EP76 Championing Harm Reduction with Danielle Ompad

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I AM GPH EP76 Championing Harm Reduction with Danielle Ompad
EP76 Championing Harm Reduction with Danielle Ompad

Alexandra Arriaga:    Hello. I am here with Dr. Danielle Ompad. How are you doing today?  

Danielle Ompad:    I'm doing really well.

Alexandra Arriaga:    Well thank you so much for joining us.

Alexandra Arriaga:    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?

Danielle Ompad:    Sure. So what may be interesting for people to know is that I was actually an air force brat.

Alexandra Arriaga:    Oh I didn't know that!

Danielle Ompad:    Yeah. So I spent my childhood moving around. I lived in the U.S. 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 even when I was in high school. The other thing that 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 or 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 U.S. 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 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 read Laurie Garrett's The Coming Plague. And when I was born there was no HIV. We didn't know about it. That's how old I am.

Alexandra Arriaga:    Oh, whatever.

Danielle Ompad:    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 and marginalized, like people who use 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 Multicenter AIDS Cohort Study or the MACS. 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 linked 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 dataset. And so that's how I started working on issues related to drug use.

Alexandra Arriaga:    Amazing. What a journey.

Danielle Ompad:    Yeah, it's been an amazing journey. The people that I worked with as a student, 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 treated me like a student and acted as though they were teachers, and it was just an amazing experience.

Alexandra Arriaga:    And so what would you say your current research is?

Danielle Ompad:    Generally my research is concerned with drug use and its consequences. 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.

Alexandra Arriaga:    It's a very holistic approach.

Danielle Ompad:    I try.

Alexandra Arriaga:    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?

Danielle Ompad:    Okay. So 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. 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 or syringe exchange. So exchanging used 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 Narcan 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 I ask students, "How many of you use drugs?" And most people aren't going to admit it-

Alexandra Arriaga:    Of course they're not going to tell you.

Danielle Ompad:    ... but let me tell you. A lot of us use drugs, right? So my drug of choice is caffeine and I drink-

Alexandra Arriaga:    Oh mine too.

Danielle Ompad:    ... 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 there illegality and whether or not they're socially sanctioned. So a lot of us use substances. With the changing marijuana laws, prevalence of marijuana usage is getting higher. But marijuana is also a substance. And it's interesting because a lot of people who smoke a joint or have an edible or whatever the case may be, may not consider themselves to be somebody who uses drugs, but in fact you are.

Alexandra Arriaga:    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, "But you're just helping these people use drugs. They're going to use more drugs." Can you drop some science on-

Danielle Ompad:    Sure. 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 neediest people, right? So it may look like 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.

Alexandra Arriaga:    Interesting. And recently you were 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?

Danielle Ompad:    Sure. Working with colleagues from here at NYU, Robyn Gershon, who is an occupational and 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 Sandh who works very closely with me. We analyzed 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 incidence of substance use and treatment access in the United States. And so this dataset 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.

Alexandra Arriaga:    Wow. So this is a question that I personally have. As I was asking you 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?

Danielle Ompad:    That's a great question. 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 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 know that they used at least once in the past month. So 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, a 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 basically very careful 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 not what this is.

Alexandra Arriaga:    Okay. I like that. And what does this new discovery mean for that profession? What lessons can we learn from the new findings?

Danielle Ompad:    Okay. 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 opioid overdose than people working in other occupations. And so what this paper does is quantify the level of use. And we also looked at some correlates of use. And the correlates that we looked at were 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. What was interesting, I think, is that the drug testing policies tended to be more associated with marijuana use than some of the other drugs.

Alexandra Arriaga:    Oh.

Danielle Ompad:    Yeah.

Alexandra Arriaga:    Wow.

Danielle Ompad:    Kind of surprising, right?

Alexandra Arriaga:    Yeah!

Danielle Ompad:    You would think like what we consider hard, I don't really like this term, but what we consider harder drugs like cocaine or opioids did not have as strong an 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 used cocaine and... Give me three people, one person who used marijuana in the morning, one person who used cocaine in the morning, one who used opioids in the morning. 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 an employer who tests 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 policies.

Alexandra Arriaga:    And what is your end goal with this study? Are you wanting these findings to somehow affect policies, or what's the main goal?

Danielle Ompad:    So, these data cannot really tell us a lot about what policies we should implement. They're 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 aren't available. So what I do think that this does is raise awareness that this is an issue in the industry. And when I was at the American Public Health Association conference I actually talked to some people from some construction worker unions. And there is a growing realization that drug use is an issue in this industry and that drug treatment needs to be available. There's concern less about use and 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 interests 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-

Alexandra Arriaga:    Makes sense.

Danielle Ompad:    ... while staying employed.

Alexandra Arriaga:    Yeah, exactly.

Alexandra Arriaga:    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?

Danielle Ompad:    When I was younger, as I think a lot of people, I grew up in the '80s. And so there were a lot of national awareness programs like D.A.R.E., 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? 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 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 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 100% of people who've ever used a drug end up having a drug problem. So I think that some of our rhetoric and 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.

Alexandra Arriaga:    What opportunities do you think are on the horizon for tackling the opioid crisis, if any?

Danielle Ompad:    There are. The federal government has a huge opioid initiative called the Heal Initiative, and there's a lot of money being pumped into effected communities. And so I think there's a lot of opportunities for research, but there's also a lot of opportunities for improving the 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 one sitting may be 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.

Alexandra Arriaga:    Okay. What is your best advice about using drugs?

Danielle Ompad:    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 a purpose. Some people find them fun. What I will say is that you should be careful, you should be thoughtful. You should, if you're unsure of what you have and there is 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 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. You 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. 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. DanceSafe 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.

Alexandra Arriaga:    And switching gears a little bit, what advice would you give to master's or doctoral students thinking about focusing their career on tackling drug disorders and similar public health issues?

Danielle Ompad:    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 Hagan who is faculty here. And it supports more than a hundred investigators that are doing work at the interface of HIV and drug use. And 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, right? So go to PubMed. PubMed is their name, find their last 5 to 10 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 an informational interview or 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 a 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 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 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.

Alexandra Arriaga:    That is excellent advice.

Danielle Ompad:    I'm very practical.

Alexandra Arriaga:    I like that. I love that. And then lastly, where does your motivation come from to put in the hours and do this work, both inside the classroom, lab, and out in the community?

Danielle Ompad:    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 situations. So as a military brat, the military was very diverse. I lived in Hawaii, and the high school that I ended up graduating from, white people were actually a minority and the majority was Asian or Pacific Islander.

Alexandra Arriaga:    Wow.

Danielle Ompad:    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. 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 ticks me off. So that's 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?

Alexandra Arriaga:    And you've definitely given back.

Danielle Ompad:    I hope so. 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.

Alexandra Arriaga:    Absolutely. Well, thank you so much for all the information. It was great.

Danielle Ompad:    Thank you.