By Laura Robinson, Intern to Sally Bagshaw*
Heroin-induced overdose deaths have risen steeply in King County and the United States in recent years. In the King County Board of Health report delivered in March 2015, heroin involved deaths jumped from 21 in the first half of 2010 to 69 in the first half of 2014. Heroin is now the most common drug identified in overdose deaths in King County, accounting for 45% of all overdose deaths. This was the steepest rise in local drug-related deaths in the last 17 years.
The overdose problem has been growing quickly and we must start responding with education and solutions, as a city and as a country. In Seattle, we have organizations doing the tough work of treating opiate addiction – but their relatively limited resources are stretched thin. Directing resources and increasing funding for intervention (such as rehab/drug treatment programs) and prevention (through outreach and education) are important steps our city and state must take to combat this ever-growing problem. Substance addictions, especially opiate addictions, may seem like an overwhelming issue to tackle, but we must start responding to an issue that should truly be considered a public health crisis.
How serious is the problem?
The National Center for Disease Control (CDC) reported in 2014 that accidental poisoning deaths (i.e. overdoses) are now the leading cause of injury death for 25-65 year-olds nationwide coming in ahead of motor vehicle accidents, homicides and suicides. That’s a startlingly high rate. The Department of Justice reported that opioid overdose deaths rose nationwide 45% from 2006 to 2010. Another CDC report found in 28 states heroin deaths doubled between 2010 and 2012 and Washington State is now ranked 23rd highest in the country with 13.7 overdose deaths for every 100,000 people. The graph on the left shows heroin use increases from 2002 to 2011, as reported by Substance Abuse and Mental Health Services Administration.
The issue is growing and it touches everyone in our community, from funding dollars necessary for medical care on down to providing housing for addicts. For a long time, substance addiction has carried a stigma, and society has preferred to keep it hidden in the shadows. This has to change for our response to be effective. There has already been a great deal of research done around the best treatment methods for opiate addiction, as well as the most common paths leading to addiction. The research and knowledge already available are important starting points for our city and community to begin addressing the epidemic.
What’s the pipeline for heroin addiction?
According to the CDC Director Tom Friedan, three quarters of all opiate addictions begin with prescription opiate painkillers. Many legal opiates (think OxyContin and Percocet) are dangerously addictive, and widespread prescriptions make them relatively easy to procure. Currently there are enough prescription painkillers prescribed annually for every adult in the country to receive a full bottle.
Consider a standard root canal procedure – a patient may be written a prescription for a full bottle of painkillers, even though for a standard recovery, a patient would need 1-2 days of high-strength painkillers, before easily making do with some form of ibuprofen. Bottles of leftover prescription painkillers are sitting unused in medicine cabinets and increasingly young people are experimenting with painkillers readily available in their homes and the homes of friends. If there’s something that should be labeled a gateway drug, these legal opiates are it. Molly Carney, Executive Director of Washington’s Evergreen Treatment Services recommends that all opioid painkiller prescriptions include a mandatory lockbox for storage, because of the high risk these drugs pose when they are freely procured.
Once prescription painkillers become too expensive or difficult for addicts to obtain, they switch to heroin. It’s an alarmingly simple leap to make. Heroin has become one of the most heavily trafficked drugs into the United States from Mexico and has become readily available and cheap on our streets, with a single dose costing only $10.
The reliance in our medical community on treating pain with highly addictive painkillers is a major contributing factor in the rise in opiate addictions. Nicholas Kristof wrote in the NY Times, “Many Americans, often military veterans, get hooked on pills, and then, unable to afford prescription painkillers, turn to heroin as a much cheaper alternative. We talk about personal responsibility as a factor in drug abuse, and that’s real; but so is corporate irresponsibility.” This pipeline to opiate addiction is obvious and one that we will need to fight with both preventative education and treatment interventions.
What treatment practices work?
Heroin and opiate addictions are not new. There are already two medications, Methadone and Buprenorphine, which are FDA approved and have very good success in blocking cravings and withdrawal symptoms. Because these two treatments are heavily regulated at the federal level, opiate addictions are often treated with an abstinence approach. Most treatment facilities are limited in the amount of methadone/buprenorphine they can prescribe, so there is still reliance in rehabilitation facilities across the country to treat opiate addictions with behavioral treatment instead of medical assistance.
Abstinence-based programs means no medication of any kind can be used in treatment of an addiction – the argument being that the medications become an alternative dependency for addicts. However, opiate addictions are very difficult to treat with an abstinence-based behavioral approach. This type of treatment can work well within the supportive and strict structure of a rehabilitation facility, but there is an incredibly high rate of relapse after release for opiate addicts. An unsettling side effect of abstinence-based treatment is if addicts do relapse (and a large proportion do), their lowered tolerance puts them at incredibly high risk for overdose. This Huffington Post article makes a strong argument for medication assisted treatment programs for opiate addictions.
Getting funding and increased resources to Medication Assisted Treatment (MAT) programs will be a crucial aspect of our intervention response in the future.
