A Needle Exchange Project Modeled on Urban Efforts Aims to Save Lives in Rural Nevada

Five years after HIV tore through a rural Indiana town as a result of widespread drug use, a syringe and needle exchange program was set up in rural Nevada to prevent a similar event.

ELKO, Nev. — Richard Cusolito believes he’s saving lives by distributing clean syringes and needles to people who use drugs in this rural area of northeastern Nevada — but he knows some residents disagree.

“I’m hated in this town because of it,” said Cusolito, 60. “I’m accused of ‘enabling the junkies,’ pretty much is the standard term. People don’t get the impact of this whole thing.”

Drugs, including heroin and other opioids, are readily available in Elko, and Cusolito said a program like his has long been needed. Cusolito is a peer recovery support specialist and received training through Trac-B Exchange, a Las Vegas-based organization that provides a range of harm reduction services throughout Nevada.

In a city the size of Elko, with 20,000 residents, Cusolito’s work has hit close to home. He helped his daughter access rehabilitation services, and earlier this year, she died from an overdose.

“I just keep up hope for the ones that I can help,” he said.

Cusolito has run the exchange program since 2020, when the Elko City Council approved a resolution that gave him permission to hand out needles and syringes at the city’s camp for homeless people. The agreement was originally for one year, but the council recently renewed it for three.

Elko officials’ approval of Cusolito’s work comes as leaders in small, often conservative cities have been asked to adopt policies forged in large, more liberal cities, such as New York and San Francisco. Federal reports show people who use needle exchange programs are five times as likely to start drug treatment programs and three times as likely to stop using drugs as people who do not, but programs in Nevada and other states have faced similar pushback.

Scott Wilkinson, assistant city manager for Elko, said the city’s ability to provide resources to people who use drugs is limited. “We’ve done what we can do to try to help out, but we don’t have a health department,” Wilkinson said.

Trac-B Exchange funds Cusolito’s project, and he provides reports to the city about how many syringes and needles he distributes and collects for disposal.

Needle exchanges are part of efforts known as harm reduction, which focus on minimizing the negative effects of drug use, rather than shaming people. In recent years, harm reduction tactics have begun to spread to rural areas, said Brandon Marshall, an associate professor of epidemiology at the Brown University School of Public Health.

Marshall said a 2015 HIV outbreak fueled by drug use in rural Austin, Indiana, became a “canary in the coal mine,” showing how shared needles could spread the virus. A syringe exchange program could have averted the outbreak or reduced the number of people who were infected, according to a modeling study that Marshall co-authored in 2019.

Cusolito is trying to prevent that kind of disaster in Elko. His small office, in a gray building just off the main street near downtown, isn’t eye-catching from the outside. A “Trac-B Exchange” placard is posted outside, but it doesn’t identify the space as a syringe and needle exchange. Yet Cusolito estimates he sees 100 to 150 people a month, relying on word-of-mouth.

He also visits the jail, helping people booked on drug charges complete assessments required to receive treatment at rehabilitation facilities.

He is adamant that participants turn in their used syringes and needles before getting replacements. The old ones go into a sharps container — a sturdy plastic box — that he sends to Trac-B Exchange in Las Vegas, where they are sterilized and pulverized for safe disposal.

Trac-B Exchange’s harm reduction efforts also reach other areas of rural Nevada: A peer recovery support specialist runs a needle exchange program in Winnemucca, 124 miles from Elko and home to 8,600 people. In Hawthorne, which has fewer than 3,500 residents, leaders approved installing a vending machine that is operated by the organization and contains clean syringes and needles, as well as condoms, tampons, and body soap. In 2019, the organization installed two sharps containers in Ely, a city of fewer than 4,000 residents.

Trac-B Exchange program director Rick Reich said the organization has been offering services in rural areas to help people there use drugs more safely or find resources so they can become and stay sober. The services include assistance in obtaining identification documents, housing, and jobs.

“You’re trying to get a carrot that someone will go after,” he said, referring to the clean needles and syringes. “Then as they come to you, to get that carrot and eat that carrot, they can see that you have other things available and that you aren’t the scary person that they thought you were in the nightmare that they were living.”

In 2020, the overdose death rate in Nevada was 26 per 100,000 people, 27th-highest among states, according to the Centers for Disease Control and Prevention. That year, as the spread of covid-19 spurred stay-at-home orders and shuttered businesses, more than 800 Nevadans died from overdoses.

Seven years since the 2015 HIV outbreak in Indiana, seven states still don’t have any syringe exchange programs, according to a KFF analysis. In some states, harm reduction workers could face criminal penalties for carrying clean syringes or strips that detect the presence of the synthetic opioid fentanyl, which is 50 to 100 times as strong as morphine.

Nevada’s legislature passed a law in 2013 that legalized syringe and needle exchange programs so peer recovery support specialists like Cusolito can do their work.

But that doesn’t mean such efforts are always accepted.

Cusolito said he can put aside nasty comments because he believes in the work he’s doing. He recalled a client who had one of the worst heroin addictions he’d ever seen. “I didn’t think he’d survive,” Cusolito said. After connecting with Cusolito and going through treatment, the client went back to work, bought a house, and got married. He still checks in with Cusolito every couple of months to tell him about his latest achievements.

Clients with stories like those help Cusolito move forward when other challenges of the job weigh on him. The hardest part is losing clients.

“Sometimes I feel really strong and like I can beat the world,” he said, “and other times I think about when I got the knock on the door, you know? I want to lock the door and not let anybody in because I don’t want to deal with anybody else who might die.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

They Call It ‘Tranq’ — And It’s Making Street Drugs Even More Dangerous

Xylazine, an animal tranquilizer, has made it into the illegal drug supply of opioids and cocaine. It is changing the way outreach workers treat overdoses and may be responsible for grisly injuries and infections among people who unknowingly inject it.

Approaching a van that distributes supplies for safer drug use in Greenfield, Massachusetts, a man named Kyle noticed an alert about xylazine.

“Xylazine?” he asked, sounding out the unfamiliar word. “Tell me more.”

A street-outreach team from Tapestry Health Systems delivered what’s becoming a routine warning. Xylazine is an animal tranquilizer. It’s not approved for humans but is showing up in about half the drug samples that Tapestry Health tests in the rolling hills of western Massachusetts. It’s appearing mostly in the illegal fentanyl supply but also in cocaine.

“The past week, we’ve all been just racking our brains — like, ‘What is going on?’” Kyle said. “Because if we cook it up and we smoke it, we’re falling asleep after.”

(NPR and KHN are using only first names in this article for people who use illegal drugs.)

Kyle’s deep sleep could also have been triggered by fentanyl, but Kyle said one of his buddies used a test strip to check for the opioid and none was detected.

Xylazine, which is also known as “tranq” or “tranq dope,” surged first in some areas of Puerto Rico and then in Philadelphia, where it was found in 91% of opioid samples in the most recent reporting period. Data from January to mid-June shows that xylazine was in 28% of drug samples tested by the Massachusetts Drug Supply Data Stream, a state-funded network of community drug-checking and advisory groups that uses mass spectrometers to let people know what’s in bags or pills purchased on the street.

Whatever its path into the drug supply, the presence of xylazine is triggering warnings in Massachusetts and beyond for many reasons.

As Xylazine Use Rises, So Do Overdoses

Perhaps the biggest question is whether xylazine has played a role in the recent increase in overdose deaths in the U.S. In a study of 10 cities and states, xylazine was detected in fewer than 1% of overdose deaths in 2015 but in 6.7% in 2020, a year the U.S. set a record for overdose deaths. The record was broken again in 2021, which had more than 107,000 deaths. The study does not claim xylazine is behind the increase in fatalities, but study co-author Chelsea Shover said it may have contributed. Xylazine, a sedative, slows people’s breathing and heart rate and lowers their blood pressure, which can compound some effects of an opioid like fentanyl or heroin.

“If you have an opioid and a sedative, those two things are going to have stronger effects together,” said Shover, an epidemiologist at UCLA’s David Geffen School of Medicine.

In Greenfield, Tapestry Health is responding to more overdoses as more tests show the presence of xylazine. “It correlates with the rise, and it correlates with Narcan not being effective to reverse xylazine,” said Amy Davis, assistant director for rural harm-reduction operations at Tapestry. Narcan is a brand name of naloxone, an opioid overdose reversal medication.

“It’s scary to hear that there’s something new going around that could be stronger maybe than what I’ve had,” said May, a woman who stopped by Tapestry Health’s van. May said that she has a strong tolerance for fentanyl but that a few months ago, she started getting something that didn’t feel like fentanyl, something that “knocked me out before I could even put my stuff away.”

A Shifting Overdose Response

Davis and her colleagues are ramping up the safety messages: Never use alone, always start with a small dose, and always carry Narcan.

Davis is also changing the way they talk about drug overdoses. They begin by explaining that xylazine is not an opioid. Squirting naloxone into someone’s nose won’t reverse a deep xylazine sedation — the rescuer won’t see the dramatic awakening that is common when naloxone is administered to someone who has overdosed after using an opioid.

If someone has taken xylazine, the immediate goal is to make sure the person’s brain is getting oxygen. So Davis and others advise people to start rescue breathing after the first dose of Narcan. It may help restart the lungs even if the person doesn’t wake up.

“We don’t want to be focused on consciousness — we want to be focused on breathing,” Davis said.

Giving Narcan is still critical because xylazine is often mixed with fentanyl, and fentanyl is killing people.

“If you see anyone who you suspect has an overdose, please give Narcan,” said Dr. Bill Soares, an emergency room physician and the director of harm reduction services at Baystate Medical Center in Springfield, Massachusetts.

Soares said calling 911 is also critical, especially when someone has taken xylazine, “because if the person does not wake up as expected, they’re going to need more advanced care.”

‘Profound Sedation’ Worries Health Providers

Some people who use drugs say xylazine knocks them out for six to eight hours, raising concerns about the potential for serious injury during this “profound sedation,” said Dr. Laura Kehoe, medical director at Massachusetts General Hospital’s Substance Use Disorders Bridge Clinic.

Kehoe and other clinicians worry about patients who have been sedated by xylazine and are lying in the sun or snow, perhaps in an isolated area. In addition to exposure to the elements, they could be vulnerable to compartment syndrome from lying in one position for too long, or they could be attacked.

“We’re seeing people who’ve been sexually assaulted,” Kehoe said. “They’ll wake up and find that their pants are down or their clothes are missing, and they are completely unaware of what happened.”

In Greenfield, nurse Katy Robbins pulled up a photo from a patient seen in April as xylazine contamination soared. “We did sort of go, ‘Whoa, what is that?’” Robbins recalled, studying her phone. The image showed a wound like deep road rash, with an exposed tendon and a spreading infection.

Robbins and Tapestry Health, which runs behavioral and public health services in Western Massachusetts, have created networks so clients can get same-day appointments with a local doctor or hospital to treat this type of injury. But getting people to go get their wounds seen is hard. “There’s so much stigma and shame around injection drug use,” Robbins said. “Often, people wait until they have a life-threatening infection.”

That may be one reason amputations are increasing for people who use drugs in Philadelphia. One theory is that decreased blood flow from xylazine keeps wounds from healing.

“We’re certainly seeing a lot more wounds, and we’re seeing some severe wounds,” said Dr. Joe D’Orazio, director of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia. “Almost everybody is linking this to xylazine.”

This article is part of a partnership that includes WBURNPR, and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Datos de las sobredosis, obtenidos por colaboración colectiva, resaltan en dónde hace falta la ayuda

El proyecto de la Universidad de Texas, llamado TxCOPE, busca resolver un problema que mantiene en vilo a los funcionarios de todo el país en su esfuerzo por reducir el número récord de muertes por drogas: obtener una imagen clara y precisa de las sobredosis no mortales y mortales.

EL PASO, Texas – Los hombres hacían fila en el exterior de Corner of Hope, un centro de recursos para personas sin hogar, esperando recibir los productos gratuitos que distribuía una furgoneta blanca.

Algunos querían bolsas con artículos de aseo personal o preservativos, pero otros se llevaban kits que los ayudan a consumir drogas de forma segura, o naloxona, un medicamento para revertir una sobredosis de opioides.

Gilbert Shepherd, trabajador social de Punto de Partida, una organización sin fines de lucro que atiende a las personas que hacen uso indebido de las drogas, interroga amablemente a quienes se llevan los kits de seguridad. Un hombre con anteojos de sol y camiseta negra le explicó que, no hace mucho, se tomó una pastilla que compró por $1,50 y perdió el conocimiento durante horas. Otro, con camisa a cuadros y pantalones caqui, contó haber visto a alguien sufrir una sobredosis tras tomar una pastilla azul.

Esas dos sobredosis se añadirán a una nueva base de datos de Texas llamada Texans Connecting Overdose Prevention Efforts, cuyo objetivo es mejorar el seguimiento de las sobredosis de drogas en el segundo estado más grande del país.

El proyecto de la Universidad de Texas (UT), conocido como TxCOPE, busca resolver un problema que mantiene en vilo a los funcionarios de todo el país en su esfuerzo por reducir el número récord de muertes por drogas: obtener una imagen clara y precisa de las sobredosis no mortales y mortales.

Los grupos comunitarios utilizan ahora los paneles de datos y los mapas de calor de TxCOPE para ver dónde aumentan las sobredosis, y dirigir así los esfuerzos de prevención a esos puntos conflictivos, con suministros de naloxona y personal que explique cómo usarla, dijo Christopher Bailey, coordinador de Project Vida, una clínica de El Paso.

Se trata de uno de los pocos proyectos en Estados Unidos que reúne datos de sobredosis recopilados de forma sistemática por grupos de reducción de daños (es decir, obtenidos por crowdsourcing), según Leo Beletsky, experto legal en salud pública de la Northeastern University. Estos proyectos compensan la falta de una imagen precisa de la crisis de sobredosis que dura décadas. “Es un escándalo”, añadió Beletsky.

Más de 107,000 estadounidenses murieron por sobredosis en 2021, según los Centros para el Control y la Prevención de Enfermedades (CDC). Pero no hay un recuento nacional de cuántas personas sobreviven a las sobredosis de drogas. Los CDC ni siquiera tienen un método estándar que los estados puedan utilizar para contar las sobredosis no mortales. Suma los datos de sobredosis de las visitas a las salas de urgencias basándose en los códigos clínicos y de facturación de los estados participantes, pero eso excluye a las personas que no interactúan con el sistema médico, señaló Bradley Stein, director del Rand Opioid Policy Center. Se trata de un “enorme punto ciego”, según Stein.

Además, los datos de sobredosis mortales suelen publicarse semanas o meses después, una vez que el informe oficial del médico forense o los resultados toxicológicos muestran qué sustancias causaron las muertes. “A los opioides los miramos por el retrovisor”, añadió Stein.

Otros proyectos que contabilizan las sobredosis no mortales, como el ODMAP, se basan en los informes de las fuerzas del orden o de los primeros intervinientes. Pero muchos consumidores de drogas no llaman a los servicios de emergencia ni informan de las sobredosis por miedo a ser arrestados, deportados o a otras consecuencias, como la pérdida de sus hijos o de su vivienda debido al consumo de drogas, afirmó Traci Green, profesora y directora de la Opioid Policy Research Collaborative de la Universidad de Brandeis.

“Los actuales sistemas nacionales de datos no han estado a la altura de la magnitud de la epidemia de sobredosis”, escribió el doctor Rahul Gupta, director de la Oficina de Política Nacional de Control de Drogas, en un llamamiento a la acción publicado el 30 de junio en JAMA. Añadió que es esencial crear un mejor sistema de datos y que su organismo se ha reunido con otras agencias federales para mejorar el seguimiento de los datos sobre sobredosis no mortales.

