Healthcare, Policy, and the Opioid Crisis: Bridging Gaps in Access with Zoe Lindenfeld
Transcript
Stuart Shapiro
Welcome to EJB Talks. I’m Stuart Shapiro, the Dean of the Bloustein School. And the purpose of this podcast is to highlight the work my colleagues and our alumni in the fields of policy, planning and health are doing to make the world a better place.
Today I’m speaking with one of our newer assistant professors in health administration, Zoe Lindenfeld. Welcome to the podcast, Zoe!
Zoe Lindenfeld
Thanks for having me. Very happy to be here.
Stuart Shapiro
So long time listeners know I always start with an origin story question. Let’s start with yours. How did you decide to study healthcare?
Zoe Lindenfeld
Great question. So, my interest in… so I mainly study substance use disorders. And my interest in substance use mainly started when I was graduating college and I was starting my career. And this is mainly because this was a really big problem at the time. Tens of thousands of Americans were dying of overdose and there was a lot of reporting on this issue. Really, we know that the increase in deaths due to opioid overdoses, in particular, started way back in the 90s.
But in 2017, when I was sort of starting my career, graduating college… that was the year that actually, the opioid crisis was declared a public health emergency by the U.S. government. It was very much on my radar. And what was you know, so unique and also so terrible about this crisis, this epidemic was that, it started within healthcare systems.
So the question of how do we address this epidemic, this problem, that very much started, you know, because of over prescribing and inappropriate prescribing of opioid-based medications such as oxycodone and Oxycontin. How do we address this using the tools that we have within the healthcare system, because there are tools. It was a really interesting question to me. I’ll also say that I’ll just give a plug to a book I really loved that a lso really piqued my interest. The book is called Beautiful Boy. It’s by David Sheff. Have you read it or…?
Stuart Shapiro
I don’t know that one. No, I actually thought there was another one you were going to mention about the opioid epidemic, but go ahead.
Zoe Lindenfeld
Yeah, there’s a few good ones, but this one, so it’s written by David Sheff. He’s the author and it’s about his perspective on his son’s methamphetamine addiction. So, part of the book is this very, you know, moving story about how addiction affects the family. How, you know, the decisions a family has to make and helping a loved one with an addiction. But also David Sheff is a journalist. That’s his job and so, a lot of the book, he conducts interviews with sort of, the top addiction medicine specialists across the U.S. So that was a really… really made me, really interested in this field. Also, I will note there is a movie that they made an adaptation with Timothy Chalamet. I don’t recommend the movie actually, I didn’t like it. I would read the book.
Stuart Shapiro
The newly, extremely famous, Timothy Chalamet. Really.
Zoe Lindenfeld
Yeah, yeah. I mean, he’s a good actor. I, yeah, I didn’t love the movie.
Stuart Shapiro
So your work certainly includes a lot of stuff on opioid use, but you’ve also looked at telemedicine, mental health, s bunch of other things. Is there a theme that sort of weaves its way through through all of this?
Zoe Lindenfeld
So a cross-cutting theme I would say, across all my work is about closing the access gap. Increasing access to care. So for substance use, for example, as I mentioned previously, there are a lot of tools that are, actually, pretty good treatments to treat opioid use disorder in particular. There is medication for opioid use disorder. But only about 10% of people who can benefit from these medications actually receive them. So, a lot of my work is about, how do you close that gap in access?
And then with telemedicine, so my work around telemedicine really began with the COVID-19 pandemic. Where, you know, pretty much everyone had these new access gaps to care because of the clinic closures or the social distancing requirements. So, my work there was evaluating how telemedicine technologies, either audiovisual or phone technologies, can be used to enable people to obtain medical care. Also related to substance use with the COVID-19 pandemic, there were all these new flexibilities that were allowed with substance use treatment. For example prior to the pandemic, in order to receive these medications I keep mentioning, medication for opioid use disorder. A patient had to have an in-person evaluation with a provider prior to being prescribed this medication.
Obviously this could create big gaps in access if someone’s in a rural area, or if someone’s in an area that doesn’t have a lot of people who are licensed to prescribe this medication. Because you need a special license, or you did in that part of 2023, to prescribe this medication. So, these new flexibilities, which were as part of the Ryan Haight Act, created a really unique opportunity to see whether telemedicine could be used to improve access to these treatments.
