it in the type of place that might be more comfortable for you. And as long as you're able to, you know, support that and to stay engaged in that, you're likely to do, there will be people who will choose that and their sort of, their opportunities may not be consistent.

Otherwise people will have major disruptions. But one of the things that you can certainly learn from that is how do you come up with ways to safely transition people? between programs whenever they're unable to sort of sustain that from their, you know, their own efforts. I mean, one of the reasons why people may choose that kind of system is they do need to work.

They don't have the luxury of, of coming between nine and 10 o'clock in the morning in the middle of their workday to get treatment. And so, you know, we do need these alternative models and I mean, there's still things to fix about it, but boy, you know, Take advantage of what's there and think of it as a population health benefit.

Absolutely.

Right? So over time, despite the fact that that private market isn't available to everyone because of resource inequities, right? The public market has the opportunity to learn. Why are people going to this other clinic? Oh, maybe we can adopt that characteristic in our program. And, they are, everyone who gets treatment is making a pro social decision that protects the larger public health, um, which is what we're all after.

Right? I mean, I think that people who use substances in general do not get much credit for making pro social decisions, but entering treatment is a pro social decision.

Rick: And, and just to put some numbers on this, in Ukraine, you know, we've got pretty good numbers for the people who are in governmental clinics, you know, we've gone, we've, we've sort of.

There's over 10, 000 people on that treatment. So roughly a third of the people who are getting the public health benefit are happening in this alternative system. And I would probably say that it might even be double that. It's just only a handful of clinics are reporting it. But there is a privatized system there that is certainly a little bit under the radar, but it is providing some kind of benefit and, you know, potentially almost the same amount of scale up.

Rick: So my proudest achievement has nothing to do with my work. It's having two beautiful twins. And so in a family, that's my proudest achievement overall. I would say that my proudest. Professional achievement is being able to really create meaningful relationships with colleagues across many different settings in the world and helping them, you know, by working together, make a difference.

You know, I've been able to help other people elevate and, you know, you sort of all rise together. So that's my biggest achievement are these sort of longstanding, important, you know, relationships that have only gotten, you know, better so much so that, you know, some of my colleagues want to give me a sheep's head as a, as a thank you.

I mean, you know, it's okay.

Claire: I need to know. I need to know everything about the sheep's head.

Lynn: I can tell you a little bit about that. As you know, Dr. Altice and I have been working in Central Asia in Kazakhstan, Kyrgyzstan, and Tajikistan for the last couple of years together. And last year in Kazakhstan, which was our first kickoff meeting of a new grant that we are, that we are co That we are co running and we were presented with a sheep's head as the guests of honor.

And then this year in Kyrgyzstan in, in Bishkek, just a couple of weeks ago, similarly at a lovely dinner, we were presented with a sheep's head. And once again, our fearless leader rose to the occasion, there is photographic evidence. Right. Um, and he, he ate the, he ate the, the eyeball. So now he's truly all seeing, Claire.

Claire: I need to see this photographic evidence. I think that should accompany this podcast. That is incredible. I

Lynn: will send it to you, the head itself, and then, you know, our contemplation of it.

If, and it's a question for both of you, this one. If you could rip up the rule books and how things are done and the norm, if you like, or make sweeping changes as to how we as a society tackle substance abuse. What would you do? I give you free reign, whatever you want. What's holding back your incredible work?

Rick: So from my perspective, I think historical legacy is what gets in the way. People believe what they believe based upon, you know, mountains of old information and old ways of thinking. And what doesn't happen and what needs to happen is that it really should be focused on a sort of an achievable goal. In other words, to get as many people on the treatment who need it as you possibly can.

And that's what I would change is, is to be very Manhattan project oriented. with addressing the, the epidemic as opposed to all of these sorts of things that people put as a reason for why things don't get done. I'm, I really don't want to hear explanations anymore. I want to hear outcomes. What about you, Stathlin?

We don't stigmatize them because they've developed these illnesses. Stigma is highly, highly responsible for these Difficult rule structures that Rick was just alluding to, and for the lack of funding in many cases that it would take to really care for people, but if we could just think about teaching people what they need to know to take care of themselves, let them into treatment, stop restricting them from coming into care, let them be their own best advocates, trust them.

Claire: I can't think of a better way of ending the podcast. I feel passionately about the work that you guys do, as you know. And it's never going to get, we're never going to get a better soundbite than that. So thank you so, so much. I cannot thank you enough. To find out more information about what the Apt Foundation do, check out the website, which is aptfoundation.

org. I'm also going to put links to both Lynn and to Rick in the show notes of this. Find out more, educate yourself, and uh, guys, just keep trying to fight the good fight.

Claire: Listen, he eats eyeballs as well.

I mean,

Lynn: the man

Claire: is a living legend

Lynn: at this point. I can't tell you what I, where I think he can see from as a result, but the truth is I was going to say, they

Rick: tell me that I'm awesome.

Claire: Thank you so much for a fantastic podcast and being a part of open access, open mic, the podcast for the app foundation.

Thank you. Thank

Rick: you.

Claire: Take

Rick: care. So much. Good talking to everybody.

The APT Foundation [00:47:00] values their help in serving our New Haven area clients. Their Long Wharf location provides medications for treatment of substance use disorders by prescription from our primary care doctors who are also trained in addiction medicine. Visit hancocklongwharf. com This podcast was created and produced by Red Rock Branding.

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