Medication Assisted Treatment Quick Facts:
• Scientifically proven in repeated studies to be the most effective treatment for opioid dependence
• Cost of providing treatment is 10% of cost of incarceration and hospital costs if individuals are left untreated
1. Methadone – Mitigates withdrawal symptoms and at higher doses blocks the effects of heroin and other opiates
*Only available at approved outpatient treatment programs; daily doses are provided until patient is stabilized enough for take-home doses
*Used successfully for more than 40 years as treatment for opioid addictions
2. Buprenorphine – Suppresses withdrawal symptoms; effects are milder than Methadone
*Can be prescribed by a family physician and taken at home, allowing for a normal life without daily commute to a methadone clinic
*Cannot be used to get high
*WA state law requires counseling before it can be prescribed; with a 12 month lifelong limit on prescription
3. Naloxone – Reverses overdoses
*WA among 34 states that make Naloxone available; distributed at dozens of sites
*Safe, non-addictive, cannot be used to get high and can be administered by anyone
Who is doing it right?
Evergreen Treatment Services is an Opiate Treatment Program (OTP) that has been doing medication assisted treatment for over 40 years in Western Washington. The private non-profit organization treats 2,500 patients throughout Western Washington with three clinics and a mobile van. The medication predominantly used at Evergreen is Methadone, though they also prescribe Buprenorphine. As clients regain stability with the help of the medication, the many resources at Evergreen help them to rebuild relationships with friends and family and eventually return to school or work.
Evergreen uses an interdisciplinary team of physicians, psychiatrists, nurses, pharmacists, counselors and social workers to provide support throughout treatment for clients. An ETS patient was quoted saying, “Treatment has helped me to become the person I was before I started using drugs.” Click here for inspirational short clips of Evergreen clients whose lives have been transformed with the help of Evergreen treatment services.
Currently Evergreen’s programs are full and enrollment lists are growing. Because each clinic is limited in the amount of methadone it can dispense, the biggest need in our region is simply more methadone clinics more widely dispersed throughout the region. Evergreen is also seeking sites for their mobile van clinic, so that clients who live further afield can be better served. Evergreen’s resources will be increasingly stretched thin as opiate addictions continue to increase, if their services are not expanded. An opiate addict seeking treatment is taking a huge step towards recovery – we must make sure those doors are open.
As a city, Seattle must continue to support Evergreen Treatment Services especially as opiate addictions continue to increase. Additionally, support and advocacy for medication-assisted treatment on the state and federal levels will be especially crucial in the next years as we continue to respond to the increase.
Importance of Prevention and Education
Prevention and intervention are both important aspects of how we respond to this rising epidemic. Prevention comes down to education.
I had a teacher at Garfield High School who often educated us about topics outside of his class subject matter. I remember vividly a story he recounted about a lengthy hospital stay during which he was prescribed daily opiate painkillers. Soon enough his whole world was starting to revolve around the arrival of the pills each day. Not around family visits, not around his recovery, but around the pills. It was a powerful warning for me about the dangerously addictive nature of medications patients regularly receive from trusted health care professionals. Not only was it a powerful warning, it was the ONLY warning I received from education providers throughout my high school and college years.
Education is our greatest tool when it comes to prevention. We are making some progress on that front: pharmacists are now required to give instructions about safely using and storing opiates to patients filling prescriptions. But there’s significantly more to do; better education for young people, and research into pain reliever alternatives/solutions.
Part of this simply comes down to spreading the word and increasing awareness. Parents may not be aware of the pressing need to educate their children on this subject. Seattle’s human services and public health departments could work in conjunction with UW researchers and providers such as Evergreen to release quick facts sheets and addiction information. The dangers of substance addiction should be openly discussed amongst families and communities. Teachers may not have time in the classroom to address these topics – but a quick workshop once a year could jumpstart awareness and conversation. The devastating effects of opiate addiction are real and apparent throughout our city streets and if we don’t start talking about it, it will only get worse.
Our emerging doctors, dentists and health care professionals are receiving more education about the dangers of opioids. But education should be a prerequisite for every person given a prescription for prescription painkillers, along with the mandatory lockbox. And as we move forward, discussions about alternatives for treating pain beyond dangerously addictive opioids should become common practice in hospitals and clinics.
2016 Presidential hopeful Hillary Clinton is already discussing opiate addiction on the campaign trail (check out her address to voters in Iowa here) so it’s possible that there will be federal action on this issue in the next few years. But for now, the city and local agencies need to start addressing this crisis, holistically and aggressively.
Supporting organizations like Evergreen Treatment Services to grow where they are able and develop more treatment centers is crucially important as the need increases. The pilot Law Enforcement Assisted Diversion program (LEAD) is a coalition of King County and Seattle service providers, police, attorneys, and community members committed to a new diversion approach for addressing drug and prostitution activity. LEAD is a good example of cutting edge community practices that are making a difference. Diversion into treatment programs is significantly less expensive than prison or hospital expenses – however we need the space in treatment programs for this to work.
Finally, the importance of education cannot be overestimated. The notion that opiate painkillers are safe because they are prescribed by physicians is patently untrue. We need more education for doctors, pharmacists and any member of the public who is written a prescription. This is a problem we already have solutions to – we just have to start putting them in action.
I challenge the City of Seattle and regional partners to continue finding ways to address the heroin epidemic, from funding Evergreen Treatment Services, to engagement with LEAD, to instituting preventative education programs. Let’s collaborate to address heroin use in our community.
*Laura Robinson is my summer intern. She graduated from Whitman College and is returning this fall to Emory University where she will be a second year seminary student. Laura is exploring a passion for civil politics that encompasses social justice and care for marginalized populations. Explore her other summer blog posts here. – Sally Bagshaw