The Epidemic and the Pandemic: A Conversation with Epidemiologist Alex Kral On His Work Combatting Opioid Use Disorder

Has the opioid epidemic brought the consequences of addiction home to many more Americans?

Twenty years ago most Americans did not know somebody who had died of drugs. In that same 20 years we have had about 600,000 people who have overdosed and died. Just by sheer numbers, that almost guarantees that everybody either knows somebody or knows somebody who knows somebody who has died of drug-related causes…that definitely does sensitize you to the issues around drugs. 

Could you discuss some areas of your research? 

Drug use is my main focus. I am an epidemiologist, and I’ve been studying drug use for 27 years. Depending on drug trends, I have been working on methamphetamine at some times and other times on heroin, and now it’s coming around again to methamphetamine. 

Most of my work is at the intersection of illicit drug use, poverty, the criminal justice system, and infectious diseases and trying to evaluate policies and interventions that will improve the lives of people who are harmed by them.

How has the COVID-19 pandemic affected your work?

The majority of my research is community-based. We do surveys of people — we go out in the community and learn about what’s happening on the ground. It has been harder for us to maintain that approach. We are supposed to be sheltering in place. We’ve had to move some of our data collection to phone interviews, which has been OK, but it would be better in person. 

Has the pandemic exacerbated drug use and more importantly those already addicted to opioids?

Because of the pandemic, lots of people are losing their income, losing housing, and losing hope. Those are the kinds of conditions whereby some people might find that drug use is one solution for them, or it’s the way they end up coping. I fear we are in a situation where we’re going to see a lot more drug use. This situation appears not to be going away, and the economic reverberations are going to continue for many years. 

Overdose deaths are up tremendously because of this pandemic. Many people are listening to the shelter-in-place orders and staying home, not associating with many people. For someone using opioids, the problem is that if they are alone, if they accidentally overdose on opioids, there is no one there to revive or resuscitate them with naloxone. 

We are seeing people being quarantined in hotels on their own, and then when they’re using heroin or other opioids in their room by themselves, they are dying because there is no one there to resuscitate them should they overdose. The COVID-19 pandemic might not be increasing the number of overdoses, but it’s increasing the number of overdoses that end in death. 

Could we talk a little bit about the concept of harm reduction? 

Harm reduction is a set of practical strategies and ideas aimed at reducing any negative consequences of drug use. It’s non-judgmental — it tries to meet people where they are. How people come to use drugs is not necessarily as important as what they can do now to make some sort of incremental change to improve their situation.

I don’t see myself as somebody who should be adjudicating one way or another about the morality or ideology of things. My role is to apply epidemiology to see what works. Over the last two decades, most drug policy solutions that have shown the most promise have been created, piloted, and implemented by people who have used drugs themselves. For much of my career, what I’ve been doing is to see what those interventions are, and then see if there is a scientific basis to test whether those kinds of interventions are effective. My task has always been to say, ​“Look there are a lot of innovative things that people are trying out there,” and so what I can do is be the scientific lens to see if these things are workable or effective. 

Tell me about solutions for harm reduction, such as safe consumption sites. 

We just published results in the New England Journal of Medicine from an Arnold Ventures-funded evaluation of an unsanctioned safe consumption site in the U.S. We found that the site had supervised over 10,000 injections, of which 33 led to overdoses, all of which were saved by the staff at the site. This confirms data from similar sites in Europe, Canada, and Australia. These sites, at their simplest form, ensure that people using opioids (or other drugs) are supervised and that there’s someone there who can revive them with readily available medication in the form of naloxone. 

These sites can also offer more extensive wrap-around services, including drug treatment and medical care, but at the very core these sites ensure that there is someone monitoring people when they are using opioids, that there is someone who can save them in case they overdose. 

Evaluations around the world have found these sites help in decreasing HIV, viral hepatitis, overdose mortality, and facilitating people to access drug treatment. They also help the neighborhoods where they are located by reducing public injection, needles in the streets, and crime around the sites. 

Safe consumption sites seem like a very cost-effective measure when you think of the cost we pay to first responders, emergency room visits, and so on. 

We published a paper in the Journal of Drug Issues which showed that putting one safe consumption site in San Francisco would save the city $3.5 million annually. These places are clean and safe, and if people do overdose because of the drugs that they are bringing in with them, there are people there who can save them and stop them from dying. There have been tens of millions of injections in these safe injection sites all over the world, and nobody has ever died of one. Put that in contrast with 70,000 Americans who die every year of overdoses in their communities, and this suddenly starts to look like something that’s very important.

I understand that some countries take it even farther than safe consumption sites. What about the Portuguese model?

Portugal had a big overdose problem 15 or 20 years ago. Not as big as the U.S. right now, but they had a big problem. Their solution was to decriminalize drugs and provide people with treatment and help: needle exchange, harm reduction sites, and harm reduction measures. What happened was their overdose rate plummeted. Prior to that, people had been using unsafely, at home, and this often involved black market transactions. Portugal changed that by admitting people who are using drugs in unhealthy ways should be helped through health care instead of the legal system. Since this policy was enacted, the prevalence of drug use, deaths, overdoses — all the various indicators — have plummeted. It’s a great place to look at to see what benefits an approach like that might have.