Stuart Shapiro
I’m sure you saw last week that a new drug had been approved for pain that’s non-addictive. It would be interesting to see how that changes the dynamics with opioids. Although as you talk about access, I’m thinking about how expensive that drug is going to be, at least at first.
Zoe Lindenfeld
Yeah, I did see that. Yeah, it’ll be interesting.
Stuart Shapiro
So I want to talk a little bit about a recent paper that you wrote. An article on the fiscal determinants of overdose deaths. Obviously there’s access issues here, but is that what motivated the work or was there something else that sort of pushed you in that direction?
Zoe Lindenfeld
Yeah, there was a bit of a different motivation behind this work. So, the main motivation, the top line summary, was to understand how do local government decisions around spending and resource generation impact overdose deaths? So just for some background, within my field of research which , you know, could broadly encompass public health, health policy, obviously health administration. There’s been a growing focus on understanding how the social determinants of health, non-medical factors that impact health, contribute to differences in health outcomes.
So in short, we could think about this as understanding how do the places in which people live work grow, age, impact health outcomes. And this generally tends to encompass factors such as the demographic characteristics of a neighborhood or the socio-economic characteristics: poverty rates, educational attainment, housing availability. And which is obviously very important to understand. But I was, at a certain point, a little bit frustrated with this work because it’s very much about who’s living in a certain area. Who’s living in a place rather than, what’s going into the place? What are the resources available? What are the investments in in an area?
And that’s really important, right? Because counties and neighborhoods are not just places where people live. They are places where decisions are made, including decisions around spending. So, for this paper in particular, I was very interested in first understanding how local government expenditures and health and policing are associated with overdose stats. And then also understanding, how do the ways in which local governments raise revenue impact overdose deaths. And I was specifically interested in one kind of revenue, which is revenue generated from fines and forfeitures, which we could think of as traffic tickets or fines or other types of criminal justice-related activities.
Stuart Shapiro
That’s fascinating, and warms a public policy scholar’s heart. Those of us particularly that say, show us your budget we’ll show you your values. So how did you get at this topic?
Zoe Lindenfeld
Okay, so great question. And I’m very happy to actually say that all this work was done using completely free, publicly available data. So I used four government data sets. The main data set I used was this data set called the Census of Government. It’s a survey conducted by the US Census Bureau, which collects information on state and local government’s revenues and expenditures.
My main outcome, which was overdose deaths, I got from the CDC, the Centers for Disease Control and Prevention, which releases data on mortality. I got data on some of these more classic social determinants of health measures from the American Community Survey, which was also conducted by the US Census Bureau. And then, just as a another… because the outcome was overdose deaths, I also obtained data from what’s called the NIFLIS, the National Forensic Information Library System, which is from the US Drug Enforcement Agency on the percentage of drug seizures in a state. It’s a state level measure that tests positive for fentanyl. Fentanyl is a really deadly synthetic opioid. I think as of 2023, it accounts for… or was detected in 65% of overdose deaths. So you know, any study that has overdose as the outcome, it is important to, you know, control for the entrance of fentanyl in the drug supply. So long story short. I think this is a good message to students and even other researchers who might think you need a lot of funding or some, you know, a lot of money to do a really great analysis. But really, you could do some pretty cool things just with public data that’s available at no cost.
Stuart Shapiro
I have to ask. The datasets you used. Have you checked to see if they’re still available after the events of the past week?
Zoe Lindenfeld
Well, I have them downloaded on my computer. But I think they’re I think they’re available, yeah.
Stuart Shapiro
I know the Census froze access to a lot for at least a little while last week. I don’t whether they’re back up yet or not. All right, so what did you find? You had the researchers dream of finding something relatively counterintuitive there. So tell me about that.
Zoe Lindenfeld
Yes. So, well, the main finding was that higher police expenditures, higher per capita police expenditures, were associated with overdose deaths. So counties with higher expenditures on policing had higher rates of overdose deaths. And this relationship was actually stronger in counties that had higher revenue generated from fines and forfeitures. Which implies that it’s a certain type of policing, particularly a policing link to extractive revenue strategies that is associated with overdose deaths. And this extractive policing is a policing aimed at revenue generation. So, maybe instead of public safety it’s prioritizing generating revenue.
