It isn’t hard to administer the naloxone nasal spray.
Hold it to the patient’s nasal passageway and press the plunger. That’s about it. It’s a lifesaving drug that turns around the effects of opioids, be they prescribed or otherwise. There is a trick, of course. Naloxone is effective only if you are there when the overdose happens.
That’s why health care professionals distribute naloxone to people who use: They aren’t going to be able to save themselves, but maybe they can be saved by someone else if things go too far.
These harm reduction policies keep people alive as our society tries to solve one of the most deadly epidemics in decades, one caused in part by the pharmaceutical industry, which marketed these painkillers as safer than they were despite evidence to the contrary.
The medical community accepts that addiction is a disease, not a crime. It is a disease that has fomented because of the unnecessary prescription of opioids that caused people to turn to illicit drugs such as heroin and its more powerful cousin, fentanyl. It is a disease that the government says is killing almost two people everyday in this state. It is also one that causes real harm, not just to people struggling with addiction but also to their family members and even their neighbors.
So over the next few months, Real Change will be exploring the facts behind opioid use and the efficacy of the government strategies implemented to help with the crisis.
To be sure, the scope of this crisis is enormous. In 2016, nearly 1,500 people were hospitalized for an overdose and 694 died. Of the estimated 259,000 people in Washington over the age of 12 who use opioids for nonmedical reasons, only 14,389 were admitted to substance-abuse treatment.
According to the Alcohol and Drug Abuse Institute (ADAI) at the University of Washington, more King County residents who called the Recovery Helpline in 2017 asked for information about and referrals to an opioid use disorder treatment called buprenorphine than any other year — up 48 percent from just the year before.
The Buprenorphine Pathways Program was opened by Public Health-Seattle King County in January 2017 and was at capacity within 13 weeks. The program provides same-day medication starts onsite, a crucial component to the success according to research by the National Council for Behavioral Health. ADAI researchers reported that people lined up two hours before the clinic opened to get care.
Not all government policies help. State law caps the number of patients who can be treated with opioid agonist pharmacotherapy at 350 per dispensary location unless counties specifically request a waiver. Advocates recommend reducing that barrier to care.
Each year, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducts a survey trying to pin down the number of people who use and abuse various substances, legal and illegal. In 2017, SAMHSA found that 11.4 million people over the age of 12 had misused opioids. The vast majority of those — 92.2 percent — had misused only pain relievers. Only 7.8 percent, or roughly 886,000, had used only heroin.
As big as this number is, it is likely an undercount. SAMHSA captures only housed people, but even if every single unhoused person in the United States was found to have a problem with opioids (which is clearly not the case), the number of housed opioid abusers would far outstrip those without housing.
But, like most things that are out of sight, out of mind, opioid abuse becomes a problem when the aftermath plays out in public.
No one wants to see used needles, known as sharps, on sidewalks, on the roadsides or, as some reports have mentioned, near schools.
In August of 2016, Seattle Public Utilities (SPU) started a pilot program to collect sharps, which has collected 10,000 of them from public right of ways. City drop boxes, started in Feb. 2017, have collected 100,000.
That is a lot of needles, and clearly doesn’t count those collected by private persons or businesses; collection boxes can also be found in restrooms maintained by large retailers, and others may be disposed of in other, less appropriate waste receptacles. KIRO7 reported that Starbucks baristas had been pricked by sharps discarded in the café’s bins for used menstrual products.
For people who had to go on antiretroviral drugs to protect themselves from diseases like HIV/AIDS, it isn’t much comfort to know that the vast majority of sharps never show up on the radar. King County’s needle exchange program distributed more than 7 million syringes in 2017, and nearly two-thirds of them were used for heroin or other opioids. More than two-thirds of people who used the service were impermanently housed, 20 percent had overdosed in the prior year and 62 percent currently had naloxone. ADAI reported that most wanted to stop or reduce their drug use.
Needle exchanges are another evidence-based practice proven to reduce the transmission of life-threatening illnesses, prevent more needle litter from appearing on streets and help connect people to treatment. Still, commentators in local media question their efficacy and the money that the county puts behind them.
