Tag: medication assisted treatment

Addiction, Drugs, Health

King County is on Pace for a Record Year of Overdose Deaths
Overdoses in King County, 2012 (L) and 2021 (R)
Overdoses in King County, 2012 (L) and 2021 (R)

By Andrew Engelson

Tricia Howe, who directs an outreach program for drug users at REACH, Evergreen Treatment Services’ homeless outreach program, had firsthand experience of King County’s overdose crisis earlier this summer. In a matter of weeks, there were two overdoses outside REACH’s Belltown office.

“One of our case managers came into my office and said, “I think there’s somebody outside who doesn’t look like they’re breathing,” Howe said. “I grabbed a whole bunch of Narcan out of my drawer and ran outside.”

The man’s lips were blue, Howe said, and he wasn’t breathing, though he did have a pulse. She gave him a standard dose of naloxone nasal spray (Narcan), which can reverse the effect of opioids and restore a person’s breathing, but he failed to revive. So Howe gave him a second dose. “He took one deep breath, but was still not responsive,” she said. As Howe was preparing to administer a third dose, first responders arrived, put the man on oxygen, and he finally started breathing.

Based on the man’s response, fentanyl was almost certainly involved. The drug, which is up to 50 times more potent than heroin, can cause overdoses even among frequent opioid users. According to Howe, because fentanyl is cheaper to manufacture, it is quickly replacing heroin and oxycontin as the primary drug available to people who use opioids.

Data from the Washington State Patrol shows that the share of fentanyl in King County drug seizures has climbed dramatically, from around 10 instances in 2018 to more than 100 in 2021. Howe said that all of the counterfeit oxycodone (OxyContin) pills her staff have recently tested have been positive for fentanyl.

“It’s so available now and people are actually seeking it out at this point, where that was not the case before.” According to Howe, because fentanyl is cheaper to manufacture, it is quickly replacing heroin and oxy, and is making overdoses more common and more difficult to reverse. 

Though former mayor Ed Murray expressed early support for what would have been the first such sanctioned site in the US, Jenny Durkan’s administration showed little enthusiasm for supervised consumption. Durkan downgraded the plan in 2019 to a single site in a mobile van, citing concerns about the Trump administration’s legal action against a proposed consumption site in Philadelphia. 

A 2017 study showed that 83 percent of fentanyl overdoses in Massachusetts required a second dose of naloxone. Howe notes that overdoses of heroin or oxy were easier to reverse than fentanyl. “In the past, you could definitely expect the person to wake up and almost walk away,” says Howe.

Seattle and King County are in the midst of a severe overdose death crisis that began to spike during the pandemic and shows no sign of abating. People without shelter are particularly at risk. A ten-year study published in September by the King County Medical Examiner’s Office and Public Health Seattle-King County found that that accidental deaths nearly quadrupled  between 2012 and 2021 among people living unsheltered, and that overdoses now account for 71 percent of such deaths. 

As of last week, according to King County Public Health, there had been at least 710 fatal overdoses in the county this year. Of those, at least 473 involved fentanyl. That number has already eclipsed last year’s 708 overdose deaths, including 385 caused by fentanyl.

“When we first started our heroin and opioid task force in 2015, there were three fentanyl overdose deaths,” said Brad Finegood, a strategic advisor at the public health department. “The numbers have grown exponentially.”

Drug users tried to avoid fentanyl when it first arrived on the West Coast, Finegood said, but that attitude has dramatically shifted, and now people are actively seeking out fentanyl. According to a Pew study published in 2019 on drug use in San Francisco, more than half of opioid drug users now actively seek it, despite the dangers. Complicating matters, fentanyl is either smoked or vaporized and then inhaled, so traditional initiation barriers have fallen away.

“For younger people who are experimenting with drugs,” Finegood said, “that makes it much more feasible because they don’t have to use a needle.” Public Health and REACH have had to counter the misinformed belief that fentanyl is safer because it’s smoked rather than injected.

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According to the US Department of Justice, most fentanyl originates in China and is made into pills or powders by cartels based in Mexico. Batches of fentanyl that are poorly blended can result in what Finegood calls the “chocolate chip cookie effect,” in which pockets of higher concentrations cause accidental overdose.

A young man named Ian who was living in an encampment near the Home Depot in the Bitter Lake neighborhood said in August that he had no choice but to start using fentanyl. Originally from Wasilla, Alaska, Ian said he first became addicted to opioids while taking Oxycontin for pain. “Then oxy disappeared,” he said. In 2016, the CDC advised doctors to lower prescription levels of oxycodone and this, combined with the Drug Enforcement Agency’s recent crackdown on illegal and fraudulent prescriptions, has made medical-grade pills rare.

