Author: Nicholas Skoda

[00:00:00] Narrator Globalization, geopolitical conflicts, climate change, and advancements in technology are making the biological threat landscape more complex than ever before. This is Countermeasures, where we explore health threats impacting communities around the world, brought to you by Emergent, a leading public health company that delivers protective and life-saving solutions to communities around the world. From zoonotic disease to bioweapons, orthopoxviruses, and more, we’ll explore what it means to protect public health and how preparedness today can lead to a safer tomorrow. In recent years, outbreaks of avian influenza, commonly known as bird flu, have raised alarm around the world. Infections in wild birds and poultry are nothing new. But as the virus spreads into new species, including mammals, and as the pace of zoonotic spillover accelerates, experts warn the risk of human-to-human transmission is growing. At the same time, the world is still grappling with lessons from COVID-19. How do we prepare for the next outbreak? How do we detect it early enough to stop it from spreading? And how do we build resilience across human, animal, and environmental health systems? We begin with Dr. Amesh Adalja, senior scholar at the Johns Hopkins University Center for Health Security. His career has been devoted to infectious disease and health security. Here he explains what drew him to the field and why avian influenza has long been on his radar.

[00:01:28] Dr. Amesh Adalja I sort of always loved infectious disease. I was the son of two physicians, so I was brought up around medicine. And within medicine, I think infectious disease as a career, especially when you’re thinking about health security, pandemic preparedness, emerging infectious disease, which is the focus of my work at the Center for Health Security, it really tries and to meld all of that together. There’s the medicine healthcare side of it, then there’s the national security aspects of it, then there’s the anthropology, the epidemiology. So it really keeps you kind of in touch with everything going on in the planet with respect to infectious disease and threats, because infectious disease is the only branch of medicine that affect impacts everyone and touches every aspect of life, as we saw during the COVID-19 pandemic. In the field of emerging infectious disease, it’s always something new that’s coming up, something coming down. It’s very dynamic. And there’s not always one that people keep an eye on. Try to keep an eye on the entire field and try to understand what might become a bigger infectious disease threats, if not the biggest that the human species has ever faced. I think that one is always going to be at the top of most people’s lists. And then all of the zoonotic infections that might be occurring and kind of each time they jump into humans, they might get a little bit further but then burn out.

[00:02:44] Narrator But what do emerging diseases such as avian influenza look like on the ground today? And why are scientists more concerned now than in the past? For that, we turn to Lindsey Shields, Deputy Director of PATH’s Epidemic Preparedness and Response Initiative.

[00:03:00] Lindsey Shields PATH is an international NGO that supports local organizations, government institutions, and international partners to achieve health equity and public health solutions for all. So I’ve been with PATH now for about six years, and our program really focuses on infectious disease surveillance programs. So, how do we ensure that we are capturing infectious disease outbreaks when they happen? How do we help country governments and local partners to respond to those disease outbreaks in a timely fashion? Hopefully to improve health for all. So most of our work is in sub-Saharan Africa and Southeast Asia.

[00:03:32] Narrator From Lindsey’s perspective, two factors are driving this increased concern.

[00:03:38] Lindsey Shields Think about them in two buckets. One is sort of geography buckets where we’re looking at land use changes that are bringing humans and animals into closer contact. We have a globalized world and society. You can get from one side of the world to the other now in less than 24 hours. And that brings people closer together and also pathogens closer together. We also see viral evolution. And so you’re seeing over time, especially with influenza viruses, they’re able to change and mutate quickly, where that allows them to adapt to different species. So they’re able to test positive for strains of different types of viruses, including avian influenza. And what that means is every time they’re jumping into a new population, that virus is learning how to do a better job at infecting that other group, other species, other location. And so I think these two things together are really driving a lot of the escalation. And as we’re seeing transmission amongst mammals, certainly that’s something that we’re keeping an eye on and worrying about. Human-to-human transmission is always the thing that public health professionals are keeping the closest eye on when we think about emerging infectious diseases. And actually, history has shown us that oftentimes these viruses, especially those that are zoonotic in nature, will make an initial jump from an animal population to a human population, but they won’t have figured out how to transmit from human to another human. And so when you look at the history of these viruses, they are learning over time to adapt, to be better spreaders, to be better at infecting a human. And so once we start seeing that sustained human-to-human transmission in an emerging disease, that’s when we start to get really, really worried. With H5N1, for example, even influenza, we’re seeing that that is happening in more and more species, which means that virus is adapting and more and more likely to have sustained human-to-human transmission.

[00:05:17] Narrator Bird flu is evolving, but how do we even know when it’s happening? The key is surveillance, the early detection systems for diseases, similar to how smoke alarms warn of a fire. Dr. Jennifer Nuzzo, epidemiologist and director of the Pandemic Center at Brown University, explains why.

[00:05:37] Dr. Jennifer Nuzzo Early detection is absolutely critical. The single biggest thing we could do to be ready for future events is to have systems in place that detect them as soon as they happen, or in some cases, perhaps anticipate that they could happen so that we can just snap into action quickly and prevent the, you know, the disease, for instance, if we’re talking about an outbreak from really taking off and spreading, you know, beyond our abilities to control it. That the idea of being able to detect it early and to swiftly respond and contain it at its source is really, really key. That said, as important as early detection, early warning are, it’s not the only form of disease surveillance we need. We need the surveillance that enables us to make good decisions about what to do about the events that we detect. And that’s I think a piece where we really need to, you know, put some more emphasis and do some more work. During this last pandemic, the COVID-19 pandemic, there are a lot of questions about what to do and what strategies were the right ones and how we could best, you know, mitigate the spread and prevent people from becoming severely ill and dying. And so having better surveillance systems and better data collection efforts to answer those questions are just as important, I think, as early detection.

[00:06:50] Narrator Avian influenza doesn’t just require monitoring birds. Surveillance requires monitoring across species, from wild waterfowl to poultry to mammals, and finally to humans.

[00:07:02] Dr. Amesh Adalja Surveillance for avian influenza is very scattered and it’s kind of disparate because it’s not just one thing. It’s not just looking at human infections, it’s looking at infections in avian species. It’s looking at infections in mammals, it’s looking at infections in certain poultry species. And part of that’s going to involve a lot of work with the agriculture side and the veterinary side of this to see what’s making animals sick, surveying flu viruses that are constantly circulating in waterfowl or constantly circulating in swine. And then when we think about human infections, making sure, particularly with severe infections or infections in individuals who have epidemiological exposures of certain animals, that we’re trying to figure out what type of influenza A is it? Is it something novel? Being able to run that down. And oftentimes I find that our healthcare system, the ability to run down an infectious disease to a very specific diagnosis is really lacking. It doesn’t happen very often. People will stop at influenza A versus influenza B, or maybe they figure out it’s an H1N1 versus an H3N2 influenza, but there’s not much incentive to go further. And I think that’s one of the areas where when you think about avian influenza, our surveillance needs to be better. We need to be looking, I think a lot deeper to try and understand how frequently these viruses are jumping into humans and how frequently we’re missing them when they do. Because I think when there is an avian influenza pandemic, these first cases are likely to be missed. They’re likely to be mixed in with other respiratory viruses, other influenza cases. And so I think that the surveillance is something that’s been really lacking. It’s been lacking for a long time, and it’s and it continues to lack. Not because we don’t have technological solutions. It’s just that it’s not set up in a way that we’re able to do this in a really proactive manner.

[00:08:46] Narrator As Amesh mentioned, proper surveillance requires an integrated system between agriculture, animal health, and human medicine. Spillover can happen outside of isolated environments like laboratories. It can happen in common environments like farms, markets, and even within households. Lindsey describes what those spillover points can look like and why they matter.

[00:09:10] Lindsey Shields Vietnam, we took some of these participants to a few areas and had them sort of think about where are the interactions between these different species, wildlife, humans, and livestock. And the first was a farm area, right? A beautiful farm. They were raising, I think, chickens and ducks. But it was outside farming, right? And so that meant that we also were seeing wild birds coming in and grazing in the same lands that these ducks were grazing. And that that creates that spillover potential between the wild, the wild birds that host many of these avian influenza viruses and the livestock that are then in very close contact with people. We also took them to live animal market. These are extremely common all around the world. And it is a wonderful place for potential viral spread and spillover because you have animals in close conditions. Many times these animals are stressed and or immunocompromised. And when we see that happening in animals, they’re more likely to be shedding viruses, they’re more likely to get sick. And you’re also exposing people to animal processing in some places where they may be slaughtering the animals there. And again, that’s another place where you’ll see that potential for spillover. Literature reviews and research has definitely shown that the most common spillover from animals to humans often happens in that butchering step when you are most risk, most at risk for perhaps cutting the animal and then accidentally cutting your own skin and really injecting yourself with something. And that can all be managed through appropriate biosecurity measures. Are you washing your hands? Are you handling the knives correctly and safely? Do you have veterinarians present supporting slaughterhouse evaluations so that you can identify those potentially ill animals? And so I think there is really a need, especially for zoonotic spillover events to have strong collaboration between your human health sector, which is maybe going to be the first responders to see some of these novel diseases in human populations and the animal health specialists who are going to be able to recognize what they’re seeing in the animal populations.

[00:11:09] Narrator Farms, markets, and slaughterhouses are front lines for potential outbreaks. The information generated by surveillance or the information we fail to generate helps determine how fast we can respond. Dr. Nuzzo explains why disease surveillance gaps are not just national problems, but global ones.

