The Council heard a fascinating presentation yesterday from Dr. Caleb Banta-Green of the UW School of Public Health, a member of the Seattle and King County Heroin and Prescription Opiate Addiction Task Force on its recent report.
You can watch it here (jump to 18:45) — and please do. It’s absolutely worth it.
The statistics related to the heroin and opiate crisis are jaw-dropping.
According to Banta-Green, the root cause of the epidemic is a dramatic rise in doctors prescribing various opiates for chronic pain, including oxycontin and codeine; 1 in 5 adults and 1 in 10 children are prescribed an opiate in a given year. For many people, that is the start of dependence and addiction. But it’s also common for people to have extra pills left over at the end of their treatment, which they keep in their medicine cabinet at home. This has created what Banta-Green calls an “opiate soup” of leftover medications to be discovered and consumed by other family members. His organization asked kids “have you used a prescription opiate in the last 30 days?” In 2006, 5% of the population answered “yes.” By 2010 the figure was 10% — about 3 kids in every classroom. And because prescription opiates are circulating in every community that has a pharmacy, the opiate addiction issue is everywhere, not just in urban areas.
Prescription opiates have created the demand, but the second half of the problem is the wide availability of illicit heroin on the street. When the prescriptions run out but the addiction continues, people buy heroin on the street.
Banta-Green gave a detailed explanation this morning of “opiate use disorder” and its unique and challenging aspects. He explained that it’s wrong to think of treatment as “detox” because it isn’t “one and done.” Opiates permanently disrupt the normal system of receptors in their brain, and people with opiates use disorder need opiates constantly on their receptors in order to feel normal. That will be true for years, decades, and quite possibly for the rest of their lives. The only effective treatment for opiates use disorder is really a long-term maintenance program using a drug such as methadone which replaces heroin or other strong prescription opiates. Methadone is a “pure opiate,” and the more you take, the more effect you get. You can be maintained on a safe dose of methadone for a long time, but you can also overdose. Because of that, the approved treatment requires a highly structured model of care in a clinical setting where the patient can be monitored. Physicians need to be specially certified to prescribe methadone, and may only do so under an approved program to monitor patients.
The task force made several recommendations for addressing the opiate addiction crisis, organized around three big themes: prevention, expanding treatment, and providing health services and overdose protection.
The efforts around preventing opiate addiction center on dealing with the “opiate soup” of prescription medications out there. The task force calls for better education of physicians and patients on the adverse effects of opioid use and on safe storage of prescription medications to keep them out of the hands of children. It also suggests that programs to safely and securely dispose of leftover medications should be expanded; currently there are dropoff facilities in police stations and a handful of other places, but most pharmacies don’t have them. Earlier this year the Council passed a resolution encouraging pharmacies to have secure drop boxes, but according to Council member Burgess they have been resistant to the idea. Burgess suggested he might propose an ordinance to require drop boxes in pharmacies by the end of the year.
Expanding treatment programs — both the variety of programs and access to them — is the largest focus of the task force’s recommendations. A promising alternative treatment to methadone has been developed using a drug called buprenorphine, or “bupe.” Unlike methadone, it is a “partial opiate” and has a ceiling effect, which makes it highly unlikely that someone will overdose on it if used alone. The regimen is simple: one pill each morning, which lasts for 24 hours. Because it doesn’t require an intense model of care, physicians can prescribe it in their offices.
Bupe features prominently in the plan, through efforts to make it more accessible and available. Banta-Green described a pilot program to increase the number of physicians prescribing bupe, which had limited success due to the monitoring load placed upon those doctors. They are now looking at a “nurse care management model” which takes much of the load off the doctors. They are also devising a new program which would allow nurse practitioners to prescribe bupe.
Today it can take up to 12 weeks to get into a treatment program (methadone or bupe), during which time the person has a 10% chance of having an overdose. So they are looking at a new model, “bupe first,” in which providers can provide the first 30-60 days of bupe for patients to stabilize them starting with a day of requesting it (and with a very low threshold to get into the program), and then after the stabilization phase they are transferred to a maintenance program in their community. The philosophy behind this approach is that every day they are on bupe their overdose risk is cut in half, and it gives them the opportunity to “re-emerge” back to their normal selves without the constant craving for opiates.
