On this episode, we speak to Dr. Robert a Professor of Epidemiology and Pharmacology at the Yale School of Public Health.

Dr. Heimer's major research efforts include scientific investigation of the mortality and morbidity associated with injection drug use. Areas of investigation include syringe exchange programs, virus survival in syringes, hepatitis B vaccination, hepatitis C transmission risks, overdose prevention and resuscitation, and pharmacological treatment of opiate addiction. His research combines laboratory, operational, behavioral, and structural analyses to evaluate the effectiveness of intervention programs in preventing the negative medical consequences of injection drug use.

Join us as we talk about the life changing and life saving work of the APT Foundation. The APT Foundation has been committed to the promotion of health and recovery since 1970.

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 Welcome to the latest episode of Open Access Open Mic, the podcast with the APT Foundation. The APT Foundation is here to help employers, communities, and families care for people who may be living with opioid or other substance use disorder. Serving the Greater New Haven community through an evidence-based open access model.

Get in touch with us to find out more@aptfoundation.org. Welcome along to the latest episode of Open Access Open Mic, the podcast with the APT Foundation. Now on this episode, I'm super excited to be joined by Dr. Robert Heimer. Now, Robert is a professor of epidemiology and pharmacology at the Yale School of Public Health.

Dr. Heimer, welcome to Open Access Open.

Well, thank you. But let's start with your use of the word substance use disorders, which is the medical term that has replaced the term addiction, which is a plus, but it also is a limitation. I really think that overly medicalizing the problems that people develop from.

Uncontrolled substance use simplifies the issue. There are so many social determinants and external forces that promote unsafe drug use that I prefer. To differentiate drug use into non-problematic versus problematic, and it's when that use becomes problematic that I think it's important that open access programs like the App Foundation are around to meet people where they're at in a non-judgmental way.

I love that. It's like the language matches the attitude of being so nonjudgmental and just the process of wanting to help people. I really like. That's a great correction. What a great way to start the podcast. So come on, tell me a little bit about yourself. What, was there a fire in your belly? What made you wanna get into this field of work in the first place?

Weirdly, I got into this work because of failure. I was doing a molecular biology postdoc that it turned out after two and a half years was going to go. So I asked people, all the people I knew, I'd been at Yale for many years already. What do I do if you're not gonna have enough to be promoted from a postdoc to a faculty position?

And everyone told me the same thing. You know, get another postdoc, teach somewhere where you don't do research. It was the. Burgeoning days of the biotech world, you know, go into biopharmaceuticals. And none of that appealed. And the chief of medicine at the time said, oh, and by the way, there's this needle exchange program starting in New Haven, and they need someone with molecular biological skills to be part of the analysis.

Are you interested? And I said, absolutely, yes. It was consistent with my more left wing political philosophy. But also it was a chance to take the work that I was doing, which was, you know, purely sort of basic science and apply it to a real world practical problem.

I love that. I love it. So you were essentially trying to get a promotion

I was, no, actually, I had a wife who was earning a decent salary and two young children. So we actually needed two decent salaries. ,

Yes. The city of New Haven had pushed for three years to try to change the laws in con. To set up a needle exchange program. At that point, con, new Haven and Connecticut had a very substantial problem with H I V. In people who use drugs, 75% of the H I V cases in the city, 50% of the cases in the state were attributable to unsafe injection as compared to 15, 18% nationwide.

The city had to do something and push the state to change the rules, and the state set up allowed for a demonstration program to be set up to run for one year. In New Haven, they needed a way to evaluate it. You couldn't do classical epidemiological research in one year with a relatively small population.

There wouldn't be enough new cases of H I V to say you'd made the diff any kind of difference. So what was set up was a syringe tracking and testing system in which every syringe that the needle exchange gave. Had a code on them. And that code, we knew who the syringe went out to. We know who returned the syringe.

All anonymously, people chose their own monikers. And then we tested in the lab over the course of four years, about a hundred thousand syringes to demonstrate that the program very, very quickly reduced the likelihood of HIV transmission by about 30%. And over those three to four years by 45%. Basically, wow.

