EP76 Championing Harm Reduction with Danielle Ompad

I am GPH, I am GPH, I am GPH, I am GPH, I am GPH, I am GPH, I am GPH, you're listening to the I am GPH podcast where we bring you community conversations from the New York University College of Global Public Health. From student internships to cutting edge faculty research, from alumni insights to the insider scoop on campus life. It's all right here on the IMGPH podcast. Hello everyone and welcome to another episode of IMGPH. My name is Alexandra Riaga and today we are going to talk to our own Dr. Daniel Ampad, who is an associate professor of epidemiology here at NYU's College of Global Public Health. As I mentioned, she is an epidemiologist and her work is focused in the areas of urban health, HIV, illicit drug use and adult access to vaccines. With respect to illicit drug use, her work has banned the entire natural history of addiction, from initiation to cessation, with particular attention paid to risk for infectious diseases such as HIV, hepatitis B and C and STIs. She has primarily worked with people who use heroin, crack, cocaine and/or club drugs. Please make sure to join us because we are going to be discussing the concept of harm reduction, drugs in the workplace and tackling the opioid crisis. I am here with Dr. Daniel Ampad, how are you doing today? I'm doing really well. Well thank you so much for joining us. I would like to begin by asking you about your story. Can you tell us a little bit about your background and the intellectual trajectory that led you to be doing the research you are currently working on? Sure, so what may be interesting for people to know is I was actually an Air Force brat. What do you know about that? Yeah, so I spent my childhood moving around. I lived in the US and in Europe. And when I was about 11 or 12 years old, I read a novel by Robin Cook called Outbreak. And it was about this female epidemiologist who was running around the United States investigating Ebola outbreaks. And at that age I decided that's what I want to do. I want to be an epidemiologist. And it's a little unique because people of my generation often came to public health and to epidemiology after they'd already studied medicine or nursing or had some type of clinical experience. So I was very unusual in that I wanted to be an epidemiologist like even when I was in high school. The other thing that kind of influenced me and got me working in this area is when I was in high school, I was a debater. So I was actually a little bit of a nerd and a captain of the debate team. And in my senior year, junior senior year, I forget, the debate resolution for policy debate was about homelessness. And so we came up with this really innovative debate brief that argued that Native Hawaiians were homeless because their monarchy had been overthrown by the US government. And so by definition, all Native Hawaiians were homeless because they had lost their homeland. And in the process of researching that debate brief, it became very clear that Native Hawaiians had some of the worst outcomes among people living in the islands. They had like the highest suicide rates, the highest diabetes rates, the highest obesity rates. And so as a high school student, I was like, this is really messed up. This is their land. And they have some of the worst outcomes. They also were among the poorest people. And so I really became interested in health disparities. So fast forward to graduate school. I went to Johns Hopkins. And at the time, I was really interested in emerging infectious diseases. So I had red-lory carrots, the coming plague. And when I was born, there was no HIV. We didn't know about it. That's how old I am. And so I was really interested in HIV. And again, it became very clear as I was growing up that HIV was not randomly distributed in the population. Some groups were more affected than others. And some of those groups were really stigmatized, marginalized, like people who used drugs and gay, bisexual, and other men who have sex with men. And I just was not down for those inequities. And so when I was at Hopkins, there were two major domestic studies of HIV. One was the multi-center AIDS cohort study or the max. And that was primarily among gay, bisexual, and other men who have sex with men. And it was primarily a white population. The other study was the alive study, which was the AIDS link to the intravenous experience study. And it was a study of people who inject drugs in Baltimore. And it was more diverse. So the sample had white and African American participants. And because I was really interested in racial and ethnic disparities, I ended up doing my master's thesis in that data set. And so that's how I started working on issues related to drug use. Amazing. What a journey. Yeah, it's been, it's been an amazing journey. The people that I worked with as a student, like I, if you saw the wire, I was working in some of those neighborhoods. The people that we worked with were really amazing. The participants in our study, they were really engaged. They were protective of us because they knew that we were there for a good reason. And they were my teachers. So I had professors who taught me epidemiology and biostatistics and about infectious diseases. But I also had teachers in the community who taught me really about drug use and what it's like to live in neighborhoods that are really burdened by a lot of social determinants of health. And they basically like treated me like a student and acted as though they were teachers. And it was just an amazing experience. And so what would you say your current research is? So generally, my research is concerned with drug use and its consequences. And primarily