As German Lopez has reported in Vox, exchanges are the gold standard in patient care, and the United States is far behind other rich nations in terms of the number and availability of exchanges. They are stigmatized and seen as enabling drug use, but the data doesn’t back up that claim. Instead, studies demonstrate that needle exchanges prevent disease transmission.
Another proven intervention: safe consumption sites, also called Community Health Engagement Locations (CHELs). The Seattle City Council set aside $1.3 million to open a CHEL, one of at least two recommended by the Heroin & Opiate Addiction Task Force convened by King County.
Research shows that CHELs have an impeccable track record in preventing overdose deaths. Literally no one has died of an overdose in the sites in the 30 years that they have been open in countries around the world. They have other public benefits as well. A study in Sydney, Australia found that ambulance calls related to opioid overdoses declined significantly in the areas where a safe consumption site opened.
These sites also connect people to services. Insite, one of the most famous and well-studied programs, was founded in Vancouver, B.C., in 2003. The city saw a 30 percent increase in the use of detoxification services and clients who used the program regularly were 33 percent more likely to have started addiction treatment than those who didn’t.
These findings are promising. A large percentage of folks who use the local needle exchange program said that they were interested in safe consumption sites, and 39 percent said that they would use one daily.
Despite the evidence, these programs are controversial because, again, they are seen as enabling drug use. A court recently tossed out an initiative, I-27, meant to prevent sites from opening in King County. Supporters of the initiative acknowledge that heroin use is “a growing public health crisis” but then argued that “[s]upervised drug consumption sites are inconsistent with protecting citizens and helping drug addicts,” neatly ignoring that people suffering from use disorders are also citizens.
Instead, they support encouraging local governments to “offer treatment instead of continued drug use.”
Some in the community have even suggested forcing people into treatment. Others believe that using drugs is a crime, people who use them are criminals who should be incarcerated where they can dry out.
But research on compulsory treatment either isn’t there or isn’t particularly strong. A 2016 literature review looked at 430 studies and found only nine that met the researchers’ criteria. According to that review, published in the International Journal of Drug Policy, only two of those studies found positive impacts of forced treatment.
The evidence wasn’t strong enough for the doctors conducting the study.
“Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms,” the researchers wrote.
Governmental policies have helped. The Medicaid expansion, embraced by 37 states and the District of Columbia, vastly increased insurance coverage for people suffering from opioid abuse. According to an analysis by the Center for Budget and Policy Priorities, the share of uninsured hospitalizations related to opioid use disorders dropped from 13.4 percent in 2013 to 2.9 percent two years later.
Part of that was a matter of changing the rules. CBPP reported that a substance use disorder by itself wasn’t considered a disabling condition under Medicaid. That meant that low-income adults didn’t qualify for care until the federal government expanded the program to include people who made 138 percent of the federal poverty line.
People struggling with opioid addiction literally couldn’t afford to get clean because they couldn’t afford to see a doctor in the first place.
To sum up: giving people access to health care got more people into treatment. Meeting them where they’re at, even when they’re using, facilitates getting them into care. Penalizing people for their drug use is at best a wash and at worst a death sentence. Forcing an adult into a treatment program or simply cutting them off doesn’t seem to do much good either, and may be a human rights abuse.
Solving the opioid epidemic, a crisis of our own making, will be an uphill battle. It is still relatively easy to get the drugs and their newer versions, like fentanyl, are insanely powerful. Some drug makers have even sought to profit off of the epidemic by raising the cost of Narcan, which reverses overdoses, by 600 percent. Solutions are there, but aren’t politically palatable. Existing laws restrict access to treatment, even when it is the only solution some people will accept.
In the meantime, people are dying. More people died of opioid overdoses in 2017 (72,000) than were killed in car crashes (37,461). Only the HIV/AIDS epidemic has rivaled the death toll. The United States eventually managed to get that health crisis under control, but it took a massive effort at a national scale. The good news is that society already have tools to conquer opioid abuse. It’s just a matter of whether or not we will use them.
Ashley Archibald is a Staff Reporter covering local government, policy and equity. Have a story idea? She can be can reached at ashleya (at) realchangenews (dot) org. Follow Ashley on Twitter @AshleyA_RC
Read the full Dec. 12 - Dec. 18 issue.
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