[00:11:28] Dr. Jennifer Nuzzo Surveillance has changed a lot since I got into this field, you know, several decades ago. I think there have been some really key improvements, but there’s also a lot of challenges. So when we’re talking about surveillance, we are largely talking about what happens at the national level, right? Countries are ultimately responsible for what happens within their borders. They are people who are elected to run countries, they’re responsible to the people who elect them. So we talk about national surveillance. Now, in a place like the United States, national surveillance may be deeply dependent on and frankly contingent on there being state and local surveillance because we are a federal country, the constitutional responsibility for public health rests with states. So states conduct surveillance and we roll that information up to the national level. When we talk about global surveillance, what we’re really talking about is countries deciding to share information so that we can get a global picture of what is happening. And that’s really, really key, particularly when you’re dealing with something that’s global in nature, like a pandemic. You need to know not just what’s happening in your own country, but possibly what’s happening in the countries that neighbor you or in countries where your citizens may be traveling to and from. So global surveillance is also important. But, you know, national surveillance can’t happen without local surveillance. Global surveillance can’t happen with national surveillance. So we need strong capacities at the local level and the national level. And there is still a lot of work that needs to be done in countries all over the world in terms of being able to do that.

[00:12:58] Narrator Some communities may face higher risk of spillover because of factors such as geography, farming practices, or weaker health systems. Other places may lack the resources to detect and respond quickly. Lindsey says this is why the idea of One Health, linking human, animal, and environmental health systems, has become so important.

[00:13:18] Lindsey Shields I love the question about what is One Health because depending on who you talk to, it can mean a whole lot of different things. I think the classic way that One Health has been interpreted is often related to zoonotic diseases, right? And it’s really like animal and human health, and how do we work together across those two sectors to make it better? And that really neglects the third piece of this. It’s really animal, human, and environmental health because all three of those sectors are intricately intertwined. You affect the health of one of those three areas and it will have impacts on the other two. We see this often with climate change, with the changing patterns of climate in various locations. You end up having different types of diseases emerging. You have different types of challenges emerging. We’re seeing higher rates of diseases associated with pollution, we’re seeing higher rates of arboviral diseases with increases in the mosquito population. And so I think infectious diseases is a great example of how One Health is used, but One Health itself is really understanding that human environmental and animal health is intricately intertwined and that you must be taking into account the health of each of them in order to address the health overall.

[00:14:28] Narrator But establishing a One Health approach means addressing barriers both formal and informal to collaboration. Lindsey says progress is happening, but that it can be uneven.

[00:14:40] Lindsey Shields The barriers to integration and collaboration between human and animal health. There’s sort of the formal barriers and then there’s the informal barriers. The formal barriers are often, you know, there’s some need to have a formal standard operating procedure or a plan for how you’re going to connect. There’s in some countries, that means there’s a national One Health platform set up so that you start having routine meetings and the sharing of data happens more naturally. Sometimes that means, you know, joint response activities. So in some countries, there are actually One Health rapid response teams that when a zoonotic disease outbreak has occurred, they will actually send representatives from both animal health and human health to that location to be able to respond to it. That’s sort of the formal barriers. And I think countries are really starting to put more time and effort into that. You’re seeing national One Health action plans being prepared, you’re seeing One Health woven into their national health security plans as well. Then I think there’s the informal barriers, and that’s the one that I think is most interesting to see coming around over time. And that’s especially in a local setting. If you have the if you have figured out ways to lower the barriers for communication. Just to pick up the phone and call the animal health person. If you’re aware of, hey, we just had a case of anthrax come into our hospital. Let me just call up my friend who’s not now, you know, this formal communication mechanism and give them a heads up that something is happening. I think this removal of those barriers for informal communication can be really helpful. We’ve seen that happen in some places where, you know, there’s a fora that happens, either a community of practice around One Health that brings together people from different sectors once a month, once a quarter. And in those areas, we just see a lot more willingness to kind of share information and share data, even in an informal setting, because there’s that personal relationship.

[00:16:26] Narrator Breaking down silos is one part of the preparedness equation. Another is resources. Lindsey warns that without equity and surveillance and preparedness, global health security will remain fragile.

[00:16:39] Lindsey Shields I think there’s been a lot of progress over the last decade or so on surveillance systems, whether it’s a high-income country, a low-income country, or a global or regional initiative. A couple that come to mind that have been around for quite some time is called GOARN, which is the Global Outbreak Alert and Response Network. This is a really great human health focused organization that helps to identify disease outbreaks and and respond in a coordinated fashion. On the animal health side, there is also GLEWS, which is the Global Early Warning System. And that also allows capture of infectious disease outbreaks in the animal population.

[00:17:15] Narrator The COVID-19 pandemic exposed many of these gaps. Lindsey reflects on what preparedness looks like today and why preparedness projects can often lose funding between crises.

[00:17:28] Lindsey Shields We often have a hard time getting funding for preparedness because it’s much easier to be responsive to something. Outbreak response, it’s very clear we have an outbreak, we need to respond to it. It’s really hard to track, categorize, and understand the impact of the work that we do in preparedness because you don’t have the outbreak that occurs as a result. And so I think it’s really critical that investment in preparedness is increased and sustained over time. Historically, what we see in preparedness investments is very much cyclical. You’ll see an outbreak of a major disease happening, you’ll see an influx of substantial funding to address that disease that then transitions into recovery and then preparedness. And then over time that kind of peters out. And then all of a sudden you have the next outbreak, and everyone goes, didn’t we do this a year ago? Didn’t we plan for this? And so the preparedness piece is really, really critical. And I think a lot can be done to leverage the One Health approach in order to be prepared for pandemics or for emerging diseases in general.

[00:18:26] Narrator For Jennifer, the lesson is not only about funding, but about trust and communication.

[00:18:34] Dr. Jennifer Nuzzo So, I mean, first of all, trust isn’t built in the midst of an emergency. You have to build trust in advance of an emergency. And part of making sure that people trust government or trust, you know, the recommendations being made is about showing up in people’s lives in a meaningful and productive and welcome way in advance of an emergency. One of the kind of things that really stuck with me during the COVID-19 pandemic, and I, you know, was fortunate to be able to talk to really hundreds of maybe even more people from all walks of life, you know, all sorts of people during the COVID-19 pandemic and learn a lot from those conversations. But at the beginning, you know, I was hearing a lot from people. They would ask all these really thoughtful questions and they’d be really distressed. And, you know, very frequently I would hear them say to me, oh, I just don’t know who to trust.

[00:19:23] Narrator Lindsey highlights some of the scientific advances and global initiatives that could make a difference for the next outbreak.

[00:19:32] Lindsey Shields In order to be prepared for pandemics or for emerging diseases in general. I think one of the things that came out of the COVID-19 pandemic that I think is really positive is the 100 days mission. You know, CEPI is really driving the charge on this, but the 100 days mission is basically saying we want to get vaccine to disease outbreaks of novel viruses sooner. So there’s a lot of learning going on right now of how do we decrease the barriers from you’ve identified a new novel disease to we are rolling out a new vaccine that can actually address it. And I think COVID-19 put a ton of pressure globally on people to think more strategically. We had massive advances in rapid diagnostic testing. We had rapid advances in the types and styles of vaccines available. And I think those learnings need to be utilized as we start preparing for the next one. Yeah, I think public health, especially after the COVID-19 pandemic, we learned a lot about how we need to be better communicators. People in public health tend to be very technical in nature. We love talking about epidemiology and getting really into the weeds about all these different things. But the general public needs clear messaging and they need to be able to understand how it relates to them. And so as we’re thinking about messaging around public health, One Health, and pandemic threats, I think we need to do a better job of being able to tell a story that is directly applicable or relatable to the general public.

[00:20:55] Narrator And for Lindsey, there is an optimism in how the scientific community continues to adapt to get ahead of outbreaks.

[00:21:04] Lindsey Shields The Vietnam work, I think, was really exciting because we were looking at how to improve community-based surveillance. So people who are maybe community health workers, they may not actually have access to diagnostic tools, etc., but they were trained on specific events that would trigger a response or trigger an outbreak investigation. Historically, that had only include human health signals, right? Somebody’s got a weird fever or somebody’s really sick, or a school has a bunch of kids that are out sick suddenly. And what we did was we actually incorporated training for also understanding when to notify on animal health events that might have really strong impacts, right? A sudden illness in a flock of birds or, you know, cow found dead, right? These would be some other examples of things that would trigger a response. Now, especially at the community level, people have very differing levels of education. They may not actually have, you know, to that point about technical people being very technical. We utilized a combination of brief trainings that were rolled out at subnational level, but also images that were not required to have very that didn’t require a lot of words and require people to know how to read. So you would see the image and you would understand, okay, this is the type of event that I would need to report on. And so I think looking at modifying our communication methods to be more responsive to where the community is really critical. And that allowed then, you know, rural communities in Vietnam to start reporting suspected cases of illness that could be anything ranging from anthrax to avian influenza to something else that could be both a threat to that livestock population, but also a critical threat to the human population in the community.

[00:22:46] Narrator As we’ve heard, surveillance, One Health, preparedness, and communication are not luxuries. They are necessities. The expertise of Amesh, Lindsey, and Jennifer show us that science and systems matter, but so do relationships, trust, and persistence. We can’t predict exactly where the next spillover will occur, or which virus will trigger the next pandemic. But we can prepare. And the more we invest in preparedness today, the better chance we have of tackling the next public health threat. Thank you for listening to this episode of Countermeasures. If you enjoyed this episode, please consider leaving a rating or review.

