Indiana’s Drug Czar: The Worst Is Yet To Come

On his first day in office, Governor Eric Holcomb appointed Jim McClelland Indiana’s first drug czar, and tasked him with what seemed like the impossible: coordinate the state’s efforts in combating the opioid crisis. With that move, Indiana became at least the third state to create such a position, behind Idaho and New Hampshire.

Now, the former CEO of Goodwill Industries of Central Indiana marshals the efforts of nine different state agencies. IM sat down with McClelland in October to check in on the state’s progress. McClelland had some bleak news to share: Indiana hasn’t reached the peak of the opioid epidemic yet.

What’s been keeping you busy since your appointment?
A little bit here, a little bit there. The more you learn about this issue, the more you realize how complex it is and how many pieces there are to it. It’s massive, and it’s taken 20 years to develop the problem that we have now, and there are no quick, or easy, or simple solutions to it. It’s not something that’s going to be fixed overnight. It’s going to require a lot of concerted effort over a pretty long period of time, but we’re going to make a dent in this thing. We’re going to make a significant dent in it, and we’re going to make some headway. A lot of the work that we’ve been doing, it’s going to start bearing some fruit, I think next year, over the next year, and beyond. But I guess the complexity of it and the magnitude of it are what surprised me more than anything else.

How did your time at Goodwill prepare you for this job?
The last eight or 10 years I was with Goodwill, we were heavily focused on trying to find ways to reduce inter-generational poverty. The more we got into this, the more we saw how so many of our social problems in this country—poverty, low education levels, crime rates, first young unwed mothers, a whole host of health issues—are all interrelated in the reinforcing and compound each other. But it seemed to us that we have not been, in many cases, treating them as if they were related. We’ve had a tendency to treat them in isolation, one from another.

A lot of that does apply here because what we’re trying to do, and my job really is at its essence, it’s coordinating, aligning, and focusing the relevant resources of all the state agencies that touch this issue in one way or another, and categorize some overall guidance and direction, and then trying to leverage the resources the state has with those of other sectors—business, higher education, the healthcare sector, philanthropies, faith-based organizations, and other community-based organizations—and try to bring those pieces together in a way that’s gonna give us the best chance to really have the long-term impact that we need.

Lawrence and Madison Counties have recently closed down their needle exchanges. That seems like a setback, as a range of federal agencies, including the NIH, have endorsed needle exchanges as a way to prevent public-health disasters.
They’re counterintuitive when you look at the data. I mean, on the surface, if you don’t know anything about this problem, it doesn’t seem to make sense. But then when you really start to learn more about it and you understand it, and you see the data behind it, you think, Oh, we have to do this.

These programs are incredibly effective at reducing the spread of infectious diseases, especially HIV and hepatitis C. From a public-health standpoint, they’re incredibly effective. They also have proven to be a path to treatment. In Scott County—always everybody’s first example, whether it’s here or elsewhere in the country—there are over a hundred people who’ve used that program down there who are now enrolled in treatment programs. The likelihood that that would have happened without coming through that, without getting the information and the encouragement from that syringe exchange program down there, is nil. That wouldn’t have happened.

It helps, too, that the treatment facility is right next door to the syringe-exchange services program. From a standpoint of helping to get people into treatment, which ultimately is the only good outcome that you can have from this, is people get treated. They attain recovery, and then they’re able to maintain recovery. That’s what we’re really striving for—plus, you’re reducing the spread of infectious diseases. If you just look at it from an economic standpoint, the average lifetime cost to treat someone with HIV is $400,000. Well, yeah, $400,000. In Scott County, little Scott County, the number of new cases diagnosed dropped from an average 22 a month down there to two a month after this program was started. Twenty times $400,000. Do the math—$8,000,000 just in one month of future cost avoided. It’s not really costs saved—it’s future costs avoided.

And $80,000 for hepatitis C.
Yeah. It almost sounds inexpensive compared with HIV, but 80,000 bucks is a lot of money. It makes an enormous amount of sense from just about any way you look at it, except a lot of people don’t know. They don’t understand the full picture of it, and it’s still counterintuitive, and so we see things happen like happened in Madison and Lawrence County.

Have you made that case to the Attorney General, who opposes needle exchanges?
Well, we just have a difference of opinion on this issue.

But, to hear you tell the story, it doesn’t sound like it’s a difference of opinion—it sounds like a different understanding of the data.
I really can’t comment at all what somebody else thinks or believes. I know what I see and how we interpret it, and that’s all I can go on.

Do you think that it’s contributing to a culture of stigma in certain parts of Indiana?
I think the stigma’s already there. I think that we just have an awful amount of work to do to eradicate it. It’s been there. I mean, I’ll be honest with you. A few years ago, if somebody had said anything to me about needle exchange, I would have had the same reaction. I didn’t know anything about the issue. My daughter, who’s a registered nurse in New Jersey and works for an organization that sees a lot of people who have substance-abuse problems, she’s the one that started educating me. They don’t operate one there, but she’s very familiar with them, and she knows a lot about the topic. She carries Narcan with her. She revived somebody who had overdosed on the sidewalk outside their building a couple of weeks ago. She’s the one who started educating me before I ever came into this position.

I mean, I can understand why people who haven’t been exposed to it, they’re not knowledgeable about it, would have the opinion that they do. As [U.S. Surgeon General] Dr. [Jerome] Adams has said many times, there’s nothing pretty about it. I think he had some reservations about it in the beginning, as well, until he really dove into it and learned more about the issue.

Why is this epidemic hitting this part of the country so hard compared to other epidemics?
This epidemic is in cities and suburbs and small towns and rural areas. It cuts across all socioeconomic lines. I mean, there are people from Carmel and every upper-income area in the state who are affected by this, and I know some of them and how they’ve been affected. I know they’ve lost people, and people died from this. I know that some have spent hundreds of thousands of dollars on treatment. I’m aware of this. I know some of these individuals, but this is an epidemic that tends to thrive in areas of greater economic challenge.

Have we reached the peak of this epidemic in Indiana yet?
No.

Has the state developed a scoreboard or set of metrics to measure our daily progress in fighting opioids?
Not yet. We’re working on it. We’re looking at locks on distributions, but they’re not complete. We’re looking at overdoses. We’re looking at locks on uses. We’re looking at deaths, but there’s always a lag in death reporting.

The other thing that we’re really interested in is opioid prescription rates, because that has been at the root of so much of this, and they’re really trending downward, and this is a really good thing. Those rates are down 25 percent over the last four years. We’re still have the 11th-highest opioid prescription rate in the country, but we used to have the ninth-highest, so we’re improving at a rate that’s greater than that of most states. We’ve got a ways to go yet.