Ian said that in the absence of oxy, he did heroin for a while. “Then that disappeared. Now it’s all fetty.”

Half a dozen people at the encampment told me they use fentanyl and know many others who do. Nearly everyone had witnessed overdoses and several said they knew people who’d died.

“Everyone’s doing fetty,” said Jessie, who’s 26 and has been using drugs, including meth, since she was 11 years old. She didn’t live in the Bitter Lake camp, but was helping a friend pack up their belongings before the city came to sweep the site. “I’ve been sober, but it didn’t last,” she said. When asked if she’d seen friends overdose, Jessie said, “Yeah, of course.”

The transformation of fentanyl from risky outlier to the opioid of choice in King County mirrors national trends. In 2021, fentanyl accounted for the majority of overdose deaths in the U.S, though methamphetamine continues to be a close second, both nationally and locally. 

Although Seattle, King County, and the cities of Renton and Auburn formed an opiate overdose task force in 2015, local leaders have shelved a key recommendation from the task force’s report: establishing two supervised consumption sites in King County. 

Seattle could have been home to the first such sanctioned site in the U.S., following the lead of Vancouver, B.C. and 200 other sites currently operating elsewhere in Canada, Europe and Australia.

Though former mayor Ed Murray expressed early support for what would have been the first such sanctioned site in the US, Jenny Durkan’s administration showed little enthusiasm for supervised consumption. Durkan downgraded the plan in 2019 to a single site in a mobile van, citing concerns about the Trump administration’s legal action against a proposed consumption site in Philadelphia. 

“It’s a no-brainer. If you don’t want people to use right in front of you and you don’t want needles all over your parks, then you’ve got to give people a place where they can go.”—Tricia Howe, REACH

Even as the Biden administration changed course and said it would consider allowing sites, neither Durkan nor Mayor Bruce Harrell followed through on the scaled-back plan. Earlier this year, New York City moved past Seattle and opened two safe consumption sites that have already succeeded in preventing 500 deaths.

Kris Nyrop, who spent two decades working on HIV prevention among drug users in Seattle and helped design Seattle’s Law Enforcement Assisted Diversion (LEAD) program, says the window for action in King County is quickly closing.

“We have two years,” Nyrop said. “Biden is not going to prosecute if Seattle moves forward. So how do we get Mayor Harrell and a majority of the council behind this?”

In fact, Councilmember Lisa Herbold added $1.1 million to the 2021 Human Services Department budget to create safe consumption spaces in existing social services facilities. The city did not move forward on that approach and Harrell’s proposed 2023-2024 budget does not fund it. 

Instead, Mayor Harrell has vowed to crack down on people who sell and use drugs, in a highly publicized effort to target “hot spots” such as the intersection of 12th and Jackson in Little Saigon. Anyone walking through the area today can see that this short-term strategy was ineffective at reducing public drug use and sales in the area.

Howe said that the only effective way to reduce visible drug use on the street isn’t more policing, but sanctioned consumption sites. “It’s a no-brainer. … If you don’t want people to use right in front of you and you don’t want needles all over your parks, then you’ve got to give people a place where they can go.”

In the absence of sanctioned sites, Public Health has been quietly moving forward on other, lower-profile strategies aimed at empowering drug users to consume drugs as safely as possible. 

In addition to social media campaigns to educate young people about the extremely high risks of fentanyl pills (“blues”), Finegood says Public Health is doing more targeted educational outreach to users about safer consumption practices. 

This includes training drug users to recognize the symptoms of overdose, encouraging people not to use alone, and making the overdose reversal medication naloxone widely available. Finegood said Public Health has set up the first mail-order naloxone program in the country, and is working extensively with local pharmacies to offer the drug free, without a doctor’s prescription. “We’ve also set up a couple naloxone and fentanyl tester vending machines,” Finegood said. Continue reading “King County is on Pace for a Record Year of Overdose Deaths” →

Addiction, criminal justice, Drugs, human services

Barriers to Access, Changing Drug Trends Hinder Jail-Based Treatment Program
The number of patients in the King County jail’s opioid use disorder treatment program has nearly tripled since the start of 2021.

By Paul Kiefer

The number of patients in the King County jail’s opioid use disorder treatment program has nearly tripled since January 2021, reaching a high of 156 people by March 31. That trend is showing no sign of slowing, particularly as both Seattle’s mayor and city attorney suggest using the jail as an entry point into addiction treatment as part of the city’s new public safety strategy.