I'm interested in infectious diseases. So I study HIV, hepatitis B, hepatitis C, sexually transmitted infections like chlamydia, gonorrhea, syphilis, herpes, human papilloma virus. And I'm also interested in other types of consequences of drug use like overdose. And also the criminal consequences. But the criminal consequences in terms of how they impact health outcomes. And then what we call the natural history of substance use. So from initiation to cessation, how do people initiate drug use? When does drug use become problematic? Because not all drug use is problematic. And not all people who use drugs have a drug use problem. And then how people decide to stop using drugs or how they decide to reduce any harms associated with drug use. It's a very holistic approach. I try. And can you talk about the concept of harm reduction in contrast to the idea of abstinence? What's the difference? And what are the pros and cons? Okay. So I'm a, I should let you know from the outset, I'm a huge proponent of harm reduction. So harm reduction, particularly related to drug use is about meeting people where they're at and trying to reduce any of the harms associated with drug use. So those harms could be the risk for infectious diseases like HIV and hepatitis C and hepatitis B, the risk for overdose, the risk for sexually transmitted infections, the risk for incarceration. And so the outcome of harm reduction is not necessarily abstinence. Abstinence is along the harm reduction continuum, but it's not the goal for everybody. So the goal in harm reduction is basically to help people live the healthiest lives possible. And so what are some harm reduction strategies that can include things like needle exchange, right, or syringe exchange. So exchanging use needles for new needles. It could include safer injection facilities or safer consumption sites where people bring their drugs and use them in front of clinical staff who can help prevent overdose. Harm reduction includes having narchand available to rescue people who experience an overdose. Harm reduction could be drug treatment. So there's a wide range of activities that fall under harm reduction. Abstinence on the other hand is generally not using any drugs at all. But I always ask students, when we talk about harm reduction or, you know, I ask students, how many of you use drugs? And, you know, most people aren't going to admit it. Of course, I'm not going to tell you. But let me tell you some of a lot of us use drugs, right? So my drug of choice is caffeine and I drink a lot of caffeine, right? And it is a substance, right? The difference between caffeine and, say, opioids in addition to their mechanisms of action is their illegality and whether or not they're socially sanctioned. So a lot of us use substances with the changing marijuana laws, prevalence of marijuana use is getting higher. But marijuana is also a substance and it's interesting because a lot of people who, you know, smoke a joint or have an edible or, you know, whatever the case may be, may not consider themselves to be somebody who uses drugs, but in fact, you are. And so something that is really interesting to me is you're saying, well, let's work on harm reduction instead of abstinence. What do we say to the people that listen to that and say, well, but you're just helping these people use drugs? They're going to use more drugs. Can you drop some science on? Sure. So the first thing I would say is that for a lot of people, harm reduction is a low threshold entry into some type of care. So a lot of people who use drugs, particularly people who use drugs that are illegal or not socially sanctioned. Maybe people who are using methamphetamine or cocaine or heroin or non-medical use of prescription opioids experience a lot of stigma. And they're quite frankly not treated very nicely. They often go into emergency rooms and people may automatically assume that they're drug seeking. And so harm reduction programs are basically like, come to me as you are and let me see what resources I have to help you. And sometimes those relationships that are built over time can actually facilitate people getting access to other types of care, including drug treatment. But that's not always the goal. And so there's actually been studies that have suggested that harm reduction programs actually do not increase drug use. They tend to serve the people, the neediest people, right? So it may look like, you know, harm reduction programs increase drug use. But it's actually the people who are already needing those types of services are more likely to go. Interesting. And recently your lead author on a study that examined a list of all professions in the United States and discovered that construction workers were the most likely to use opioids and cocaine. Can you tell us about this study? Sure. So working with colleagues from here at NYU, Robin Gershon, who is an occupational environmental epidemiologist. She's here at the College of Global Public Health. Joseph Palomar, who incidentally is an alumni of the PhD program in public health here at NYU. But he's also faculty at the School of Medicine, Patricia Acosta, who works very closely with Dr. Palomar and a doctoral student named Simon Sand, who works very closely with me. We analyze data from the National Survey on Drug Use and Health. So we call this NSDUH. And it is a very large annual survey that basically looks at prevalence and incidents of substance use and treatment access in the United States. And so this data set from 2005 to 2014 had data on occupation. After 2014, they stopped collecting data on occupation, which is why we couldn't analyze more recent years. And so we looked at occupation and particularly