Heroin task force report: another weapon of mass distraction

A full read of the 99-page report of the Heroin and Prescription Opiate Addiction Task Force paints a very different picture than what the press reported. The report isn’t without its faults, but nevertheless it’s worth understanding what it actually says — and doesn’t say.

If you read the major-media stories, you’d think that the whole report only has one issue and one recommendation: opening up safe consumption sites. But it actually lays out three big problems, and eight recommendations to address them. Safe consumption sites are only a small part of that much bigger picture.

The three problems are:

  1. Heroin and opiate addiction has risen dramatically since 2007.

According to the report, while addiction is trending down for alcohol, methamphetamines, and even cocaine, heroin and opiates are bucking the trend. In King County, heroin and opiates have even surpassed alcohol as the primary drug for people admitted into detox services.

heroin-use

Public health and medical professionals believe that over-prescription of opiates by doctors is an underlying driver of this, partly because of a lax system surrounding it: there is no comprehensive program to monitor patients who are prescribed opiates to look for signs of addiction, nor are there effective, widespread programs to “take back” leftover doses.

opiates-sold-in-wa

The dramatic increase in opiate medications (mostly for managing chronic pain) has thus created a large quantity of “loose” doses for addicted patients as well as their family members who help themselves. The effect on kids in particular is horrifying:

10th-grade-rates

While it’s nice to see the trend line go down, in 2014 a full 5% of 10th graders still reported using prescription opiates to get high in the past month — and 19% of those have tried heroin.  According to studies, youth ages 14-16 represent the peak time of initiation of opiate misuse, and the majority of young adults who use heroin report being hooked on prescription opiates prior to using heroin.

And the opiate epidemic is only going to get worse, because of fentanyl: a synthetic opiate that is 80 times more potent than morphine, 50 times more potent than heroin, and cheaper than heroin to produce. Many cities are now seeing a dramatic upswing in fentanyl being sold on the street, and along with it a spike in fatal overdoses since the difference between an effective dose of fentanyl and an overdose is tiny.

 

2. The treatment program capacity and options don’t match the need.

The report describes several different treatment options for opiate addiction, including detox/withdrawal management, outpatient therapy, residential treatment programs, and medication-assisted treatment with an “opioid agonist” drug that relieves drug cravings without providing a euphoric “high.”  Medical professionals believe that having a menu of possible treatment options is important; there is no one treatment that is effective for all patients, and those patients ought to have a say in the treatment choice. Also, studies have show racial disparities exist in which treatment options are offered to different groups of people.

The University of Washington Alcohol and Drug Abuse Institute believes that as many as 5,000 people in King county may be interested in treatment for opioid use. Unfortunately, in a classic NIMBY move, Washington state law caps the number of clients permitted to be served medication-assisted treatment at an opioid treatment program at 350. That limitation has resulted in up to 150 people on a wait-list at any given time to get into a program.

Medication-assisted treatment has also evolved. The traditional treatment uses methadone, and as of a year ago there were about 3,600 people currently taking methadone through a treatment program in King County. But the newer treatment uses buprenorphine, or “bupe,” instead — a drug much like methadone but that can be prescribed by a doctor in an office setting and obtained at a pharmacy (methadone can only be given out by licensed programs). Unfortunately bupe-based treatment is not widely available yet and those who are getting it today are more likely to be white and have higher incomes than those receiving methadone.

 

3. The public health issues downstream from the large population of untreated heroin addicts are many and very serious.

map-of-overdose-deaths

Let’s start with overdose deaths. According to the report, in 2013  heroin overtook prescription opiates as the primary cause of opiate overdose deaths. In 2014, there were 156 heroin-involved deaths in King County, the highest level since 1997 and a huge jump up from 49 in 2009 and 99 in 2013. The figure dropped a bit to 132 in 2015. According to the CDC, more people in the U.S. die annually from drug-related overdoses than from auto accidents. Overdoses are now responsible for the majority of deaths among the homeless population in King County.

In addition, drug paraphernalia, particularly shared needles and syringes, are a major vector for the spread of disease — notably HIV and Hepatitis C. And since the drug-addicted population is not a closed community, that means it’s a vector for those diseases out into the broader population through sexual activity and poor hygiene.

There are additional disparate impacts with racial and social-equity impacts as well. Statistics show, for example, that blacks tend toward smoking heroin while whites tend toward injecting it, so to the extent that public health responses give more attention to injecting users over others, the black community of users will get less assistance. The report also suggests that there are “disparities in accessing opioid medication for pain, particularly for African Americans” — hinting that other pain-management therapies that pose less risk are made more available for other demographics.

