 This is Think Tech Hawaii, Community Matters here. This is Much More on Medicine. I'm your host, Craig Thomas, assisted by engineers Ray Enrich, part of Think Tech Hawaii's live stream series, and joining me today is Dr. Dan Galanis from the State Department of Health and Injury Prevention. It's wonderful to have you here, Dan. Thanks very much for having me. You know, I've known you for a long time because shortly after you arrived in Hawaii, which I know was more than 20 years ago, we embarked on a crusade down at the legislature on some junk driving legislation, and our data was really helpful then. Then over the years, the next time I saw your name, it was associated with the fact that, sadly, leading cause of death among children between zero and one years is a murder. And it took a while to sort that out. It's what data will do for you, and it triggered, honestly, a lot of interventions, which I'm pleased with. And then we collaborated with Ocean Safety on some jellyfish studies where we learned that it doesn't matter much what you put on them, it doesn't work. So I've been tremendously appreciative over the years of you applying data to what's hurting people or what helps and what doesn't. So thanks for coming. Thanks, Craig. Likewise. It's always great. I mean, that's how public health works best is when we collaborate with folks that are sort of on the front lines and try to take shape of the problem. Yeah. And, you know, there are a lot of ways we get into trouble. Some of them avoidable, some not. Some dramatic, some they're sort of part of our regular life. For example, my theory of what the most dangerous thing you can do at a beach after shark is sighted is get in your car and drive home. But certainly in terms of how many people get bumped off, that would certainly be true. And there are many things like that. Today I think we're going to talk about things people do to themselves that are likely to cause trouble for themselves and others, sadly. And the item in the news and also what is working through the legislature on developing a strategic plan is the opioid epidemic, which has received a lot of attention nationally and certainly significant attention here. And as a practicing emergency physician, I'm pretty aware of it. So why don't we flash up that graphic, which is honestly kind of busy and confusing because it's a busy and confusing subject. And my sense is why don't you tell us where we started, a couple of the items that got us to the peak and where we are now. Oh, great. Yeah. Apologies for these sort of, this is meant to, looks a lot prettier when you present it in its original PowerPoint. But honestly, I like it this way and the reason is nothing's clean and simple. Okay. No, seriously. I have a theory of how this started, but it's your slide, go for it. Let me speak to that real quick. This is, I have to acknowledge Dr. John Strelzer for sort of putting this timeline or connecting these dots to where we are today in terms of opioid overdoses. And basically, and the numbers are obscured by these callouts, but back in the mid-90s and the late-90s, there was a mindset, I guess you'd say, among physicians that it's time that they start. I'd like to correct you. Okay. I don't think the mindset was among physicians. Okay. Here we go. I think it was actually among, here we go. I mean, honestly, we doctors, we want to manage pain. We want our patients to do well, both clinically but in terms of comfort. So it wasn't that physicians were against it, but I don't think we were actually the genesis either. Sure. Yeah, perhaps I misspoke, but I would say some of the lead agencies in medicine more or less issued statements saying we're undervaluing pain or we're not seeking out how the patient's doing in regards to their pain. That's well phrased. Okay. So there was a, what was it called, the APS statement namely, we're under treating pain. And then this became, as it often does, part of sort of a process. So the joint commission, which I think was called something different back then, issued a statement. Calling the pain as the fifth vital sign, for example, to be routinely monitored and queried about. Feeding on arrival, recorded on arrival, and a number was assigned to it, zero to 10, anybody who's been in the ER is probably familiar with that or little kids get to pick tiny, smiley, frowny faces. And on the face of it, all that was reasonable. You want people to be comfortable. Something that was unrecognized at the time, I believe, certainly not by me, was the behind the scenes influence of pharmacy and, I'm embarrassed to say, medical researchers working for a pharmaceutical company, which basically at the time said, look, we're under treating it. These things work great for acute and chronic pain and they're so safe. Yes, clearly, they had a role to play in the dramatic increase in basically consumption of opioids over, say, early 2000s, up till it began tailing off a little in, I believe, around 2011, 2012. And now we see much more cautionary messages coming from medical societies. Right, and it has peaked and is coming down some. And I've also seen some recent literature that compares our consumption patterns to the rest of the world. It's staggering. It is, yes. And I think the rest of the world has probably always thought they were only good in short courses for acute pain. We got into a whole bunch of other realms, none of which it works. Right, right. So, so now we're seeing, I guess you would say, sort of the pendulum