Bad medicine

America is poisoning itself, and no one seems to have an antidote. Overdose deaths from illicit drugs are taking a tremendous toll in our communities without regard to age, race or economic background, and we’re collectively failing our most vulnerable and our most marginalized.

Experts agree the problem is rooted in a chronic over-prescription of opioid painkillers like Oxycodone over the past decade and a half. Individuals are increasingly becoming addicted to their medications, and when they can no longer get pills, they turn to hard drugs like heroin and fentanyl.

The tension between the legality and severity of the problem, the conflict between personal responsibility and the science of addiction as well as the dark shadow of stigma cloaking the myriad issues involved while people die in the streets are leaving local leaders desperate for solutions.

Coming to Grips with the Problem

Hadi Sedigh, Associate Legislative Director at the National Association of Counties (NACo) explains it was becoming clear around late 2014 that counties across the country were in the midst of an emergency. Many members of the association were looking for the reasons overdose deaths and heroin addiction rates were booming in their communities and were reaching out to NACo for guidance. 

Looking for solutions, NACo leadership contacted their partner organization, the National League of Cities, who was also hearing similar stories from their membership. In 2015, the two organizations formed the National City-County Task Force on the Opioid Epidemic. 

The Taskforce’s initial objectives were to assess the response to the crisis at the local level and to lay out a roadmap for how impacted communities could respond to the epidemic. 

“We wanted a clear idea not only of what this problem looks like in different parts of the country,” Sedigh says, “but how counties and cities are responding, and what responses were proving to be effective.”

Unfortunately, the prognosis was not good. 

“The instance that sticks out to me the most from the work that we did within the task force was more than one member labeling the situation in their city or county as an ‘existential crisis,’” Sedigh says. “This is a challenge that is threatening the very fiber of some communities in every sense… It’s unlike anything we’ve seen.”

Through examining numerous case studies and speaking with local leaders in the trenches, the task force made several recommendations, the totality of which take a holistic approach to the problem. Local leadership, however, is critically important in reaching a solution on all fronts.  

“The role of governmental leadership is two-fold,” Sedigh says. The first is as a convener. By organizing and collaborating with community stakeholders, local leadership becomes the driving force in solving the issue. The second, he says, is to set the tone of the conversation in the community. Stigma is a major impediment to reaching a solution, he says. 

Addicted individuals are often reluctant to seek help as they are afraid they will be perceived a certain way, judged harshly or face legal action, and it’s up to local leadership to chip away at this perception and attempt to normalize getting help.

While framing the conversation and setting the tone is critically important, it’s not an immediate solution. Every minute life and death situations are occurring in our communities that our first responders must deal with. According to the National Institute on Drug Abuse, in 2016, more than 64,000 individuals died of drug overdoses in America – about 6,000 more than died in the Vietnam War. Tremendous pressure has been placed on the shoulders of law enforcement to push back against this wave of death, and for better or worse, naloxone seems to be the best, most immediate answer.

Naloxone – A Second Chance?

Naloxone, or as it’s more commonly referred to by its brand name, Narcan, is typically administered as a nasal spray to individuals who are actively overdosing. Clermont County, Ohio, Sheriff Robert Leahy explains that when an individual is experiencing an overdose, their central nervous system becomes depressed. Naloxone, an antagonist, reverses the effect of the overdose and revives the individual. 

Recommended by their local opioid taskforce, Leahy says Clermont was one of the first communities in Ohio to utilize the drug, and its impact has been significant. 

What initially led to Narcan’s use in the county was the exponential pace at which people were dying from overdoes. “From 2000 to 2010, our drug overdose deaths in the county increased by 2,300 percent,” Leahy says. While long-term, systemic solutions needed to be explored, it was clear immediate action was needed to save people’s lives.

While Leahy says there are many logistical and legal reasons for carrying Narcan, there is an important human reason as well for his deputies. At the end of the day, it allows them to save lives. 

Leahy admits initially his deputies were hesitant to the idea of administering medication to addicts, but “after two or three months, and four of five saves, some of the deputies were coming to me saying, ‘you know what, Chief, I’ve had the ability to save someone’s life – I’ve never had that.” 

The other side of this coin, Leahy says, is the perception that those being saved are deeply sick individuals, who may end up as “frequent flyers” – those who overdose numerous times and require multiple treatments. Even though Narcan has saved scores of lives across the county, because of this notion, some feel its use enables addicts. Sheriff Richard Jones of neighboring Butler County, Ohio, believes this and says it makes Narcan an unsustainable solution.

Jones likens the problem to a balloon with a hole in it. “You can keep pumping air into the balloon,” he says, “or you can plug the hole.”

Jones recently made national headlines when he declared his deputies would never carry Narcan, and while some may view this decision as calloused and punitive, Jones says the safety of his men is his priority.

