DAVID LEVIN: You’re listening to Harvard Chan– This Week in Health. I’m David Levin.
MARY BASSETT: Well, we’ve seen a real transition from handcuffs to help, and the idea that people who have problem drug use are people who need help, not punishment.
DAVID LEVIN: That’s Dr. Mary Bassett, Director of Harvard’s FXB Center for Health and Human Rights. In our last few podcasts, she interviewed experts in the field about new solutions to the opioid crisis that’s spreading around the country. Today, we’re going to flip that script. You’ll hear from Dr. Bassett about her time as New York City’s health commissioner, a post she held until coming to Harvard in early 2019. In this episode, she talks about her experience with Dr. Kimberlyn Leary, a psychologist at Harvard’s McLean Hospital who specializes in public health policy.
KIMBERLYN LEARY: Dr. Bassett, you’ve just joined us here at Harvard. You’ve been here about a year, is that right?
MARY BASSETT: Yeah. My appointment was announced about a year ago, and I actually moved to Boston in January of this year. So nine months by my reckoning.
KIMBERLYN LEARY: That’s terrific.
MARY BASSETT: Anyway, who’s counting?
KIMBERLYN LEARY: Now, in your previous role, you were the commissioner of health, the health commissioner for the city of New York.
MARY BASSETT: That’s right.
KIMBERLYN LEARY: Yes. Tell us, if you can, about what you saw in the city of New York as the opioid overdose crisis began to take shape and as it reached your desk.
MARY BASSETT: Yeah. Well, when I first arrived as health commissioner, we were all very concerned about the problem of opioid misuse and prescription opioids in Staten Island, which is one of the five counties that makes up New York City. And there, they’d seen a real increase in the number of fatal overdoses related to prescription opioids, painkillers. Really, we thought of it as a Staten Island issue because they had the highest rate of fatal overdoses in the city.
And the previous commissioner had already been to Staten Island to talk to the medical community about what we called judicious prescribing because, in many ways, this current opioid overdose crisis has its origins in health care worker’s prescribing habits. So that had been our focus that we needed to make sure that people weren’t over-prescribing opioid painkillers. And our focus was on Staten Island.
That was all going to change. The number of fatal overdoses continued to rise in New York City. When we looked at where the deaths were occurring, the bulk of them were in Bronx and in Brooklyn. So thinking about it as to Staten Island was not right.
KIMBERLYN LEARY: So that was the first bit of new insight about this. This was not just a localized Staten Island–
MARY BASSETT: No.
KIMBERLYN LEARY: –concern.
MARY BASSETT: That’s correct. But it was different than our previous heroin epidemics. New York City’s been a heroin town for a long time. But this time, the typical victim, if I can use that word of a fatal overdose, was a white, middle-aged man. And that was different.
KIMBERLYN LEARY: Mm-hmm.
MARY BASSETT: But it quickly also became clear that heroin was a problem, not just prescription painkillers. So we came up with a multifaceted approach. And I think a lot of the things that we are doing are what had been done around the country where we’ve seen people bend the curve and see the number of fatal overdoses decline, which we have now as a nation.
KIMBERLYN LEARY: So you said a couple of really important things, it seems to me. The first is that the opioid overdose crisis has its origins in prescribing behavior, in the way in which our prescribers– physicians, nurses, and others– how they have responded to requests for pain medications. Tell us a little bit about what it was like when that understanding kind of came into your sense of the challenge.
MARY BASSETT: So we began by thinking we just had to focus on the providers and convince them to prescribe more judiciously. I mean, if you asked a roomful of people, how many of you have ever gotten a 30-day course of OxyContin, one of the principal prescription painkillers, a lot of people would raise their hands. They might have gotten it from their dentist. They might have gotten it for some fairly minor problem, and they got too much of it.
New York City has very good surveillance, and we kept clocking an increasing number of fatal overdoses. So our work wasn’t keeping up with the risk to people’s lives. And this really got worse when fentanyl entered the drug supply. And across the country when you see this uptick often beginning around 2014– in New York City it was later– it’s because fentanyl had entered the drug supply, and it’s a much more potent opioid than heroin.
KIMBERLYN LEARY: You observed earlier that you started to see, at the outset of this overdose epidemic, that the prototypical person who was coming into the emergency room or coming to the attention of law enforcement was a middle-aged white male.
MARY BASSETT: That’s right.
KIMBERLYN LEARY: Yeah. And that’s, unfortunately, when we think about our stereotype of a person who’s using drugs, it’s often not someone who is a middle-aged white male.
MARY BASSETT: That’s right. The previous waves of opioid epidemics in New York were heroin epidemics, and they were confined largely to black and brown communities. And so that’s how people thought about people who were dependent on heroin, that they were black or brown. And in the last round of heroin in New York, because these things happen in waves, it was greeted with a blistering criminal justice response, what we now call the war on drugs.
KIMBERLYN LEARY: Right. So the war on drugs, when we think about that, we have to appreciate that it was a war on drugs users who were mainly black and brown.
MARY BASSETT: That’s right.
KIMBERLYN LEARY: Mm-hmm. And as the picture of you started to change with the advent of opioids and fentanyl, and we saw this older demographic, white and male, how did the approach, or the thinking, or just the framing, the concerns about opioids, how did that begin to change?