[00:00:00] Maryann Mason We think of grandma baking cookies. But think about it now generationally, these grandmas wore miniskirts and listened to rock and roll and, you know, did recreational drugs. So that stereotype of grandma sitting in a rocking chair doing all those things prevents us from seeing them in their whole totality of how they’ve lived their lives and what social influence and some conditions are under. So sometimes it’s just stops people from asking, could this behavior be substance use related? It’s not even on the table for many people. I think that’s one of the big things. The other is stereotypes of what aging is like, where cognitive decline is expected. And so sometimes people will have that stereotype and not think, could this be due to miss substance misuse? And so they won’t investigate that alley.  

[00:01:07] Narrator This is Countermeasures, brought to you by Emergent, maker of NARCAN^® Nasal Spray. Join us as we explore the shifting complex world of the opioid crisis. Today, opioid overdose is a leading cause of accidental death for so many families, loved ones and friends behind these lives lost. This season, we’ll continue to explore some of the communities hit the hardest by the crisis. From prisons and construction sites to schools and elderly care. We will hear from changemakers offering a new way forward. When many of us think of the opioid crisis, we might not think of older adults. Stereotypes of what it means to age can prevent signs and symptoms of opioid misuse and dependency from being caught by medical professionals, friends and family and caregivers. However, older adults are a population that is deeply impacted by the opioid crisis and has historically been under addressed by education, harm reduction and treatment options. Maryann Mason is a sociologist and an associate professor of emergency medicine at Northwestern University. She’s been working in the area of substance and opioid misuse for ten years with a focus on older adults.  

[00:02:27] Maryann Mason There has been an increase in opioid overdose deaths in older adults. Older adults are just like younger adults, but their rates are a little lower, but they have followed the curve of everybody else. So since 1999, which is the reference point, most of us use older adult overdose deaths have increased enormously over a thousand percent. There are certain periods during that 1999 to 2024 where the increase has been steeper. And about 2014, 2013 is when the increase started going steeply up and there have been permutations in the rates, but pretty much upwardly ever since. The major reasons for the increase are the same reasons really behind the overdose increase in general. It began with the overprescription of opioids by physicians, and then it morphed into illicit opioids like heroin. And then when the crack down came in that and it was harder to get heroin, fentanyl made its way into the drug supply and increase things. And now more recently, we have poly substance driving the increases. So people who are using opioids and stimulants and opioids and alcohol, those are the substances behind the increase. And just want to point out something really interesting about older adults. I’ve been looking closely at the most recent data. And overall in the United States, it looks like drug opioid drug overdoses are going down slightly from 2022 to three and then to 24. But that’s not the case for older adults. They’re continuing to climb for older adults.  

[00:04:31] Narrator Mary Nguyen is a Doctor of Pharmacy graduate from the University of Waterloo outside of Toronto. She has worked as a pharmacist in a rural community in Ontario, where she saw the effects of the opioid crisis on older adults in the community. Like Maryann, she says that most people don’t think about the impact of the opioid crisis on older adults and that stereotypes of aging can prevent opioid misuse from being identified.  

[00:04:57] Mary Nguyen It’s surprising how often older adults are affected, even though we don’t typically associate them with opioid misuse. You know, people rarely imagine someone like 80 year old Martha down the street struggling with addiction. But the opioid crisis really started in the 90s with OxyContin. And now that baby boomer generation who were highly prescribed opioids are older. So we’re really seeing that lasting effect. Now, to put it in perspective, one in six older adults have taken opioids. Opioid use disorder among this group tripled from 2013 to 2018. Older adults are actually the largest users of prescription opioids. So when you think about it that way, it’s not as surprising that opioid use disorder is prevalent in the population. Unfortunately, we see a lot of stigma in opioid use or misuse in this population, so it can prevent a lot of diagnosis and treatment.  

[00:05:57] Narrator Mary found that the dangers of developing dependency were not fully understood by patients, especially if they were taking prescription opioids, and that many of these issues were exacerbated by the rural setting.  

[00:06:09] Mary Nguyen The lack of resources, especially for comprehensive care and follow up, really makes it difficult to manage opioid dependency. You know, I’ve seen many of my patients struggle with dependency, whether or not they realize it, mostly because their long term use of opioids is often for legitimate reasons, like for chronic pain management. And they’re not always the most eager to explore safer options, especially when they think that opioids work the best for them. People also don’t realize how easily dependency can develop. You know, it can take as little as a couple of weeks. And then tolerance is a big issue as well. The longer you’re on opioids, the less effective they become, which leads to taking higher doses and a greater risk of dependency. Many assume that because a medication is prescribed, it’s safe. Especially if something they’ve been taking for a long time, they’re less likely to stop because they don’t think it’s an issue. You know, our health care system in Canada is quite strained. Doctors’ offices are overloaded. Sometimes they don’t have time to give proper education or ongoing check-ins for these patients who are on long term medications.  

[00:07:25] Narrator In rural settings, especially, tools like naloxone can be crucial.  

[00:07:32] Mary Nguyen It’s really important to reduce that stigma around naloxone. Many people hesitate to carry naloxone or take it when it’s offered because they think it implies that they’re an addict of some sort. I like to reframe it as a safety tool. It’s like having a fire extinguisher in your kitchen just in case of emergencies. It’s not that we think you’re abusing your medications, but if you were to accidentally take too much or if someone else were to get into your medications, it’s there as a safety net. And I think, you know, with the evolution of injectable naloxone to nasal naloxone kits, people are less hesitant to carry it because it’s a lot easier to use. Most people don’t want to carry around a needle and syringe and have to poke someone in an emergency.  

[00:08:20] Narrator While one way older adults are affected by the opioid crisis is misuse of opioids that were prescribed to them. Some older adults may have a long history of using illicit drugs. The rise of fentanyl has put this population at greater risk.  

[00:08:35] Maryann Mason Older adults, there’s kind of two types of opioid misuse. One, is early onset where people may have a 20, 30, 40, 50 year history of substance misuse. And then late onset, that happens in their older years and that’s mostly prescription oriented. So you kind of have to think about two distinct groups of people, older adults who are using. So the younger onset people, there could be a variety of reasons why they’re they’ve misuse and continue to misuse, including untreated pain, mental health issues, sort of cultural norms, generational cultural norms. And then for the older adults who initiate, it’s more likely to have to do with prescription abuse that builds dependency. The disparities are very stark. So among older adults, it’s the 55 to 64 year olds who are disproportionately affected and then men and then African-American men. And so while there is not a ton of definitive research on this, I think the general thought is that it’s a generational impact, meaning that it’s a group that’s likely had early onset use and maintain their use over decades. And so they’ve I mean, they’re survivors. Right. They’ve been able to survive with substance use for 30, 40, 50 years. But now we’re in a situation where the potency of the drug supply combined with their aging has put them at proportionate risk. So the older adults or the young old, as I like to call this group of African-American men, sort of have a generational legacy in that way, in that if you think back to the 1970s, there was a heroin epidemic. A lot of us don’t think that far back, but that was the population ensnared in that epidemic. And I think this population now, they’re older adults. They have continued to use and are ensnared in the new epidemic with greater risk.  

[00:10:55] Narrator Jessica Liebster is a case manager at West Neighborhood House, a multi-service organization in Toronto that serves the community to address critical issues through personal and social change. A large portion of their programing is targeted at older adults in the community, some of whom have struggled with chronic opioid misuse. One of their programs includes volunteers going into the homes of seniors in the community who might be isolated.  

[00:11:21] Jessica Liebster That program provides volunteer support to connect with participants, so sometimes they will get a weekly call if they would like to just chat and have a connection on a weekly basis. So through that, then we’re able to link up to other support services. So sometimes people don’t identify, they don’t want to ask for services that they think maybe are for other people, right? It’s like people are sometimes very proud or they don’t want to access charity because they don’t see themselves in that light. But we know that all of these social supports most people can benefit from, right? So but some people will then say, yeah, you know, I am kind of lonely. It would be nice to connect with a volunteer. But the volunteer then can identify all kinds of needs and supports. And when things deteriorate as they can, in terms of health or mental health or what have you, then the friendly visitor or the family connection volunteer can say, Hey, this person is struggling a bit and gets some advice or support on how they can refer them to other services. So that piece is, I think, really significant because it captures a lot of folks who wouldn’t necessarily see themselves as needing case management, but there is an element of identifying with some of the needs through that program.  

[00:12:43] Narrator Like both Mary and Maryann, Jessica has seen the intersection of social isolation, poverty and substance misuse.  

[00:12:53] Jessica Liebster Substance use, we’re maybe thinking of a younger population, so there’s less awareness and not always less awareness always leads to like less access to service as well as maybe somebody not identifying their own needs in that regard as they see themselves as different from other substance users that, you know, maybe are kind of sensationalized in the media or what have you. Right? So I think that ensuring that we’re kind of shining a light on substance use with older adults is really important. And I also think to like the older adult population within, you know, homeless or under housed folks is not really acknowledged. You know, we see lots of older adults who are unhoused, maybe living in shelter for a long time or living sleeping outside using substances. And so, you know, that piece, I think can also get missed because we’re looking at the impact of poverty, like severe poverty in addition to aging, in addition to substance use. So there’s some very specific needs there that, you know, require a bit of a nuanced perspective to respond to.  