Green calcula que, a nivel nacional, un 50% de las sobredosis no mortales no se notifican, y que el recuento es mayor en los lugares donde la aplicación de la ley es más estricta y en las comunidades de color. La parte que falta en esta historia “es la de la diversidad”, apuntó.

En Texas, hasta el 70% de las sobredosis, en su mayoría no mortales, no se denuncian, estimó Kasey Claborn, investigadora principal del proyecto TxCOPE y profesora de la Facultad de Medicina Dell y de la Facultad de Trabajo Social Steve Hicks de la UT.

Según cifras oficiales, unos 5,000 tejanos murieron de sobredosis en 2021. Claborn cree que es un recuento insuficiente porque el estado tiene oficinas de examinadores médicos en solo  15 de sus 254 condados. La mayoría de los condados tienen jueces de paz que no siempre solicitan las costosas pruebas de toxicología para determinar la causa de la muerte.

El estado registró casi 4,000 llamadas relacionadas con los opioides a la Red de Control de Venenos de Texas el año pasado y casi 8,000 visitas a las salas de emergencia relacionadas con los opioides en 2020. Claborn analiza cómo se comparan los datos que recoge TxCOPE con esas estadísticas oficiales.

Los expertos en drogas han mostrado su frustración porque consideran que Estados Unidos no trata la epidemia de sobredosis con la misma urgencia que covid-19. Las muertes por drogas se dispararon durante la pandemia, ya que el fentanilo ilegal, que es entre 50 y 100 veces más potente que la morfina, inundó el suministro de drogas en las calles del país y la gente se quedó sin apoyo por abuso de sustancias.

Pero mientras las autoridades de salud pública basaban las restricciones de la pandemia en el número de casos locales de covid y en el recuento de muertes, los expertos y los trabajadores sociales carecían de datos en tiempo real que les permitieran reaccionar con intervenciones que pudieran salvar las vidas de los consumidores de drogas.

“¿Cómo ayuda eso en una emergencia de salud pública?”, se preguntó Daniel Sledge, un paramédico que ha puesto a prueba TxCOPE en el condado de Williamson, al norte de Austin.

Esa información podría ayudar a los trabajadores sanitarios a identificar qué zonas deben cubrirse con naloxona o si necesitan educar a la gente sobre drogas mezcladas con fentanilo letal.

TxCOPE, financiado por la subvención estatal contra los opioides y la Administración Federal de Servicios de Salud Mental y Abuso de Sustancias, comenzó en El Paso en junio de 2021 y luego se amplió a Austin, San Antonio y, posteriormente, al condado de Williamson. El lanzamiento oficial está previsto para el 1 de septiembre, con un despliegue al resto del estado en etapas.

Antes de que el grupo se pusiera en marcha, la difusión era más aleatoria. Se trataba de “atrápame como se pueda”, dijo Bailey, del Project Vida. Al igual que muchos grupos de reducción de daños, hacían un seguimiento informal de las sobredosis, que a menudo se producían entre una población itinerante.

Pero no tenían una forma de poner en común esa información con otros grupos de la ciudad ni de generar mapas para impulsar el alcance comunitario. TxCOPE ha ayudado al grupo a encontrar personas en riesgo para poder ofrecerles prevención de sobredosis, apoyo entre pares o derivaciones a tratamientos. Ahora “podemos centrarnos realmente en esas zonas, enfocados como un láser”, apuntó Bailey.

Paulina Hijar, trabajadora social de Punto de Partida, por ejemplo, contó que se encuentra habitualmente con personas que inyectaron a sus amigos con remedios caseros contra sobredosis que son peligrosos e ineficaces —leche o una mezcla de agua y sal— o que consiguieron naloxona y nunca llamaron a las autoridades. Aseguran que gracias a que los trabajadores sociales se han ganado la confianza de sus comunidades, ahora pueden recopilar información sobre las sobredosis, incluyendo cuándo y dónde se produjeron, algo que normalmente se omitiría en las estadísticas oficiales.

La privacidad es una clave del proyecto TxCOPE: las personas necesitan poder compartir información acerca de las sobredosis sin temor a las consecuencias, indicó Claborn. Texas aprobó en 2021 una ley para proteger a las personas que llamen a los servicios de emergencia durante una sobredosis, pero su alcance es muy limitado. Las personas que tienen una condena por delito de drogas, por ejemplo, no califican. Y alguien está protegido de la detención solo una vez. TxCOPE cuenta con un certificado federal de confidencialidad que lo protege de las órdenes judiciales, y Claborn no comparte los datos generales con el Estado.

Claborn quiere utilizar el proyecto, que está siendo renovado este verano antes de su lanzamiento, para traer más dólares federales al estado. “Hemos tenido dificultades para demostrar que existe un problema real en Texas, porque se ha ocultado”, afirmó.

Ha estado trabajando en una función que permitiría a cualquier persona de la comunidad informar de las sobredosis, un esfuerzo para mejorar los recuentos en las partes del estado que no cuentan con grupos de reducción de daños. Con el tiempo, Claborn quiere cotejar los datos obtenidos por el público con los informes toxicológicos.

Por ahora, sin embargo, el proyecto se basa en las pruebas anecdóticas de los consumidores de drogas y otras personas de la comunidad que informan de que han reanimado a alguien con naloxona, o que han visto a alguien perder el conocimiento, o sufrir otros efectos de tomar demasiada droga.

Una tarde reciente, Shepherd e Hijar reconocieron a un hombre en el parque Houston de El Paso. Les habló de una mujer que había muerto sola en su apartamento hacía una semana y media tras tomar una mezcla de drogas. También mencionó a un individuo al que pudo reanimar con naloxona unos dos meses antes. Los detalles fueron mínimos.

Los investigadores y los grupos de reducción de daños dicen que estos datos imprecisos son mejores que los que han tenido en el pasado. Aunque los datos anecdóticos del proyecto no se han comprobado a fondo, se trata de un gran paso hacia adelante, dijo Stein. “No tenemos nada más en este momento”, concluyó.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Crowdsourced Data on Overdoses Pinpoints Where to Help

University of Texas researchers are testing a program that would allow harm reduction groups to crowdsource data on fatal and nonfatal drug overdoses statewide. While the data relies on word of mouth, they say, it is more comprehensive than anything that exists now and can be used immediately to prevent overdoses.

EL PASO, Texas — Men lined up outside the Corner of Hope, a homeless resource center, eyeing free supplies on plastic shelves inside a white van.

Some wanted bags with toiletries or condoms, but others took kits that help them safely use drugs or naloxone, an opioid overdose reversal medicine.

Gilbert Shepherd, an outreach worker for Punto de Partida, a nonprofit that serves people who misuse drugs, gently questioned those who took the drug safety kits. A man wearing sunglasses and a black T-shirt explained that not long ago he took a pill he bought for $1.50 and, within minutes, he passed out for hours. A man in a plaid shirt and khaki pants described seeing someone overdose after taking a blue pill a month before.

Those two overdoses would be added to a new Texas database called Texans Connecting Overdose Prevention Efforts, which aims to improve drug overdose tracking across the nation’s second-largest state.

The University of Texas project, known as TxCOPE, is one attempt to solve a problem exasperating officials nationwide who are trying to lower the record number of drug deaths: getting an instant, accurate picture of both nonfatal and fatal drug overdoses. Community groups are now using TxCOPE’s data dashboards and heat maps to see where overdoses are spiking and then target those hot spots with prevention efforts such as naloxone training and supplies, said Christopher Bailey, project coordinator at Project Vida, a health center in El Paso.

It is one of the few projects in the U.S. pooling crowdsourced overdose data from harm reduction groups in a systematic way, according to Leo Beletsky, a public health law expert at Northeastern University. Such projects compensate for the lack of an accurate picture of the decades-long overdose crisis. “It’s scandalous,” Beletsky said.

More than 107,000 Americans died of drug overdoses in 2021, according to the Centers for Disease Control and Prevention. But there is no national count of how many people survive drug overdoses. The CDC doesn’t even have a standard method that states can use to count nonfatal overdoses. It aggregates overdose data from emergency room visits based on clinical and billing codes from participating states, but that excludes people who don’t interact with the medical system, said Bradley Stein, director of the Rand Opioid Policy Center. It is a “huge blind spot,” Stein said.

Plus, fatal overdose data is often published weeks or months later, once an official medical examiner’s report or toxicology results show what substances caused the deaths. “We’re looking in the rearview mirror with opioids,” Stein said.

Other projects that count nonfatal overdoses, such as ODMAP, rely on reports from law enforcement or first responders. But many drug users won’t call emergency services or report overdoses for fear of arrest, deportation, or other consequences such as the loss of their children or housing due to drug use, said Traci Green, a professor and the director of the Opioid Policy Research Collaborative at Brandeis University.

“Simply put, current national data systems have not kept up with the scale of the overdose epidemic,” wrote Dr. Rahul Gupta, director of the Office of National Drug Control Policy, in a call for action published June 30 in JAMA. He added that building a better data system is essential and that his agency is convening with other federal agencies to improve the tracking of nonfatal overdose data.

Nationally, Green estimated, about 50% of nonfatal overdoses go unreported, with a higher undercount in places with stricter law enforcement and among communities of color. The missing part of the picture “is a very diverse one,” she said.

In Texas, up to 70% of overdoses, mostly nonfatal, go unreported, estimated Kasey Claborn, lead researcher on the TxCOPE project and an assistant professor at UT’s Dell Medical School and Steve Hicks School of Social Work.

Officially, about 5,000 Texans died of a drug overdose in 2021. Claborn believes that is an undercount, too, because the state has medical examiners’ offices in only 15 of its 254 counties. Most counties have justices of the peace who don’t always request pricey toxicology tests to determine the cause of death. The state recorded nearly 4,000 opioid-related calls to the Texas Poison Control Network last year and nearly 8,000 opioid-related emergency room visits in 2020. Claborn is analyzing how the data TxCOPE collects compares with those official statistics.

Drug experts are frustrated the U.S. doesn’t treat the overdose epidemic with the urgency it does for covid-19. Drug deaths surged during the pandemic as illegal fentanyl, which is 50 to 100 times more potent than morphine, flooded the nation’s street drug supply and people were cut off from substance abuse support. But while public health authorities based pandemic restrictions on local covid caseloads and death counts, experts and outreach workers have lacked real-time data that would allow them to react with interventions that could save drug users’ lives.

“How is that helping in a public health emergency?” said Daniel Sledge, a paramedic testing TxCOPE in Williamson County, just north of Austin.

That information could help health workers identify which areas to blanket with naloxone or whether they need to educate people about a batch of drugs laced with lethal fentanyl.

TxCOPE, funded by the state’s opioid grant and the federal Substance Abuse and Mental Health Services Administration, started in El Paso in June 2021 and then expanded to Austin, San Antonio, and later Williamson County. An official launch is planned for Sept. 1, with a rollout to the rest of the state in stages.

Before the group started, outreach was more haphazard. “It was catch as catch can,” said Bailey, with Project Vida. Like many harm reduction groups, they would informally track overdoses, which often occurred among an itinerant population. But they didn’t have a way to pool that information with other city groups or generate maps to drive outreach. TxCOPE has helped the group find pockets of at-risk people so they can provide them with overdose prevention, peer support, or treatment referrals. Now “you are able to really home in on those areas with laserlike focus,” he said.

Punto de Partida outreach worker Paulina Hijar, for example, said she routinely meets people who injected their friends with dangerous and ineffective homemade overdose remedies — either milk or a mixture of water and salt — or got naloxone and never called authorities. Because outreach workers have built trust in their communities, they say, they can gather information about overdoses, including when and where they occurred, that would normally be omitted from official statistics.

Privacy is a key feature of the TxCOPE project — people need to be able to share overdose information without fear of consequences, Claborn said. Texas passed a law in 2021 intended to shield from arrest people who call emergency services during an overdose, but it’s narrowly tailored. People who have a felony drug conviction, for example, don’t qualify. And someone is protected from arrest only once. TxCOPE has a federal certificate of confidentiality that protects it from court orders, and Claborn doesn’t share raw data with the state.

Claborn wants to use the project, which is being revamped this summer before the launch, to bring more federal dollars to the state. “We’ve had difficulty proving there is an actual problem in Texas, because it’s been hidden,” she said.

She has been working on a feature that would allow anyone in the community to report overdoses, an effort to improve counts in parts of the state without harm reduction groups. Eventually, Claborn wants to check the crowdsourced data against toxicology reports.

For now, though, the project relies on anecdotal evidence from drug users and others in the community who report reviving someone with naloxone or seeing someone lose consciousness or suffer other effects of taking too much of a drug.

On a recent afternoon, Shepherd and Hijar recognized a man in El Paso’s Houston Park. He told them about a woman who had died alone in her apartment about a week and a half earlier after taking a mixture of drugs. He also mentioned a guy he was able to revive with naloxone about two months earlier. Details were minimal.

Researchers and harm reduction groups say this nebulous data is better than what they’ve had in the past. Even though the project’s anecdotal data isn’t thoroughly vetted, the step toward timeliness is great, Stein said. “We’ve got nothing else right now,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Overdose Deaths Behind Bars Rise as Drug Crisis Swells

Drug-related mortality rates have increased in prisons and jails even as the number of people incarcerated for drug offenses has dropped. The pandemic lockdowns on visitors didn’t eliminate the problem, showcasing that guards have been a source of the contraband.

Annissa Holland should be excited her son is coming home from prison after four long years of incarceration. Instead, she’s researching rehab centers to send him to as soon as he walks out the gate.

She doesn’t know the person who’s coming home — the person who she said has been doing every drug he can get his hands on inside the Alabama prison system. She can hear it in the 34-year-old’s voice when he calls her on the prison phone.

Her son is one of almost 20,000 inmates in the Alabama prison system living in conditions the U.S. Department of Justice has called inhumane. In two investigations, it found that the rampant use of drugs causes sexual abuse and “severe” violence in the state’s prisons. The department has sued Alabama, alleging conditions in its prisons violate inmates’ civil rights. According to the Alabama Department of Corrections’ own report, almost 60 pounds of illicit drugs were confiscated from its prisons in the first three months of this year.

Even if Alabama’s prisons and jails are especially overrun by drugs, death, and violence, their problems are not unique in the U.S. Within three weeks this spring, incarcerated people died of overdoses in Illinois, Oklahoma, New York, and the District of Columbia.

The alcohol and drug overdose death rate increased fivefold in prisons from 2009 through 2019, according to a recent study from the Pew Research Center — a surge that outpaced the national drug overdose rate, which tripled in the same period.

As the opioid crisis ravages America, overdose deaths are sweeping through every corner of the nation, including jails and prisons. Criminal justice experts suggest that decades of using the legal system instead of community-based addiction treatment to address drug use have not led to a drop in drug use or overdoses. Instead, the rate of drug deaths behind bars in supposedly secure facilities has increased.

This rise comes amid the decriminalization of cannabis in many parts of the country and a drop in the overall number of people incarcerated for drug crimes, according to the Pew report.

“It certainly points to the need for alternative solutions that rely less on the criminal justice system to help people who are struggling with substance use disorders,” said Tracy Velázquez, senior manager for safety and justice programs at the Pew Charitable Trusts.

For decades, drug use in America has mainly been addressed through the penal system — 1 in 5 people behind bars are there for a drug offense. Drug crimes were behind 30% of new admissions to Alabama prisons in March. Nationally, they were the leading cause of arrest, and almost 90% of arrests were for possession of drugs, not sale or manufacturing, according to the Pew study. The researchers also found that fewer than 8% of arrested people with a drug dependency received treatment while incarcerated.