sort of swinging back towards, you know, what we want to see is such more, I guess you'd say, less liberal prescribing practices. And to be specific, I think that's a fine general statement. I think specifically what we want to see is them limited to acute situations where the benefit outweighs the risk and both the provider, the prescriber and the patient are engaged about what the risks are. And personally, I think they're generally not good drugs to take. Their benefit is, I think, overrated and their risks are much higher than was initially appreciated. Let's take a look at perhaps some unintended consequence. We've already talked about the unintended consequence of making pain after the vital sign. Maybe there's consequences, they may not be avoidable, but they're certainly unintended about the impact of changing the availability of prescription narcotics. So the next slide discusses that. Yeah, and, you know, essentially with high users at that point you're dealing with addicts. Absolutely. People with addictions who will go into withdrawal within a day or two, I suppose. It depends on the, yes, absolutely. Yeah. It's better than that. And basically, as you know, there are various formulations. Some are short acting and incidentally we're talking about oral here. Most of these prescriptions are oral, essentially most, we'll stick with that. And some of them are designed for early onset brief duration, but many of them are designed for less frequent use and longer action. Those drugs, your withdrawal doesn't start quite as soon, but it'll still start as you said in a day or two for sure. Right. So, you know, perhaps a lot of people know folks who sort of go through this when, you know, if the prescribing guideline is limited to say a three day supply and if you're on day three and there's some glitch in getting a renewal, you know, I've seen where that really affects a person straight away. So, the point here is that with person who's addicted to opioids and their prescription supply is more or less curtailed, we do see that sort of dotted yellow line that we've seen in the rest of the country, the dramatic increases in heroin related overdoses. Yeah. So, unsurprising, they're the same drug really. And you either get them from your pharmacy or from your dealer. Well, you can get pills either way, but heroin is sort of the prototypical opioid. So, of course, it works. Now, unfortunately, this is a bad trend because who knows what they're actually taking. You might be taking fentanyl, for example. But fentanyl, a very potent opioid, people like it just fine. Like all opioids, it has a bunch of side effects. And its particular side effect is it's really good at stopping breathing. What happened to Prince? It happens to a lot of people. So, this is a worrisome trend. Also, if you end up shooting it up, you get the risk for all sorts of infectious diseases and other complications. So, this is disturbing. Just for the record, Hawaii is actually sort of lagged the country in opioid abuse in general, and particularly in injectable heroin use, which is a good thing to lag in. Yeah, in Hawaii, for example, our fatality rates for opioid, for prescription opioids is sort of leveled off. I think we probably peaked around 2010, 2011, whereas it continues to increase for the rest of the country. And as you're saying, for whatever reason, we have relatively less involvement with heroin in Hawaii and more in things like ICE. But even with sort of limited data we have so far that does look to be an increase in heroin-related overdoses for the last three, four years in Honolulu. Yeah, yes, I know that's what the data shows. Anecdotally in the EDs, we're seeing more. And it's entirely predictable. I don't think it's avoidable. I think it's an unintended but expected consequence is how I would describe it. Yeah, so obviously you'd like to have that sort of intermediary step where opioid-dependent patients get on to medically-assisted treatment, buprenorphine, and those sort of regimens to sort of just not end up in our heel. Exactly, and we're going to focus on how there are some options in the strategic plan. But you're pointing out exactly that if someone comes sees me, for example, they're on a chronic opioid and I deem it inappropriate for them to be on a chronic opioid because generally that's inappropriate. And I don't want to refill their prescription. I should engage them in treatment options and we'll talk about the spectrum of options and what's contemplated as we get through the rest of it. But yes, keep that in mind. OK. OK. So the next slide tells us some interesting stories about, and so this is a slide relating demographic age to opioid death risk. And this is the kind of thing you do. What are the correlations between one set of data people buying, let's say, and something else, like how old they are? Right. This is invariably a surprising thing to present to audiences that the highest risk group for fatal opioid poisonings in Hawaii is essentially my demographic. 