MARY BASSETT: Well, we’ve seen a real transition from handcuffs to help, and the idea that people who have problem drug use are people who need help, not punishment. This is the right way to respond to our current overdose epidemic. But it wasn’t the way that we saw the response occurring when it was burdening mostly black and brown communities.
KIMBERLYN LEARY: So it’s a differential–
MARY BASSETT: So for many of us, it feels bittersweet. I lived through– I was a resident in training in Harlem in the ’70s and ’80s when we saw heroin taking a terrible toll. And we didn’t see the kind of empathetic response that we’re seeing now. The response now is the right one. But there’s no doubt that it has to do with who is being affected, that it’s affected a white population.
KIMBERLYN LEARY: So we’re going in the right direction, but we still need to do more, more of a public health approach. And it sounds like you’re also saying we need to begin to address stigma in the way we enforce and punish people who have public health problems, who have a medical set of symptoms that needs a medical response.
MARY BASSETT: That’s right. I think the most useful way to think of people with problem drug use is that these are people with a chronic illness. It will be a relapsing illness, just as many people with diabetes find that their blood sugar goes out of control from time to time, or people with high blood pressure.
So not only do we not need to punish people at the front door, we need to ensure that we abandon these two strikes, one strike, three strikes you’re out, and we understand that things happen and that people need to be returned to treatment, be brought to a safer place and kept alive.
So yes, that’s the public health approach. We want to prevent deaths. We want to prevent problem drug use by working with providers. And we want to ensure that people understand that we have tools to effectively treat their addiction, but it’s never going to be simple.
KIMBERLYN LEARY: Let me ask another question about the effective treatments, because I think that is news that many families would welcome, knowing that treatment exists, and some of those treatments are use medications, medication-assisted treatment. I wondered if you might tell us about your experience in New York City where, as I understand, one of the oldest and largest jail-based opioid treatment programs in the country was situated and offered both methadone and a newer medication, buprenorphine, to patients. Can you tell us about that and what you saw?
MARY BASSETT: Yes. Sure. Now, New York City had a methadone treatment program in its jails for over 20 years. It’s unusual. These are people who are mainly pretrial or people who are spending a one-year sentence in the city jail and if they could be placed on methadone. And that was a very important achievement for the New York City jail system. Many criminal justice settings don’t permit any treatment. They only allow you to so-call detox.
And the data, actually, it’s Massachusetts data, show a huge increase in risk of fatal overdose for people after they leave incarceration. It’s, like, 120-fold increased risk of fatal overdose. So in New York, methadone had been used as treatment in the jail system for a long time.
But quite recently, they began buprenorphine, which is a drug that can be given in a primary care setting and which people can continue to get from their primary care provider. You don’t have to go to a methadone treatment center. And of course, it can be prescribed in jails. It can be prescribed in emergency departments.
We could get people onto treatment a lot faster. And we could keep people a lot safer, because the safest way to recover from problem opioid use in which you have dependence is to be on medications. I personally don’t even like the phrase medication-assisted treatment, because we don’t talk about a person with diabetes being assisted by insulin.
KIMBERLYN LEARY: That’s true.
MARY BASSETT: They need insulin. And just as the same analogy, people with problem opioid use need medication. It gives you the best chance for recovery. And this language around being clean and so on makes people feel demeaned by treatment when they should be proud of being in effective recovery.
KIMBERLYN LEARY: You know, it seems like we keep trying to find one villain, rather than recognizing the ways in which– we’re in the midst of what’s been called a wicked problem. Not wicked because it involves bad people, but wicked because there’s so many different interdependencies, that this challenge that we’re facing in our communities across the nation right now, as well as here in Massachusetts, is based on the behavior of so many different sectors, so many different professionals, individuals. It really is a problem that looks different, depending on whose eyes you’re looking through at any one time.
MARY BASSETT: Probably the most complex of the issues is a need for all of us to work to undo stigma. People should be able to say, I have a sister, brother, cousin, friend, partner who has been in recovery, and I’m really proud of them. Not just they got this great job, or they graduated from some famous college. It takes real courage to recover, and we should celebrate it.
KIMBERLYN LEARY: Well, thank you very much, Dr. Bassett.
MARY BASSETT: Thank you, Dr. Leary.
DAVID LEVIN: Special thanks to Drs. Mary Bassett and Kimberlyn Leary for sitting down to this interview. To hear more conversations with public health experts and learn about new solutions to the opioid epidemic, visit our website– that’s hsph.harvard.edu.
Before Mary Bassett was director of Harvard’s FXB Center for Health and Human Rights, she was New York City’s Health Commissioner. Bassett talks about her experience dealing with the growing opioid epidemic in the city—what worked, what didn’t, and what New York can teach other cities coping with the same problem. She sat down with Kimberlyn Leary, an associate professor at Harvard Chan School and a psychologist at McLean Hospital who specializes in public health policy.
You can subscribe to Harvard Chan: This Week in Health by visiting Apple Podcasts or Google Play and you can listen to it by following us on Soundcloud, and stream it on the Stitcher app or on Spotify.