[00:14:13] Maryann Mason And then specific to the older adult, there’s lots of different things. But key to this group are things like income inequality. So people with lower income tend to have less opportunity for medical insurance to treat pain. And so there’s this idea that people self-medicate when they’re not able to get medical care. There’s also this idea, and it’s well documented, structural racism in the United States where African Americans were actually less likely to be treated for pain with opioids than other populations. And so, again, it leads one to think about the development of illicit views. So you think about those sort of legacy factors, the fact that people don’t have health care, that they’ve experienced lifetimes of racism, that they don’t have access to things like stable housing, which could help them manage these conditions. And the fact that employment and things like that is so racialized in the United States, you can kind of see how this happened.  

[00:15:32] Narrator As a pharmacist, Mary saw the impact of the pandemic on older adults, which augments the social isolation that can contribute to substance use disorder.  

[00:15:41] Mary Nguyen Covid-19 made things much harder during the pandemic. I saw a sharp rise in opioid abuse, with more patients starting medication assisted treatment increased and relapses, more naloxone requests and treatments for other substance use disorders like alcohol use. And I really do think it’s from that isolation increase in the stress and anxiety leading to this substance use. With health care services limited during lockdowns, it’s tough to get the support you need, right? And with the pandemic, it also led to shifts in the opioid prescription regulations in Ontario, because there weren’t as many in office visit and limiting the transmission risks of Covid. They provided at the Ontario government provided looser restrictions on opioid prescription transfers and longer dispensing intervals. But that inadvertently increased the risk of drug diversion. Across Canada, we saw increases in opioid related hospitalizations and fatal overdoses, especially from fentanyl. But from my experience, the elderly patients were the most impacted by opioid disorder because those were the ones often without a strong social support and a challenge that was further exacerbated by the pandemic.  

[00:17:09] Narrator Mary has also seen that the health care profession has a ways to go when it comes to this issue, including in long-term care.  

[00:17:17] Mary Nguyen You know, a lot of times when patients go to long term care homes, the health care they receive is often okay. Is there another problem we need to address? Let’s add on medication. It’s very rarely that a doctor goes in and like, hey, let’s see what we can take away. And it’s a practice that is starting to become more popular, especially as you see so many interactions between the different medications. And, you know, just because someone needed something at one point doesn’t mean they need to be on it forever. And as pharmacists specifically coming more into long term care homes, we are coming in and doing medication reviews to do prescribe to minimize the risks. A big thing with opioid use with the cognitive decline is the fall risk. You know, older adults, if they have a bad fall, I think 50 percent of patients who had a hip fracture aren’t able to return back to their normal independent living anymore after that. So I think it’s a big intervention that pharmacists can play.  

[00:18:31] Narrator Lake Mary, Maryann believes that treatment is not curated to this population.  

[00:18:37] Maryann Mason No, I don’t think there are services tailored to older adults out there for people, or at least in the quantity and the places where people need them. They’re, first of all, there, if you are talking about recovery and treatment, there are some things older adults may need that the general population doesn’t just because of how we age. So they might have transportation or mobility barriers, so they may need a different needs there. They may have hearing or vision issues that necessitate delivering supports and services. There’s been some work done looking at sort of the culture of recovery and how that works and the idea that sort of group therapy, talking about your things in in a group is not in alignment with what many older adults feel is comfortable for them. So there are adaptations that need to be made that way, but also medication assisted recovery, which we know is an effective treatment for opioid use disorder, is less often offered to older adults than younger adults. And so, you know, should that be something people are interested in, They’re not being asked.  

[00:19:59] Narrator Maryann also believes that there is more work to be done to tailor current programs to the needs of older adults.  

[00:20:06] Maryann Mason Older adults have come of age in a time where that wasn’t a thing. It wasn’t an option for them or that you had to go to specialized treatment. So many don’t know you can get substance use disorder treatment at your primary care physicians office. So there’s a couple of things there. One is the education of the older adult community about what’s now available. But to the education of providers to offering things. And then I guess three is how do we adapt things being offered to the needs of older adults? We have a long way to go. If you think about harm reduction, harm reduction are services that can help people who use drugs be safer and less risky. And there’s a whole menu of effective strategies people can use in harm reduction, anything from syringe distribution to test strips so you can test your drug supply to drug checking. All of those things are in the harm reduction menu or bucket. But there’s evidence showing that older adults are less often touched by harm reduction. And there’s again, a couple of theories about why they’re less often reach. But part of it has to do with stigma. And you think about this population generationally. There was this whole, I’m going to use a word we don’t use anymore, but this junkie label for people where there is a quite a bit of shame and personal failing associated with substance use. So people do not want to identify with that. Sometimes for older adults, they may have gone through a period of abstaining for a number of years and then have recently or more recently gone back to use. And so they really don’t want to go out to the mobile van and stand in line for services because they don’t want to self identify as someone who is using again. The other factors transportation and mobility. People aren’t in the places where they used to hang out and use drugs in their older days, so they’re they can’t be reached in those places and stuff. And so I think we’ve got a ton of work to do around strategies to reach this group with those this population, with those strategies.  

[00:22:41] Narrator Older adults are a large, complex and diverse group, and opioid dependency looks different among different populations. However, stereotypes about aging and stigma surrounding opioid misuse can prevent older adults from seeking treatment or for dependency to be caught in the first place. In addition, harm reduction services and supports tailored to older adults are lacking. Increased interest and research into this area will help improve outcomes for everyone. Thank you for listening to this episode of Countermeasures. To learn more about what Emergent is doing to help address public health challenges like the opioid crisis, visit www.emergentbiosolutions.com. If this episode resonated with you, consider reading and reviewing Countermeasures on your preferred podcast platform.  

[00:00:02] Bella Grumet I think when you’re directing harm reduction efforts toward college students and students of this generation, I think one of the things that makes us so successful is our peer-to-peer modeling, because we’re the generation of D.A.R.E., where I have been signing drug free pledges since I was in the first grade and didn’t really know what a drug was. So I think people in that generation kind of have a kneejerk reaction to any sort of harm reduction or drug focused efforts because they think they’re being judged and are being told to do something. But we really value kind of meeting people where they are and saying you’re you’re an adult, you’re going to do what you’re going to do, but please listen to us and how to do it safely. 

[00:00:48] Narrator This is Countermeasures, brought to you by Emergent, maker of NARCAN® Nasal Spray. Join us as we explore the shifting complex world of the opioid crisis. Today, opioid overdose is the leading cause of accidental death for so many families, loved ones and friends behind these lives lost. This season will continue to explore some of the communities hit the hardest by the crisis, from prisons and construction sites to schools and elderly care, we will hear from changemakers offering a new way forward. At colleges nationwide, each new school year, students eagerly move into dorms and select their classes. For many, college is a time of firsts. The first time living on their own. The first time meeting so many people at once. And for some, the first time they will experiment with illicit substances. Coming from a diverse range of educational backgrounds, when it comes to drugs and alcohol, many students don’t know the dangers of accidental overdose or why accepting a pill to help them study harder or be more social has the potential to end their lives. In this episode, we speak with college students, researchers and educators about how to make campuses safer for everyone. The Carolina Harm Reduction Union, or CHRU, is a peer-to-peer student-run, faculty-monitored harm reduction organization that provides education and harm reduction materials at the University of North Carolina at Chapel Hill. 

[00:02:25] Riley Sullivan My name is Riley Sullivan. I’m the Executive Director and co-founder of the Carolina Harm Reduction Union, and I’m also a senior at the University of North Carolina at Chapel Hill. 

[00:02:37] Bella Grumet My name is Bella Grumet. I’m a senior at the University of North Carolina at Chapel Hill studying neuroscience, and I am the Director of Communications for the Carolina Harm Reduction Union. 

[00:02:47] Kathleen Ready I’m Kathleen Ready. And I’m Director of Education and kind of volunteer coordination with the Carolina Harm Reduction Union. 

[00:02:57] Bella Grumet One of the reasons getting involved in this organization was important to me is I was actually touched by a loss we had due to an accidental opioid poisoning related to a student on our campus and in the past years was three alumni and students overdosing on an opioid related to UNC’s campus. And so I just really saw a need to get education and awareness out to the student population to prevent another tragedy. 

[00:03:24] Narrator Members of CHRU saw the need for education on their campus, as well as the importance of peer-to-peer education. 

[00:03:32] Kathleen Ready We do a lot of different educational presentations as well as actual distribution and handing out of naloxone and fentanyl testing strips. And one of the great things about at least UNC and just like the general community is, there are so many different groups of people with different interests and different background knowledge. It’s like we’ve presented two groups of people that are EMTs and we’ve also presented to Greek life in different cultural groups, and each of them have different interests and kind of baseline knowledge. So we create tailor presentations that are tailored to what they think is important for whoever is in the organization to learn about. So do we do a lot of that and working with groups of students and people in the community and as well as distribute naloxone. So every week we have we put a table on campus for a couple of hours and hand out naloxone and Fentanyl testing strips and train the kids who come to the table how to use these resources and how to spot an overdose and what to do if you’re ever put in that situation. Just generally raise awareness on campus. 

[00:04:40] Narrator Administrators are key in supporting students. Alexis Drakatos at the University of Oregon, oversees substance misuse prevention services. She says the student perspective, like the one brought by Riley, Bella and Kathleen, is crucial. 