Another of the counterintuitive finding, I think that you mention, is that we actually did not find that health spending was associated with overdose deaths. You know, my hypothesis was that, you know, would be that higher health spending would be associated with decreased in overdose deaths. Really we did not find association, in part, this is likely because this is a very “noisy” measure, so to speak? We’re not only looking at health expenditures that are tied to addressing the overdose crisis.
In fact, we can’t really detect that at all, even if the county has any of their health expenditures going towards overdose. It’s possible, especially because the period under study overlaps with the COVID-19 pandemic, this could have been all diverted to address COVID. We really can’t tell. I think it’s a great area for future research. Especially right now we have ongoing distribution of funds from the national settlement agreement with opioid distributors and manufacturers. There’s millions and millions of dollars that will be going to state and local governments. Actually, 50% of all these funds are earmarked for local governments. So it’ll be interesting to see in the future whether, you know, the influx of these funds, the higher local spending on the overdose crisis, in particular, is associated with decreases in overdose deaths.
Stuart Shapiro
So I would love to dive deeply into both of those findings, because you’re right. They’re both very interesting. But maybe you can quickly give me the why of both of them, in your mind. Because obviously, we don’t know that. Why do extractive police practices lead to more opioid, or are correlated at the very least, with more opioid deaths? And why isn’t health spending correlated there?
Zoe Lindenfeld
Yeah. So for the extractive revenue, extractive policing, there are few hypotheses we have why this might be impacting overdose deaths. First by eroding trust in law enforcement among people who use drugs. So in areas where the police are incentivized to ticket more and raise money this way, this behavior might discourage people who use drugs from seeking help.
Secondly, on the flip side, on the policing side, the pressure to generate revenue through fines and forfeitures and through policing could, theoretically, disincentivize police from engaging in more community-oriented policing strategies or public health-oriented policing, or even developing partnerships with community-based organizations aimed at addressing overdose risk in communities. Because these activities do not generate revenue.
In terms of health, again, it’s I think partly why it was hard to detect a relationship is because again, we can’t really tell what these counties were spending on. Hard to say.
Stuart Shapiro
So there might be types of health spending that work and other types that don’t.
Zoe Lindenfeld
Right. I mean, there are definitely many activities that counties, especially local governments, can do to address the overdose crisis. They could distribute naloxone, which is an overdose reversal drug. They could distribute fentanyl testing strips. They can create partnerships amongst different public sectors, for example. Help foster partnerships between public health and police agencies. But again, it’s hard to tell exactly what the counties included in our study were doing and if they were doing anything.
Stuart Shapiro
All right, let me let me wrap up by bringing us back to teaching a little bit here. You’re in your first year teaching health administration for us. How have you found that all this fascinating research that you do connects to your teaching?
Zoe Lindenfeld
So for this research in particular, I’ll say that, you know, I think when, what most people think of health administration for example. Or at least when I think of health administration, I think what pops into your head are, you know, healthcare systems. Maybe a hospital, maybe a primary care office. But these organizations really don’t exist in a vacuum. They’re embedded in communities where people live. Their patients are embedded in communities. They might be the biggest employer if they are a hospital in their community. So the decisions made around spending. They really impact these healthcare systems. What happens, you know, outside the four walls of the hospital is incredibly relevant to the healthcare that is ultimately administered by this organization.
As part of the Affordable Care Act non-profit hospitals, which are the most common type of hospital in in the United States re actually required to conduct what are called community health needs assessments. Which are comprehensive assessments of the health needs of their communities. And they’re actually also required to identify implementation strategies and make a plan to address these needs. So the fiscal policies of a local government, the resources available in a community, the type of policing strategies that residents are exposed to, this also affects the work of healthcare systems and ultimately what they will need to do in their communities. So I view this is very, very much tied to health administration.
Stuart Shapiro
Excellent, Zoe. Fascinating stuff. And you got a lot of other work that I’d love to talk about. Maybe w ll have you back on. Thank you so much for coming on the podcast!
Zoe Lindenfeld
Thank you for having me!
Stuart Shapiro
Also a big thank you to Tamara Swedberg, our producer, and Karyn Olsen, who helps out on the podcast. We’ll be back in another week or two with another episode of EJB Talks. Until then, stay safe.