50 to 59 or broadening it out maybe 50 to 65. And in Hawaii, where we're kind of off the curve compared to the rest of the nation is we have relatively low rates for younger adults, say 20 to 40-ish. So it's really that sort of, I can be charitable, that middle-age part of the age spectrum, so 50 to 65. So let me ask you, how many 130-year-old guys you know? I'm just trying to get the middle-age thing sorted out here. Because I'm on favor of being middle-age since I'm 66, but I don't think I can sell that anymore. I know, right? Let's say AARP eligible. Let's put it that way. There you go. That's funny. And then the other thing to point out is, so the blue, it's broken up by gender here. And males generally have higher rates, but they're really comparable at a lot of ages to the rates with females, which is unusual for a lot of trauma-related outcomes. And it just shows that there's a fair amount of women who are affected by this addiction, this issue. Yeah. I mean, as you point out, the guys are worse, but the female numbers are very real. And the disparity between the genders for some other things is much greater in favor of females, I should point out. Right. They're smarter than us, let's say. I wasn't going to say it, but yeah. You can't deny the data, right? Yes. Yeah, in a lot of cases, drowning, homicides, etc., suicides, it's 4 to 1, 5 to 1 male, so. Yeah, what's the ratio for impaired driving fatalities and or convictions? On that order, it's generally 80% male, it's going off the top of my head, yeah. Because, and we'll circle to these themes as we go along, opioid is the current hot topic. It's definitely deserves to be, and to the extent that the medical profession is a significant player in this problem, and it clearly is, we've got to solve it. And we're culpable. I'm there. And we'll resume this chain after the break. I look forward to more visiting. Great. This is Think Tech Hawaii, raising public awareness. I'm Ethan Allen, host of Likeable Science on Think Tech Hawaii. Every Friday afternoon at 2 p.m., I hope you'll join me for Likeable Science, where we'll dig into science, dig into the meat of science, dig into the joy and the light of science. We'll discover why science is indeed fun, why science is interesting, why people should care about science, and care about the research that's being done out there. It's all great, it's all entertaining, it's all educational, so I hope to join me for Likeable Science. Welcome back. This is your host, Greg Thomas, on Much More on Medicine, and with Dan Galanis, PhD epidemiologist from the State Department of Health. Welcome back, it's nice to see you again. Thanks. And as we were discussing before the break, clearly the opioid epidemic is the current hot topic, but we shouldn't forget other behaviors that we may be more used to, but which have a big impact. And let's talk a little bit more about alcohol. It has a deleterious impact on many aspects of health. It's also interesting because probably more than almost any other sort of pharmaceutical intervention, and it is, it has impact on others. So one rough metric of the impact of alcohol is drunk driving fatalities. So how do those numbers stack up to the opioid overdose? It's still an issue with us in society, impaired driving. Cars are getting safer, trauma system is getting better, and as a result of probably those things, the number of crash-related fatalities in Hawaii has halved in the last, say, 10, 15 years. But within those who still die from crashes, at least roughly half of them are related to impaired driving. Oftentimes, the other vehicle, you might say. So we're seeing encouraging trends in overall motor vehicle safety, but the proportion that is related to impaired driving really hasn't changed over time. Which is really disappointing to both of us. We've been working for years in ways that we think like the impact. And so far, I'm disappointed to say I don't think it really has, because like most things, prevention is key. Interestingly, as in the opioid situation, our comparable countries around the world have very different approaches. Lower blood alcohol levels to drive essentially zero. And some other things too. Lower speed limits, roundabouts instead of stoplights, lots of things. And the net result is the fatality per million miles is extraordinarily different in countries like Sweden or Finland or most of Europe, despite the autobahn reputation. So yes, it's a... I didn't want to just focus on opioids. And in fact, another hot topic, and maybe we should have you come back for this at some stage, is gun violence. YA is blessed with a pretty low level, but I think largely due to our gun laws, although I appreciate it. Controversial topic, but yeah, the correlation between access to firearms and the homicide rate is very high. Anything to add to that? Well, when you're talking about epidemiologists, it's undeniable and this is like cigarettes and cancer, honestly. And you're right, Hawaii has spent for a long time had the lowest rates of firearm related violence, be it homicide, be it self-inflicted and suicides, for example. So that's one area where Hawaii is a good example of how legislation can help control some of these issues. Yeah, I view it as encouraging. So hopefully we'll get more data over time. I think that there actually will be some more firearm safety related research and we can act in appropriate ways. Well, let's get back to the topic of the day. So this is a pretty interesting slide. It relates the per capita consumption by county across the state. Yeah, and this and I want to point out this is only for two substances, hydrocodone and oxycodone, two specific prescribed opioids. This data is from the prescription database that's managed by Public Safety Department for Hawaii. And these numbers looking over at the right there for Hawaii County and Maui County. So that means there were 50 dispensed prescriptions for these substances per 100 residents in those counties, which is fairly