Velázquez said a lot of drug use is spurred by people with mental health issues attempting to self-medicate. Almost 40% of people in prisons and 44% in jails have a history of mental illness, according to the Bureau of Justice Statistics.

Holland said her son was diagnosed with schizophrenia and PTSD six years ago after struggling with drug use since his teens. The son, who asked that his name not be published for fear his comments could jeopardize his release from prison or subsequent parole, said a schizophrenic episode in 2017 led him to break into a house during a hurricane. He said he didn’t realize people were in the house until after he ate a sandwich, got a Coke from the fridge, and looked for dry clothes. They called the police. He was sent to prison on a charge of burglary.

“They don’t put the mental health patients where they should be; they put them in prison,” Holland said.

She’s not only frustrated by the lack of medical care and treatment her son has received, but also horrified at the access to drugs and the abuse she said her son has suffered in the overcrowded, understaffed Alabama prison system.

He told KHN he’s been raped and beaten because of drug debts and put on suicide watch more than a dozen times. He said he turned back to using heroin, meth, and the synthetic drug flakka while incarcerated.

“We need to really focus on not assuming that putting someone in jail or prison is going to make them abstinent from drug use,” Velázquez said. “We really need to provide treatment that not only addresses the chemical, substance use disorder, but also addresses some of the underlying issues.”

Beth Shelburne, who works with the American Civil Liberties Union, logged 19 drug-related deaths in Alabama prisons in 2021, the most she has seen since she started tracking them in 2018.

She said those numbers are just a snapshot of what is going on inside Alabama’s prisons. The Justice Department found the state corrections department failed to accurately report deaths in its facilities.

“A lot of the people that are dying, I would argue, don’t belong in prison,” Shelburne said. “What’s so disgusting about all this is we are sentencing people who are drug-addicted to time in these ‘correctional facilities,’ when we’re really just throwing them into drug dens.”

The corrections department’s reports reveal at least seven overdose deaths in 2021, three of which officials classified as natural deaths. It reported 97 deaths in the first three months of this year that have yet to be fully classified.

Though Republican Gov. Kay Ivey recently announced a grant of more than $500,000 for a program to help incarcerated people address drug use disorders, the number of graduates of drug treatment programs in the state’s prison system has plummeted in the past decade to record lows. About 3% of prisoners completed a treatment program in 2021, down from 14% in 2009.

In contrast, California reported a 60% reduction in overdose deaths in its prisons in 2020, which state officials attributed to the start of a substance use treatment program and the widespread availability of medication-assisted therapy.

Alabama’s system is developing a medication-assisted treatment plan with its health contractor, said Alabama Department of Corrections spokesperson Kelly Betts. Before 2019, medications that curb drug cravings or mute highs were given only to those who could be separated from the general prison population, according to Deborah Crook, the department’s health services deputy commissioner.

“The science has changed considerably and there are more medication options that are safer to prescribe — even in general population,” she wrote in a statement.

Though prison officials have long blamed visitors for bringing in drugs, the ban on visitation during the pandemic did not lead to a drop in drug use inside. Multiple officers were arrested in Alabama last year and accused of bringing drugs into jails and prisons, and the Department of Justice’s 2019 report found dozens of officers arrested in the previous two years on charges related to drug trafficking and other misconduct.

Illegal drugs are “a challenge faced by correctional systems across the country,” Betts wrote in an email. “The ADOC is committed to enforcing our zero-tolerance policy on contraband and works very hard to eradicate it from our facilities.”

Betts did not specify how these policies are enforced. The department also refused to respond to a detailed list of questions about drug use and overdoses in its prisons, citing the litigation with the Justice Department.

Holland doesn’t know what will happen when her son gets out. He said he hopes he can restart his business as an electrician and provide for his family. But the four years of his so-called rehabilitation have been a nightmare for both of them.

“They’re released messed-up, hurt, and deeply dysfunctional. What do you do with someone that’s been through all that?” Holland said. “That’s not rehabilitation. It’s not.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Sobering Lessons in Untying the Knot of a Homeless Crisis

The homeless tragedy in Portland, Oregon, now spills well beyond the downtown core, creating a crisis of conscience for a fiercely liberal city that has generously invested in homeless support services.

PORTLAND, Ore. — Michelle Farris never expected to become homeless, but here she was, sifting through garbage and towering piles of debris accumulated along a roadway on the outskirts of Northeast Portland. Farris, 51, has spent much of her adult life in Oregon, and has vivid memories of this area alongside the lumbering Columbia River when it was pristine, a place for quiet walks.

Now for miles in both directions, the roadside was lined with worn RVs and rusted boats doubling as shelter. And spilling out from those RVs, the trash and castoffs from this makeshift neighborhood also stretched for miles, making for a chaos that unnerved her.

Broken chairs, busted-up car parts, empty booze bottles, soiled blankets, discarded clothes, crumpled tarps. Every so often, it was more than she could bear, and she attacked the clutter around her own RV, trying furiously to organize the detritus into piles.

“Look at all this garbage out here — it used to be beautiful nature, but now it’s all polluted,” she said, as a stench of urine and burned rubber hung in the damp air. “The deer and river otters and beavers have to live with all this garbage.”

She paused a moment, glancing in the distance at a snow-capped Mount St. Helens. A line of RVs dotted the horizon.

Portland’s homeless problem now extends well beyond the downtown core, creating a crisis of conscience for this fiercely liberal city that for years has been among America’s most generous in investing in homeless support services. Tents and tarps increasingly crowd the sidewalks and parks of Portland’s leafy suburban neighborhoods. And the sewage and trash from unsanctioned RV encampments pollute the watersheds of the Willamette and Columbia rivers.

The RV encampments have emerged as havens of heroin and fentanyl use, a community of addiction from which it is difficult to break free, according to interviews with dozens of camp inhabitants. Even while reflecting on their ills, many of the squatters remarked on the surprising level of services available for people living homeless in Portland, from charity food deliveries and roving nurses to used-clothing drop-offs and portable bathrooms — even occasional free pump-outs for their RV restrooms, courtesy of the city.

Giant disposal containers for used syringes are strategically located in areas with high concentrations of homeless people. Red port-a-potties pepper retail corridors, as well as some tony family-oriented neighborhoods. In parts of the city, activists have nailed small wooden cupboards to street posts offering up sundries like socks, tampons, shampoo, and cans of tuna.

“Portland makes it really easy to be homeless,” said Cindy Stockton, a homeowner in the wooded St. Johns neighborhood in north Portland who has grown alarmed by the fallout. “There’s always somebody giving away free tents, sleeping bags, clothes, water, sandwiches, three meals a day — it’s all here.”

Portland, like Los Angeles, Sacramento, and much of the San Francisco Bay Area, has experienced a conspicuous rise in the number of people living in sordid sprawls of tents and RVs, even as these communities have poured millions of tax dollars — billions, collectively — into supportive services.

Portland offers a textbook example of the intensifying investment. In 2017, the year Mayor Ted Wheeler, a Democrat, took office, Portland spent roughly $27 million on homeless services. Under his leadership, funding has skyrocketed, with Wheeler this year pushing through a record $85 million for homeless housing and services in the 2022-23 fiscal year.

Voters in the broader region of Multnomah, Washington, and Clackamas counties in 2020 approved a tax measure to bolster funding for homelessness. The measure, which increases taxes for higher-income businesses and households, is expected to raise $2.5 billion by 2030.

But as debate roils about how best to spend the growing revenue, Portland also offers a sobering lesson in the hard knot of solving homelessness, once it hits a crisis level.

What Portland has not managed to do is fix the housing piece of the homeless equation. The city has about 1,500 shelter beds, not nearly enough to meet the need. It lacks ready access to the kind of subsidized permanent housing, buoyed by case managers, medical care, job placement, and addiction treatment, that has proven successful in cities such as Houston in moving people off the streets.

Nor has Portland come close to replenishing the stocks of affordable housing lost as its neighborhoods have gentrified and redeveloped.

Wheeler rejects claims that Portland has attracted homeless people to the region with its array of day-to-day services. But he acknowledged that the city does not have enough housing, detox facilities, or mental health care options to meet the need: “We are not appropriately scaled to the size and scope of the problem.”

“And, you know, is that our fault?” he said, calling for more state and federal investment. He pointed to “a foster care system that delivers people to the streets when they age out,” and a prison system that releases people without job training or connections to community services.

Meanwhile, the mission has grown more daunting. The 2019 homeless count in the Portland region, a one-night tally, found more than 4,000 people living in shelters, vehicles, or on the streets. This year, that number stands at roughly 6,000, according to the mayor’s office, a 50% surge that is, nonetheless, widely considered an undercount.

Making it more humane to live homeless in Portland, it turns out, has not moved people in large numbers off the streets. Nor has it kept those who have found housing from being replaced by people in yet more donated tents and more battered RVs.

⯁⯁⯁

South of the Columbia River in an industrial section of north Portland, not far from Delta Park’s bustling soccer and softball complex, another RV encampment lines a side street that juts off the main drag. Many of the camp’s inhabitants have parked here for years and are protective of their turf. Group leaders hold down the numbers — no more than 20 or so RVs. And they enforce tidiness rules, sometimes using physical force, so as not to draw undue attention from city code enforcement.

“We’ve maintained a symbiotic relationship with the businesses here,” said Jake Caldwell, 38, who lives in an RV with his girlfriend, Sarah Bennett. “We keep it clean and orderly, and they let us stay.”

Nearly all those interviewed in the encampments said they have noticed a sharp increase in the number of people living out of RVs in Portland, a trend playing out up and down the West Coast. Some of the newcomers lost their jobs in pandemic-related shutdowns and couldn’t keep up with rent or mortgage. Others, already living on the edge, described being kicked off couches by family or friends as covid made cramped living situations dangerous.

They’ve joined the ranks of the more entrenched homeless and people who can no longer afford to live here. Minimum-wage earners who grew up in the region only to be priced out of the housing market as wealthier people moved in. People who lost their financial footing because of a medical crisis. People struggling with untreated mental illness. People fresh out of prison. Street hustlers content to survive on the proceeds of petty crime.

And an overwhelming theme: People left numb and addled by a drug addiction. Some lost jobs and families while struggling with drug and alcohol use and ended up on the streets; others started using after landing on the streets.

“It’s like a hamster wheel — once you get out here, it’s so hard to get out,” said Bennett, 30, a heroin addict. “My legs are so swollen from shooting heroin into the same place for so long, I’m worried I have a blood clot.

“I feel like I’m wasting my life away.”

Most of the RVers interviewed in these north Portland encampments openly discussed their addictions. But they routinely cited a lack of affordable housing as a key factor in their predicament, and blamed homelessness for exacerbating their mental and physical ailments.

“You get severe depression and PTSD from being out here,” Bennett said.

Still, she and others consider themselves lucky to have scored an RV, which even broken down can cost a few thousand dollars. One camp dweller said he bought his using unemployment funds after losing his job in the pandemic. Caldwell and Bennett, who both use and deal heroin, said they purchased theirs with help from drug money. Some RVs are stolen; others were donated or simply taken over after being abandoned.

The benefits, RVers said, are innumerable compared with tent-living: Portland weather is notoriously soggy, and RVs offer more reliable shelter. They have doors that lock instead of zip, so you’re not ripped off as often. Women feel less vulnerable. It’s easier to organize possessions.

They also spoke of downsides. With the exception of the “high rollers” who can spare a few hundred for a portable generator, most of the RVers have no electricity. Nor hookups for the septic systems. The city comes by on occasion to pump out the waste, but more often it’s illegally dumped into rivers and streets. Most of the RVs are no longer drivable; occupants have them hauled from site to site. Bennett was among dozens of people who complained about the rats that regularly chew up through the undercarriages.

“A lot of people out here are criminals, flat-out,” said James Carter, 60, who became homeless after losing his job as an automotive refinish technician early in the pandemic and now lives out of a cargo van. “Stolen cars get dropped on this road constantly. There have been dead bodies.”

Carter, too, uses heroin. He and others said they support their habit by using food stamp benefits to purchase palettes of bottled water, then empty the water and recycle the bottles for cash. Some said they steal electronics from big-box stores and resell the goods. They say the retailers generally don’t try to stop them, worried about the risk of violence to their employees.

“We call it getting well, because you feel like shit until you get high,” said Carter, describing a heroin habit that costs him about $40 per day. “There’s a lot of people who need help out here.”

⯁⯁⯁

Laurelhurst Park is a forested oasis in east Portland. Situated south of the Columbia River with the mighty Willamette to the west, it spans 32 acres and features a spring-fed duck pond, running trails, tennis courts, horseshoe pits, and a playground.

But the recreational areas are often littered with debris from a homeless encampment in the park that ballooned during the pandemic and has proven difficult to disband despite a series of law enforcement sweeps. Many homeowners in the surrounding neighborhood, a historical enclave of Craftsman and Colonial Revival-style homes, say they’ve been thrust into the role of vigilantes, leaning on the city to do something about the mess.

They feel Portland’s charm ebbing, as the lives of the unhoused collide with the lives of the housed.

“This used to be the most beautiful, amazing city — now people’s houses and cars are getting broken into, and you can call 911, but no one is going to come,” said TJ Browning, who chairs the public safety committee for the Laurelhurst Neighborhood Association.

“We’re a progressive city, I’m a progressive, but the worst part is I can feel the compassion leaving,” she said. “I recognize people are self-medicating mental illness with drugs, but so many people like me just don’t care anymore. We want the criminal element out, even if it means taking people to jail.”

It’s her job to collect neighborhood complaints, and there has been no shortage as the city has allowed the amorphous encampment to take root in the park and smaller offshoots to pop up on surrounding streets. Every so often, when the neighborhood has complained enough, authorities sweep the camps, only to see them take shape once more.

One night, a propane tank exploded, causing a fire. Children have picked up used needles. Some of the homeless campers rant at parkgoers and wade into traffic. She fields calls from neighbors concerned about nighttime prowlers.

“It’s just not safe anymore,” Browning said. “It’s hard to feel compassion for the person creating the problem, when the problem is a threat to you or your family.”

Like many residents interviewed, Browning is a longtime Democrat who has watched in dismay as her liberal values give way to frustration and resentment. And she understands the good intentions, spawned by liberal policies, that brought Portland to this tipping point.

They include a dedicated effort to decriminalize low-level drug possession; a shift toward “harm reduction” programs that offer addicts shelter and medical care without coercing abstinence; court rulings that make it difficult to clear homeless encampments if the city can’t offer beds to the people displaced.

The problem is not so much the policies, in theory, as it is how they play out in Portland’s broader reality. Drug users stay out of jail, but Oregon has too few drug treatment programs and no easy way to mandate participation. Advocates for the homeless ardently protest efforts to roust the encampments, arguing people have nowhere else to go.

And cuts to police services have left housed residents feeling they are on their own to deal with the repercussions.

In recent years, Portland has made major cuts to police funding, spurred in part by the movement to “de-fund police” and shift resources into economic development and social services. In 2020, the Portland Police Bureau took a funding cut of $26.9 million, and eliminated officer positions assigned to a gun violence reduction team, narcotics, organized crime, neighborhood safety, schools, and traffic patrol.

There are 774 sworn officers in Portland today, down from 934 in 2020.

“The Police Bureau is the smallest it has been in modern times, with fewer sworn members than any time in anyone’s memory,” said Sgt. Kevin Allen, a spokesperson for the bureau.