construction trade and extraction workers versus other occupations. And we looked at three main drugs, marijuana, cocaine, and non-medical use of prescription opioids. And we basically found that when you compared construction trade and extraction workers to everybody else, they were more likely to use all three of those drugs. Wow. So this is a question that I personally have. As I was asking about your research, it felt kind of wrong to say, oh, construction workers are using opioids and cocaine. It sounded harsh. And I don't really want to say that in a way that is offensive or stigmatizing. So what are some tips to talk about the issues, certain groups or populations undergo without stigmatizing them? That's a great question. And in the last few years, we've actually really confronted the type of language that we use when we describe people. And so there's a big push more recently to use people first language. And so by people first language, I mean people who use drugs, right? As opposed to injection drug users or drug users or addicts, addicts is like the word that I hate the most. It's very judgmental. There's a lot of stigma associated with that word. And not all people who use drugs have problematic drug use. So the first thing I would say is we try to use people first language. The next thing I would say is that we really try to contextualize people's use. So not all use is problematic use and not all people consistently use. And so there's a continuum. So the data that we looked at was whether or not people had used drugs in the past month. Yes or no. We did not look to see whether they had a drug use problem. The other thing is what I worry about with this paper in particular and I've tried to make very clear when I've done interviews with the press is that we actually don't know when people are using. So we don't know that people are using at work. We don't know if they're using at home. We don't know how much they're using. We don't we know that they use at least once in the past month. So I don't I've been very careful to say that we don't actually know how many of the people that we analyze data from were actually working and impaired right because impairment is a big issue right because people they could be using at home or on the weekends or in the evenings and they come to work and they're good to go. They could be using a little bit you know pick me up or something to get them through the day and still be good to go right they're not necessarily impaired and these data are not such that we could clarify that question. So we try to be very basically very careful in in being very clear about what we're talking about using people first language and trying not to imply that there's anything bad about individuals. That's that's not what this is. Okay I like that and what does this new discovery mean for that profession what lessons can we learn from the new findings. Okay so that's a great question. One of the things that instigated this analysis is there was a report that came from the Massachusetts Department of Health and then there was another news report that came from Ohio and these reports demonstrated that construction workers in those states were six to seven times more likely to die. From a opioid overdose than people working in other occupations and so what this paper does is kind of quantify the level of use and we also looked at some correlates of use. So and the correlates that we looked at were kind of employment types of variables and what we found is basically people who are a little bit more precariously employed were more likely to use these drugs and then we looked at workplace drug policies. So whether or not they had written workplace drug policies and whether or not they did drug testing and whether that was associated with prevalence of drug use. So what was interesting I think is that the drug testing policies tended to have more and of be more associated with marijuana use than some of the other drugs. Yeah kind of surprising right like you would think like what we consider heart I don't really like this term but what we consider harder drugs like cocaine or opioids did not have a strong association with the drug testing policies as marijuana did. We don't know why this is but we have speculated a little bit one thing is that if somebody use cocaine and give me three people one person who's marijuana in the morning when he's in person who's cocaine in the morning one who used opioids in the morning right if somebody smoked marijuana in the morning you're probably going to smell it right so there's already an indicator that someone might have used something so they may be more likely to be tested if a company is testing right. But cocaine and opioids depending on how they're using them don't necessarily have an obvious smell right so just three people there the one who's smoked marijuana I'm going to smell it and if I'm a if I'm an employer who test I might decide to quote unquote randomly test you right. So that's one reason why we think marijuana is a little bit more affected by some of those workplace drug drug policies. And what is your end goal with these with this study are you wanting these findings is somehow affect policies or what's what's a main goal. So these data cannot really tell us a lot about what policies we should implement their cross sectional data meaning that we don't know if the drug policies actually reduce prevalence. We just know that there's an association and there's a lot of things that we don't know because those variables aren't available those data are available. So what I do think that this does is kind of raise awareness that this is an issue in the industry and I've when I