[00:04:56] Alexis Drakatos The student perspective of our work is really important, and we do have I’d say our efforts are primarily student led or student inspired. And so within my team, I do have a staff, a staff of students. We have about five or six, I’d say, that are peer, we call them substance abuse prevention peer educators. And so their role is really helping develop education and leading a lot of our workshops, doing outreach and things of that sort. So it’s really important to us to bring in students and have them be that, be that face. And also they’re the ones that are amongst their peers. They know they’re on the ground seeing what’s happening, seeing the types of questions. And so that allows us to really involve students, one, because their perspective is so important, but also when it comes to the actual moments where we’re educating a group of students, having that peer to peer model we find just allows to meet students where they’re at. But I think it also allows for just a comfort as being able to ask questions that they may be less willing to ask if I’m in the room or other professional staff are in the room. And so I think it really allows for a healthy balance. 

[00:06:08] Narrator Cori Hammond is the Director of Prevention Services at Partnership to End Addiction, a national nonprofit with a mission to transform how addiction is addressed by empowering families, advancing effective care, shaping public policy, and trying to help change the culture. Cori says that most overdoses in the college age demographic occur because people don’t realize they are taking an opioid. 

[00:06:32] Cori Hammond The risk factors for this college age group, the risks are similar to what we see in adolescents, in some ways. The the prefrontal cortex of the brain, which is that part of the brain that’s responsible for critical thinking and risk management that’s not fully developed in the late teens and early 20s. And so because of this college age people are more likely to take risks just in general. Sensation seeking, like, in males peaks at age 19, which is conveniently freshman year for most of them. But that’s common risk factors for all substances, specifically for opioid overdoses. We think about unintentional overdoses due to mostly fake pills for this age. So the overwhelming majority of young people who have a fentanyl or an opioid overdose, they didn’t mean to take fentanyl. They, you know, the overwhelming majority of them are not addicted to opioids. They thought they were taking a legitimate pharmaceutical pill that they bought from a pal or they’re taking a bump of cocaine, not realizing that fentanyl or any of these other ultra potent synthetic opioids were present in what they were taking. So that’s the main risk on college campuses. And, you know, college students are under a lot of pressure, you know, pressure to make good grades, attend class, be social, be involved and figure out their life plan, which is all part of the whole experience of college. But it’s really stressful. So it’s understandable that they could be tempted by a lot of different substances to help cope with all of that, you know, things like amphetamines that they think are going to help them stay up to study, you know, cocaine or MDMA that they think is going to make them social or fun at this party, Xanax, that they think is going to help them relax when they’re anxious. And, you know, they may be getting these substances from someone that they trust completely, but who is that person getting substances from? So we know that the illicit drug market is not safe and these fake pills can be like they can’t be identified just by looking at them. And so these are the situations that we know put college students at risk for an accidental overdose. 

[00:08:58] Narrator At the University of Oregon, incoming students are required to complete online training that includes education about fake pills. 

[00:09:07] Alexis Drakatos We do have students from all over the world. And so it is important to recognize that the education that our students may be coming in with specific to alcohol and other drugs is going to look really different just depending on the state, the country that they’re coming from, even the community and then even the individual school and what their K-12 education might have looked like. So we want to try to have a baseline education for all our students to educate them on specific campus policies, state policies, and maybe even in some cases, federal regulations. So the baseline education for incoming students is we utilize the so online prevention, especially knowing that we have such a large incoming class of students. And so our students, during their first term or quarter on campus, they’re required to complete some online modules that focus on alcohol, cannabis, prescription medication. And then we also focus on Title IX and some other sexual assault, consent and consent education. And so all students are required to complete those modules. We also do require students when they come for orientation, freshman or first year student orientation. We have them go through an in-person workshop that’s led by students. 

[00:10:28] Narrator Certain groups of students are at higher risk of substance misuse. And Alexis emphasizes the importance of reaching and educating these groups. 

[00:10:37] Alexis Drakatos How we go about educating specific communities or assessing maybe trends or levels of risk within specific communities on campus. I think areas that we do spend a great deal of our time in the three that come to mind immediately would be fraternity and sorority life. And so we recognize that their data shows and I think even anecdotally you will see that I think students that are engaged in fraternities where you guys might be at utilize substances at greater rates than non-fraternity and sorority life peers. They’re also at greater risk for other other harmful behaviors as well. And so that’s a really important group for us to be working with and having targeted education towards. And we also like to focus on athletics and so working broadly with our athletic teams. And then I think the other I’d say is working with incoming or first freshman year students as well. And so what that education might look like as much as possible is involving students from those populations and that education. So, for example, a fraternity sorority life, part of my role is overseeing we call it the Safety Wellness Board here on campus. And so it’s we have members that are all in fraternities and sororities that lead this board. And so we have staff that are working with these students that are peer leaders. And then those are the students that are leading education to the greater fraternity sorority life community. So again, it’s that model of having student leaders involved saying, okay, what do we need to talk about? What are the trends you’re seeing? What do we need to do to address these things? And so having that support to help them tailor education for those students. 

[00:12:24] Cori Hammond In general, we know students are at a higher risk of substance use disorders during college if they binge drink, if their peers use if they’re a member of a fraternity or sorority, and if they kind of believe that substances are super harmful. We also know that female students are more than twice as likely as male peers to seek out stimulants for non-medical use, which puts them at higher risk of coming into contact with laced or fake pills. Bisexual women, for instance, are at an increased risk for opioid misuse and opioid use disorder. We know in general that students who are struggling with low GPAs or have difficulty in socializing are more likely to use opioids than their peers. Prescription opioid misuse is highest among students who report psychological distress or depression or suicidal thoughts. 

[00:13:22] Narrator As you’ve heard, conversations about prevention for college students are changing. Students are calling for open, nonjudgmental conversations rather than scare tactics. 

[00:13:33] Bella Grumet So I think when you’re directing harm reduction efforts towards college students and students of this generation, it’s really I think one of the things that makes us so successful is our peer-to-peer modeling, because we’re the generation of D.A.R.E. where I was signing drug free pledges since I was in the first grade and didn’t really know what a drug was. So I think people in that generation kind of have a kneejerk reaction to any sort of harm reduction or drug focused efforts because they think they’re being judged and they think they’re being told to do something. But we really value kind of meeting people where they are and saying, you’re like, you’re an adult. You’re going to do what you’re going to do, but please listen to us and how to do it safely. And I’ve gotten a lot of feedback from people on how they’re so much more open and willing to listen to a peer talk to them because they know they’re not being judged. They know it’s not some message being forced at them. It’s someone on their in their circle, on their level, like meeting them where they are, that’s coming from a place of just wanting to help and not to judge. 

[00:14:39] Riley Sullivan I won the D.A.R.E. essay contest in fifth grade and reflecting on that curriculum that I’ve had to go through my entire childhood and to college it’s largely corny and you make everything seem like the worst thing in the world. And even recall a video of like some dude dressed up as Mario saying, if you do drugs, you go to hell before you die. And it kind of brings us to this point where it’s almost like The Boy Who Cried Wolf, when there’s something that is actually incredibly harmful, we’re less likely to listen because we’ve been programed to kind of ignore some of that messaging. 

[00:15:24] Narrator Another important element in this shifting conversation has been about dispelling the myth that it’s normal to use substances in college. 

[00:15:33] Cori Hammond The conversation around prevention has changed a lot. You know, we’re doing a lot of work to try to dispel some of the myths and misconceptions about substance use in young adults and adolescents. A big one is this idea that substance use as a teen or a young adult is an inevitable part of life, that it’s a rite of passage. It’s something that everyone does, and that’s something that we know is just not true. For high schoolers, for instance, the number of total abstainers, those who have never used any substances at all is increasing year after year. Like last year, 30 percent of high school seniors said that they had never used any substance before, and that’s including alcohol and nicotine. For 18 to 20 year olds, which is a big subset of the college population, only about 35 percent said that they had used any illegal substance in the past year. And there was a recent systematic review of all of these different studies that found the prevalence of prescription opioid misuse on college campuses is generally below 10 percent. So this is certainly not something that everyone is doing. And talking about substance use, like everyone’s doing, it just really normalizes it unnecessarily. So instead of focusing so much on the negatives, like don’t do this, it’s bad for you. Prevention is really trying to focus on the positives, like this idea that most of your peers aren’t using substances. We’re definitely moving away from that just say no approach. And it’s been a slow shift. Like over over the last century, we’ve had a shift in the way that the medical community in the scientific community thinks about addiction. So first we had what could be called like a moral model, this idea that people believed drug addiction was a moral failing. And if you just have enough willpower, you can overcome it. And then we kind of moved to something that would be called like a biomedical model, where we realized the role that genetics and biology play in substance use and addiction, learning how addiction is a progressive brain disease. And finally, we realized that even that was kind of too reductive. And it’s not just biology. And so we landed on a much more comprehensive model, which most would call the bio psychosocial model. So taking into account biology, psychology, the socio economics and all of these cultural factors contribute to someone’s risk and should be taken into account for both prevention and treatment. And so that shift in understanding mirrored the way that we have shifted in prevention too. So first we used scare tactics meant to terrify kids, to not try drugs, and then we moved into kind of just psycho education. And if we just teach them the facts, then they’ll be able to say no. And it wasn’t until the 90s or so that we saw a significant shift towards evidence-based programs. And then finally later, a shift in this more comprehensive approach took hold. And so once we’re thinking comprehensively about someone’s risk landscape, their biology, psychology, socioeconomic status, culture, it becomes really obvious why just teaching kids to say no is not enough. 

[00:19:13] Narrator The CHRU team has seen that students are very responsive to open and honest conversations about prevention and harm reduction. 