It was the first start in this state to reducing h, hiv V transmission in people who injected drugs. And we have been remarkably successful. Incredible. Uh, when I first started doing this work, there were about 650 new h i v diagnoses every year in people who injected drugs. The last five years, there's been an average of.

Good. 97.5% reduction. The only public health programs that are as effective as that are really good vaccination programs. Yes. Right. So we are as good as a vaccine for drug users in this state. Primarily because people have access to clean syringes and they don't have to share. Obviously, our work has been enhanced by the development of effective treatment so that people who are drug users, even if they're drug users, can get antiretroviral treatment that makes them undetectable and therefore they can't transmit the virus to others.

Even if we're keeping them alive. There are no threat to anybody. It

is incredible. It's incredible. And, and over the time that you've been working, I guess in the field, you must have seen some incredible changes, development success stories, and I guess a few failures as well along the way. What has been, I guess, some of your, the highlights of the development in the field of, a dare to say it, uh, substance use disorders or a problematic substance use?

I mean,

it almost seems like I often liken this to ballroom dancing. It's like two steps forward and one step back. Yes. I mean, at the same time that we've been tremendously successful against H I V, we've been less successful against Hepatitis C Tran preventing that transmission simply because it's so much more contag.

Probably an order of 10 fold more contagious. Uh, we've been almost completely unsuccessful in our efforts to slow the opioid overdose epidemic. So in a sense, my career has followed the transition initially with H I V and the good bit of work on Hepatitis C, and now my focus has to be on opioid overdose and treatment for people to prevent overdose in.

To deal with the current crisis epidemic, whatever you wanna call it, of opioid use, leading to overdose, leading to death. Some of this is a consequence of the single-minded attempts to control access to illicit drugs using a supply side. So when all of a sudden people started, you know, using pharmaceutical opioids, we cracked down on pharmaceutical opioids.

Gee, what a surprise. We didn't treat their dependence on these drugs. We didn't increase drug treatment. So what did they do? They had very little choice but to turn to illegal opioids. Yeah, to in order to prevent withdrawal, in order to stay on these drugs that were at least fulfilling some real need for people who were using.

Yeah, no, great shock. Now, once that market made a transition from. Over predominantly heroin to heroin and fentanyl, and now overwhelmingly fentanyl, a much more potent drug, A drug that if the people who are selling the packets and preparing the packets of drugs for sale on the street miscalculate, or they're not professional compounding.

Pharmacists, right? , they're, they're amateurs and if they screw up and a packages, set of packages is particularly strong, people are going to get a dose they weren't intending. Yeah. Uh, and it could be, it could prove fatal. So the question is, what do we do in this new era? Yeah. And I think one of the things that works best in this new era is to make it easier for people who.

Problematic drug use to get treatment for that problem. Yes. Now, that's not gonna completely solve the opioid epidemic or the opioid crisis, but it certainly will reduce the number of people who are at risk for overdosing. Yeah. And, and

looking for those alternatives.

Yeah. And my main concern, In some ways is keeping people alive, improving their, not just their health, but their sense of wellbeing.

And I think a comprehensive open access model like the Appt employees is particularly well suited for this. It, yeah. I've also worked with people at the app. Promote treatment for Hepatitis C, which many people who inject drugs develop. I think in this state about 40% of the people who are injectors are, have been infected with hepatitis C.

Within 15 years, we developed effective curative. Treatments for this virus that have very few side effects. They're expensive. Yes, but they're not more expensive than many other drugs that are a whole lot less effective. Yeah, so everyone should be treated. There is an international and national plans for hepatitis C elimination.

It is possible to eliminate hepatitis C the same way we have with smallpox, not by vaccinating people, but by treating everyone who's infected. There is no animal reservoir. The virus doesn't survive more than a few days outside. Of the body, it'll survive a couple of weeks in syringes. So obviously we want people to have clean syringes.

Yes. But we can control the transmission of this by treating people. Treatment is prevention and one of the best places to. treat people and cure them of their hepatitis C is where they are in receiving treatment for their problematic drug use.

