Part 2 of a two-part series on the recommendations of the Seattle/King County Heroin and Prescription Opiate Addiction Task Force. Part 1 ran yesterday. 

That the city and county would appoint a task force on heroin and prescription opiate addiction—rather than, say, crack or alcohol addiction—is understandable: In 2014, according to the report, “heroin-involved deaths” in King County topped out at 156, the highest number since 1997. The number of overdose deaths tripled in King County between 2009 and 2014, and from 2010 to 2014 the number of people entering publicly funded treatment for heroin addiction grew from 1,439 to 2,886. Detox admissions for heroin in King County now outnumber those for alcohol. As Auburn mayor Nancy Backus said at Thursday’s press conference, “There isn’t one face of addiction any longer. We can no longer drive by or walk by any one person and say, ‘Oh, that person is addicted to drugs. That’s not the one face anymore. It’s our sons, our daughters, our our mothers and fathers and our loved ones, and we no longer have the luxury of saying that it doesn’t impact us.”

In a way, though, that’s a problem: The drugs “we” had “the luxury” of ignoring, which include drugs that are mostly smoked like meth and crack (which, not coincidentally, isn’t the drug of choice for the white suburban teenagers Backus may be thinking of when she talks about “our sons and daughters”), didn’t go away. And if we build a giant infrastructure laser-focused on heroin addiction now, there may not be leftover dollars, or political will, to address meth or crack addiction when addiction to those drugs reaches “epidemic” proportions.

You may not remember it now, but just 15 years ago, King County was having this same conversation about the heroin epidemic of the late 1990s. They even created a 30-member task force to deal with it

Because the fact is, drug epidemics are cyclical. Including heroin. You may not remember it now, but just 15 years ago, King County was having this same conversation about the heroin epidemic of the late 1990s. They even created a 30-member task force to deal with it; their report, titled “Heroin Task Force Report: Confronting the Problem of Heroin Abuse in Seattle and King County,” was released in August 2001, 15 years and two weeks before the Heroin and Prescription Opiate Addiction Task Force released its Final Report and Recommendations. That earlier task force came up with many of the same solutions, including wider access to medication-assisted treatment with methadone or buprenorphine, as this one.

As Kris Nyrop, a longtime Seattle drug-policy activist and project director for the Public Defender Association’s Law Enforcement Assisted Diversion (LEAD) program, told me after the press conference, the 2001 task force recommendations “just kind of went away” after that heroin epidemic started to wane. “If we  set up all this infrastructure specific to dealing with heroin addiction, what are you doing about all the folks addicted to cocaine and meth?” Already, heroin overdose deaths appear to be on the downswing; last year, heroin-related deaths declined 15 percent in King County, from 156 to 133. Meanwhile, ominously, deaths from methamphetamine rose, as did calls to the King County drug helpline related to meth; according to the University of Washington’s 2015 drug use trends report, “[a] steady increase in police cases positive for methamphetamine was seen from 2011 to 2014, with a plateauing in 2015 at 336 cases, just barely second to heroin.”

Of course, many meth users do inject the drug rather than smoking it (that same UW report found that 58 percent of needle-exchange clients reported shooting meth by itself in 2015 and 37 percent reported injecting it with heroin, up from 32 percent and 14 percent, respectively, in 2011), but the report includes other recommendations that, by their nature, cannot address non-opiate addictions. Specifically, the task force recommends making it much easier for doctors in regular clinical settings (as opposed to drug treatment centers and methadone clinics), to prescribe buprenorphine (AKA suboxone), making it accessible to people who aren’t able to adhere to stringent treatment requirements, like showing up for appointments regularly, submitting to urinalysis tests, and participating in behavioral treatment programs.