Seattle/King County Public Health is apparently fully bought in to the “bupe first” approach and is moving quickly to implement it.
But Banta-Green also acknowledges that the are some people who need the highly structured model of care in a methadone program, so there should be a variety of treatment options available so that people can choose a program that will work for them.
Among the task force’s recommendations for expanding health services and overdose prevention for users is an increase in availability of naloxone, an emergency overdose treatment medicine that can be administered as a nasal spray with little training. They are currently evaluating where naloxone kits should be distributed, including police departments, fire departments, jails, homeless shelters, and syringe exchange facilities, and other places where homeless people and/or people with substance abuse disorders frequent. A pilot program to equip and train SPD bike officers with naloxone kits began last spring, and is under close evaluation to see whether it has been effective compared to other options.
Banta-Green wisely saved the most controversial issue for last: the proposal to set up two safe consumption sites, one in Seattle and one elsewhere in King County. The philosophy is straightforward; it’s an application of harm reduction in preventing overdoses and deaths. But the sites would also have services present, to provide health services for some of the most marginalized people in our communities and to provide counseling and get them into drug treatment programs as soon as they request.
The objections to safe consumption sites are well known: the beliefs that they will encourage drug use, normalize use, and create problems in the neighborhoods where the sites are placed. Banta-Green responds by noting that people are already using drugs in our communities, but where there are safe consumption sites:
- there is less public consumption;
- there is less infection disease transmission;
- there is good evidence that there are fewer overdose deaths;
- there will still be people using drugs, but they will be in a safer setting and will be able to get connected to services;
- the safe consumption sites aren’t placed randomly; they are put where the people are and where they want to be using safe consumption facilities.
That last point led to broader discussion of the importance of “being nearby” for treatment facilities and safe consumption sites as one aspect of how hard we make it for users to get treated. Banta-Green pointed out that most people using drugs don’t want to be. He discussed a 2015 survey of 1000 users at 18 syringe exchanges around Washington state. Fully 2/3 of the people not already in treatment said that they wanted help reducing or stopping their use. But most can’t or don’t want to access the resources that are out there, because today treatment — if they can get it — is a big burden. It’s easier for them to wake up in withdrawal, go find something to steal, find a place to sell it, buy drugs, find a place to consume the drugs, and repeat that four times a day than it is for them to get a dose of bupe for about $12 a day and not have to use drugs for 24 hours.
And that is the key opportunity that Banta-Green sees: if Seattle and King County can make low-barrier, low-intensity services available then he believes people will absolutely take advantage of them. By his estimates, there are between 5,000 and 10,000 people who should be in opiate use disorder treatment programs in King County. It will be no small feat to stand up programs at that scale, but in tandem with an expansion of the prevention programs it would make an enormous difference in addressing the current crisis.
If the biggest obstacle to treatment is the ‘big burden” wouldn’t it be easier all the way around to simply reduce the burden? Have treatment processes broadly communicated in areas where the most addicts exist, have access simplified and drive as many people as possible to treatment versus enabling their usage prior to any treatment. Did the council hear from any ex addicts?
Those are good questions.
This isn’t a plan to do just one thing; it does several in parallel. The long-term strategy is exactly what you said: expand treatment programs so they are widely and immediately available. But you can’t do that overnight; it will take several months, if not years. Facilities need to be acquired, built out, certified, staffed and provisioned. Healthcare staff need to be recruited and trained. Medicines need to be acquired, which means building up the production. And money needs to be raised to do all of this. In the mean time, they want to do things that will reduce harm and save lives.
(and they want to roll out prevention programs)
And it’s debatable whether safe consumption sites are “enabling their use.” The people with opiate use disorder will find and use drugs regardless of whether safe consumption sites exist. They already do. The sites don’t make it easier, they just make it safer, and they create an opportunity to connect people with the services they need when they are ready to accept them.
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