“I believe it’s dangerous for them to use Narcan,” Jones says. “They have to get down on their knees to use Narcan, they have to risk their lives to use Narcan.” He goes on to explain that when individuals are revived using the drug they can come to in a confused, delirious state – often ready to fight. Although this assertion has been disputed by experts, Jones and others worry using the drug places officers in a precarious position. 

Furthermore, Jones argues it’s not an officer’s responsibility to administer medications. While he agrees it’s his duty to save lives, he points out his deputies don’t administer seizure medication, insulin or carry EpiPens for those in anaphylactic shock. “That’s what paramedics do,” he says. 

Referencing his balloon analogy, Jones views Narcan as pumping in the air without first plugging the leak. Addiction to these substances is so powerful, he says, that Narcan only enables addicts, and law enforcement should be focused on preventative measures. He shares one particularly powerful example to illustrate this point: “I had a prisoner who was released from my jail – his mom picked him up,” he says. “She brought enough heroin so they could shoot up in the parking lot. That didn’t end well for either of them.”

However, the “frequent flyer” argument doesn’t hold up for Leahy, who reports that since the end of 2014 through 2017, Narcan has been administered in the county 102 times. Of those incidents, 99 were people were saved. Of those 99, only two were repeats. 

“I’m sure that’s not the case in other agencies or other jurisdictions,” Leahy says, “but for me…  I’m a believer in it, and as the Sheriff, I think it’s the right thing to do.”

The argument over the propriety of law enforcement carrying and administering Narcan can be summed up with two opposing ideas. Those like Leahy feel that it’s a dangerous road for officers to go down to start making decisions about who lives and who dies, while others like Jones argue the addict made that decision when they picked up a needle in the first place.

It’s clear some feel law and order will prevail, while others are taking a more compassionate approach – even going so far as to help addicts have access to the drugs that are killing them.

A Counterintuitive Solution

Someone dies from an opiate overdose every day and a half in King County, Wash. Dr. Jeffery Duchin, health officer for Seattle & King County and Heroin and Prescription Opiate Addiction Task Force co-chair, says one of the main reasons the problem has become so extreme and so persistent is the stigma surrounding addiction. 

“The science is clear – opiate addiction is a chronic disease of brain chemistry,” Duchin says. “[Once addicted] it’s no longer a matter of choice… it’s not a moral failure or something that can be cured with an adequate amount of willpower.” 

With this in mind, Duchin says King County is attempting to approach the problem with understanding and empathy. Part of this approach is a plan to open two safe injection sites – one in Seattle and one elsewhere within county limits – where addicts can use drugs without fear of legal repercussion while under medical supervision. Understandably, the plan is controversial. 

Currently, there are no officially sanctioned safe injection sites in this country, Duchin says. The Seattle site would be the first of its kind in America, but other cities globally have seen successes with them. Additionally, such sites are widely sanctioned in the medical community, Duchin says, with organizations including the American Public Health Association, the American Medical Association and the Infectious Disease Society of America all endorsing the idea.

“From the medical and public health professional perspective the idea is not highly controversial,” Duchin says. “It’s a logical extension of widely accepted harm-reduction programs like needle exchanges.” 

In the community, however, it’s a different story. Many community-led organizations have sprouted up with the intention of blocking the passage of legislation critical to building such a site. 

“There are certainly people who feel like providing addicts a place to safely use drugs would empower them to continue to use and is enabling this behavior,” Duchin says, “even though the research does not show this.”

The reason for these programs, Duchin explains, is that people are currently using drugs in public locations – parks, alleyways, restaurant bathrooms and the like. They are overdosing unattended and they die. The research shows that where these sites have been established, there is no evidence of increased levels of drug use or increased levels of initiation of new drug users. “In fact, what they have been shown to do is decrease overdose deaths, decrease the amount of unsafe injection equipment that has been discarded in the community and to encourage people to enter treatment,” Duchin says. “That’s really our end goal; it’s not to legitimize bad behavior, it’s to allow the people who are frequently the most marginalized and most stigmatized… to recover.”

At the time of this writing, Seattle has approved funding for the establishment of a safe injection site, Duchin says, and is searching for the appropriate venue. 

A human-centric focus is, of course, important in dealing with the ravages of the opioid epidemic, but some communities are taking the battle to the courtroom in attempts to stop the problem at its source.

Closing the Tap 

Baltimore County, Md. has now joined a growing number of communities across the country taking legal action against these manufacturers and distributors.

“We became interested in discussing how the opioid crisis accelerated,” Baltimore County Executive Kevin Kamenetz says. “The more we started analyzing it, we became convinced that the drug manufacturers and distributors have had a great role in [the problem].”