This is undeniably a necessary step for some opiate users—suboxone cuts a user’s odds of dying in half, according to the report, and “treatment capacity for buprenorphine is limited and far exceeded by demand.” However, as task force co-chair Brad Finegood, head ofKing County’s behavioral health and recovery division, acknowledges, “there’s no medication as a treatment for methamphetamine.” Or, for that matter, cocaine, or benzodiazepines, or alcohol. Just as harm reduction for heroin could end up taking precedence over harm reduction for those substances (safe smoking rooms, supervised “wet” housing, and other programs that keep users safer while they’re using), treatment for heroin with suboxone, which involves taking a pill every day, could end up taking precedence over longer-term, more resource-intensive solutions like residential inpatient treatment (which is not just an order of magnitude more expensive than a drug prescription but is in desperately short supply in King County) and long-term intensive therapy to help them figure out how to cope with life without their drug of choice.

You might be forgiven for thinking, based on such statements and on the report itself, that MAT stands not for “medication-assisted treatment” but for “medication AS treatment.”

Finegood says King County understands the need for other types of treatment, which are mentioned in the report under a section called “Develop Treatment on Demand for all Modalities of Substance Use Disorder Treatment Services .” (“Providing individuals seeking treatment with multiple treatment options supports the many pathways of recovery and respects client choice and autonomy.”) “Buprenorphine isn’t a miracle drug,” he says. However, the report, and the elected officials touting the report on Thursday, places a very heavy emphasis on medication-assisted treatment, to the exclusion of other treatment options.

This emphasis is reflected in the press coverage of the report, and in elected officials’ response to it. For example, one reporter called the drug “the closest thing to a silver bullet” we have to treat opiate addiction, and the head of the city’s public health committee, Sally Bagshaw, highlighted the drug in her statement about the recommendations, saying, “I’m particularly drawn to the Task Force’s recommendation that we enhance access to buprenorphine, which is an effective tool to treat opioid addiction. As Council considers next year’s annual City budget, I intend to identify funding for a Belltown facility that will provide professional buprenorphine access for those looking to conquer or suppress their addictions.” You might be forgiven for thinking, based on such statements and on the report itself, that MAT stands not for “medication-assisted treatment” but for “medication AS treatment.”

Finegood, whose own brother died of an overdose 15 years ago, says the report shouldn’t leave the impression that the county wants to push people toward long-term suboxone maintenance as the only solution to drug addiction. “We’re trying to stand up models like at the downtown public needle exchange, where people can get started on initial doses of buprenorphine without getting through the barriers of psychosocial treatment first, with the goal of getting them stabilized on medication and then starting on psychosocial treatment,” he says. “I don’t know that it’s an ‘and/or,’ I think it’s an individual need issue. What I’m trying to work on is getting more outpatient providers to start prescribing buprenorphine [instead of] what was traditionally an abstinence-based” approach.

“I would not say this is a miracle cure-all pill, where people don’t need to learn to change their habits, but let’s say it’s a situation where somebody got prescription medication from their doctor, and they got hooked and can’t deal with the cravings, and they’re freaking out,” Finegood says. “They may just need that prescription.” (For more on the difference between addiction and dependence, check out my interview with author and former heroin user Maia Szalavitz). Finegood adds that the county has plenty of openings for outpatient treatment (which relies on drug users showing up and not using in between appointments) but is woefully short on detox and treatment beds.

The recommendations, though (arguably) flawed, will represent a huge leap forward for the way King County thinks about and treats opiate and heroin addiction—if they’re implemented. As task force member and People’s Harm Reduction Alliance founder Shilo Murphy said Thursday, “We spent a lot of time and energy on all these proposals, and I don’t want them to die in committee. I don’t want them to be forgotten. I really want to know that you guys are going to fight for these” recommendations.

In the report itself, the task force “recommends that local government and other partners begin to implement the recommendations contained in the report as soon as possible,” and that the work groups established by the task force continue to meet and guide the implementation of the recommendations. Within 90 days, the county and its cities are supposed to provide a response, and at that point the task force will reconvene to assess it. The recommendations don’t have much to say about costs, as Constantine acknowledged Thursday. “We are just getting the report, so we don’t know what the cost is of any of the elements of it is,” Constantine acknowledged. “King County is famously short on cash. But this is important.” If that’s true, expect to see the conversation shift to the political challenges of acknowledging and dealing with our county’s drug addiction problem. If not, expect to see reporters digging up this report in 15 years to compare its recommendations to those of the 2031 Heroin and Opiate Addiction Task Force.

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