“It is not surprising that people believe they aren’t seeing as quick a response, or as many officers on patrol — because there aren’t as many. We have to prioritize what we can do based on our resources.”

With crime on the rise — property crimes are up 33% over last spring, and homicides last year eclipsed a three-decade record — Mayor Wheeler has restored some of the funding as part of a broader investment in public safety. But residents say they can’t rely on police to respond to emergency calls.

“If nobody is dying,” Browning said, “no police officer is going to show up.”

In some ways, Portland’s liberal constituency is at war with itself, the devout at odds with the disillusioned.

“We want a more holistic solution to support people out here, and for this neighborhood to be livable regardless if you are housed or unhoused,” said Matchu Williams, a volunteer with the Mt. Scott-Arleta Neighborhood Association.

Williams is helping lead efforts to bring in more public restrooms, free shower services at a community center, and “community care cabinets” with donated items like toothbrushes and canned vegetables. “This is just neighbors coming together buying what they can to put in here, and it’s usually stocked full,” he said. “It’s small, but meaningful.”

Williams gives voice to another core constituency in Portland who say the city has a responsibility to ease the burden of living homeless, while also investing more energy and resources to address the affordable housing shortage he sees as the genesis of the problem. On a brisk spring day, walking past the slick coffee shops and brew houses that have made Mt. Scott-Arleta a draw, he recounted the city’s difficult slog pushing through a 100-unit affordable housing complex in his neighborhood.

Portland residents are quick to approve funding for homeless services, he noted, but more resistant when it comes to supporting sites for low-income and homeless housing.

“There’s been a lot of frustration with how slow things are moving,” Williams said. “It’s important to understand how we got here, but also how we get out of it.”

Others, like Cindy Stockton, whose north Portland neighborhood sits at the confluence of the Willamette and Columbia rivers, wonder if there are lessons to be gleaned from more conservative cities. Phoenix, for example, takes a less accommodating approach to encampments. People living homeless are steered to a loosely designated encampment in the city center that is cordoned off by chain barriers and patrolled by police. Campers are supplied with food, water, sanitary facilities, and medical treatment. But the arrangement comes with the understanding that camping generally is tolerated only within those boundaries.

“I’m a lifelong Democrat, but I find myself wondering if we need to elect Republicans,” Stockton said. “We’ve been Democratic-led for so long in this state, and it’s not getting us anywhere.”

Browning, in Laurelhurst, described a similar transformation: “I look in the mirror, and I see a hippie — but a hippie wouldn’t be advocating for more police. I sometimes can’t believe I’m having these thoughts: ‘Why don’t these people get hauled to jail? Why can’t they get a job?’

“I wonder, what the hell happened to me?”

⯁⯁⯁

Buffeted by the political crosswinds of Portland’s homeless dilemma, Mayor Wheeler is looking to adjust course. Wheeler, who took office in 2017, was elected as part of a wave of progressive politicians seen as standard-bearers for a more socially conscious approach to social ills.

That has meant a focus on police reform, and a host of programs anchored in the concept that people living homeless, addicted, or with untreated mental illness are victims of a broken system. Rather than blaming them for their plight, the idea is to meet their immediate needs with sensitivity while working to get them services to address the issues that put them on the street.

In vogue is a push to create permanent housing options with wraparound services that can start before someone is stable or sober; frowned upon are the old-school emergency shelters with curfews and drug bans that many advocates denounce as warehousing.

But it takes time — and funding and zoning changes and neighborhood buy-in — to design and approve sites for the longer-term programs. Portland’s homeless population has outpaced the city’s efforts.

“Fentanyl is making the rounds, and we have a major meth and heroin problem,” Wheeler said. “There are a lot of people living on the edge, and more and more are living in their RVs. It’s a catastrophe for people living on the streets, and they are absolutely traumatized, but we also acknowledge that this creates a problem for the entire community — for public safety and the environment.”

In the short term, Wheeler said, Portland is trying to address the public health risks by installing public restrooms and hygiene stations and offering RV sewage services. And, he has riled some liberal allies by adopting the stance that the city has an obligation to clear out more encampments and move people into emergency shelters for their own health and safety.

Wheeler’s budget for the coming year, recently approved by the city council, calls for 10 new shelter programs offering nearly 600 beds. He wants to reserve 130 apartments for people living homeless and 200 motel rooms for older homeless people with chronic conditions, and to expand drug treatment options. Most controversial, the city would funnel $36 million over two years to help create eight “safe-rest villages,” a mix of tiny homes and RV parking with support services and space for up to 1,500 people.

The proposal is mired in controversy, with many neighborhood groups opposed. At the same time, Wheeler said, “I am hearing overwhelmingly from the people in this city that they do not want to simply criminalize homeless people and throw them in jail because they are homeless. I don’t think that’s a real solution.”

Larry Bixel, who lives in a 1987-issue Fleetwood Bounder near Delta Park, has his doubts about the city’s ability to put a dent in the homeless numbers, much as he’d like a real house. “I don’t recognize Portland anymore,” he said. “There’s tents all along the freeway. It’s the pills and drugs everywhere.”

A former car salesman, Bixel, 41, said his free fall into homelessness started after he got addicted to painkillers prescribed for a shoulder tear sustained while playing softball at Delta Park nearly 20 years ago. He progressed from Vicodin to OxyContin to heroin, a cheaper habit that his wife also took up. Life spiraled as he wrecked his car and racked up felony convictions. Over time, the couple lost their jobs, their home, and custody of their three young children.

“I went from painkillers after the accident to addiction taking over my life,” he said.

But Bixel hasn’t given up on himself. He thinks with the right opportunities — a job, a landlord willing to take a chance on him — he could find the motivation to get clean again.

“My wife and I, we’re looked at like scum now,” Bixel said. “But honestly, this is also one of the best things that has happened to me. I used to look down at homeless people for not having a job, and if somebody asked me for change, I’d say, ‘I worked hard for this.’

“Now, if someone asks me for a cigarette, I’ll give them two.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Sobering Lessons in Untying the Knot of a Homeless Crisis

The homeless tragedy in Portland, Oregon, now spills well beyond the downtown core, creating a crisis of conscience for a fiercely liberal city that has generously invested in homeless support services.

PORTLAND, Ore. — Michelle Farris never expected to become homeless, but here she was, sifting through garbage and towering piles of debris accumulated along a roadway on the outskirts of Northeast Portland. Farris, 51, has spent much of her adult life in Oregon, and has vivid memories of this area alongside the lumbering Columbia River when it was pristine, a place for quiet walks.

Now for miles in both directions, the roadside was lined with worn RVs and rusted boats doubling as shelter. And spilling out from those RVs, the trash and castoffs from this makeshift neighborhood also stretched for miles, making for a chaos that unnerved her.

Broken chairs, busted-up car parts, empty booze bottles, soiled blankets, discarded clothes, crumpled tarps. Every so often, it was more than she could bear, and she attacked the clutter around her own RV, trying furiously to organize the detritus into piles.

“Look at all this garbage out here — it used to be beautiful nature, but now it’s all polluted,” she said, as a stench of urine and burned rubber hung in the damp air. “The deer and river otters and beavers have to live with all this garbage.”

She paused a moment, glancing in the distance at a snow-capped Mount St. Helens. A line of RVs dotted the horizon.

Portland’s homeless problem now extends well beyond the downtown core, creating a crisis of conscience for this fiercely liberal city that for years has been among America’s most generous in investing in homeless support services. Tents and tarps increasingly crowd the sidewalks and parks of Portland’s leafy suburban neighborhoods. And the sewage and trash from unsanctioned RV encampments pollute the watersheds of the Willamette and Columbia rivers.

The RV encampments have emerged as havens of heroin and fentanyl use, a community of addiction from which it is difficult to break free, according to interviews with dozens of camp inhabitants. Even while reflecting on their ills, many of the squatters remarked on the surprising level of services available for people living homeless in Portland, from charity food deliveries and roving nurses to used-clothing drop-offs and portable bathrooms — even occasional free pump-outs for their RV restrooms, courtesy of the city.

Giant disposal containers for used syringes are strategically located in areas with high concentrations of homeless people. Red port-a-potties pepper retail corridors, as well as some tony family-oriented neighborhoods. In parts of the city, activists have nailed small wooden cupboards to street posts offering up sundries like socks, tampons, shampoo, and cans of tuna.

“Portland makes it really easy to be homeless,” said Cindy Stockton, a homeowner in the wooded St. Johns neighborhood in north Portland who has grown alarmed by the fallout. “There’s always somebody giving away free tents, sleeping bags, clothes, water, sandwiches, three meals a day — it’s all here.”

Portland, like Los Angeles, Sacramento, and much of the San Francisco Bay Area, has experienced a conspicuous rise in the number of people living in sordid sprawls of tents and RVs, even as these communities have poured millions of tax dollars — billions, collectively — into supportive services.

Portland offers a textbook example of the intensifying investment. In 2017, the year Mayor Ted Wheeler, a Democrat, took office, Portland spent roughly $27 million on homeless services. Under his leadership, funding has skyrocketed, with Wheeler this year pushing through a record $85 million for homeless housing and services in the 2022-23 fiscal year.

Voters in the broader region of Multnomah, Washington, and Clackamas counties in 2020 approved a tax measure to bolster funding for homelessness. The measure, which increases taxes for higher-income businesses and households, is expected to raise $2.5 billion by 2030.

But as debate roils about how best to spend the growing revenue, Portland also offers a sobering lesson in the hard knot of solving homelessness, once it hits a crisis level.

What Portland has not managed to do is fix the housing piece of the homeless equation. The city has about 1,500 shelter beds, not nearly enough to meet the need. It lacks ready access to the kind of subsidized permanent housing, buoyed by case managers, medical care, job placement, and addiction treatment, that has proven successful in cities such as Houston in moving people off the streets.

Nor has Portland come close to replenishing the stocks of affordable housing lost as its neighborhoods have gentrified and redeveloped.

Wheeler rejects claims that Portland has attracted homeless people to the region with its array of day-to-day services. But he acknowledged that the city does not have enough housing, detox facilities, or mental health care options to meet the need: “We are not appropriately scaled to the size and scope of the problem.”

“And, you know, is that our fault?” he said, calling for more state and federal investment. He pointed to “a foster care system that delivers people to the streets when they age out,” and a prison system that releases people without job training or connections to community services.

Meanwhile, the mission has grown more daunting. The 2019 homeless count in the Portland region, a one-night tally, found more than 4,000 people living in shelters, vehicles, or on the streets. This year, that number stands at roughly 6,000, according to the mayor’s office, a 50% surge that is, nonetheless, widely considered an undercount.

Making it more humane to live homeless in Portland, it turns out, has not moved people in large numbers off the streets. Nor has it kept those who have found housing from being replaced by people in yet more donated tents and more battered RVs.

⯁⯁⯁

South of the Columbia River in an industrial section of north Portland, not far from Delta Park’s bustling soccer and softball complex, another RV encampment lines a side street that juts off the main drag. Many of the camp’s inhabitants have parked here for years and are protective of their turf. Group leaders hold down the numbers — no more than 20 or so RVs. And they enforce tidiness rules, sometimes using physical force, so as not to draw undue attention from city code enforcement.

“We’ve maintained a symbiotic relationship with the businesses here,” said Jake Caldwell, 38, who lives in an RV with his girlfriend, Sarah Bennett. “We keep it clean and orderly, and they let us stay.”

Nearly all those interviewed in the encampments said they have noticed a sharp increase in the number of people living out of RVs in Portland, a trend playing out up and down the West Coast. Some of the newcomers lost their jobs in pandemic-related shutdowns and couldn’t keep up with rent or mortgage. Others, already living on the edge, described being kicked off couches by family or friends as covid made cramped living situations dangerous.

They’ve joined the ranks of the more entrenched homeless and people who can no longer afford to live here. Minimum-wage earners who grew up in the region only to be priced out of the housing market as wealthier people moved in. People who lost their financial footing because of a medical crisis. People struggling with untreated mental illness. People fresh out of prison. Street hustlers content to survive on the proceeds of petty crime.

And an overwhelming theme: People left numb and addled by a drug addiction. Some lost jobs and families while struggling with drug and alcohol use and ended up on the streets; others started using after landing on the streets.

“It’s like a hamster wheel — once you get out here, it’s so hard to get out,” said Bennett, 30, a heroin addict. “My legs are so swollen from shooting heroin into the same place for so long, I’m worried I have a blood clot.

“I feel like I’m wasting my life away.”

Most of the RVers interviewed in these north Portland encampments openly discussed their addictions. But they routinely cited a lack of affordable housing as a key factor in their predicament, and blamed homelessness for exacerbating their mental and physical ailments.

“You get severe depression and PTSD from being out here,” Bennett said.

Still, she and others consider themselves lucky to have scored an RV, which even broken down can cost a few thousand dollars. One camp dweller said he bought his using unemployment funds after losing his job in the pandemic. Caldwell and Bennett, who both use and deal heroin, said they purchased theirs with help from drug money. Some RVs are stolen; others were donated or simply taken over after being abandoned.

The benefits, RVers said, are innumerable compared with tent-living: Portland weather is notoriously soggy, and RVs offer more reliable shelter. They have doors that lock instead of zip, so you’re not ripped off as often. Women feel less vulnerable. It’s easier to organize possessions.

They also spoke of downsides. With the exception of the “high rollers” who can spare a few hundred for a portable generator, most of the RVers have no electricity. Nor hookups for the septic systems. The city comes by on occasion to pump out the waste, but more often it’s illegally dumped into rivers and streets. Most of the RVs are no longer drivable; occupants have them hauled from site to site. Bennett was among dozens of people who complained about the rats that regularly chew up through the undercarriages.

“A lot of people out here are criminals, flat-out,” said James Carter, 60, who became homeless after losing his job as an automotive refinish technician early in the pandemic and now lives out of a cargo van. “Stolen cars get dropped on this road constantly. There have been dead bodies.”

Carter, too, uses heroin. He and others said they support their habit by using food stamp benefits to purchase palettes of bottled water, then empty the water and recycle the bottles for cash. Some said they steal electronics from big-box stores and resell the goods. They say the retailers generally don’t try to stop them, worried about the risk of violence to their employees.

“We call it getting well, because you feel like shit until you get high,” said Carter, describing a heroin habit that costs him about $40 per day. “There’s a lot of people who need help out here.”

⯁⯁⯁

Laurelhurst Park is a forested oasis in east Portland. Situated south of the Columbia River with the mighty Willamette to the west, it spans 32 acres and features a spring-fed duck pond, running trails, tennis courts, horseshoe pits, and a playground.

But the recreational areas are often littered with debris from a homeless encampment in the park that ballooned during the pandemic and has proven difficult to disband despite a series of law enforcement sweeps. Many homeowners in the surrounding neighborhood, a historical enclave of Craftsman and Colonial Revival-style homes, say they’ve been thrust into the role of vigilantes, leaning on the city to do something about the mess.

They feel Portland’s charm ebbing, as the lives of the unhoused collide with the lives of the housed.

“This used to be the most beautiful, amazing city — now people’s houses and cars are getting broken into, and you can call 911, but no one is going to come,” said TJ Browning, who chairs the public safety committee for the Laurelhurst Neighborhood Association.

“We’re a progressive city, I’m a progressive, but the worst part is I can feel the compassion leaving,” she said. “I recognize people are self-medicating mental illness with drugs, but so many people like me just don’t care anymore. We want the criminal element out, even if it means taking people to jail.”

It’s her job to collect neighborhood complaints, and there has been no shortage as the city has allowed the amorphous encampment to take root in the park and smaller offshoots to pop up on surrounding streets. Every so often, when the neighborhood has complained enough, authorities sweep the camps, only to see them take shape once more.