[00:19:21] Bella Grumet I’ve actually been really moved by how positive the response has been. I have people coming up to me and public being like, it’s the naloxone girl. And then that kind of sparks conversation of them, asking more questions, asking for more resources, asking for us to come back and present to their new members of their organizations. And I think what’s been really important to me is it’s generated a conversation around the naloxone and around opioid overdoses that has been absent. And the absence of that conversation was causing people to die. Because I think in college, there’s kind of a you can sweep it off mentality to a lot of things that go on. And I think getting this conversation started has made people take a critical lens to what’s going on in their lives. And the hope is that if there is ever an emergency situation, instead of hoping someone will sleep it off. They’ll know the signs, they’ll know the symptoms, they’ll know to call 911, which has been what has been missing in the cause of some of the recent deaths we’ve experienced in our campus network. 

[00:20:26] Kathleen Ready And to kind of add on to that, not only are students super receptive and excited to get the resources themselves and have us present. There also as the person who’s in charge of volunteers, very excited to become involved themselves. Like I trained two kids this morning and I have like ten more than I’m going to train this weekend. Everyone on campus is excited about it and they too want to help spread the word and communicate to the people they know. 

[00:20:54] Riley Sullivan I’m like constantly surprised with the things that happen around our work with CHRU. And like our first couple of weeks trying to start this thing out. It’s as somebody pointed us in the right direction to get mass quantities in naloxone, which I didn’t even know would be a possibility. And then we get offered to go on like NPR, and then people are listening to us. And it’s obviously been incredible to watch and see people like Bella come on and Kathleen. 

[00:21:29] Narrator Another important element of modern harm reduction and prevention is understanding the intersection of substance use and other factors like mental health. This is taken into account on the University of Oregon campus. 

[00:21:41] Alexis Drakatos In general, substances are can be used as a way to cope with whether it’s stress, if it’s stress of academics and trying to get everything done and managing things. And so maybe we know prescription stimulant misuse on college campuses in particular is, you know, as a as a as an issue that we see on campuses. And so whether it’s stress of just try academic performance and trying to do as many as much as possible and perform well. But then also on the other side, we know that our most college campuses, I would say, are seeing increased rates of students feeling, having anxiety, having depression. And so and I think that using substances to cope is not something we just on campuses, but I think in society those things coexist. And so recognizing that those things are real, that these intersections are real and we know that they’re happening, that’s something that I think a lot of our work and collaborations on campus really target, is how can we help students identify maybe when they are when maybe substance use isn’t something they’re just doing recreationally, but it is turning into more of a crutch or a tool to help them cope. So offering trainings and information, just normalizing that it’s okay to be stressed, it’s normal to be stressed, it’s normal, you know, mental health and all these things are normal. But then how can you and also asking and seeking support is normal and really important as well. And so resources that that are available on our campus and I would imagine other campuses have similar might look different, but there’s lots of similarities. 

[00:23:19] Narrator While progress has been made, stigma still plays a role in conversations about substance use. 

[00:23:25] Cori Hammond As much progress as we’ve made in normalizing talking about addiction and mental health disorders, they are still stigmatized. A huge part of what we call secondary prevention is learning to get help when you need it before things get worse. And it’s understandably hard for young people to say, I have a problem and I need help. It’s tough to admit that you’re having difficulty with substances or difficulties with your mental health and opening yourself up to judgment from adults or your peers. You know, in college age students, they’re probably wondering like, what are what are my professors going to think? What will my parents think when I have to drop out? When in actuality we know how common this is and that there is effective support and treatment out there. And stigma in harm reduction is still a massive problem. You know, many people take an abstinence only approach to drug use, thinking, you know, my child’s never going to use drugs. Why would I ever have a discussion with them about how to use them safely. Which is very reminiscent of my child’s never going to have sex, so why would I ever talk to them about contraception, which is problematic in so many ways. And so we really need to break through that way of thinking. You know, young people are are dying and we have access to tools that can save them. We want adolescence and college to be a time where kids can make risky decisions and learn and grow from them. And in today’s world, we need harm reduction to do that. The alternative is that a young person can make one poor decision and their life is over. 

[00:25:19] Narrator While there is still lots of room to grow, conversations about prevention and harm reduction on college campuses have come a long way. Student led initiatives like the CHRU administrators like Alexis and educators and researchers like Cori are all doing their part to prevent accidental overdose on campuses and educate college students about the risks associated with substances. Thank you for listening to this episode of Countermeasures. To learn more about what Emergent is doing to help address public health challenges like the opioid crisis, visit www.emergentbiosolutions.com. If this episode resonated with you, consider rating and reviewing Countermeasures on your preferred podcast platform. 

[00:00:00] Lorraine Martin I’ll give a little story here that is firsthand for me because it’s one of my reports. Her son-in-law was at work. He hurt his knee doing whatever physical activity he does. His buddy says, I’ve got my prescription in my pocket, my painkiller here. This will help you get you through your shift. This was not someone who had a substance use disorder. They were trying to get through their shift. Their buddy gave them something they’d gotten over the Internet. It had fentanyl. The son-in-law of my employee was blue and dead in their bed that night. Thankfully, their spouse somehow woke up, was able to call 911. They got naloxone into their place. The gentleman was able to live. But this was just an employee trying to get through their shift. And what happened to him, I would call a poisoning. He took something he didn’t know what he was taking, and it caused him to potentially lose his life. Those kinds of stories when you can can bring it home either through a workplace related incident like that or a family member situation, or telling a story about someone who just was recently working for the White House and had been in recovery and had been saved several times. 

[00:01:06] Narrator This is Countermeasures brought to you by Emergent, maker of NARCAN® Nasal Spray. Join us as we explore the shifting complex world of the opioid crisis. Today, opioid overdose is a leading cause of accidental death for so many families, loved ones and friends behind these lives lost. This season will continue to explore some of the communities hit the hardest by the crisis, from prisons and construction sites to schools and elderly care. We will hear from changemakers offering a new way forward. Overdose can happen anytime, anywhere, including at work. According to the CDC, workplace deaths due to accidental overdose increased by 500 percent from 2012 to 2020. Some workplaces have a higher risk than others, notably in industries where employees perform difficult or dangerous work, such as construction, extraction and hunting and fishing. However, accidental opioid overdose can happen in any workplace. There are also countless people in recovery who are reentering the workforce, maybe for the first time in years. Some workplaces have started to provide naloxone and training to employees to help them be prepared to act in the event of an opioid emergency. But there are still gaps to address when it comes to employers’ responses to the opioid crisis. Lorraine Martin is the CEO of the National Safety Council, a nonprofit safety advocate founded in 1913. They help workplaces navigate important safety issues that could be impacting employees. 

[00:02:44] Lorraine Martin Our mission statement is to save lives from the workplace to any place. So we look at those things that are preventable, things that we can take action around and make sure that we create a culture of people being safe in their workplace beyond, in their communities. So literally, we can all live our fullest lives. We have more than 13,000 members that are members of the National Safety Council, including federal agencies, and that represents about 41,000 work sites around the nation. And what we do is we tackle the big issues. We look at the data, what’s causing people to get injured or to lose their life, and what can we do about it. So back in 1962, we led the National Educational Campaign about seatbelt use, and then two years later really campaigned the issue of how to drive defensively. And in the 70s, we advocated for the formation of OSHA, which is our government agency that helps make sure workplaces know what’s safe. So we’ve been looking at all of the issues and the dangers that we face in our daily lives, and they change. So today we are looking at the data and informing workplaces about the dangers of opioid overdoses and really advocating for lawmakers to pass legislation. 

[00:03:53] Narrator Something the National Safety Council emphasizes is building a strong safety culture at work that includes having lifesaving tools like naloxone on job sites. 

[00:04:03] Lorraine Martin So we often talk about building a strong safety culture and having your safety culture be truly of value, not a priority, because priorities can change day to day in your life, in your workplace. So really understanding that safety is the top value, that everyone has to go home safe at night or whenever their shift ends and understanding that we all play a role in making not only ourselves safe, but those around us, and that every employee feels safe not only to do their work, but to raise concerns and bring their voice. And that’s where you get to the culture issue, that you really have an environment where leaders value employees input. They respond proactively to the issues that might be putting them at risk. And there’s never any kind of blame or punitive actions. It’s all about making sure that everybody gets to live their fullest life, whatever that might be. 

[00:04:53] Narrator Desiree Voshefsky is a community impact manager at Community Medical Services for Eastern Arizona. In her role, she hands out naloxone to local businesses and says that many businesses want to have the power to keep employees and community members safe. 

[00:05:07] Desiree Voshefsky I think it’s important for businesses to be trained on how to use naloxone because you never know if somebody, whether it’s in the workplace or outside of the workplace is going to overdose you. You honestly just don’t know. It could be a fake pill that they thought was something else or, you know, anything like that that can happen. Again, anything could happen. As far as having that medication on hand, I think is the first step and not being afraid to have it on hand either, because I do see that a lot. We went out with the Tucson Fire Department. A lot of the businesses were grateful that we came around and handed out. We did, you know, hit some stake in my own with some people that were kind of like, why are you doing this? I’m not going to use this, that kind of thing. And, you know, just insuring them that there’s limited liability that comes around with it, that they’re able to administer it and it doesn’t have an adverse effect if somebody is not in an overdose. And just continuing with the message that it’s better to have it and not need it and need it and not have it. 

[00:06:07] Narrator Cal Beyer, the senior director for SAFE Workplaces at SAFE Project, a nonprofit dedicated to helping overcome the addiction epidemic in the United States. As part of their SAFE Workplaces program, they provide employers and employees with the tools and resources necessary to address issues of behavioral health and achieve emotional well-being in the workplace. Like Lorraine, Cal believes that the culture at an organization is key to employee safety. For Cal, this begins with having open conversations about mental health. At SAFE Project, they encourage employers to create a wellness culture. 