Yeah, absolutely. And that leads me on so nicely too. Tell me a little bit about how you first became involved with APT and how you've seen it grow and develop over the years and your involvement

now.

I don't want to. Sound too harsh, but when I first started this work, the model of the app foundation was impediment to good, good care for people who use drugs. I'm not gonna go into the details of that. Let somebody else with a better sense of the history do that. But I never found a reason to want to work with them because their attitudes about drug.

Or sort of conflicted with mine. Let me put it that way. My feeling is that people are willing to go to treatment that ought to treat them humanely, non-judgmentally, non-stigmatizing fashion, and shouldn't be penalizing them for continuing to use drugs. We all know that. We define the medical community defines substance use disorder as a chronic relapsing.

Why are you surprised when people relapse? Why are you surprised? When people continue to use, we don't take people off of their anti-hypertensive drugs because they eat a bag of salty potato chips, right? Why are we throwing people out of. Treatment because they're using drugs that are maybe not even the drugs they're being used for.

Why when someone has a, you know, a test positive for having used cocaine and they're being treated for opioid use disorder, are we gonna throw them out of an opioid use treatment program? Makes no sense. APT changed its model to a more progressive harm reduction focused approach, which is much more consistent with my.

Yep. And so when that happened, I was more than happy to find out what I could do to cooperate with them, to work with them. We've had some of my students, my MPH students who need thesis projects work with them to evaluate some of their programs. We've tried to put in place intervention programs associated with their Hepatitis C treatment program.

Will help reduce the likelihood of people who are successfully cured from becoming reinfected. We are trying to expand the access to especially methadone in communities that are currently underserved in the southeastern part of the state of Connecticut, all of which can be done because of the genuine commitment on the part of the people at app to want to put in place a, the.

Quality kind of treatment for people with problematic opioid use

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 samh sa.gov/find treatment.

That's SAM hs sa.gov/finet treatment to start medicine and begin your recovery, brought to you by the APT foundation.org. , when I spoke to Lynn in the very beginning, when we first started doing this podcast, I think one of the things I started doing my research was it's the open access model. Which from where I'm from and from Europe, I have not heard of or experienced anything quite like it.

There's a fight to get funding to go to treatment to become abstinent. That's the path that people were, are desperate to follow, and my eyes were wide open. I'm like, wow. They get to choose from a menu. Of services, they get to be seen on the day they get an immediate personalized plan put in place. It blew my mind and I feel quite passionate about the, the open access element of it.

What's your take

We don't have mobile methadone in this country. We finally in the. Most recent federal legislation to deal with opioid use disorder. We're gonna permit mobile methadone. Again, we are waiting for the state of Connecticut to issue guidance so that we can implement it. We know it can work, we just haven't allowed it.

Hmm. One of my colleagues, uh, Don Dejala, many years ago said, look, there were three kinds of. There are evidence-based policies. If we know the data, we know it works, we try to implement it. There are evidence free policies. Those ones where we don't know anything, we try something based on first principles, based on logic.

We see if they work. If they work, we continue them. Many times they work, but we don't have the money and they stop. And then there's the third kind, which are evidence, proof policies. No matter how much evidence you have that a policy. Is terrible. You can't change it. And for many years I thought we were up against this with mobile methadone.

Of course, for many years we were up against this in many parts of this country with syringe exchange. Both of those things now seem to be changing. Syringe exchange seems to be the norm. Harm reduction is now a word you can say. At to the Feds. You, I was told never to say this in a grant application for many, many years.

our first application, in fact, to, to get federal funding to test the needle exchange program in New Haven. We couldn't even say the word needle exchange. We called it a syringe testing and tracking system for HIV epidemics. Wow. Wow. Oh my goodness me, our project officer at ni, at at Nation Center Drug Abuse, Peter Hearts.

I say, don't say needle exchange.

