Spotlight On…Traci Green

Traci Green, PhD, MSc, Co-Investigator of the Boston ARCH 4F study and Assistant Professor of Emergency Medicine and Community Health Sciences, Boston University School of Medicine and Boston University School of Public Health. 

As told to URBAN ARCH Admin Core staff, September 2017

Tell us more about your background. How did you become interested and involved in addiction, HIV, and injury research?

I started out doing activist work in high school, lobbying on HIV/AIDS bills. I got a lot out of being part of the community, broader access to healthcare, and prevention efforts. I was really invigorated by that. Over the years, I was personally and professionally affected by the toll that substance use takes on the community. So I thought there would be a way to continue doing science and math, but a little more focused. I started to think about how I could merge the two passions, and I found epidemiology as my first job out of college. I thought that being a scientist, while thinking about social justice and public health advocacy, I could use science and statistics as a way to parametrize conversations and shift policy. Harm reduction seemed like such a logical way to package that work, so I continued to do advocacy in that arena, and I love it. Additionally, as a public health outcome, I came across drug overdose through my HIV work, and was fascinated by the fact that this was a totally preventable health problem that we just weren’t acting on. I thought a lot about working as an epidemiologist and how you imagine to work toward improving response time and response location, which gets us thinking about where substance use occurs, why it occurs, and why people use it in certain ways. The world of injury prevention and HIV risk behaviors resonated quite a lot with me, as well as how you can use epidemiology to explore and track it to prevent them.

In your work with EDs, what have you learned that could be applied to a wider setting?

I’ve discovered that emergency departments are a complex microcosm of the hospital – each setting requires a lot of tailoring, in terms of interventions. After a recent effort where we put together a document to standardize care of opioid use disorder and overdose in emergency and hospital settings, it is conceptualized that there are levels of care or degrees of capacity for hospitals and EDs, and that it may differ and it’s okay. I’ve learned that it’s important to create structures collaboratively with institutions that are helpful and beneficial not only to public health, but to the institutions themselves. The most important thing when you create structures or documents is that they are actually going to be implemented. It does no good to flex control over an entity or to assert some degree of authority, especially for me as a scientist and not as the Department of Public Health. The real goal of public health is application of these changes, and not just acknowledging that these are things we should do. It really is terrible that there is no current standardization of care for opioid use disorder in the hospital or emergency department setting. For overdose care, some are prescribed naloxone, some are given a paper with NA/AA numbers on it, or others may be encouraged to start buprenorphine in an hour or two. Although it should be very different and improved, in the meantime, the importance is trying to get institutions to come together to act upon and make change that is meaningful to people. The goal is not to be overbearing and right, but to be collaborative and better.

A lot of your work has been focused on the widespread distribution of naloxone. What is something you wish everyone knew about this medication?

That it is easy to use and accessible. A lot of the work we are doing is in the pharmacy environment and trying to improve pharmacy access to naloxone, and to encourage people to ask for it in the pharmacy setting. However, I am still surprised there are so many misconceptions about what naloxone is, what it does, how hard or easy it is to get, and questions such as “Don’t you need a prescription for that?” “Don’t you have to be actively using drugs to get it?” “Doesn’t it cost $6,000?” We try to convey that it’s accessible and that there are lots of different forms of it, so people can choose what they want.

With the increased attention locally and nationally to addiction and overdose, what is working well and what still needs to happen to improve care and save lives?

I think that there has been enormous improvement in the attention of two things. First, there has been heightened awareness of naloxone and the role of naloxone in reversing overdoses. The expectation of a lot of people is that providing naloxone alone will be sufficient, in that naloxone will help sustain someone’s life. It means that you care for and value the person’s life. However, there is the critical piece of making sure people have other choices, especially ones that are treatment oriented, evidence-based, and effective. Those are really critical, but we have not fully realized the capacity of our need. So I think that on the naloxone front, encouraging unfettered access to naloxone not just for first responders, but also for people living in the community who are more likely to respond immediately and can be easily trained to recognize an overdose. So that’s one of the pieces – not just the availability, but the accessibility of naloxone.

The other piece continues our thinking about fentanyl and illicitly manufactured fentanyl as a prominent driver of the opioid epidemic. There is no shortage of articles now between the New York Times, Washington Post, and various other publications that very clearly convey that we have a different epidemic right now—one that is totally supply driven. Fentanyl is profound in its role on mortality, but the critical part is recognizing that our response to date, when it comes to drug-related problems, has been one of criminalization. If we can acknowledge that, then as a public health strategy, it is probably worthwhile to think about the prison and criminal justice environment as one that has a lot of potential for enormous public health impact. We need to refocus our efforts in criminal justice populations to provide medication for addiction treatment behind the walls, provided that there is some place for them to go in the community to continue their care after their release. I think that is a huge disconnect that is not happening in our backyards, and we as a society continue to criminalize drug use and have multiple consequences.

The tools of criminal justice continue to be a real problem. Acknowledging that we are doing that and infusing it with a treatment-based approach is one way we might be able to reduce the epidemic, if we bring it to scale. The U.S. continues to be an anomaly, as most of the industrialized world invests in treatment for incarcerated populations, even though they don’t have as high incarceration rates as the U.S. Between the two factors, the population attributable risk is substantial, which means the population benefit would be substantial if we did it right. This would not have been the case if you back 10 years ago when we were talking about the prescription opioid epidemic. Don’t get me wrong – incarceration has always been a risk factor and contributor to overdose, because of the tolerance effect and some of the social isolation that we know occurs and contributes to fatality with opioid exposure and relapse. However, the prescription opioid epidemic did not produce the same degree of involvement in criminal justice and mortality. Now we have an illicit-driven epidemic, and we have so many more people for whom criminal justice involvement is a factor, so we can expect that it will be larger.

You recently joined Boston ARCH as a co-investigator. What are you most looking forward to in the 4F study?

Selfishly, I am really excited about the intervention pilot, which I’ll be involved with later in the study. I have just completed my first intervention randomized control trial of a text message intervention compared to patient navigation, in a study funded by the Patient Center Outcomes Research Institute. I’ve always been a scientist who supports behavioral interventions, and this was my first foray into intervention development. I enjoyed that far more than I was expecting – both the intervention development aspects and the trial implementation. Even though the 4F intervention is a small pilot that is still developing and forming, I think this study will be really fun, and I’m really looking forward to it.

Tell us something surprising about yourself.

I like insects, and I have an insect collection. My husband also has a butterfly collection which I love, so together we have quite the naturalist wall in our house. Everywhere I travel I try to find either a bug or a butterfly to add to the collection. I became interested in it because my husband always loved butterflies from West Africa, and I’ve always loved beetles, so when we first travelled together we went to Nepal and Tibet, there were some amazing specimens and we decided to collect them. Nature is fascinating, and it’s fun to step outside yourself and explore a whole other scale of the world. One summer we went to Indonesia, and we bought a number of insects. Later that year, there was a horrible nor’easter, so we decided to take them out and mount them. It’s so fun – it feels like you are in a totally different century. You hold it up and you’re like “Is this real?” I like the double-sided frames because you can see the underside of the bugs – they’re camouflaged, so to predators they look like a stick, but underneath there are vibrant other colors. My kids really like them too.