Substance abuse issues have also been connected to homelessness — as both a cause and an effect. And since homelessness has a disparate impact on people of color, that magnifies the impact of substance abuse on those underserved communities.

 

The task force’s eight recommendations map to the three problems above. For the first, they have three recommendations that focus on preventing people from becoming addicted to opiates:

  • Raise awareness and knowledge of the possible adverse effects of opioid use, including overdose and opioid use disorder.
  • Promote safe storage and disposal of medications.
  • Leverage and augment existing screening practices in schools and health care settings to prevent and identify opioid use disorder.

To implement these recommendations, the task force suggests a variety of tactics. It calls for much broader education to health care professionals as well as consumers — and especially to students. It calls for much broader use of Washington’s Prescription Monitoring Program. It suggests that pharmacies have a larger role in counseling patients to securely store opiate prescriptions in their homes, and that prescription take-back programs should be expanded (including distributing mail-back envelopes with every prescription). And it calls for both expanded screening for signs of opioid abuse in schools (and other community organizations) and creating a referral process for high risk youth to substance abuse treatment programs.

 

The task force’s three recommendations for improving substance-abuse treatment are bolder:

  • Create access to buprenorphine in low-barrier modalities close to where individuals live for all people in need of services.
  • Development treatment on demand for all modalities of substance abuse disorder treatment services.
  • Alleviate barriers placed upon opioid treatment programs, including the number of clients served and siting of clinics.

The task force presents a new and different view on bupe-based treatment. It calls it “buprenorphine first,” in the same spirit as the homelessness crisis approach of “housing first,” and argues that using bupe to stabilize addicts as a first step “is an alternative approach to opioid treatment that is client-centered, focused on harm reduction, and designed to engage a greater number of individuals experiencing opioid use disorder in effective opioid treatment.” It says that “buprenorphine first” will be much more effective for a broader set of people including those experiencing homelessness, those with limited or no support systems, and those with complex medical and behavioral health needs. But to execute on this tactic, access to bupe needs to be dramatically expanded.

The task force also argues that there needs to be a “treatment on demand” approach, where the full variety of treatment options are available immediately, without delay, to all individuals requesting care. That provides better and more customized care with a higher chance of success, and it also alleviates racial disparities since everyone receives the same options. Of course, that means building out additional capacity for the full range of services so that they are consistently available.

And it notes that pressure should be put on the state government to lift restrictions on the size of treatment programs, and on local agencies with the authority to issue waivers to those restrictions to more proactively invoke that authority.

 

For the third problem, the task force made two recommendations, both controversial:

  • Expand distribution of naloxone in King County.
  • Establish on a pilot program basis, at least two Community Health Engagement Locations where supervised consumption occurs for adults with substance abuse disorders n the Seattle and King County region.

Naloxone is a drug used for emergency treatment of opiate overdose. Opiates cause “respiratory depression,” i.e. you breathe less and shallower. Opiate overdose causes you to stop breathing entirely — killing you — but naloxone can reverse that effect and restart breathing.  First responders and emergency room staff sing its praises, and some Seattle Police officers have begun carrying a dose of naloxone with them while on duty. The task force argues that doses of naloxone — which is now packaged in a form that they argue could be administered by almost anyone — should be distributed widely. There are the obvious places such as needle-exchange sites and homeless shelters, but they argue that they should also be in all correctional facilities, schools, and essentially all healthcare facilities at all levels of service. They also content that pharmacies should stock it — and perhaps be allowed to give it out with every opioid prescriptions. And insurance companies should be instructed to cover naloxone to encourage pharmacies to keep it stocked and to make it affordable for high-risk individuals. And they would like outreach workers to be able to distribute take-home naloxone kits as well.  In all, that is a huge commitment to reducing opiate overdose deaths. And like the EpiPen, its per-dose price has shot up recently.

But all the media attention has been on the final recommendation: open up two “safe consumption” sites.  The task force prefers the name “Community Health Engagement Location” (CHEL) to either “safe injection site” or “safe consumption site.” They also argue that it’s very important that it be not just “injection,” returning to their earlier point that opiates are ingested in different ways and just focusing on injecting users will create racial disparities in how this service is provided.

The case for a CHEL is multi-faceted, but at its heart it stems from an increasingly popular philosophy called “harm reduction.” Under the harm reduction approach, when a problem can’t be entirely solved the focus turns to taking actions that will reduce the amount of harm the problem or behavior is causing. It argues that a heroin addict is better off still alive but regularly consuming until some future point in time when the person’s addiction can be addressed, than he would be if dead from an overdose — and thus interventions which prevent overdosing but allow him to keep consuming would be appropriate. Along those lines, someone who is addicted but disease free is better off than someone who is addicted and infected with HIV; and the community is better off as well, since that person is not at risk of spreading HIV to others — thus needle and syringe exchanges would be justified.