The impetus of the issue, according to Kamenetz, is the over-prescription of opioid drugs in communities across the county. 

“We have a belief that [opioid] manufacturers and distributors engaged in deceptive and fraudulent marketing practices,” Kamenetz says. “We feel they tried to pressure and cajole physicians into prescribing opioids for chronic pain opposed to acute pain, which was the original restriction for the use of the drug.” 

Kamenetz explains this distinction is important in understanding the root cause of the opioid epidemic. These highly addictive drugs were never intended to be taken in such massive quantities over long periods of time. The result of this over-prescription, he says, has been an explosion in addiction rates in his community, and an increase in heroin use when the prescription drugs are no longer available. “We believe [manufacturers and distributors] vastly misrepresented the risk of addiction to physicians,” he adds. “And this was motivated solely by a desire to increase profits.” While understanding that the solution to this problem must be holistic in nature, Kamenetz says the county is owed compensation from the drug manufacturers responsible for flooding the community with dangerous substances.

There are three potential damages for which the county is seeking restitution, says Kamenetz. First, the county is the employer of over 20,000 people for which it provides health care and prescription benefits. As the county is self-insured, it pays the costs associated with over-prescription and resultant healthcare costs associated with addiction and treatment out of pocket. Secondly, the county incurred costs by providing first responder care to addicted residents as well as the resultant care and recovery programs the county offers for these individuals. Finally, the 70 percent of the county’s revenue is derived from collecting property taxes and income taxes. When people become addicted, many are no longer able to remain employed. This creates a loss of revenue to the county for which it will be seeking reimbursement.

“By going after the drug manufacturers and distributors, we can stop the overflow of prescriptions for opioids – we think that’s a major initiative of addiction,” Kamenetz says, adding that this suit accomplishes the goal of closing the open tap on the prescription side of the problem.

While these varied and specific approaches will all play important roles in ending the opioid crisis,  what if there was a way to visualize the issue from a perfect vantage point – to see all of its moving parts, and to understand how an uncountable number of factors have created the problem, and how seemingly innocuous changes could make huge differences in preventing addiction from ever taking root?

Better Data, Better Outcomes? 

To find the solution, we need to have a handle on the problem. Richard Leadbeater, the state government industry manager for Esri, says data analysis is the best way for us to understand the entirety of the opioid crisis, and without accurate data, there is no way to discuss the problem intelligibly. Quantifying the problem has to be the first step if a solution is to be found, he says.

In 2016, Leadbeater was asked to join in the first meeting of the National City-County Task Force. While it was clear those gathered were passionate about finding a solution, he says he wasn’t impressed with their ability to speak factually about the problem.

“It was anecdotal information at best, and the most detailed piece was ‘I’m seeing a trend,’” Leadbeater says. “Other than that, it was ‘I heard…’ or ‘I’m thinking…’” 

The problem, he says, is there simply wasn’t enough quantitative data to discuss actionable solutions. The limited numbers that were offered were old and taken from Medicare and Medicaid data sets that were at least three years old at that point. 

“This was the best data they had,” says Leadbeater. “It didn’t by any means represent the entire population. It had me spinning.”

Leadbeater illustrates the problem by giving the example of a discussion he had with a mayor whose community had been hit hard. He says the mayor assumed the issue was centered in the low-income areas of his community – an “us versus them” problem. However, after Leadbeater was able to drill into the data and visualize it using analytical tools, it was revealed the biggest hotspot of drug activity and overdose incidents was actually in the mayor’s own affluent neighborhood. 

This is the power of data, Leadbeater says, but in order for the problem to be accurately communicated to the community and for viable solutions to be put in place, silos of information need to be removed. The mayor, like many, assumed the problem was where drug use would “typically” be. It wasn’t until hard data from numerous sources was collected and interpreted that the reality of the situation was exposed.

Healthcare, law enforcement, social services and many others all touch a part of this problem, “but I can not point to an example where the silos have broken down,” says Leadbeater. “There are examples of stakeholders getting in the same room and talking, but are there examples of pure fluidness in data? I’m not seeing it.” 

The barriers around our data and the resultant disconnect they create will forever create a response to the problem that is fundamentally lacking. “Until these silos are broken you’re always going to have the police action and the healthcare action and the social action, but you’re never going to have a complete response,” Leadbeater says.  

Since Richard Nixon declared the War on Drugs in 1971, it appears drugs have been winning. This isn’t for lack of effort – enforcing the war on drugs costs the U.S. more than $51 billion each year, according to the Drug Policy Alliance.  “I think it’s time to declare this isn’t working,” Leadbeater says. 

If we continue to use the tactics we’ve always used, we’re missing the opportunity of this crisis affords – to break down the walls we’ve put up between our departments and between our individual experiences so leaders can create complete solutions.

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