One night, a propane tank exploded, causing a fire. Children have picked up used needles. Some of the homeless campers rant at parkgoers and wade into traffic. She fields calls from neighbors concerned about nighttime prowlers.

“It’s just not safe anymore,” Browning said. “It’s hard to feel compassion for the person creating the problem, when the problem is a threat to you or your family.”

Like many residents interviewed, Browning is a longtime Democrat who has watched in dismay as her liberal values give way to frustration and resentment. And she understands the good intentions, spawned by liberal policies, that brought Portland to this tipping point.

They include a dedicated effort to decriminalize low-level drug possession; a shift toward “harm reduction” programs that offer addicts shelter and medical care without coercing abstinence; court rulings that make it difficult to clear homeless encampments if the city can’t offer beds to the people displaced.

The problem is not so much the policies, in theory, as it is how they play out in Portland’s broader reality. Drug users stay out of jail, but Oregon has too few drug treatment programs and no easy way to mandate participation. Advocates for the homeless ardently protest efforts to roust the encampments, arguing people have nowhere else to go.

And cuts to police services have left housed residents feeling they are on their own to deal with the repercussions.

In recent years, Portland has made major cuts to police funding, spurred in part by the movement to “de-fund police” and shift resources into economic development and social services. In 2020, the Portland Police Bureau took a funding cut of $26.9 million, and eliminated officer positions assigned to a gun violence reduction team, narcotics, organized crime, neighborhood safety, schools, and traffic patrol.

There are 774 sworn officers in Portland today, down from 934 in 2020.

“The Police Bureau is the smallest it has been in modern times, with fewer sworn members than any time in anyone’s memory,” said Sgt. Kevin Allen, a spokesperson for the bureau.

“It is not surprising that people believe they aren’t seeing as quick a response, or as many officers on patrol — because there aren’t as many. We have to prioritize what we can do based on our resources.”

With crime on the rise — property crimes are up 33% over last spring, and homicides last year eclipsed a three-decade record — Mayor Wheeler has restored some of the funding as part of a broader investment in public safety. But residents say they can’t rely on police to respond to emergency calls.

“If nobody is dying,” Browning said, “no police officer is going to show up.”

In some ways, Portland’s liberal constituency is at war with itself, the devout at odds with the disillusioned.

“We want a more holistic solution to support people out here, and for this neighborhood to be livable regardless if you are housed or unhoused,” said Matchu Williams, a volunteer with the Mt. Scott-Arleta Neighborhood Association.

Williams is helping lead efforts to bring in more public restrooms, free shower services at a community center, and “community care cabinets” with donated items like toothbrushes and canned vegetables. “This is just neighbors coming together buying what they can to put in here, and it’s usually stocked full,” he said. “It’s small, but meaningful.”

Williams gives voice to another core constituency in Portland who say the city has a responsibility to ease the burden of living homeless, while also investing more energy and resources to address the affordable housing shortage he sees as the genesis of the problem. On a brisk spring day, walking past the slick coffee shops and brew houses that have made Mt. Scott-Arleta a draw, he recounted the city’s difficult slog pushing through a 100-unit affordable housing complex in his neighborhood.

Portland residents are quick to approve funding for homeless services, he noted, but more resistant when it comes to supporting sites for low-income and homeless housing.

“There’s been a lot of frustration with how slow things are moving,” Williams said. “It’s important to understand how we got here, but also how we get out of it.”

Others, like Cindy Stockton, whose north Portland neighborhood sits at the confluence of the Willamette and Columbia rivers, wonder if there are lessons to be gleaned from more conservative cities. Phoenix, for example, takes a less accommodating approach to encampments. People living homeless are steered to a loosely designated encampment in the city center that is cordoned off by chain barriers and patrolled by police. Campers are supplied with food, water, sanitary facilities, and medical treatment. But the arrangement comes with the understanding that camping generally is tolerated only within those boundaries.

“I’m a lifelong Democrat, but I find myself wondering if we need to elect Republicans,” Stockton said. “We’ve been Democratic-led for so long in this state, and it’s not getting us anywhere.”

Browning, in Laurelhurst, described a similar transformation: “I look in the mirror, and I see a hippie — but a hippie wouldn’t be advocating for more police. I sometimes can’t believe I’m having these thoughts: ‘Why don’t these people get hauled to jail? Why can’t they get a job?’

“I wonder, what the hell happened to me?”

⯁⯁⯁

Buffeted by the political crosswinds of Portland’s homeless dilemma, Mayor Wheeler is looking to adjust course. Wheeler, who took office in 2017, was elected as part of a wave of progressive politicians seen as standard-bearers for a more socially conscious approach to social ills.

That has meant a focus on police reform, and a host of programs anchored in the concept that people living homeless, addicted, or with untreated mental illness are victims of a broken system. Rather than blaming them for their plight, the idea is to meet their immediate needs with sensitivity while working to get them services to address the issues that put them on the street.

In vogue is a push to create permanent housing options with wraparound services that can start before someone is stable or sober; frowned upon are the old-school emergency shelters with curfews and drug bans that many advocates denounce as warehousing.

But it takes time — and funding and zoning changes and neighborhood buy-in — to design and approve sites for the longer-term programs. Portland’s homeless population has outpaced the city’s efforts.

“Fentanyl is making the rounds, and we have a major meth and heroin problem,” Wheeler said. “There are a lot of people living on the edge, and more and more are living in their RVs. It’s a catastrophe for people living on the streets, and they are absolutely traumatized, but we also acknowledge that this creates a problem for the entire community — for public safety and the environment.”

In the short term, Wheeler said, Portland is trying to address the public health risks by installing public restrooms and hygiene stations and offering RV sewage services. And, he has riled some liberal allies by adopting the stance that the city has an obligation to clear out more encampments and move people into emergency shelters for their own health and safety.

Wheeler’s budget for the coming year, recently approved by the city council, calls for 10 new shelter programs offering nearly 600 beds. He wants to reserve 130 apartments for people living homeless and 200 motel rooms for older homeless people with chronic conditions, and to expand drug treatment options. Most controversial, the city would funnel $36 million over two years to help create eight “safe-rest villages,” a mix of tiny homes and RV parking with support services and space for up to 1,500 people.

The proposal is mired in controversy, with many neighborhood groups opposed. At the same time, Wheeler said, “I am hearing overwhelmingly from the people in this city that they do not want to simply criminalize homeless people and throw them in jail because they are homeless. I don’t think that’s a real solution.”

Larry Bixel, who lives in a 1987-issue Fleetwood Bounder near Delta Park, has his doubts about the city’s ability to put a dent in the homeless numbers, much as he’d like a real house. “I don’t recognize Portland anymore,” he said. “There’s tents all along the freeway. It’s the pills and drugs everywhere.”

A former car salesman, Bixel, 41, said his free fall into homelessness started after he got addicted to painkillers prescribed for a shoulder tear sustained while playing softball at Delta Park nearly 20 years ago. He progressed from Vicodin to OxyContin to heroin, a cheaper habit that his wife also took up. Life spiraled as he wrecked his car and racked up felony convictions. Over time, the couple lost their jobs, their home, and custody of their three young children.

“I went from painkillers after the accident to addiction taking over my life,” he said.

But Bixel hasn’t given up on himself. He thinks with the right opportunities — a job, a landlord willing to take a chance on him — he could find the motivation to get clean again.

“My wife and I, we’re looked at like scum now,” Bixel said. “But honestly, this is also one of the best things that has happened to me. I used to look down at homeless people for not having a job, and if somebody asked me for change, I’d say, ‘I worked hard for this.’

“Now, if someone asks me for a cigarette, I’ll give them two.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

DEA El Paso Division warns of overdose cases, drugs mixed with synthetic opioids

by Fallon Fischer | 

The Drug Enforcement Administration El Paso Division said in the past few days, it has learned of several instances of individuals who used illegal drugs and then experienced overdose symptoms.

A total of nine patients were transported to local hospitals exhibiting signs of drug overdose in a period of 36 hours, according to the DEA El Paso Division.

Two overdose deaths occurred on May 23 bringing the total number of recent overdose incidents to 11.

It is suspected that the illegal drugs may be mixed with a synthetic opioid, according to the DEA.

The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations

The deadly synthetic opioid has spread across the nation during the pandemic, and the problem is disproportionately affecting Native Americans.

BROWNING, Mont. — As the pandemic was setting in during summer 2020, Justin Lee Littledog called his mom to tell her he was moving from Texas back home to the Blackfeet Indian Reservation in Montana with his girlfriend, stepson, and son.

They moved in with his mom, Marla Ollinger, on a 300-acre ranch on the rolling prairie outside Browning and had what Ollinger remembers as the best summer of her life. “That was the first time I’ve gotten to meet Arlin, my first grandson,” Ollinger said. Another grandson was soon born, and Littledog found maintenance work at the casino in Browning to support his growing family.

But things began to unravel over the next year and a half. Friends and relatives saw Littledog’s 6-year-old stepson walking around town alone. One day, Ollinger received a call from her youngest son as one of Littledog’s children cried in the background. He was briefly unable to wake Littledog’s girlfriend.

Ollinger asked Littledog whether he and his girlfriend were using drugs. Littledog denied it. He explained to his mom that people were using a drug she had never heard about: fentanyl, a synthetic opioid that is up to 100 times as potent as morphine. He said he would never use something so dangerous.

Then, in early March, Ollinger woke up to screams. She left her grandchildren sleeping in her bed and went into the next room. “My son was laying on the floor,” she said. He wasn’t breathing.

She followed the ambulance into Browning, hoping that Littledog had just forgotten to take his heart medication and would recover. He was pronounced dead shortly after the ambulance arrived at the local hospital.

Littledog was among four people to die from fentanyl overdoses on the reservation that week in March, according to Blackfeet health officials. An additional 13 people who live on the reservation survived overdoses, making a startling total for an Indigenous population of about 10,000 people.

Fentanyl has taken root in Montana and in communities across the Mountain West during the pandemic, after formerly being prevalent mostly east of the Mississippi River, said Keith Humphreys of the Stanford-Lancet Commission on the North American Opioid Crisis.

Montana law enforcement officials have intercepted record numbers of pale-blue pills made to look like prescription opioids such as OxyContin. In the first three months of 2022, the Montana Highway Patrol seized over 12,000 fentanyl pills, more than three times the number from all of 2021.

Nationwide, at least 103,000 people died from drug overdoses in 2021, a 45% increase from 2019, according to data from the Centers for Disease Control and Prevention. About 7 of every 10 of those deaths were from synthetic opioids, primarily fentanyl.

Overdose deaths are disproportionately affecting Native Americans. The overdose death rate among Indigenous people was the highest of all racial groups in the first year of the pandemic and was about 30% higher than the rate among white people, according to a study co-authored by UCLA graduate student and researcher Joe Friedman.

In Montana, the opioid overdose death rate for Indigenous people was twice that of white people from 2019 to 2021, according to the state Department of Public Health and Human Services.

The reason, in part, is that Native Americans have relatively less access to health care resources, Friedman said. “With the drug supply becoming so dangerous and so toxic, it requires resources and knowledge and skills and funds to stay safe,” he said. “It requires access to harm reduction. It requires access to health care, access to medications.”

The Indian Health Service, which is responsible for providing health care to many Indigenous people, has been chronically underfunded. According to a 2018 report from the U.S. Commission on Civil Rights, IHS per patient expenditures are significantly less than those of other federal health programs.

“I think what we’re seeing now is deep-seated disparities and social determinants of health are kind of bearing out,” Friedman said, referring to the disproportionate overdose deaths among Native Americans.

Blackfeet Tribal Business Council member Stacey Keller said she has experienced the lack of resources firsthand while trying to get a family member into treatment. She said just finding a facility for detoxing was difficult, let alone finding one for treatment.

“Our treatment facility here, they’re not equipped to deal with opioid addiction, so they’re usually referred out,” she said. “Some of the struggles we’ve seen throughout the state and even the western part of the United States is a lot of the treatment centers are at capacity.”

The local treatment center doesn’t have the medical expertise to supervise someone going through opioid withdrawal. Only two detox beds are available at the local IHS hospital, Keller said, and are often occupied by other patients. The health care system on the reservation also doesn’t offer medication-assisted treatment. The nearest locations to get buprenorphine or methadone — drugs used to treat opioid addictions — are 30 to 100 miles away. That can be a burden to patients who are required by federal rules to show up each day at the approved dispensaries to receive methadone or must make weekly treks for buprenorphine.

Keller said tribal leaders have requested assistance from IHS to build out treatment and other substance use resources in the community, with no results.

The IHS’ Alcohol and Substance Abuse Program consultant, JB Kinlacheeny, said the agency has largely shifted to appropriating funds directly to tribes to run their own programs.

The Rocky Mountain Tribal Leaders Council, a consortium of Montana and Wyoming tribes, is working with the Montana Healthcare Foundation on a feasibility study for a treatment center operated by tribes to build capacity specifically for tribal members. Tribes across both states, including the Blackfeet, have passed resolutions supporting the effort.

Blackfeet political leaders declared a state of emergency in March after the fentanyl overdoses. A short time later, some of the tribal council chairman’s children were arrested on suspicion of selling fentanyl out of his home. The council removed Chairman Timothy Davis from his position as tribal leader in early April.

The tribe has created a task force to identify both the short- and long-term needs to respond to the opioid crisis. Blackfeet tribal police investigator Misty LaPlant is helping lead that effort.

Driving around Browning, LaPlant said she plans to train more people on the reservation to administer naloxone, a medication that reverses opioid overdoses. She also wants the tribe to host needle exchanges to reduce infections and the spread of diseases like HIV. There’s also hope, she said, that a reorganization of the tribal health department will result in a one-stop shop for Blackfeet Nation residents to find drug addiction resources on and off the reservation.

However, she said resolving some of the underlying issues — such as poverty, housing, and food insecurity — that make communities like the Blackfeet Nation vulnerable to the ongoing fentanyl crisis is a massive undertaking that won’t be completed anytime soon.

“You could connect historical trauma, unresolved traumas in general, and grief into what makes our community vulnerable,” she said. “If you look at the impact of colonialism and Indigenous communities and people, there’s a correlation there.”

Marla Ollinger is happy to see momentum building to fight opioid and fentanyl addiction in the wake of her son’s death and other people’s. As a mother who struggled to find the resources to save her son, she hopes no one else has to live through that experience.

“It’s heartbreaking to watch your children die unnecessarily,” she said.

This story is part of a partnership that includes Montana Public RadioNPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

¿Puede una inyección mensual frenar la adicción a opioides? Expertos dicen que sí

Una opción inyectable mensual para el tratamiento de la adicción a opioides no logra llegar a todos los que la necesitan por las trabas burocráticas para obtener el medicamento.

Oakland, California.- El doctor Andrew Herring tiene un objetivo claro con los pacientes que buscan medicamentos para tratar la adicción a opioides: persuadirlos de que reciban una inyección de buprenorfina de liberación prolongada.

En su clínica de adicciones en el Hospital Highland, un centro público en el corazón de Oakland, Herring promueve la administración de una inyección de buprenorfina en la barriga para proporcionar un mes de tratamiento, en lugar de recetar versiones orales que deben tomarse a diario.

Asegura que esta opción es un “cambio de juego” y que puede ser su única oportunidad de ayudar a un paciente vulnerable en riesgo de sobredosis.

En California, donde las muertes por sobredosis han estado aumentado, expertos en adicciones dicen que administrar un mes de medicamento tiene un gran potencial, particularmente para las personas sin vivienda o que luchan contra otras formas de inestabilidad.