was at the American Public Health Association conference I actually talked to some people from some construction worker unions and there's a growing realization that drug use is an indicator. Drug use is an issue in this industry and that drug treatment needs to be available there's concern more less about you some more about impairment right so they want people to be safe on the job and it's also a challenge I think if companies are drug testing especially to become employed that people are having a hard time finding employees. And there's a labor shortage in the construction industry right now so I think what I hope is that this paper begins to raise awareness about these issues and interest people in thinking a little bit more deeply about what are solutions for people working in this industry. So we can understand who's at risk what they might be at risk for and reduce the harms related to drug use and make sure that people are working safely. Makes sense while staying employed yeah exactly and as you got deeper into your research over the years has your understanding of drug disorders evolved over time and if so what do you understand now that you didn't in the past. So when I was younger as I think a lot of people I grew up in the 80s and so there were a lot of like national awareness programs like dare which incidentally the research shows did not work. But it basically demonized drug users it made drug use seem like the most dangerous thing in the world and if you smoked a little bit of marijuana you were going to be addicted right I mean that's how things were framed. And the older I got the more research I've done the more people that I've talked to who have different experiences with drug use the more I realized that those fear mongering types of media campaigns are damaging and not all that evidence based. And so there's a continuum of drug use there are some people who try it decide they don't like it they're like I'm good don't need to do that again there are some people who use it it serves a purpose in their life whatever that may be and they may use a little bit here and there right. And then there are some people who use it more frequently but they still are productive members of society and then you know along this continuum you have people who use too much too frequently and it creates a lot of problems in their lives. But there's a continuum and the vast majority of people are not in that last category of people who have problems associated with their drug use. And if you look at the national data you will see that it's not like you know 100% of people who have ever used a drug end up having a drug problem. So I think that some of our rhetoric and kind of common understanding of drug use is not rooted in reality and it's created a lot of problems for preventing drug use and preventing problematic drug use. And what opportunities do you think are on the horizon for tackling the opioid crisis. So even there are so the federal government has a huge opioid initiative called the heal initiative and there's a lot of money being pumped into affected communities. And so I think there's a lot of opportunities for research but there's also a lot of opportunities for improving those types of services we deliver. We have some really good treatments for opioid dependence and opioid use disorders and buprenorphine and methadone are well established treatments abstinence only programs don't work for everybody. And in fact is should not be the standard of care for people with opioid use disorders. And so that money hopefully will be pumped into communities and provide opportunities for people who need it to have access to treatment. But by the same token what often happens is we get so focused on one problem that we ignore other problems and then they rise up and become problematic. And so what we do know, even though fentanyl and opioids are big problems, there's a growing issue with stimulants, methamphetamine and cocaine. And a lot of the overdoses that we see are actually not purely fentanyl. A lot of them are often what we call polysubstance use or polydrug use and so people have more than one drug in their system when they overdose. And so in fact a lot of people who use substances, they're not just using one, a lot of them over the course of a month or even in kind of one setting, sitting maybe using multiple drugs. And so we need to pay attention to stimulant use. We also need to think about benzodiazepines and the combination of benzodiazepines and alcohol or benzodiazepines and opioids is not a good combination. That's a dangerous recipe and it puts people at risk for opioid use. And so making sure in a harm reduction way that people understand what happens when you mix drugs and to educate them so that they're making the best choices they can when they're deciding what they're going to use and how much they're going to use. I guess what is your best advice about using drugs? My best advice about using drugs, I'm not going to say not to use drugs because I do think for some people they serve in a purpose, some people find them fun. What I will say is that you should be careful, you should be thoughtful. If you're unsure of what you have and there's no drug testing available, like in some places you can go to a club and you can give them your pill or your powder and they'll test you and test it for you and tell you what's in it. If that's not available and you still feel the need to use what you have in your hand, then you should probably do a little bit. Try it out, see what the effect is so that you don't run into trouble. Probably shouldn't use drugs alone, particularly if you're not certain of what you have and make sure to reach out