It’s important to keep in mind that harm reduction is a philosophy rooted in our real, messy world.  There often aren’t the resources available to give everyone the treatment they need for their addiction (and other issues), and the outreach and healthcare professionals who work in this field recognize that addicts need to be ready to accept help if the treatment is to be effective.

A CHEL is intended to do many things. At the highest level, it provides supervised consumption to prevent overdoses — both during and after dosing. There is proof that the model works for this purpose: the highly-publicized supervised consumption site in Vancouver, B.C. has had 221 overdose interventions since its inception in 2003, and not a single overdose death. But it also serves as a needle and syringe exchange and provides a hygienic space and sterile supplies (as well as condoms) to prevent the spread of disease. It provides some basic medical treatment and referral for more advanced medical needs.  It can potentially be a service point for bupe and naloxone distribution. But equally important to all of the above, a CHEL is an outreach site where the people who need help come to them: where workers can build a long-term relationship with individuals with substance abuse issues, sense when the time is right, and immediately refer someone who is ready to accept help into a treatment program. This is what the Vancouver site does, and since 2003 it has  made 3,383 clinical treatment interventions, 5,268 referrals to other social and health service programs, and 458 admissions to its own onsite detox program.

That’s the pitch for the CHELs. If you don’t buy into the harm reduction philosophy, you almost certainly won’t buy into safe consumption sites (or needle exchanges, or stopping the homeless encampment “sweeps” for that matter). But at the moment it’s the view that is driving city and county government, and it’s the view that led the task force to make its recommendations.

It should be noted that the task force reached a general consensus on many points, but it wasn’t unanimous. In particular its recommendations on naloxone and CHELs had dissenters.

recommendation-vote-tally

The most obvious fault with the task force report is that it fails to prioritize its recommendations — while recognizing that they need to be prioritized and even suggesting the factors that should be weighed in doing so:

  • evidence base of effectiveness
  • population health/safety impact
  • community support
  • equity
  • complexity/feasibility
  • legal considerations
  • cost
  • sustainability

That looks like political cowardice, especially with the nod to “community support” in the list. It’s not the task force’s job to sell it to the public; its job is to recommend what has the best chance of successfully addressing the heroin and opiate addiction crisis, based upon facts, science, history, and expert opinion.

And in the absence of stated priorities, the press and the public have latched onto the most controversial recommendation as representative of the whole report. It clearly isn’t. If the main goal of the response is to reduce the number of people who are addicted to opiates, than CHELs are a minor factor (acknowledging that as a site for outreach they will make a small contribution). But the task force allowed people to hijack the debate by focusing attention on that one recommendation.

We have the same problem with the debate over the homeless crisis in Seattle. Rather than focus our attention on preventing people from becoming homeless and stabilizing and re-housing those who are currently unsheltered, we have allowed enormous amounts of precious time, energy and resources to be sucked into an argument over “sweeping” unsanctioned homeless encampments, when neither option (sweeping or leaving them in place) is humane and neither contributes to sheltering the encampment residents.

Here’s Council member Sally Bagshaw’s statement on the task force report, in which she makes reference to the call for wider access to buprenorphine and to “treatment on demand.” Kudos to her for not speaking to the CHEL recommendation. And here is the press release from King County Executive Dow Constantine and Seattle Mayor Ed Murray, which lists all the recommendations but only explicitly voices support for the expanded access to naloxone (which to some extent has already begun so it represents an easy layup).

I struggle to see this as leadership from our elected officials. It feels more like outsourcing. All the special interests, task forces, and advocacy groups get asked for their views, and they add their voices to the cacophony of responses to every policy initiative. But time and time again, our leaders don’t even bother trying to unite us and sell us on a vision of where we should go together; they simply pick a side, gather their supporters, and cast their vote, and in so doing reinforce the fractures in our community. The response to the heroin crisis is now indelibly tagged with an argument over safe consumption sites, and there will be heated debate on that issue every single time the crisis response comes up for deliberation.

The heroin addiction task force report is informative, with thoughtful recommendations based on facts, science, and emerging best practices. It can inform our thinking on a difficult problem. But without a sense of priorities, and without the leadership to “sell” it to the community and build a consensus view beyond the flashy distraction of a controversial issue, it may end up just one more task force report in a filing cabinet.

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