At a press conference last month, Mayor Bruce Harrell commented that “one of the best times to treat someone with drug and alcohol problems, unfortunately, could be when they’re arrested.” Two weeks later, Seattle City Attorney Ann Davison launched an initiative to prioritize booking “high utilizers of the criminal justice system” into jail, ostensibly to “intervene” in their behavioral health crises before finding them treatment opportunities.

But the growing number of patients, staffing shortages at both the jail and community-based care providers, and changes in the landscape of drug use in King County limit the jail’s ability to address the ever-worsening addiction crises that sent overdose deaths skyrocketing in the past three years.

King County’s jails first began offering medication-based treatment for opioid addiction in 2018, allowing patients who had existing prescriptions for buprenorphine—an opioid used to manage and treat addiction—to receive their prescriptions while in jail. In 2019, the jail began connecting new patients to buprenorphine, and in March 2021, Jail Health Services removed a cap on the number of patients allowed in the treatment program, opening buprenorphine access to anyone with a moderate to severe opioid addiction experiencing serious withdrawal in jail.

The program only offers short-term treatment. When a patient is scheduled for release, jail health staff meet with them to develop a plan for continuing their treatment outside of jail; that plan can include a next-day appointment at a medical or addiction treatment provider, a shelter referral, or a seven-day supply of buprenorphine, along with a separate supply of the overdose-reversing drug naloxone. In theory, jail health staff can also offer a “warm hand-off” to community-based addiction treatment providers when their patients leave the jail—a way to start a patient’s release on the right foot.

“When people lack housing and other basic needs, immediately when they’re released from jail, they often go back into survival mode. If we can provide some sort of outreach at the time of release, and if we build trust with people by showing up when we promised to show up, we find that people are much more willing and able to follow through with a care plan.”—Michelle Conley, director of integrated care for REACH

Until January 2021, jail health staff weren’t alerted when a patient was scheduled for release, making “warm hand-offs” difficult. Then, during the COVID-19 pandemic, a staffing shortage left the jail’s opioid treatment nurses stretched too thin to connect their patients to community-based healthcare providers when they leave jail. Sharon Bogan, a spokeswoman for King County Public Health, which oversees Jail Health Services, says that two of the five positions on the opioid use disorder treatment team are currently vacant, leaving the remaining staffers to handle excessive caseloads. The ideal ratio of health staff to patients in the treatment program, she added, is 1 to 25, meaning that the jail could need to add positions to the treatment team if the number of patients grows.

For now, says Michelle Conley, the director of integrated care for REACH, the jail’s release plans for patients in the opioid use treatment program are often at risk of falling apart from the outset. “There are a lot of providers who can and do receive people from the jail, but there’s often a disconnect in terms of getting someone to treatment,” she said.

“A large part of that,” Conley added, “is because Medicaid does not reimburse the costs of going to the jail picking a patient up and transporting them to housing or medical care.” Conley also noted that after leaving jail, a person may need to reactivate their Medicaid benefits to pay for prescriptions and doctor’s visits—a process that can take days or weeks.

Without a direct hand-off to a care provider, Conley said, people leaving jail may not have an easy way to make it to an appointment at a treatment facility or clinic. “When people lack housing and other basic needs, immediately when they’re released from jail, they often go back into survival mode,” she said. “If we can provide some sort of outreach at the time of release, and if we build trust with people by showing up when we promised to show up, we find that people are much more willing and able to follow through with a care plan.”

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For people leaving jail, the medications used to treat opioid use disorder are available both through appointments and through a daytime hotline run by the nonprofit healthcare provider NeighborCare. Dr. Matt Perez, a primary care clinician for NeighborCare, says that the current system is a vast improvement from the recent past. “Up until about 10 years ago, the jails offered no treatment for addiction whatsoever, so people were just going into withdrawal and leaving with nothing,” he said. And while about one-fifth of buprenorphine patients at his clinic—including people leaving the jail—don’t show up for their appointments, Perez says that his ability to coordinate with jail health staff to provide buprenorphine to people after their release is improving.

But while no care providers dispute that giving people in jail access to medications like buprenorphine is better than nothing at all, some addiction treatment specialists say that the current medication-based treatments for opioid addiction offered to people in jail don’t match current trends in drug use. Dr. Cyn Kotarski, the medical director for the Public Defender Association in Seattle, says that the spread of fentanyl as a cheaper and more potent replacement for opioids like heroin has rendered current medication-based treatments ineffective at best and counterproductive at worst.

“It takes time for medical research to catch up to realities on the ground,” she said. “Drug use has changed so significantly in Seattle in the past three to five years—in other words, since we first started offering medication-assisted treatment for opioid use disorder to people in jail—that if we don’t try to rework our approach, we’re going to wind up offering only an obsolete program.”