Sin embargo, el uso de buprenorfina inyectable sigue siendo bastante limitado, especialmente en comparación con otras formas de medicación para la adicción. Los investigadores aún tienen que publicar estudios que comparen diferentes formas de administrar buprenorfina.

La buprenorfina, uno de los tres medicamentos aprobados en los Estados Unidos para tratar el trastorno por uso de opioides, funciona uniéndose a los receptores de opioides en el cerebro y reduciendo las ansias y los síntomas de abstinencia.

Así, si un paciente toma una dosis alta de una droga como la heroína o el fentanilo, es menos probable que sufra una sobredosis. Los pacientes a menudo usan buprenorfina durante años.

Si Herring receta un suministro de buprenorfina en forma de tableta o de una tira que se coloca debajo de la lengua, el paciente debe comprometerse a tomar el medicamento al menos una vez al día, y muchos dejan de hacerlo.

“Es como algo religioso: tienes que levantarte cada mañana y repetir tus votos”, dijo Herring. “En realidad, hay muchas personas que merecen un tratamiento y que no pueden cumplir con ese requisito”.

Las formas orales de buprenorfina han estado disponibles para tratar la adicción desde 2002 y se pueden comprar como genéricos por menos de $100 al mes.

La buprenorfina inyectable, vendida bajo la marca Sublocade, recibió la aprobación de la FDA en 2017. Tiene un precio de lista alto, de $1,829.05 por una inyección mensual. El fabricante Indivior reportó ganancias de $244 millones por la venta de la droga, solo el año pasado, y pronostica alcanzar los $1,000 millones. No hay disponible una versión genérica o competidora del medicamento.

La mayoría de los pacientes no pagarán el precio completo, dice Indivior, su fabricante, porque la mayoría de los planes de salud cubren el medicamento. Los médicos, sin embargo, dicen que el alto costo puede ser una barrera para los pacientes con planes privados, que a veces se resisten a cubrir el medicamento.

Medi-Cal, el programa de seguro médico de California para personas de bajos ingresos, cubre Sublocade sin autorización previa, lo que hace que el tratamiento sea accesible para la mayoría de los pacientes de Herring.

Aún así, expertos en adicciones dicen que el uso de Sublocade sigue siendo limitado debido a los obstáculos normativos necesarios para administrarlo.

Los proveedores deben registrarse en la Administración de Control de Drogas (DEA) y obtener una exención para recetar buprenorfina porque se considera una sustancia controlada. Además, las clínicas deben completar un programa de certificación de seguridad de la FDA para dispensar el medicamento. Y solo puede pedirse a través de una farmacia especializada, aprobada por la FDA.

“En muchos hospitales, eso significará un retraso en la obtención de este medicamento o simplemente optar por no recibirlo”, dijo el doctor Rais Vohra, director regional de California Bridge Network, un programa financiado por el estado que apoya a los hospitales para que ofrezcan tratamiento para adicciones, incluida la clínica de Herring.

Vohra dijo que el Centro Médico Regional Comunitario en Fresno, donde trabaja como médico de emergencia, todavía está revisando los requisitos para ver si la farmacia del hospital puede distribuir el medicamento, lo que lo convertiría en uno de los pocos proveedores del Valle Central.

La buprenorfina oral, por el contrario, es una receta simple que la mayoría de las farmacias locales tienen en stock.

“Todos los obstáculos que los médicos y los pacientes tienen que superar para obtener este medicamento son una locura. No hacemos eso para ninguna otra enfermedad”, dijo la doctora Hannah Snyder, quien dirige la clínica de adicciones en el Hospital General Zuckerberg de San Francisco.

Varios médicos señalaron que el acceso sigue siendo un problema incluso con formas orales de buprenorfina. A pesar de una cascada de estudios que prueban la eficacia del tratamiento asistido por medicamentos, muchos médicos se resisten a recetarlo, especialmente en comunidades de color.

“La pregunta más importante no es si la bupre inyectable de acción prolongada es una mejor solución”, dijo el doctor Michael Ostacher, profesor de la Escuela de Medicina de la Universidad de Stanford, que compara las versiones inyectables y orales de buprenorfina a través de Veteran Affairs. “La pregunta más importante es cómo aumentamos el acceso al tratamiento para todas las personas que lo necesitan”.

Angela Griffiths se encuentra entre los pacientes que dicen que Sublocade ha cambiado sus vidas. Griffiths, de 41 años, de San Francisco, usó heroína durante 18 años. Cuando estaba embarazada de su hija en 2016, los médicos le recetaron metadona, lo que la hizo sentir “miserable”. Hace tres años cambió a tiras de buprenorfina, pero llevar las tiras a todas partes todavía la hacía sentir atada a su adicción.

Cuando los médicos de la clínica general de SF la cambiaron a inyecciones mensuales de Sublocade, describió el cambio como “extraordinario”.

En los estados donde los planes de Medicaid aún pueden requerir autorización previa, las esperas para Sublocade pueden extenderse a meses. Al otro lado de la frontera, en la clínica Northern Nevada Hopes en Reno, Nevada, por ejemplo, la doctora Taylor Tomlinson dijo que les dice a los pacientes que, entre las batallas por la cobertura y los retrasos en las farmacias, es posible que tengan que esperar dos meses para recibir una inyección.

“El tiempo de espera crea una barrera para la atención”, opinó Tomlinson

El programa de Medicaid de California no requiere autorización previa, pero proporcionar Sublocade sigue siendo un desafío. Herring ha podido reducir parte de la burocracia en su clínica de Oakland trabajando con la farmacia de Highland para almacenar y distribuir Sublocade.

Tan pronto como un paciente acepta una inyección, Herring simplemente llama a la farmacia al final del pasillo y se la administra en el acto.

Herring ve la urgencia de aumentar el uso de buprenorfina inyectable a medida que aumenta el uso de fentanilo en California. Durante años, el mortal opioide sintético se concentró principalmente en la costa este; en 2018, el 88% de estas muertes ocurrieron en los 28 estados al este del río Mississippi.

Pero más recientemente, el fentanilo ha comenzado a infiltrarse en los estados occidentales. De 2018 a 2020, las muertes por sobredosis de fentanilo en California se quintuplicaron, según datos estatales.

“Nadie entiende a lo que se enfrenta”, dijo Herring sobre la potencia del fentanilo. “Este es el momento en el que ocurrirán un mayor número de muertes”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Can a Monthly Injection Be the Key to Curbing Addiction? These Experts Say Yes

In California, where overdose deaths are on the rise, physicians say administering anti-addiction medication as a monthly injection holds tremendous potential. So, why aren’t more patients getting it?

OAKLAND, Calif. — Dr. Andrew Herring has a clear goal walking into every appointment with patients seeking medication to treat an opioid use disorder: persuade them to get an injection of extended-release buprenorphine.

At his addiction clinic at Highland Hospital, a bustling public facility in the heart of Oakland, Herring promotes administering a shot of buprenorphine in the belly to provide a month of addiction treatment rather than prescribing oral versions that must be taken daily. For him, the shots’ longer-acting protection is a “game changer” and may be his only chance to help a vulnerable patient at risk of overdose.

“At any point in time, they’re just a balloon that’s going to go,” Herring said. “You might only have this one interaction. And the question is, how powerful can you make it?”

In California, where overdose deaths have been rising for years, addiction experts say administering a month’s worth of anti-addiction medication holds great potential, particularly for people without housing or who struggle with other forms of instability. Yet despite its promise, the use of injectable buprenorphine remains fairly limited, especially compared with other forms of addiction medication. Researchers have yet to publish studies comparing different ways to administer buprenorphine.

Buprenorphine, one of three medications approved in the U.S. to treat opioid use disorder, works by binding to opioid receptors in the brain and reducing cravings and withdrawal symptoms. And because it occupies those receptor sites, buprenorphine keeps other opioids from binding and ensures that if a patient takes a high dose of a drug like heroin or fentanyl, they are less likely to overdose. Patients often stay on buprenorphine for years.

If Herring prescribes a supply of buprenorphine as a tablet or film that is placed under the tongue, the patient must commit to taking the medication at least once a day, and many fall out of treatment. He said this is especially true for his patients experiencing homelessness and those who also use methamphetamine.

“It’s like a religious thing — you have to wake up every morning and repeat your vows,” said Herring. “In reality, there are a lot of people who deserve treatment who can’t meet that requirement.”

Oral forms of buprenorphine have been available to treat addiction since 2002 and can be purchased as a generic for less than $100 a month. Injectable buprenorphine, sold under the brand name Sublocade, received FDA approval in 2017. It has a hefty list price of $1,829.05 for a monthly injection. The drugmaker Indivior reported $244 million in revenue from Sublocade last year alone, with a company goal to eventually make $1 billion in annual sales. No generic or competing version of the drug is available.

Most patients won’t pay full price, Indivior says, because most health plans cover the drug. Physicians, however, say the high cost can be a barrier for patients with private health plans, which sometimes resist covering the medication. Medi-Cal, California’s health insurance program for low-income people, covers Sublocade without prior authorization, making the treatment accessible to the majority of Herring’s patients.

Still, addiction experts say, Sublocade use remains limited because of the regulatory hurdles required to dispense it.

Providers must register with the U.S. Drug Enforcement Administration and obtain a waiver to prescribe buprenorphine because it’s considered a controlled substance. In addition, clinics must complete an FDA safety certification program to dispense the medication. And Sublocade can be ordered only by a specialty pharmacy, which must also pass the FDA program.

“At many hospitals, that will mean either a delay in getting this medication on our shelves or just opting out,” said Dr. Rais Vohra, regional director for the California Bridge Network, a state-funded program that supports hospitals in offering treatment for substance use disorders, including Herring’s clinic.

Vohra said Community Regional Medical Center in Fresno, where he works as an emergency physician, is still looking through the documentation requirements to see if the hospital’s pharmacy can distribute the medication — which would make it one of the few Central Valley providers to do so.

Oral buprenorphine, by contrast, is a simple prescription that most local drugstores keep in stock.

“All the hoops that clinicians and patients have to jump through to get this medication is crazy. We don’t do that for any other disease,” said Dr. Hannah Snyder, who runs the addiction clinic at Zuckerberg San Francisco General Hospital across the bay.

Several clinicians noted that access remains a problem even with oral forms of buprenorphine. Despite a cascade of studies proving the effectiveness of medication-assisted treatment, many patients across the country struggle to find a provider willing to prescribe buprenorphine in any form — especially in communities of color.

“The most important question isn’t whether long-acting injectable bupe is a better solution than sublingual buprenorphine for opioid use disorder,” said Dr. Michael Ostacher, a professor at Stanford University School of Medicine, who is comparing injectable and oral versions of buprenorphine through Veterans Affairs. “The bigger question is how we increase access to treatment for all people who need [the medication].”

Angela Griffiths is among the patients who say Sublocade has changed their lives. Griffiths, 41, of San Francisco, used heroin for 18 years. When she was pregnant with her daughter in 2016, doctors put her on methadone, which made her feel “miserable.” Three years ago, she said, she switched to buprenorphine films, but carrying the strips with her everywhere still made her feel tied to her addiction.

“The ritual of taking something every day plays something in your mind,” Griffiths said.

When doctors at the SF General clinic switched her to monthly Sublocade injections, she described the change as “extraordinary.”

“I’m not reaching for my drawer anymore for a fix,” she said. “I have the freedom to wake up and start my day however I want, whether it’s to go to the patio and drink a cup of coffee or to snuggle with my daughter in bed a little longer. It’s there; I don’t have to take anything.”

In states where Medicaid plans may still require prior authorization, waits for Sublocade can stretch into months. Across the border at the Northern Nevada Hopes clinic in Reno, Nevada, for example, Dr. Taylor Tomlinson said she tells patients that between battles for coverage and pharmacy delays, they might have to wait two months for an injection.

“I’m always going to offer it to a patient who I think would be a good candidate, but in the time they have to wait, they get interested in other things,” said Tomlinson. “It creates a barrier to care.”

California’s Medicaid program does not require prior authorization but providing Sublocade is still a challenge. At the Placerville clinic supported by the California Bridge Network, Dr. Juliet La Mers, the director, said a quarter of her buprenorphine patients get injections. Still, they often wait two weeks before Sublocade arrives from the specialty pharmacy.

Herring has been able to cut through some of that red tape at his Oakland clinic by working with the Highland pharmacy to stock and distribute Sublocade. As soon as a patient agrees to an injection, Herring simply calls the pharmacy down the hall and administers it on the spot.

Herring sees urgency — and opportunity — to increase the use of injectable buprenorphine as fentanyl use rises across California. For years, the deadly synthetic opioid was concentrated mostly on the East Coast; in 2018, 88% of deaths from synthetic opioids occurred in the 28 states east of the Mississippi River. But more recently, fentanyl has begun to infiltrate Western states. From 2018 to 2020, deaths from fentanyl overdoses in California quintupled, according to state data.

“No one understands what they’re dealing with,” Herring said of fentanyl’s potency. “This is the time where our greatest deaths are going to occur.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist

The pandemic has shown that loosening the strict regulations on distributing methadone helps people recovering from addiction stay in treatment. But clinics with a financial stake in keeping the status quo don’t want to make permanent changes.

Days typically start early for patients undergoing opioid addiction treatment at Denver Recovery Group’s six methadone clinics in Colorado. They rise before dawn. Some take three buses to get to a clinic by 5 a.m. for a 15-minute conversation with a counselor and their daily dose of methadone, all before they go to work or take their kids to school. Some drive more than an hour each way from Longmont or Steamboat Springs.

“They’re coming from a billion miles away,” said Dr. Andreas Edrich, the clinics’ chief medical officer, noting their strong motivation to get care compared with other patients who struggle to stick to a simple medication regimen. “Most people can’t take their blood pressure to save their life, and that’s in their kitchen cabinet.”

Patients who take methadone, a synthetic narcotic used to treat opioid addiction, must jump through more hoops than perhaps any other patient group in the U.S. due to rules dating back five decades. Proponents for easing the rules say the pandemic has shown certain constraints serve more as barriers to care than protections. And consensus is growing among clinicians, patients, and regulators that it’s time for change.

“There’s probably very few folks who work in the field who feel like we should continue the status quo,” said Dr. Shawn Ryan, a board member for the American Society of Addiction Medicine.

Now officials at the Substance Abuse and Mental Health Services Administration are considering permanent changes to federal methadone rules. A National Academy of Medicine workshop on methadone regulations on March 3 and 4 may signal an inflection point.

Additionally, Sens. Ed Markey (D-Mass.) and Rand Paul (R-Ky.) have introduced a bill that would codify the rules loosened during the pandemic, which allowed flexibility on take-home doses, telehealth, and treatment vans. It would also allow pharmacies to dispense methadone for opioid use treatment.

Any changes to federal rules, however, could face significant resistance from methadone clinics — many of them for-profit — whose financial models are built on daily patient encounters, counseling, and regular drug tests.

“There are some entities who have a financial interest in keeping things the way that they are,” Ryan said. “Change costs money.”

Currently, methadone can be dispensed only through federally regulated opioid treatment centers. Patients, at least initially, have had to show up in person each day to get their dose until they had proven themselves stable, primarily out of concern that they would sell the methadone or take more than their daily dose, risking overdose.

But the covid-19 pandemic prompted federal authorities to loosen methadone regulations, allowing more patients to take doses home and rely on telehealth consultations instead of in-person visits. Studies have found the flexibility didn’t result in any increases in overdoses, illicit sales of methadone doses, or people dropping out of treatment. Instead, patients have reported greater satisfaction and a higher willingness to follow their regimens.