staggering in a single year. Which is very impressive. Now, if I understand it right, it doesn't mean that half the people got narred. Right, exactly. There's very high users and then there's, of course, the majority of the population does not have a dispensed prescriptions. That just tells you even the disproportionate consumption among individuals is extremely high users. And the nearly twofold variation by county. Right. So we have lowest consumption here in Honolulu, Oroha. So that actually leads to the next slide, which is opioid poisoning rates not to be conflated with death rates. You might end up getting some treatment in the field or in the ED, but still it does it by county. And I think, again, it's pretty interesting. Yeah, it's pretty straight correlation between consumption and risk of overdose, with highest rates being for Hawaii County residents and Maui County. And as you said, it's significantly lower for people living on O'ahu. Yeah, and just kind of eyeballing it. It looks like about a 60% increase from the lowest to the highest in O'ahu. Right. Which per capita increase, which is a lot. Right. So all these things lead us to the current state of developing a strategic plan for the state. You want to tell me about this sort of overall picture? Who's pushing it? Who's on board with it? What are the challenges? And then we'll deal with some of the individual aspects. Okay, great. Yeah. So this was the, I believe, it's term governor's initiative to more or less take on this issue because it cuts across a lot of parts of the administration in the state. And that was, and the Department of Health is a lead agency. But we really acted as a convener for bringing all these disparate agencies and community groups together to work on the strategic plan. That whole effort really kicked off in last July. And thanks to our partners in the alcohol and drug abuse division in DOH, we do have a draft strategic plan in place in very short order, I have to say. I think all that rolled out in four or five months' time, which was... Which is near supersonic speed for the state. Thanks for saying that. Sorry, sorry. So here we are with this draft strategic plan with seven main components which are shown on this slide here. Why don't we list the components and then we'll drill down on, so list and sort of describe, but then we'll drill down on aspects of several of them. Oh, okay. Oh, great. You're on. So what we touched on earlier, treatment access. It's interesting. You know, I've heard from the, from ADAD, the division that looks after essentially the contracts for substance abuse counselors, that they're really, in Hawaii, I think we're kind of used to we're beyond capacity for a given health issue, be it medicine or what have you. But in treatment, there is some, as I understand it, some unutilized capacity in the system. So basically you want to educate patients as well as physicians to sort of take advantage of services that might be available around the state for getting medical treatment. Well, yes, I agree completely. So the next item. Prescriber education and particularly in the context of pain management. So that kind of goes back to what we kicked off the show with, sort of making a more considered or more guided approach to dispense, to prescribing these substances to patients to try and avoid some of these. Exactly. And as we discussed, you can have unintended consequences. And I think it's largely how we got into this fix. And there will no doubt be consequences like, say, increased heroin use of dialing it back. Data and evaluation. That's obviously my department with the partners we work with on this plan. And they are all across the board. So we're really sort of, our role going forward is to basically support all the other groups in terms of what data they need to plan interventions, evaluate them, and sort of move things forward. Absolutely. So then that gets to prevention and public education. I know there's some PSAs coming out. Because my sense is expectations, education, understanding the limitations of an intervention, namely not being good for chronic pain, for example. And the risks you can get hooked are all part of this whole package. Yep. Yeah. So it's easy to make PSAs. It's much harder in public health to actually get airtime and have that sort of dissemination. But I mean, this can take the form of educating providers to, in turn, counsel their patients. Absolutely. You know, you might have someone in front of you that really is sort of demanding opioid access. Well, that takes a joint effort. Absolutely. Yep. So the other tabs, I'm going to list them in the interest of time. Okay. We're going to have to wrap up. But basically, obviously, pharmacies are involved. The first responders, naloxone administration are involved. I am definitely all over that. It's a great idea. I think that community naloxone initiatives are fabulous. And then there's this thing called SBIRT, SBIRT, which I think is a way of identifying, providers identifying people who are likely to turn to heroin if they don't get some help when you're managing their chronic pain in a new way, or that narcotics are in some way affecting their life. So I think that's fabulous. They take advantage of the resource available. Exactly, yeah. Listen, it's been wonderful having you here today. We'll have you back. We have lots of impact of data on health. So I'll look forward to next time. Great. Thank you all for joining us. This is Craig Thomas, Much Wanted Medicine.