The Pivot: Dr. Juan Hincapie-Castillo
Dr. Juan Hincapie-Castillo advocates for empathy and safety in pharmaceutical policies.
What’s your role in public health?
I call myself an advocate for evidence-based policymaking. I use my research to inform public health policies, and — because of my pharmacy background —I mostly evaluate pharmaceutical policies. My background as a pharmacist and my research interests have also led me into the area of pain management and opioid use.
I see myself as trying to inform the best policymaking that prevents harm. A lot of my focus is on advocacy and translating my research to prevent harm to patients who need opioids to work and maintain their quality of life.
I started at the Gillings School in August of 2021, but I was remote for a while because I previously worked at the University of Florida. I stayed in Florida until December, when I moved to North Carolina with my husband.
Can you describe your focus area in one sentence?
I use real world data to inform pharmaceutical health policies that prevent harm.
In pharmacy, there are a lot of opportunities to optimize pain management. I started reading more about it while I was pursuing my doctoral degree in Florida, which was during the height of opioid prescribing and the co-occurring overdose crisis.
In the early 2000s, there were a lot of issues around opioid prescribing and dosing. I started seeing a lot of policies being put in to place that were well-intended but had this blanket, one-size-fits-all approach to managing the crisis. I was concerned that such an approach would materialize into actual harm: patients dying or turning to illicit supply because they need relief.
I believe the appropriate treatment is whatever safe and effective medication works for the patient and is well-managed by a prescriber. Many policies that put well-intentioned limitations on prescribing are misleading. In my work, I’ve been very vocal about the need to evaluate the unintended consequences produced by these policies to ensure that we’re not continuing to harm people despite good intentions.
A lot of the last two years of my research has been dedicated specifically to Florida’s restrictive three days’ supply limit on opioid prescriptions for acute pain. While it was not meant to apply to chronic pain patients, we’ve seen far-reaching consequences. Doctors and prescribers simply decided not to prescribe opioids at the same level anymore. The law didn’t say anything about who can or who cannot get a prescription for opioids — it simply says to decrease the amount.
So even small legal text nuances like that are causing harm. Patients and prescribers are continuing to replace opioid prescriptions with non-steroid anti-inflammatory drugs (NSAIDs), and we have heard stories of patients taking huge amounts of ibuprofen and getting gastrointestinal bleeding to the point of anemia, or large amounts of acetaminophen — which is the number one cause of liver injury in the country — or turning to alcohol or illicit drugs. And our research into this was helpful in stopping a proposal for this kind of restrictive days’ supply limit at the federal level.
The overdose crisis continues to increase, and prescription limits are the low hanging fruit. There’s still so much more to research.
What brought you to public health?
My curiosity and interest in pain management brought me to the public health space. Pain is a universal human experience, but it’s not researched very often. I decided very early on that I wanted to have a population health angle to my pharmacy degree. That’s what got me interested in my line of research in the middle of my doctoral and pharmacy programs. Through a research internship, I learned that I could use big data to answer pharmacy questions.
There are a lot of pharmaceutical policies and procedures in place right now that are creating barriers to legal opioid access. The stigma on substance use is being applied to patients with very real pain, and you have algorithms that might flag a person seeking to fill opioid prescriptions to a pharmacy, to prescribers and to the Drug Enforcement Agency (DEA). The DEA also tracks high prescribers, which is difficult if you are a doctor who takes care of patients with conditions that are pharmacologically dependent on opioids.
This situation is different than a substance use disorder, but patients are being treated equally through existing policies. So, many prescribers are tapering people off opioids or flat out declining to prescribe them at all, even though they are one of the most effective pain management treatments. They’re very strong analgesics that need to be managed, of course, because there are risks like with any drug, but we don’t have an alternative for strong pain relief — and NSAIDs can be very harmful, too. A lot of the work right now is approaching the issue from different angles — through federal, state and local policies that reduce harm.
I don’t currently practice as a pharmacist, but I am licensed in Florida and to start doing some medication therapy management via phone consults. I am fluent in Spanish, so this will be specifically for Spanish-speaking Medicare patients.
How have you pivoted in response to the coronavirus pandemic?
I’ve been able to involve more people in my research because it doesn’t require a lab or dedicated space so long as you have computer and internet access. There are public datasets available. I’ve been able to collaborate more with undergraduates in my research.
At the start of the pandemic, my team at University of Florida created an opioid research group, which included more than 30 students and has resulted in almost 20 publications. So, while I don’t say the pandemic has helped productivity, it has helped me think about ways to involve more people in research — especially people who might not think research is accessible to them because they aren’t on a campus where they see research happening or because they don’t have lab access. It’s been an opportunity to show others that you can do research with this public data; you can analyze it and talk about it.
In terms of the overdose crisis — a more encompassing term that people in my field prefer to use instead of “opioid crisis” — overdoses did increase during pandemic, but they were mostly driven by illicit substances. Some of the changes with telehealth have really helped patients with pain. (Again, these are patients with severe disabilities or who are immunocompromised, where even leaving the house is difficult and being exposed to COVID-19 is very dangerous.) Telehealth accommodated some of their care, so they didn’t have to go to their prescriber to get a prescription refill.
We also know that telehealth helped some patients get opioid use disorder medication like buprenorphine, but now we’re reverting to processes from before pandemic. It’s hard to tell what the future will look like, because it depends on the location and the level of policy. Even at the state level, Medicaid is very different from private insurance. Context matters.
Who are you when you’re at home?
I have a husband and two brindle dogs named Marley and Bella. They’re our babies. I am originally from Colombia, so I’m planning on spending the summer there.
I also like running and being outside. I’m an ultra runner, which is a crazy type of runner who goes further than the traditional marathon distance — we’re talking 50 miles, 80 miles. I haven’t done a race in a year, but my plan is to get back into it and to explore the trails of N.C., which I’m very excited about. And I enjoy rock climbing, which I got into during the pandemic.
I also love books — everything from psychological thrillers to nonfiction leadership development. I’m not very selective!