“From that standpoint, the pandemic was an absolute blessing in disguise,” Edrich said.

One study found that the number of methadone take-home doses nearly doubled during the pandemic.

“We really couldn’t see any differences in terms of treatment adherence,” said Ofer Amram, an assistant professor studying health disparities at Washington State University.

That real-world experiment showed that many of the methadone rules might not be needed.

“In most other countries in the West, including Canada, it’s much easier to get access to methadone treatment,” Amram said. “You can get it in most pharmacies.”

But an Oregon Health & Science University survey of 170 methadone clinics found that fewer than half permitted new patients to take home a 14-day supply despite the loosened guidelines, and about two-thirds allowed existing, stable patients to receive the full 28-day allotment allowed.

“At the end of the day, patients with opioid use disorder want to be treated like everybody else,” said Dr. Ximena Levander, an assistant professor of medicine at OHSU and a co-author of the study. “There are a lot of other high-risk medications we dispense in medicine, but it’s only this one medication where it’s required for patients to go to this specific place to get treatment.”

Opioid treatment programs generally get reimbursed on a fee-for-service model: The more services they provide and the more tests they run, the more they get paid. A shift to a model in which a person comes to the clinic only once a month could severely restrict their revenue. According to a federal survey of methadone clinics, 41% were run by private for-profit companies in 2020, up from 30% in 2010.

“Most of these patients pay cash,” said Taleed El-Sabawi, an addiction and public policy professor at Georgetown University. “So if you are requiring urine tests often, if you’re requiring patients come in, if you’re requiring that they go through other hoops, they’re paying for that.”

And with cash payments, she said, no health plans are involved to question whether the services are medically necessary.

Denise Vincioni, regional director for Denver Recovery Group and a former director of Colorado’s State Opioid Treatment Authority, defended the existing regulatory framework.

“The rules and regulations protect our patients, give us parameters to work within, and also keep us safe as providers,” she said. “It’s a very risky business because you’re managing people’s lives with narcotics.”

Many patients, she said, end up appreciating the routine that creates the good habit of taking their methadone at the same time every day. Patients who haven’t put in the time or shown they’re not using illicit substances “haven’t demonstrated some of that entitlement,” Vincioni said. “Loose structure has been to their detriment.”

Vincioni suggested the clinics should have more leeway to decide when somebody is ready for take-home doses and to rely on their clinical judgment rather than strict parameters. Currently, if doses are diverted or the patient overdoses, the clinic could face repercussions.

“If something happens, it’s your butt,” she said. “That’s part of what has prevented us from doing a lot of that loosening up.”

Within the addiction treatment world, methadone patients are treated differently from patients who use other opioid addiction treatments, such as buprenorphine or Suboxone. Generally, buprenorphine is considered safer than methadone, with less risk of overdose, but methadone may be a better option for patients with chronic pain or who have been exposed to high amounts of fentanyl.

There’s also a racial-equity component. It’s often said that Black patients get methadone, which carries a stigma, while their white counterparts get Suboxone, a drug that prevents cravings for opioids. Part of that is because methadone clinics are often located in minority neighborhoods.

Levander said the recent focus on racial justice is driving momentum for changes to methadone rules.

“A lot of the federal regulations have a very racist history and undertone,” she said. “One of the things that is helping to catalyze this change is that motivation to try to right a wrong.”

Christopher Garrett, a SAMHSA spokesperson, said the agency can make some changes to methadone regulations on its own and is currently reviewing the flexibility granted during the pandemic. The agency has indicated that it plans to extend the flexibility for take-home doses another year, regardless of when the public health emergency ends.

Advocates caution that federal and state rules often conflict with each other, and sometimes are poorly aligned with the payment structure from Medicare, Medicaid, and other health plans. A Pew Charitable Trusts analysis, for example, found that in many states fewer than half of the opioid treatment providers accept Medicaid.

The two-day National Academy of Medicine workshop this month is expected to culminate in a report with possible policy change recommendations.

“I’m hoping that the momentum is now finally here,” said Dr. Gavin Bart, director of addiction medicine at Hennepin Healthcare in Minneapolis. “This is now being taken quite seriously.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

KHN’s ‘What the Health?’: The Politics of Vaccine Mandates

Like almost everything else associated with the covid-19 pandemic, partisans are taking sides over whether vaccines should be mandated. Meanwhile, Democrats on Capitol Hill are still struggling to find compromise in their effort to expand health insurance and other social programs. Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call join KHN’s Julie Rovner to discuss these issues and more. Also this week, Rovner interviews best-selling author Beth Macy about her book “Dopesick,” and the new Hulu miniseries based on it.

Can’t see the audio player? Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Should covid vaccines be mandated? The answer to that question has become predictably partisan, as with almost everything else associated with the pandemic. Even as the federal government prepares to issue rules requiring large employers to ensure their workers are vaccinated, GOP governors are trying to ban such mandates, leaving employers caught in the middle.

Meanwhile, on Capitol Hill, Democrats are still working to reach a consensus on a package of social-spending improvements, the size of which will depend largely on how much they can cut prices for prescription drugs.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Jen Haberkorn of the Los Angeles Times and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s episode:

  • Congressional Democrats’ struggle to find a compromise on a $3.5 trillion spending package for health and other social programs looks likely to push them past their self-imposed deadline of the end of October to pass a bill. Leaders are wrestling with what to cut as they meet demands from moderates in the party to bring the spending down.
  • Everything in that package appears vulnerable at this stage in the negotiations. Party leaders are considering a variety of strategies, including throwing out some proposals or setting up the new benefits over a shorter time frame to test whether they work and the public appreciates them.
  • It appears that Democrats’ priorities will include proposals to enhance benefits for children. But the health programs at stake — new benefits for Medicare, providing insurance to low-income residents of states that have not expanded their Medicaid programs, and extending the enhanced premium subsidies for the Affordable Care Act — each have strong constituencies and will be hard for leaders to settle on.
  • The proposal to add billions of dollars to long-term care programs may draw the short straw. However, it does have some strong allies in Congress, including Sens. Ron Wyden (D-Ore.) and Bob Casey (D-Pa.).
  • Democratic leaders hope to fund some of the initiatives in this package by cutting Medicare’s drug spending. A poll by KFF this week showed that is a very popular notion, even among Republicans. But drugmakers are fighting that strategy with major ad campaigns and political donations. They need to pick off only a couple of vulnerable lawmakers to thwart the effort since Democrats have razor-thin majorities in both the House and Senate. House Speaker Nancy Pelosi, however, appears determined to get some sort of provision on drug price negotiations in the bill, even without the full effect of her original plan.
  • The Department of Labor reportedly has sent a proposed rule requiring large employers to have their workforce vaccinated to the Office of Management and Budget for review. That means the rule could be coming soon. But it is bound to run headlong into opposition in conservative states, like Texas, where Republican Gov. Greg Abbott has banned mandates. The issue will likely end up in federal court.
  • The fight over vaccine mandates highlights a divide in the Republican Party between the business-oriented faction that wants to move past the pandemic and the more libertarian wing of the party. Some of the most conservative political leaders lean toward that libertarian wing and see the vaccine mandate as a way to excite the base. The experience of some major companies, however, suggests that businesses and many workers don’t object to mandates. One example is United Airlines, where 99% of workers have been vaccinated.
  • As the federal courts bat the Texas abortion law back and forth, it appears headed for a review by the Supreme Court. Some analysts suggest that the urgency of the issue could push the court to take on the Texas issue before they hear a case in December about a different law seeking to limit abortion in Mississippi. But the Supreme Court generally likes to have cases fully debated in lower courts before coming to the justices, so a decision on the Texas law may have to wait.
  • The issue of abortion is getting a good bit of advertising time in the Virginia gubernatorial race. Democratic candidate Terry McAuliffe is telling voters he will work to keep abortions legal in the state and suggesting his opponent, Glenn Youngkin, will not. It’s a strategy that California Gov. Gavin Newsom used as he successfully fought a recall in an election last month.

Also this week, Rovner interviews Beth Macy, author of the best-selling “Dopesick: Dealers, Doctors and the Drug Company That Addicted America” and an executive producer of a miniseries of the same name now streaming on Hulu.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “6 Months to Live or Die: How Long Should an Alcoholic Liver Disease Patient Wait for a Transplant,” by Aneri Pattani

Jen Haberkorn: The Washington Post’s “Covid and Cancer: A Dangerous Combination, Especially for People of Color,” by Laurie McGinley

Mary Ellen McIntire: NPR’s “Judging ‘Sincerely Held’ Religious Belief Is Tricky for Employers Mandating Vaccines,” by Laurel Wamsley

Alice Miranda Ollstein: The 19th’s “Kansas Has Become a Beacon for Abortion Access. Next Year, That Could Disappear,” by Shefali Luthra

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

As Holdout Missouri Joins Nation in Monitoring Opioid Prescriptions, Experts Worry

Missouri is the last state to create a monitoring program to help spot the misuse of prescription drugs. But some public health experts warn that the nation’s programs are forcing people addicted to opioids to seek deadlier street options.

Kathi Arbini said she felt elated when Missouri finally caught up to the other 49 states and approved a statewide prescription drug monitoring program this June in an attempt to curb opioid addiction.

The hairstylist turned activist estimated she made 75 two-hour trips in the past decade from her home in Fenton, a St. Louis suburb, to the state capital, Jefferson City, to convince Republican lawmakers that monitoring how doctors and pharmacists prescribe and dispense controlled substances could help save people like her son, Kevin Mullane.

He was a poet and skateboarder who she said turned to drugs after she and his dad divorced. He started “doctor-shopping” at about age 17 and was able to obtain multiple prescriptions for the pain medication OxyContin. He died in 2009 at 21 from a heroin overdose.

If the state had had a monitoring program, doctors might have detected Mullane’s addiction and, Arbini thinks, her son might still be alive. She said it’s been embarrassing that it’s taken Missouri so long to agree to add one.

“As a parent, you would stand in front of a train; you would protect your child forever — and if this helps, it helps,” said Arbini, 61. “It can’t kill more people, I don’t think.”

But even though Missouri was the lone outlier, it had not been among the states with the highest opioid overdose death rates. Missouri had an average annual rank of 16th among states from 2010 through 2019, as the country descended into an opioid epidemic, according to a KHN analysis of Centers for Disease Control and Prevention data compiled by KFF.

Some in public health now argue that when providers use such monitoring programs to cut off prescription opiate misuse, people who have an addiction instead turn to heroin and fentanyl. That means Missouri’s new toll could cause more people to overdose and leave the state with buyer’s remorse.

“If we can take any benefit from being last in the country to do this, my hope would be that we have had ample opportunity to learn from others’ mistakes and not repeat them,” said Rachel Winograd, a psychologist who leads NoMODeaths, a state program aimed at reducing harm from opioid misuse.

Before Missouri’s monitoring program was approved, lawmakers and health and law enforcement officials warned that the absence made it easier for Missouri patients to doctor-shop to obtain a particular drug, or for providers to overprescribe opiates in what are known as pill mills.

State Sen. Holly Rehder, a Republican with family members who have struggled with opioid addiction, spent almost a decade pushing legislation to establish a monitoring program but ran into opposition from state Sen. Rob Schaaf, a family physician and fellow Republican who expressed concerns about patient privacy and fears about hacking.

In 2017, Schaaf agreed to stop filibustering the legislation and support it if it required that doctors check the database for other prescriptions before writing new ones for a patient. That, though, sparked fresh opposition from the Missouri State Medical Association, concerned the requirement could expose physicians to malpractice lawsuits if patients overdosed.

The new law does not include such a requirement for prescribers. Pharmacists who dispense controlled substances will be required to enter prescriptions into the database.

Dr. Silvia Martins, an epidemiologist at Columbia University who has studied monitoring programs, said it’s important to mandate that prescribers review a patient’s information in the database. “We know that the ones that are most effective are the ones where they check it regularly, on a weekly basis, not just on a monthly basis,” she said.

But Stephen Wood, a nurse practitioner and visiting substance abuse bioethics researcher at Harvard Law School, said the tool is often punitive because it cuts off access to opioids without offering viable treatment options.

He and his colleagues in the intensive care unit at Carney Hospital in Boston don’t use the Massachusetts monitoring program nearly as often as they once did. Instead, he said, they rely on toxicology screens, signs such as injection marks or the patients themselves, who often admit they are addicted.

“Rather than pulling out a piece of paper and being accusatory, I find it’s much better to present myself as a caring provider and sit down and have an honest discussion,” Wood said.

When Kentucky in 2012 became the first state to require prescribers and dispensers to use the system, the number of opioid prescriptions and overdoses from prescription opioids initially decreased slightly, according to a state study.

But the number of opioid overdose deaths — with the exception of a slight dip in 2018 and 2019 — has since consistently ticked upward, according to a KFF analysis of CDC data. In 2020, Kentucky was estimated to have had the nation’s second-largest increase in drug overdose deaths.

When efforts to establish Missouri’s statewide monitoring program stalled, St. Louis County established one in 2017 that 75 local jurisdictions agreed to participate in, covering 85% of the state, according to the county health department. The county now plans to move its program into the state one, which is scheduled to launch in 2023.

Dr. Faisal Khan, director of the county department, said he has no doubt that the St. Louis program has “saved lives across the state.” Opioid prescriptions decreased dramatically once the county established the monitoring program. In 2016, Missouri averaged 80.4 opioid prescriptions per 100 people; in 2019, it was down to 58.3 prescriptions, according to the CDC.

The overall drug overdose death rate in Missouri has steadily increased since 2016, though, with the CDC reporting an initial count of 1,921 people dying from overdoses of all kinds of drugs in 2020.

Khan acknowledged that a monitoring program can lead to an increase in overdose deaths in the years immediately following its establishment because people addicted to prescription opioids suddenly can’t obtain them and instead buy street drugs that are more potent and contain impurities.

But he said a monitoring program can also help a physician intervene before someone becomes addicted. Doctors who flag a patient using the monitoring program must then also be able to easily refer them to treatment, Khan and others said.

“We absolutely are not prepared for that in Missouri,” said Winograd, of NoMODeaths. “Substance use treatment providers will frequently tell you that they are at max capacity.”

Uninsured people in rural areas may have to wait five weeks for inpatient or outpatient treatment at state-funded centers, according to PreventEd, a St. Louis-based nonprofit that aims to reduce harm from alcohol and drug use.

For example, the waiting list for residential treatment at the Preferred Family Healthcare clinic in Trenton is typically two weeks during the summer and one month in winter, according to Melanie Tipton, who directs clinical services at the center, which mostly serves uninsured clients in rural northern Missouri.

Tipton, who has worked at the clinic for 17 years, said that before the covid-19 pandemic, people struggling with opioid addiction mainly used prescription pills; now it’s mostly heroin and fentanyl, because they are cheaper. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine, according to the National Institute on Drug Abuse.

Still, Tipton said her clients continue to find providers who overprescribe opiates, so she thinks a statewide monitoring program could help.

Inez Davis, diversion program manager for the Drug Enforcement Administration’s St. Louis division, also said in an email that the program will benefit Missouri and neighboring states because “doctor shoppers and those who commit prescription fraud now have one less avenue.”

Winograd said it’s possible that if the state had more opioid prescription pill mills, it would have a lower overdose death rate. “I don’t think that’s the answer,” she said. “We need to move in the direction of decriminalization and a regulated drug supply.” Specifically, she’d rather Missouri decriminalize possession of small amounts of hard drugs, even heroin, and institute regulations to ensure the drugs are safe.