Oh my goodness. And people at night have still tried to shut us down. Yes. Even after we'd gotten an incredibly good fundable score, we persevered and we used the money from the nation to the drug of abuse to prove that this approach saves lives. You know, back to that, that's what's important. Keeping people that's approved healthy, keeping peoples, you know, free from serious diseases and keeping them alive.

Yeah, there's a commendable three targets. You mentioned earlier your students that you obviously do a number of research projects and thesis in this area. What's been, I guess, A couple of memorable pieces that have come from your students that have, I guess, show a light on a particular aspect of, of this model dealing with the, uh, problematic substance use.

The

beginning of the covid epidemic. One of my students came to me and said, we need to know, one of the first things that happened was in mid-March as the country was shutting down and samh. Instituted regulations relaxed their regulations that allowed opioid treatment programs to expand access to, uh, more take homes.

The rules prior to that were really a burden on both patients and providers that most people had to come. Five or six days a week to pick up their medications. Data that we collected at my students urging, we reached out to all the substance use treatment programs in the state, got them to complete a survey about their practices before covid and before the SAMSA relax the rules and.

And we found that some of the programs in the state followed the SAMHSA guidance and substantially relaxed their take home practices, allowing a far greater percentage of people to only have to come in a once every 14 days or once every 28 days to pick up medication, which is not only beneficial. For individuals from the standpoint of being less of a burden on them, but also reduces the the patient volume and therefore reduces the chances of covid.

Yes, absolutely. So, so it's a win-win. And the only question that was left was with all of this extra medication floating in around in the community, are we going to see methadone being diverted and is that going to increase methadone related opioid overdoses? And in fact, we looked using data from the state's office of the Chief medical examiner.

Studies. Mm-hmm. all overdoses and does postmortem toxicology. We found that there was no increase. In the percentage of methadone involved deaths, even after a huge increase in the amount of methadone that was being given out as take homes. Now, there were parts of the state, especially the southern tier, where where there are more progressive treatment programs like ABT, where there was a greater relaxation than in some of the other parts of the state.

Neither parts of the state, neither the two parts of the state were medication, were methadone involved. Deaths increased so we can safely say, I think both because of the lack of increasing percentage of methadone involvement and, and the absence of a geographical gradient that increasing access to take home methadones.

Does not have the negative downside of increased overdoses because of diversion.

Is that something that will stay in place now? We are sort of in our post Covid era, I guess you'd say.

That's an excellent question. The SAMHSA guidelines did not define what they meant when they said, Stable patients can get 28 days less stable.

Patients can get 14 days. They've come back. It was earlier this year and went and tried to put. Definitions to each of those two terms. Some programs may look at those definitions and cut, and I don't think they're gonna cut back the people who've been moved up to 14 and 28 days, but they may be more reluctant to put new patients who might qualify as more stable.

And less stable on 14 and 28 days. I guess Tom too, I think we may see some erosion of the benefits, but I don't think we're gonna see out and out reversal and I know that the more progressive programs around are going to continue to use a a much more fluid definition. A much more user-friendly, patient-friendly definition of stable and less stable,

real world definition.

Um, what topics or areas of your work are you working on at the moment that are exciting? You? What, what's, what's the future hold for your work in the field? The

one place where we have not. H I v transmission among people who use drugs is in places with poor syringe access, whether those be non-urban areas where a needle exchange can't really operate openly, or in some of those locations where needle exchanges because of political pressure are either slow to pick up speed or actually have been closed.

How does one get. Safe injection and a whole range of harm reduction supplies out to people where they don't have access to a syringe access harm reduction program. And one of the things we'd like to see is a study that compares two models of getting syringes to people right to their homes now. Most of the marginally housed homeless drug users because of the nature of American society live in cities.

Yep. But in the rural or suburban parts of the country where there are plenty of people who use drugs. Yeah, true. You know, these people are housed and they have addresses. and most of the housing is single family, maybe multi-family housing, but it's not big apartment buildings. They're not cities . Right?

Yeah. So we Why not try to get Milam? Yeah, why not? Well, that's one option. The other possibility is, and this is something that's arisen because of, you know, people being home during covid is, you know, Amazon shows up at the door in unmarked trucks much of the time. Mm-hmm. and drops packages off on people's porches every day.