[00:06:43] Cal Beyer There’s a lot of stigma associated with mental health, and especially when you think about substance use disorder or suicide prevention. You hit barriers when you talk about mental health, suicide prevention, overdose prevention in the workplace. So this concept of building a wellness culture is a gateway, a best practice to avoid that stigma of mental health. I encourage organizations to focus on the intersection of physical health and emotional well-being, and this requires leadership support to build a caring culture, so break down that stigma. But to build that culture requires really intentional effort. It requires a strategy. It requires data from various sources. Thinking about your success with recruiting and retaining staff. And then really being intentional about building an inclusive and respectful workplace culture. I think the biggest challenge that I’ve seen and the outcomes that are driven when organizations are intentional about building in positive employee experience to give a concierge approach to the employee, to let them know that they’re seen, heard and understood in the workplace, give affirmation, give recognition. And doing that by recruiting people intentionally who are going to align with the vision and values of your organization and then take time to adequately orient a new hire and onboard them, giving them career path opportunities for future development. And if you go a step further and go to wellbeing, you’ll combine physical health, nutrition, hydration, sleep along with emotional well-being, things like resilience, mindfulness, teaching people, stress management. That’s how this becomes holistic and that’s how organizations are going to have more success driving positive outcomes. 

[00:08:49] Narrator Part of a robust safety or wellness culture includes having resources for people who are in recovery or who struggle with opioid dependency. These issues don’t disappear when someone clocks in. As someone in recovery, Desiree knows what could make a workplace recovery friendly. She says it’s often about the basic things that many of us take for granted. 

[00:09:09] Desiree Voshefsky I do think the stigma does affect the person that is seeking employment. A lot of it is a lot of self-doubt. You know what’s going to happen if, again, in an argument or what happens if, you know, there’s a lot that goes into it. I think when a person is coming into the workforce that’s new to recovery and things like that, there’s a lot of self doubt. There is a lot of this may be the first time in ten years that they’re looking for a job. This is the first time that they’re having to deal with other people in the workplace that may not be in recovery themselves. So it’s kind of assimilating back into normal society, as you would call it. And that can be a challenge. And there’s a lot that somebody kind of has to go through because if you think about somebody that’s been using substances since they’re 14 and they’re now 32 and they’re just starting into the workforce, there’s a lot of things that need to be backtracked on what we need to prepare them for and prepare them to do, and that could be simplest things like sending an email, writing a resume, the how to answer the phone professionally, all that kind of stuff. We’re having to kind of step back and pretty much start at the basics. 

[00:10:19] Narrator Naloxone is an important tool to help prevent opioid overdose deaths in the workplace. However, both Lorraine and Cal have seen pushbacks from business leaders, sometimes due to stigma and also due to uncertainty about the legal implications of naloxone at their workplace. 

[00:10:35] Lorraine Martin So what we ask workplaces to do to be ready is to make sure they get education, that they have training on what the opioid crisis is all about, and then the naloxone is a mitigating tool for you. Now you get your training. And we provide free training at nsc.org for using naloxone and having a program in your workplace, and then make sure they’re making sure that you have naloxone at your workplace as you do any other emergency response. And companies have responded well to understanding that they don’t know what they don’t know. Many businesses truly they listen. They hear me out, but they have no idea unless it’s happened to them, that this is happening at workplaces. We also know that on this issue of substance use disorders, fentanyl and opioids and the harm they cause, there’s still a lot of stigma around that issue. And then helping business leaders really understand that we’re really talking about something that could impact anyone and in many cases has already impacted someone they know. And if they understand that it impacted someone in their life outside of work, to be able to translate that to it could impact someone also at work that you’re there to take care of, just like you are for any other kind of safety risk that might be about them. So they often bring up when I had no idea that the data was that much, we lose 200 people a day, 200 people a day in our country to an unattended overdose emergency that they lose their life and we can do something about it. So the first thing is education. And I will tell you, there’s a big gap. The second is giving them the tools. Once they understand, okay, I need to lean into this. The next question is always, well, I need to get my legal counsel involved to make sure I know that I’m not going to have any kind of implications if I lean into this. We have lots of resources there as well. We’ve gotten a law firm to help us with a legal brief to address the issues of Good Samaritan laws in each of our states. But they worry about that and as they should. And truthfully, when they were asked about defibrillators and putting AEDs in their workplaces, they had those same questions. Right. But we got through them. And we now understand that having that emergency response in our workplace is an imperative. Just like I am hoping naloxone will be in the same situation going forward. Quite a few are starting to stock naloxone, which is great. Very soon we’ll be able to have a list of companies that are willing to be those first leaders and have us talk about them. So we’re just getting really close to that. And about 50 percent of employees in a recent survey that we did indicated that having naloxone onsite was something that they were interested in doing it about. Only 20 percent of worksites actually have really leaned into this. So there’s a lot of work for us to do and a lot of lives that we can still save. 

[00:13:22] Cal Beyer Have I seen resistance or pushback to having naloxone in the workplace? Yes, candidly. And I understand from a risk management perspective, the entirety of my career, there was a lot of emphasis around drug testing programs, drug free workplace policies, and there was a lot of concern that maybe the perception that the presence of naloxone on a job site could encourage active drug use. But the reality is there are many ways of an overdose. So there were many dynamics that we just need to recognize. The risk is real. The Bureau of Labor Statistics has identified 10 years in a row the number of occupational fatalities attributable to an unintentional overdose is increased, and it’s now 9.5 percent of all occupational fatalities in the workplace. So in an industry like construction that has the highest rate of overdose among all other industries, we’re more likely to need naloxone on a job site to help revive an individual than we are possibly to use an AED. So we need to normalize this conversation. We need to recognize that this is part of being a prepared workplace building in naloxone training and stocking of naloxone on job sites to be able to respond appropriately to in a medical emergency and a risk management approach would show this makes good business sense. And it’s not only the right thing to do. It’s the humane thing to do. It’s the moral thing to do, but it’s the right business thing to do as well. So this should be an area of alignment. We should start seeing a lot less stigma as we educate more people about the reality and the risks and break down the myths and the disinformation or misinformation that’s been provided, and to just acknowledge let’s save lives. That’s what this is all about. 

[00:15:29] Narrator Another element of preventing overdoses in the workplace is the role of government. In Ontario, Canada’s most populous province, the government has been making efforts to ensure naloxone is in the workplace. Dr. Joel Moody is the chief prevention officer and assistant deputy minister for the Ontario Ministry of Labor, Immigration, Training and Skills Development. 

[00:15:51] Dr. Joel Moody June of 2023, the Ontario Occupational Health and Safety Act was modified and it required that naloxone be available in some of those workplaces where a worker has an opioid overdose or have risk to have an opioid overdose. So for employers to understand that they must provide that kit on site, an employer becomes aware or ought recently be aware, that’s the way it’s written in the legislation. They had to understand these tests. You know, first, that there to be a risk of worker opioid overdose in the workplace. Second, that the risk that the worker overdoses while in the workplace where they perform the work is for that employer. And then the work risk posed by the worker is also performed by the worker for the employer. So it provides a test that if all of those criteria are present, then the employer must comply with those Occupational Health and Safety Act requirements to provide naloxone in the workplace. So within the Ontario context, we’ve been very fortunate to work with some great members and stakeholders. So I’ll give you a little background. So the Workplace Naloxone program was launched in December of 2022. And for two years, the government provided free naloxone kits, nasal naloxone to businesses that were at high risk for opioid overdoses. It provided free training that was incorporated for their staff to equip them with the tools, the knowledge, the experience about how to respond to an opioid overdose. And the program has been very successful. If I could, you know, tell you about some of the numbers within that period of time, over 6000 workplaces participated, and that resulted in over 5600 workers being trained and delivering of over 5100 kits to workplaces. We still have a lot to do. The opioid epidemic is still very much still happening. But we want to find ways that we make a difference by reducing the stigma of individuals that may have a substance misuse problem as well as how do we ensure that in Ontario and maybe other jurisdictions, but definitely within Ontario we have both the healthy safe workforce because that does add to the productivity within the province as well. 

[00:18:40] Narrator Some industries are higher risk than others for a wide variety of reasons. A major factor is manual labor. In physically demanding professions, the risk of workplace injury and a subsequent prescription for an opioid is higher. 

[00:18:53] Dr. Joel Moody The profile for workplaces by risk is not the same. So when we look at the evidence or look at the data, one of the research groups that’s here in Ontario has done some work, and that is coming from the Institute for Work in Health, or IWH, they recently released a study that looked at injured workers that were found on construction sites, materials handling and processing applications. And their work, they identified that these were high risk sectors in which you saw opioid poisonings were three times higher for formerly injured construction workers compared to the general population. Another research that has also been done here in Ontario took data from Public Health Ontario, the Ontario Drug Policy Research Network, the Office of the Chief Coroner, in which they looked at data from 2018 to 2020, construction, retail trades, the transportation and warehousing sectors. And that work also identified that those were the top occupation groups among individuals who had died from an opioid poisoning. So some of the work that we’re doing is we’re taking those data and understanding better. So, for example, we know that about 1 in 13 opioid related deaths in Ontario between 2018 and 2020 occurred among construction workers. And so our Ontario Workplace Naloxone program saw the highest participation from that sector construction, and that was about 25 percent of those workplaces, 14 percent were from health care and social services, and another 12 percent were from the manufacturing sector when we ran the program December 22 to March 24. We also know that when we understand the data and understand the epidemiology, that most opioid related deaths involve a combination of opioids with other drugs and alcohol, and this is possibly reflecting upon the reliance of nonprescription opioids to manage unresolved pain. And you can see what that’s an item within the construction sector where sometimes the workplace culture, lack of job security can lead to underreporting of injuries and also wanting to get individuals back to work sooner. 