State Rep. Justin Hill, a Republican from St. Charles and former narcotics detective, opposed the monitoring program legislation because of his concerns over patient privacy and evidence that the lack of a program has not made Missouri’s opioid problem any worse than many other states’. He also worries the monitoring program will lead to an increase in overdose deaths.

“I would love the people that passed this bill to stand by the numbers,” Hill said. “And if we see more deaths from overdose, scrap the monitoring program and go back to the drawing board.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

How ERs Fail Patients With Addiction: One Patient’s Tragic Death

Two intractable failings of the U.S. health care system — addiction treatment and medical costs — come to a head in the ER, where patients desperate for addiction treatment arrive, only to find the facility may not be equipped to deal with substance use or, if they are, treatment is prohibitively expensive.

Jameson Rybak tried to quit using opioids nearly a dozen times within five years. Each time, he’d wait out the vomiting, sweating and chills from withdrawal in his bedroom.

It was difficult to watch, said his mother, Suzanne Rybak, but she admired his persistence.

On March 11, 2020, though, Suzanne grew worried. Jameson, 30 at the time, was slipping in and out of consciousness and saying he couldn’t move his hands.

By 11 p.m., she decided to take him to the emergency room at McLeod Regional Medical Center in Florence, South Carolina. The staff there gave Jameson fluids through an IV to rehydrate, medication to decrease his nausea and potassium supplements to stop his muscle spasms, according to Suzanne and a letter the hospital’s administrator later sent her.

But when they recommended admitting him to monitor and manage the withdrawal symptoms, Jameson said no. He’d lost his job the previous month and, with it, his health insurance.

“He kept saying, ‘I can’t afford this,’” Suzanne recalled, and “not one person [at the hospital] indicated that my son would have had some financial options.”

Suzanne doesn’t remember any mention of the hospital’s financial assistance policy or payment plans, she said. Nor does she remember any discussions of providing Jameson medication to treat opioid use disorder or connecting him to addiction-specialty providers, she said.

“No referrals, no phone numbers, no follow-up information,” she later wrote in a complaint letter to the hospital.

Instead, ER staff provided a form saying Jameson was leaving against medical advice. He signed and Suzanne witnessed.

Three months later, Jameson Rybak died of an overdose in his childhood bedroom.

Missed Opportunities

That March night in the emergency room, Jameson Rybak had fallen victim to two huge gaps in the U.S. health care system: a paucity of addiction treatment and high medical costs. The two issues — distinct but often intertwined — can come to a head in the ER, where patients and families desperate for addiction treatment often arrive, only to find the facility may not be equipped to deal with substance use. Or, even if they are, the treatment is prohibitively expensive.

Academic and medical experts say patients like Jameson represent a series of missed opportunities — both medical and financial.

“The emergency department is like a door, a really important door patients are walking through for identification of those who might need help,” said Marla Oros, a registered nurse and president of the Mosaic Group, a Maryland-based consulting firm that has worked with more than 50 hospitals nationwide to increase addiction treatment services. “We’re losing so many patients that could be identified and helped,” she said, speaking generally.

A spokesperson for McLeod Regional Medical Center, where Jameson went for care, said they would not comment on an individual’s case and declined to answer a detailed list of questions about the hospital’s ER and financial assistance policies. But in a statement, the hospital’s parent company, McLeod Health, noted that the hospital adhered to federal laws requiring that hospital ERs provide “immediate stabilizing care” for all patients, regardless of their ability to pay.

“Our hospitals attempt to manage the acute symptoms, but we do not treat chronic, underlying addiction,” the statement added.

Suzanne said her son needed more than stabilization. He needed immediate help breaking the cycle of addiction.

Jameson had been in and out of treatment for five years, ever since a friend suggested he try opioids to manage his anxiety and insomnia. He had insurance through his jobs in the hotel industry and later as an electrical technician, Suzanne said. But the high-deductible plans often left him paying out-of-pocket: $3,000 for a seven-day rehab stay, $400 for a brief counseling session and a prescription of Suboxone, a medication to treat opioid use disorder.

After he lost his job in February 2020, Jameson tried again to detox at home, Suzanne said. That’s what led to the ER trip.

Treating Addiction in the ER

Hospital ERs across the nation have become ground zero for patients struggling with addiction.

A seminal study published in 2015 by researchers at Yale School of Medicine found that giving patients medication to treat opioid use disorder in the ER doubled their chances of being in treatment a month later, compared with those who were given only referrals to addiction treatment.

Yet providing that medication is still not standard practice. A 2017 survey found just 5% of emergency medicine physicians said their department provided medications for opioid use disorder. Instead, many ERs continue to discharge these patients, often with a list of phone numbers for addiction clinics.

Jameson didn’t even get that, Suzanne said. At McLeod Regional, he was not seen by a psychiatrist or addiction specialist and did not get a prescription for Suboxone or even a referral, she said.

After Jameson’s death, Suzanne wrote to the hospital: “Can you explain to me, especially with the drug crisis in this country, how the ER was not equipped with personnel and/or any follow-up for treatment?”

Hospital administrator Will McLeod responded to Suzanne, in a letter she shared with KHN, that per Jameson’s medical record he’d been evaluated appropriately and that his withdrawal symptoms had been treated. Jameson declined to be admitted to the hospital, the letter said, and could not be involuntarily committed, as he “was not an imminent danger to himself or others.”

“Had he been admitted to our hospital that day, he would have been assigned to social workers and case managers who could have assisted with referrals, support, and follow-up treatment,” McLeod wrote.

Nationwide, hospitals are working to ramp up the availability of addiction services in the ER. In South Carolina, a state-funded program through the Medical University of South Carolina and the consulting firm Mosaic Group aims to help hospitals create a standardized system to screen patients for addiction, employ individuals who are in recovery to work with those patients and offer medication for opioid use disorder in the ER.

The initiative had worked with seven ERs as of June. It was in discussions to work with McLeod Regional hospital too, program staffers said. However, the hospital backed out.

The hospital declined to comment on its decision.

ER staffs around the country often lack the personnel to launch initiatives or learn about initiating addiction treatment. Sometimes affordable referral options are limited in the area. Even when the initial prescribing does occur, cost can be a problem, since Suboxone and its generic equivalent range in price from $50 to over $500 per prescription, without insurance.

In South Carolina, which has not expanded Medicaid, nearly 11% of the population is uninsured. Among patients in the state’s program who have been started on medications for opioid use disorder in ERs, about 75% are uninsured, said Dr. Lindsey Jennings, an emergency medicine physician at MUSC who works on the statewide initiative.

Other parts of the country face similar concerns, said Dr. Alister Martin, an emergency medicine physician who heads a national campaign to encourage the use of these medications in the ER. In Texas, for example, hundreds of doctors have gotten certified to provide the medications, he said, but many patients are uninsured and can’t pay for their prescriptions.

“You can’t make it effective if people can’t afford it,” Martin said.

Too Late for Charity Care

Throughout the night at McLeod Regional hospital’s ER, Jameson worried about cost, Suzanne said.

She wanted to help, but Jameson’s father and younger brother had recently lost their jobs, and the household was running on her salary as a public school librarian.

Suzanne didn’t know that nonprofit hospitals, like McLeod, are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status.

But “nonprofits are actually doing less charity care than for-profits,” said Ge Bai, an associate professor at Johns Hopkins University who published a study this year on the level of charity care provided by different hospitals.

That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection.

McLeod Regional’s most recent publicly available tax return states that “uninsured patients are screened at the time of registration” and if they’re unable to pay and ineligible for governmental insurance, they’re given an application.

Suzanne said she doesn’t remember Jameson or herself receiving an application. The hospital declined to comment on the Rybaks’ case and whether it provides “conspicuous public displays” of financial assistance.

“Not once did anybody tell us, ‘Let’s get a financial person down here,’ or ‘There are grant programs,’” Suzanne said.

Mark Rukavina, with the nonprofit health advocacy group Community Catalyst, said most hospitals comply with the letter of the law in publicizing their assistance policy. But “how effective some of that messaging is may be a question,” he said. Some hospitals may bury the policy in a dense packet of other information or use signs with vague language.

A KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. McLeod Regional hospital reported $1.77 million of debt from sending bills to such patients, which ended up going unpaid, for the fiscal year ending in 2019.

Believing they couldn’t afford in-patient admission, the Rybaks left the hospital that night.

After the ER

Afterward, Jameson’s withdrawal symptoms passed, Suzanne said. He spent time golfing with his younger brother. Although his application for unemployment benefits was denied, he managed to defer payments on his car and school loans, she said.

But, inside, he must have been struggling, Suzanne now realizes.

Throughout the pandemic, many people with substance use disorder reported feeling isolated and relapsing. Overdose deaths rose nationwide.

On the morning of June 9, 2020, Suzanne opened the door to Jameson’s room and found him on the floor. The coroner determined he had died of an overdose. The family later scattered his ashes on Myrtle Beach — Jameson’s favorite place, Suzanne said.

In the months following Jameson’s death, hospital bills for his night in the ER arrived at the house. He owed $4,928, they said. Suzanne wrote to the hospital that her son was dead but received yet another bill addressed to him after that.

She shredded it and mailed the pieces to the hospital, along with a copy of Jameson’s death certificate.

Twelve days later, the health system wrote to her that the bill had been resolved under its charity care program.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

Relaxed regulations in response to the pandemic means more access to addiction treatment medications. But recovery programs are accepting fewer people, and the danger of overdose remains high.

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Vaping, Opioid Addiction Accelerate Coronavirus Risks, Says NIDA Director

Dr. Nora Volkow, who heads the National Institute on Drug Abuse, details how emerging science points to added challenges for these patient populations and the public health system.

In 2018, opioid overdoses claimed about 47,000 American lives. Last year, federal authorities reported that 5.4 million middle and high school students vaped. And just two months ago, about 2,800 cases of vaping-associated lung injuries resulted in hospitalizations; 68 people died.

Until mid-March, these numbers commanded attention. But as the coronavirus death toll climbs and the economic costs of attempting to control its spread wreak havoc, the public health focus is now dramatically different.

In the background, though, these other issues — the opioid epidemic and vaping crisis — persist in heaping complications on an overwhelmed public health system.

It is creating a distinctly American problem, said Dr. Nora Volkow, who heads the National Institute on Drug Abuse.

Volkow spoke with Kaiser Health News about the emerging science around COVID-19’s relationship to vaping and to opioid use disorder, as well as how these underlying epidemics could increase people’s risks. Her remarks have been edited for length and clarity.

Q: We’ve already been experiencing two epidemics at once — vaping and the opioid crisis — and now we’re in the midst of a third. Does that change the nature of addressing the coronavirus in the United States?

It makes a different kind of situation than we see abroad. It forces us as a country to be urgently multitasking, to focus on the urgent needs of COVID while not ignoring the other epidemics devastating America. That’s certainly challenging.

Q: What is the evidence around the relationship between vaping and the coronavirus?

Because of the recency, there’s no data to show if there are differences in outcomes between people who vape and people who do not vape. There’s no reported scientific evidence. We will start seeing it.

We know from all the cases of acute lung injury that vaping, particularly certain combinations of chemicals that were related to vaping of THC, actually led to death. The cause of death was pulmonary dysfunction. We know from animal experiments that vaping itself — not even giving any drugs with it — can produce inflammatory changes in the lung.

We already know for COVID that, with comorbid conditions — particularly those that affect the lungs, the heart, the immune system — [patients] are more likely to have negative outcomes.

One can predict an association. In the meantime, because of the data that already exist, we should be very cautious. The prudent thing is to strongly advise individuals who are vaping to stop.

Q: Young people so far appear to have lower risks of COVID complications. Does vaping change that?

We know there have been fatalities among young people. One very important area of research is to try to understand the specific vulnerabilities among young people.

Why would you want to risk it when you already know vaping produces inflammatory changes in the lungs? We know in medicine, a tissue that has suffered harm is more vulnerable.

The big centers where you are observing the rise in COVID-19 cases, that’s where you are more likely to see the comorbidity of vaping.

It’s young people that are mostly vaping, but also older people, many of whom otherwise would be smoking tobacco. [Smoking] also raises the risk. Even though the samples have not been large enough, overall, smokers have done worse than nonsmokers when they have COVID.

Q: Let’s talk about opioid use disorder. What kind of comorbidities are we starting to see between opioid use disorder and COVID-19?

People who have opioid use disorder are also likely to be smokers. Smoking itself increases harm to your lungs.

We do know that opioids actually are immunosuppressants. This has been extensively studied. Nicotine also can disrupt immunity and actually impair the capacity of the cell to respond to viral infections.

One of the things opioids do is they depress your respiration. If it’s severe enough, they stop breathing. That’s what leads to death.

Whether you overdose or not, when you are taking opioids, the frequency of your breathing is down, and the oxygen in your blood tends to be lower.

The [COVID] infection targets the respiratory tissues in the lungs. It interferes with the capacity to transfer oxygen into the blood.

If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.

Q: What about other supports for people in recovery?

Community support systems like syringe exchange programs are closing. Methadone clinics are closing. If they’re not closing, they’re unable to process the same number of patients — because the staff is getting sick or the place where the methadone clinic was does not allow for so many people. Public transportation is not available for people to attend their methadone clinics.

We’re also hearing from our investigators they have observed a significant reduction in the capacity of the health care system to initiate people on medication for opioid use disorder — especially buprenorphine. Many of the buprenorphine initiations were done in health care facilities that are saturated with COVID.

Q: What’s happening to address those problems?

If in the past, if you were a physician or a nurse practitioner and you wanted to initiate someone on buprenorphine, the laws were that you needed to see that person physically. That’s changed. It’s now possible you can initiate someone on buprenorphine through telehealth. That’s incredibly valuable.

There’s extended reimbursement for telehealth, which expands access to treatment. There are also apps that have been created that provide individuals who have addiction [access] to mentors or coaches, as well as access to therapies and group therapies.

That is one of the aspects that has actually been accelerated by the COVID crisis. These may facilitate treatment into the future, even when COVID’s no longer there.

Coronavirus Crisis Opens Access To Online Opioid Addiction Treatment

Under the national emergency, the government has waived a law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Now they can get those prescriptions via a phone call or videoconference with a doctor. That may give video addiction therapy a kick-start.

[UPDATED on April 28]

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

Nathan Post, a tattoo artist living in Iowa City, Iowa, used a telemedicine service to help overcome his addiction to Suboxone. “This was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he says. (Courtesy of Nathan Post)

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”

They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

Sarah and Andy fell in love while working to keep drug users from overdosing. But when his own addiction reemerged, Andy’s fear of returning to prison kept him from the best treatment.

She was in medical school. He was just out of prison.

Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

“Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

Beeler had the same conviction, born from his personal experience.

“He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

“He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

Eventually, it killed him.

People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

A Shared Passion For Reducing Harm

From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

“In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

“Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

“That was really a period of a lot of terror for him,” Ziegenhorn said.

Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

An Injury, A Search For Relief

A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

“At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

“He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

A Painful Dilemma 

The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

“He was my partner in thought, and in life and in love,” Ziegenhorn said.

It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

“Andy died because he was too afraid to get treatment,” she said.

Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.”(Courtesy of Sarah Ziegenhorn)

How Does Parole Handle Relapse? It Depends

It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

“We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

“We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

“I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

“Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

Attitudes And Policies Vary Widely

Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

“It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

“We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

“When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

“They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

“There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

“Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

This story is part of a partnership between NPR and Kaiser Health News.

No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

In the first nine months of an alternative pain management program in Missouri, only a small fraction of the state’s Medicaid recipients have accessed the chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy meant to combat the overprescription of opioids.

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”