By Mark Couch
(May 2014) Ingrid Binswanger, MD, MPH, MS, associate professor of medicine in the Division of Internal Medicine, joined the University of Colorado School of Medicine in 2006. She received her medical training at the University of California, Berkeley/University of California, San Francisco (UCSF) Joint Medical Program and completed her residency at UCSF. Currently she is director of the Primary Care Research Fellowship and the Patient-Centered Outcomes Research (PCOR) Scholars Program.
In November 2013, Binswanger coauthored an article in the Annals of Internal Medicine that reviewed the use of opioids as a factor in the deaths among recently released prisoners.
Q: What brought you to the University of Colorado School of Medicine?
I trained in primary care, internal medicine, and then I did a research fellowship at the University of Washington with the Robert Wood Johnson Clinical Scholars program. I was looking for a faculty position in an environment that would support me as junior investigator and I found a position here with Jean Kutner in the division of general internal medicine that fit the bill.
In this recent article, you looked at mortality after prison release. How did that topic become something of interest to you?
I’ve been interested in issues around the intersection of criminal justice involvement and health as well as medical complications of drug use for a long time, probably since I was a medical student. Initially, I was interested in thinking about how we could deliver preventive interventions in correctional settings to try to improve the health of some of our most vulnerable populations. Individuals who interact with the criminal justice system can be very vulnerable from social, economic and medical perspectives, as well as frequently having problems with drugs, alcohol and mental health issues.
I thought if we could design interventions and try to improve the health of this population, we may really be able reach an important group that has consequences. And so when I moved to Washington state, I met the health services director of the Washington Department of Corrections and I spent some time in Washington, D.C., at the Bureau of Justice Statistics, and that’s where I got the idea initially to look at the mortality experience of people coming out of prison.
This study is really a follow-up to a project that we’ve been working on for a number of years to try to understand the health outcomes of people as they transition from correctional institutions back into their home communities.
You found that in the recently released population that opioids were involved in 14.8 percent of all deaths.
That’s correct. Opioids include pills like oxycodone or hydrocodone, commonly known by brand names like OxyContin and Percocet. But opioids also include heroin. We knew from our prior work that there was a high risk of overdose after coming out of prison, but what we found in our more recent work, in Washington state at least, is that opioids are now representing a larger share of the overdoses and the complications that we’re witnessing after release from prison.
This is also true in the general population. Drug overdose now exceeds motor vehicle accidents as a cause of death in the United States.
Is it because it’s easier to get these drugs or is it because the concentration of these drugs is more potent than it used to be?
Probably both of those factors play a role. Physicians have become much more liberal about prescribing these medications. We’ve become much more attentive to treating pain. And that’s a good thing. But on the other hand, these pills can be very potent and they do have dangers associated with them. And so I think we need to exercise as a physician community more thoughtfulness and caution in how we manage these particular medications.
How would you do that?
I think there are a number of strategies that are being tried in the general community. I’m part of the Colorado Consortium to Reduce Prescription Drug Abuse and that group is looking at a number of strategies to try to address this problem. That includes physician education. It includes encouraging safe storage of the medications in the home. It includes thinking about improving access to drug treatment among others. So there are a lot of strategies being tried.
I think there are two main strategies that I and my research colleagues have been interested in. The first is that we’ve been trying to develop ways for people to safely store their medications at home so that youth or people who are not the intended recipients of the medications don’t get access to them. That’s what I call primary prevention.
The other thing we’ve been working on at the other end of the spectrum is trying to find ways to increase access to a drug called naloxone, which is an opioid antidote and this is a medication that can reverse all signs of respiratory depression in someone who has taken opioids.
Sometimes more than one dose is required if someone is on a long-acting opioid. It doesn’t replace calling 911 in the event of an overdose, but it’s the kind of drug that could be a safety net for people at risk to have around the house or other places where they are. We have a grant from the National Institute on Drug Abuse to look at this to find out how physicians feel about prescribing this medication and also how patients on pain medications feel about receiving this medication.
One of the statistics cited says that 4.6 percent of persons 12 years old or older reported nonmedical use of pharmaceutical opioids in 2010 and 2011.
That’s data from the National Survey on Drug Use and Health. Non-medical use of opioids means using opioids without a prescription or having a prescription and using them for the feeling that they cause.
The rates of nonmedical opioid use in this country are staggering to me personally, and Colorado is the second-leading state for nonmedical pharmaceutical opioid use.
The use of these medications is very widespread for non-medical purposes and very risky because some of the medications can be quite potent, and for individuals who don’t have tolerance to the medicine, they can in particular cause respiratory depression and death. They can be taken by kids or young people who may obviously experience complications at lower doses than adults.
You note that people in prison may have a forced abstinence, and so may have a lower physiological tolerance when they come out and therefore have a higher risk of overdose.
And that phenomenon applies to a number of settings. The part that’s complicated about this particular medication is the tolerance effects. Some of the strategies that we think are intuitive and would make sense for another drug don’t apply to this particular scenario, and that’s because if you suddenly cut someone off who’s addicted or dependent on opioids and they stop them, they have a period when they are not taking them. The problem there is that when [they] relapse—if they relapse— their risk of overdosing is very high.
Not only is prison time, in the absence of any treatment, risky after release, other interruptions in treatment are also risky. If you send someone to an abstinence-based detox center, for example, then those individuals, when they come out, are also at risk for overdose if they relapse. Or if somebody is hospitalized, and they don’t have access to the same amount of medication or opioid they might have been using before they were hospitalized, they also have a high risk of overdosing after they even come out of the hospital.
You talk about having publicly funded overdose education and distribution of anti-opioid programs to help reduce the risk of death for former prisoners. If you were to try to convince politicians why they should put money toward those kinds of programs, what would you say?
I think we can’t really ignore the problem of nonmedical opioid use, opioid dependence and overdose in our state. People are dying from this problem. Lives are being very negatively influenced by these problems, and I think we need a plan of action that would, in my opinion, include the whole spectrum of involvement with opioids and the complications of opioids, one of which is overdose.
If the plan is going to address those components, those different levels of involvement and complications, it would be nice if there was funding available for overdose education, prevention and naloxone distribution. The medication itself is very, very inexpensive and many of the educational programs that are currently being implemented are being done on a shoestring budget.
Would that be done through the community-based groups that try to help people with transition out of incarceration and into society again?
I think there are a number of sites where you might target these interventions. Some of the sites might be returning inmates in parole, or re-entry settings, or even before they come out of prison. You might also consider drug-treatment settings as a good opportunity to reach people at risk. And what we’re working on in our research now is looking at prescribing this medication to people on high-dose opioids for pain. That’s a different population, but also a high-risk group that I think warrants being properly educated about safety and response in the event of something untoward happening.
It’s in all of our interests to have people successfully transition out of the criminal justice system. I want that as a community member and as a parent. I think the just and ethical thing to try to do is to enhance that transition.