[00:21:31] Cal Beyer There’s a couple of reasons why the construction industry has stood out as well as the extraction industry, but it’s been heavy, hard manual labor that does lead to an increased number of musculoskeletal injuries. And evidence shows the more likely users of opioids were individuals with those musculoskeletal injuries. And the frequency of opioid prescriptions increased with multiple repetitive musculoskeletal disorder. So that’s a really important issue. To me, that first dose prevention strategy starts with safety and injury prevention, injury reporting, injury management, and then educating employees about the risks of opioids. What I think is also important to recognize is we need to do more about workplace design and human factors engineering to reduce the repetitive motions, especially to shoulders, necks, knees and backs, using more material handling equipment on job sites to reduce repetitive lifting, lowering, twisting, turning and carrying of heavy loads. Those are some of the strategies for injury prevention that many companies are being more intentional about. 

[00:22:58] Narrator Despite many of these compelling arguments, Lorraine has met with business leaders who feel that opioid use and overdose is not a workplace issue or not something that employers should be concerned with. 

[00:23:09] Lorraine Martin So one of the things when I talk to leaders and I bring them the data and I start to help them understand that this is happening at workplaces is they’ll often say, well, not our employees. You know, we hire a different kind of employee. And I will say there’s also a bridge you have to get past when they may have had a situation, but it was a contractor, not one of their employees, that perhaps had this emergency. And there is all kinds of stigma wrapped into all of that regarding who this is really affecting. Give a little story here that that is firsthand for me because it’s one of my reports. Her son-in-law was at work. He hurt his knee doing whatever physical activity he does. His body says, I’ve got my prescription in my pocket, my painkiller here. This will help me get you through your shift. This was not someone who had a substance use disorder. They were trying to get through their shift. Their buddy gave them something they’d gotten over the Internet. It had fentanyl in it that the son-in-law of my employee was blue and dead in their bed that night. Thankfully, their spouse somehow woke up, was able to call 911, got naloxone into their place. The gentleman was able to live, but this was just an employee trying to get through their shift. And what happened to him? I would call a poisoning. He took something he didn’t know what he was taking, and it caused him to potentially lose his life. Those kinds of stories, when you can can bring it home either through a workplace related incident like that or a family member situation, or telling a story about someone who just was recently working for the White House and had been in recovery and had been saved several times herself. And now as a lawyer, you got to bring it home that this can hit anybody. This can hit anybody. And you don’t know what your employees are wrestling with, whether it’s, you know, an injury at work and someone gives them something that poisons them or having a substance use disorder that needs to be addressed. So stigma plays a big issue. And again, it’s about education, it’s about awareness, it’s about storytelling, and it’s about understanding that if that emergency is happening in front of you, there is no response other than having on hand the thing that can save that person’s life, period, end of story. No judgment belongs in that equation in any way, shape or form. 

[00:25:26] Narrator The fact that opioid use disorder and overdose is a workplace issue is clear from some of the examples that came out of Ontario’s program. Because of the training provided, employees were able to save lives. 

[00:25:38] Dr. Joel Moody Happy to to share a story that was conveyed to us as we have gone through both the program. We’re in the process of evaluating the effectiveness of that program. But a story that came to us was in the Greater Toronto area, which is what we refer to as the GTA. Within about a nine day window, there was a grocery store happen about March of 2022, two situations where naloxone training and the kits provided under the workplace naloxone program were used to save a life. And the first incident, an employee found their colleague unresponsive in a washroom. The second incident occurred at the exterior of a building. In both cases, the worker was able to, number one, identify the signs of the opioid poisoning. Number two, being able to access the naloxone that were in the kits. Number three, administer the naloxone, and they also had to provide CPR to her to revive one of the employees. And both cases, they prevented a fatality. 

[00:26:50] Narrator Desiree emphasizes that people in recovery can hold jobs and are in the workforce. Like in many places touched by the opioid crisis, stigma creates barriers. 

[00:27:01] Desiree Voshefsky I think a lot of it has to do with stigma, just personal, people not knowing what substance use disorder is, what opioid use disorder is, and not seeing it as a way that people that have these substance use disorders maybe still be able to hold a job. People in a recovery can still hold a job. We know people that are even actually using and call it functional substance use, they can actually have a job, too. So it can be a variety of ways and there’s different levels to substance misuse. It could be somebody that is taking prescription pain medication that kind of gets stuck and is become dependent on them now. So there’s kind of all levels to it. And I think that the more that we don’t talk about it, the more that we’re hurting the person that’s either seeking the job has a job or may need some help to continue doing their job. 

[00:27:52] Narrator Cal also emphasizes that beyond providing naloxone, workplaces can become recovery friendly. Many people in recovery are still going to work or are looking for employment. Lowering barriers to being in the workplace while in recovery is good for everyone. 

[00:28:07] Cal Beyer The idea of a recovery, friendly or recovery ready workplace is going to continue to expand. This has been a really positive movement. Individuals in recovery and there’s at least 21 million based on data that are in recovery. And there is evidence 70 percent of individuals with substance use disorder are in the workplace. So what a recovery-friendly workplace will do is create fewer barriers for employment, reduce the discrimination, create new career paths and give people a fresh start at a career. There is evidence that shows recovery ready workplaces are going to be more productive. They’re going to have less turnover. They’re going to have reduced health care costs. So in every angle, there’s a lot of evidence why this is important. I was one of the individuals selected by the Legislative Analysis and Public Policy Association to partner on building a model recovery ready workplace statute. There’s great information about the power of building recovery allies. And so that’s something that we’re very supportive of. But the hallmarks of a recovery ready workplace are going to be acceptance and affirmation, reducing that stigma and then the need for some flexible policies, especially around leads as individuals may need time for doctors and therapy and for ongoing recovery support. Those organizations that see the value in that flexible leave policy are going to get the benefit of more engaged workers. And then another hallmark has been peer to peer support and mentoring programs. And that even includes on site recovery meetings. But the biggest part, and it’ll be the most challenging, is going to be providing training on an ongoing basis to all employees to let them know as well people in their life may benefit from recovery, giving people a pathway to learning more, sharing resources so they can support family members or even start a recovery journey themselves. That’s what I’m excited about, this idea of recovery ready workplaces. 

[00:30:34] Narrator Lorraine believes that many workplaces and members of the public have gotten to a place where overdose is seen as an emergency like any other. And just like other emergencies, like a heart attack, the tools to save someone’s life should be close by. 

[00:30:48] Lorraine Martin So being trained to address it, just like we all went through our CPR training or other kinds of emergency response, I think is the place to start. And the fun or really exciting thing about any skill that you give an employee is they take it with them, right? Whether that’s how to drive safely or do CPR or be able to respond to an overdose. They take that with them. They take it with them when they’re on the battlefield, when they’re in their communities, and they save lives truthfully for those skills that you give them. And it’s traumatizing, truthfully, when someone around you as an emergency and you can’t you can’t do anything about it. We have workplace incidents like that all the time. And it’s not just the person in their family, which is traumatic and horrible. It’s everybody around that witnessed it, that knew that person, maybe didn’t know that person, but is in the organization where that valuable team member is no longer here. It’s a ripple effect. So knowing how to have this very simple tool and training is something that I hope everyone will lean into so that when that emergency happens, you can really be the person who saves a life. And the difference between saving that life and having someone perish in front of you because you didn’t have the skills or the tools is really just momentous. 

[00:32:02] Narrator Through his work, Cal has worked with numerous people and groups who are making an impact on this important issue. You can learn more about them in the description of this episode. He’s generally encouraged the conversations about overdose, opioid use disorder and mental health are becoming more common in workplaces. 

[00:32:20] Cal Beyer This idea of help seeking and help accepting starts with help offering. When coworkers identify that someone is not well and asks, Do you need support? How can I help you? It goes a long way to a person saying I’m going to be accepted for who I am. And this idea of no shame is filtering through many industries, many more organizations, and people are getting more help. So I’m especially encouraged by the example of the construction industry. There’s probably 40 different organizations that have provided tokens, chips that have 90 day information in the logo of organizations to say we stand in support and we’re going to support the efforts around the mental health suicide prevention crisis line. I’m just excited about more conversations becoming more natural and being more at the peer to peer level and people worrying less about the privacy confidentiality barrier that didn’t let people seek help in the past. 

[00:33:29] Narrator Opioid use disorder is something that affects every aspect of someone’s life, including work. To keep everyone safe, workplaces should be providing naloxone and the training on how to administer it to employees. Additionally, creating workplaces that encourage holistic wellness and that are supportive of recovery is good for everyone at the workplace, employers included. To learn more about the work being done by the National Safety Council, SAFE Project and the Government of Ontario, please visit the episode description. We’ll also find resources for free training and information for employees and employers alike. Thank you for listening to this episode of Countermeasures. To learn more about what Emergent is doing to help address public health challenges like the opioid crisis, visit www.emergentbiosolutions.com. If this episode resonated with you, consider rating and reviewing Countermeasures on your preferred podcast platform.