One key problem, she said, is that standard doses of buprenorphine are substantially less potent than fentanyl, so fentanyl users who suddenly transition to buprenorphine in jail often experience serious and painful withdrawal—a problem that was less pronounced before fentanyl dominated the opioid market. “The vast majority of patients I see say they’re scared to take buprenorphine because of the withdrawal symptoms,” she said. “And as word spreads that switching the buprenorphine makes you sick, that creates a dangerous narrative. If we don’t set up our treatment programs properly, we can end up with a general consensus among people using opioids that buprenorphine is harmful because we’re not using the medication in a way that’s appropriate for fentanyl.”

But changing the dosage of buprenorphine to better match the strength of fentanyl would require experimentation—something that jail health staff can’t do. “Because of the strict controls around drugs to treat opioid use disorder, people are very hesitant to make any changes to dosage unless they get directions from above,” Kotarski said. Continue reading “Barriers to Access, Changing Drug Trends Hinder Jail-Based Treatment Program” →

Addiction, Featured

Seeking a Medical Approach to Meth Addiction, Seattle Researchers Look to Other Stimulants

As meth use and overdoses spike, particularly on the West Coast, researchers in Seattle are proposing a taking a medical approach to addiction‚ replacing with other stimulants in much the same way as methadone and suboxone replace heroin with alternative opiates. But propaganda painting the drug as uniquely addictive makes funding a challenge.

Here’s an excerpt from my latest piece at HuffPost; check out the whole story As meth use and overdoses spike, researchers in Seattle are proposing a medical solution that replaces meth with other stimulants. But propaganda painting the drug as uniquely addictive makes funding a challenge. Check out my latest at HuffPost.

At some point between their son’s stints at sober houses, jail and 14 rehab centers, Annie and Richard Becker gave up hope that he would ever stop using meth.

The Beckers, who live in Seattle, haven’t seen their son in more than a year. Before meth, their son was “really caring, very funny and likable,” the kind of guy who “didn’t like to see anybody else picked on or harmed,” Richard said.

After meth, he was scary and unpredictable ― the kind of guy who thought nothing of throwing a brick through his parents’ window or threatening his mom, Annie said.

“I think when he was most dangerous to us is when he was in withdrawal and couldn’t get drugs, and we became the target,” she said.

There are medications to help with opioid addiction, including methadone ― in use since the early 1970s ― and buprenorphine, which became widely available in the last decade. Both drugs are substitute opiates that can take away the destructive urge to use and give people a chance at housing, medical care and stable relationships. But there are currently no similar treatments for methamphetamine addiction.

“I’ve always felt like, is anybody paying attention to the fact that there’s all these meth users who don’t have any kind of treatment?” Richard said.

While there have been some studies that tried substitute stimulants to treat methamphetamine addiction, the results have been mixed, leading some to conclude that a medical treatment for meth addiction is unlikely.

But a team of researchers in Seattle wants to challenge that theory. Their plan is to give relatively high doses of methylphenidate ― better known as the ADHD drug Ritalin ― to patients who are already in treatment for opiate use disorders and also use meth. The proposed pilot, which still needs about $500,000 in funding, is not yet underway. It would be a joint effort between Evergreen Treatment Services (ETS), the University of Washington and the Seattle Public Defender Association. Although the Seattle City Council declined to provide public funding for the program in its last budget cycle, researchers are optimistic that grants or federal dollars will come through. If researchers see significant results, the pilot could be expanded to include more patients.

“What we really want to see is a very substantial reduction in use, so that you could say this is making an impact on people’s lives, in terms of improving physical health, psychological health, reducing criminal activity, and improving their ability to take care of the basic things in life,” said Dr. Paul Grekin, the medical director at ETS.

Seattle seems primed for this kind of experiment. Meth use has been growing quietly across the United States for years in the shadow of the opiate epidemic, but the increase has been particularly acute on the West Coast, where meth now causes more overdose deaths than any other drug. In Washington state, meth overdoses killed about one person every day in 2016. In King County, which includes Seattle, there were 164 meth overdose deaths last year, outpacing heroin as the leading cause of overdose deaths.

Meth has become cheaper, more contaminated and more potent in the last several years, according to front-line emergency service and case workers, leading to an increase in dangerous symptoms like cardiac arrest, strokes and hyperthermia, a condition where the body essentially burns itself alive. That’s on top of the more common symptoms of meth use, such as psychosis, dental problems, injuries, malnutrition and diseases transmitted through needles or risky sex.

Continue reading at HuffPost.