It's exactly the same thing. Yep. So either you'd send it in the US post, Well, you'll have the local harm reduction teams drive to people's doors and drop it off. So now you have two different methods of delivery, but you also have a difference in that it's dropped off sort of by the postman anonymously.

Yes. The home drop off non postal could be done by a harm reduction outreach worker who can then talk to the person at the door. Ha engage in a conversation. That conversation may lead to the person using the drugs to be using those drugs more safely. It may lead to that person saying, I need these other services that the outreach worker can help them get with.

And the person may say, look, I'd love to start drug treatment, and that outreach worker can help link that person to a drug treatment pro. So we hypothesize that there would be benefits. To home delivery by outreach workers over postal delivery. But that needs to be tested. Yes, I'm funded. That's the nut.

We've tried to get this funded three times and Yep. Every time two of the reviewers really like it and one of them says, oh, H I V isn't a problem anymore. Well, oh, obviously you're not paying attention,

No, you. Globally it is. I mean, globally in terms of the US it is not, but there are pockets of H I V transmission that could be eliminated if these programs, home delivery programs became scaled up to the same extent as urban syringe access programs have been. For sure.

Absolutely. Wow. There is so much that could be done if you could click your.

And make one or two. In fact, you can have as many as you want. If you could make federal or local changes and you could make laws or, or make things easier, what would your top two or three be to solve or to go some way towards solving the situation? I

mean, some of these are culture, right? I really dislike the phrase recovery in describing.

Improvements in health associated with taking less or or eliminating the use of addictive psychoactive substances. And the reason I dislike the term so much is you recover from the flu. Most of the time you recover from a broken arm, you don't recover from a chronic disease or a chronic problem. You manage it.

And I think the term. I think needs to replace recovery is when your use has become non-problematic. You're in remission. Yes, and I'd love

to, I haven't thought of it like that. I hadn't thought of it like that.

I'd love to see that linguistic change occur. I think it has the potential for a cultural transformation.

That's one. A second is I see no benefit in incarcerating people whose or the underlying. Reason for their criminal behavior is the criminalization of personal drug use. I'm not sure what the right answer is. I certainly complete a libertarian approach would be catastrophic as probably not as catastrophic as the war on drugs, but there's gotta be somewhere in, in the.

That reduces the need to incarcerate people whose drug use may in fact be a secondary problem to an untreated mental health problem. And therefore we need a more comprehensive, and I hate to use the word holistic, but certainly a more comprehensive sense that these things occur as part. Sys Syeb is a set of problems or diseases that because of their nature, reinforce each other and make things worse.

Mm. So if I treat a substance use problem without treating a mental health problem, we're not gonna have a great deal of success in treating the substance use problem and convers. If we don't treat the substance use problem in an effective way, it's gonna be hard to deal with the underlying problem.

Many times, childhood adolescent traumas that lead to P T S D and then mental health problems. All of these things are linked, and none of these things are easy to cure, but unless we understand and commit resources, To looking at and treating the linkages between these problems or among these problems, it's more than just two.

Uh, often we're gonna continue to have a large population of people in need of care.

Absolutely a real multifaceted approach, much like what the App Foundation are doing. Dr. Heimer, it's been fascinating talking to you today. I've learned a great deal. I love your take on things. You've given me a lot to think about with the language as well.

The importance of the language that we use will ultimately, A direct result to the successful outcomes for many, many, many hundreds, maybe thousands of people. It's, it's been quite an eye-opener for me. I really have appreciated your time, and thank you so much for being a part of Open Access, open mic. I would love to reconnect in the future and, and see where your work is up to and see if we've managed to change the world yet.

uh, open some minds and some eyes, .

Well, thank, thank you for the opportunity to talk to you and, uh, we certainly can do it. I'd

love that. Thank you so much for your time. Thank you so much. Yep. Bye-bye. Thank you for taking the time to listen to this episode of Open Access Open Mic with the APT Foundation.

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