for help if you need it. And there are lots of harm reduction programs around that are not going to automatically push you into treatment but are really going to work with you to help you be as safe as possible. There are some great organizations, Dan Safe is one of them, they do a lot of work around club drugs. There are New York harm reduction educators here in New York, which is a needle exchange program. There's the corner project and hopefully we will be getting some more innovative types of programs. And switching gears a little bit, what advice would you give to masters or doctoral students, thinking about focusing their career on tackling drug disorders and similar public health issues. So here's the great thing about NYU College of Global Public Health. We have an amazing group of investigators that are doing research in drug use. We have a center that's funded by the federal government called the Center for Drug Use and HIV Research. It's headed by Dr. Holly Hagen, who is faculty here, and it supports more than 100 investigators that are doing work at the interface of HIV and drug use. So there are a lot of people here at GPH who are doing some really innovative work and it ranges from people working with people in detox programs. We have folks that are working with veterans, we have people working on a rural opioid initiative. So there's a lot of opportunities here. I guess for graduate students, and even undergraduate students, I would say find out about the faculty here, and then my advice for any graduate student who wants to talk to somebody and try to get an internship or more information, do a little homework. So go to PubMed, PubMed their name, find their last five to ten articles that their first author or last author on, and read up on what they've been doing so that when you send an email for informational interview or an ask for an internship, it's clear that you know what you're getting into and that you've done some thoughtful homework so that you can inform yourself. The other thing you can do, there's a website called ERA Commons, and it's an NIH website where all currently funded and previous funded grants are listed. So you can go to ERA Commons, you can type in a keyword, and then you can set like the state or the city, and you can look for currently funded projects or old projects, and you can see who's working in your area of interest. Then you can go to PubMed, do a little bit of homework, and then send them an email and say, "I see that you have a grant in this area, and I'm wondering if there are any opportunities to work with you on this." So you've done, you know who has active research because you've gone to see who's funded, and then you've done a little homework to see what they're actually all about. That is excellent advice. I'm very practical. I like that, I love that. And then lastly, where does your motivation come from to putting the hours and do this work, both inside the classroom lab and out in the community? So I have a lot of motivations. I think the first one is, since I was young, I was interested in health disparities, although we didn't call it that back then, or at least I didn't. I don't like to see unfairness and injustice, and I especially don't like it when there is some community who is disadvantaged often because of the way laws are, or because of history, continue to get the short end of the stick. So I'm really motivated by not really raising all boats because when you raise all boats, you can still have inequities, but I want to do something about those inequities and make life a little bit more fair. And I want the people that I care about to be healthy. So that's one thing. And I've had a lot of experiences in my life. I've been in very diverse situation. So as a military brat, the military was very diverse. I lived in Hawaii. And so the high school that I ended up graduating from, white people were actually minority, and the majority was Asian or Pacific Islander. Yeah, it was pretty amazing. I went to a historically black university for undergrad, and so I was definitely in the minority, and I lived on campus. And it was an amazing experience, like talk about being embedded and embraced by another culture. It was just amazing, but I also saw my friends experience quite a bit of racism, which just kind of ticked me off. So that's kind of a motivation too. And then the other thing is the taxpayers paid for my education. So I came out of school with significant debt. And as a PhD level person doing research in health disparities, I was eligible for the National Institutes of Health Loan Repayment Program. And so the taxpayers basically paid for most of my education, and I definitely feel obligated to give back to the taxpayers and to the world for the opportunities that were afforded me. So I have a little bit of a heightened sense of obligation, but it's also, I'm not very religious, but I do feel obligated to people. And public health is a great way to give back to millions of people, right? And you're definitely giving back. I mean, the ultimate goal is that when I get to the end of my career, a little bit of the research that I have done, because not all of it is going to be relevant, but some of my research has contributed to making a difference in the lives of people that I care about. Absolutely. Well, thank you so much for all the information. It was great. Thank you. Thanks for listening to the IMGPH podcast, brought to you by the New York University College of Global Public Health, where we believe that investing in committed people and essential resources will bring us closer to addressing the global health problems of today and tomorrow. Learn more at publichealth.nyu.edu