Tag: opiates

As King County Grapples With Heroin, Another Lethal Drug is on the Rise

Image Credit: SBSArtDept

This story originally appeared at Seattle Magazine.

As political leaders focus their attention on the ongoing epidemic of heroin and prescription opiate addiction—an epidemic that claimed 132 lives in King County in 2015, the last year for which statistics are available—another drug crisis may be developing right under their noses.

Since 2010, according to data just released by the University of Washington, the number of deaths related to methamphetamine has risen steadily throughout Washington State—from 1.8 deaths per 100,000 state residents in 2010 to 4.9 per 100,000 in 2015. In King County, the number of meth-related overdoses increased by 257 percent between 2003 and 2015. Dr. Michael Sayre, the medical director for the Seattle Fire Department and a Harborview-affiliated emergency medicine doctor, calls the uptick in meth ODs “the most significant trend in drug-related mortality” in the region.

Caleb Banta-Green, a researcher with the University of Washington’s Alcohol and Drug Abuse Institute and a member of the King County Heroin and Prescription Opiate Addiction Task Force, says one reason for the uptick in meth use is the fact that “cocaine availability has tanked in the last five years.” Meanwhile, meth has become more potent and readily available than ever before. People appear to be using meth as a cocaine substitute, even though, according to Banta-Green, the two drugs are quite different—cocaine is shorter-lived and less intense than meth, which can provide 20 times the dopamine hit and last many hours longer.

“You don’t hear a lot of people saying, ‘I use cocaine because it helps me stay at my job longer.’ You do hear people say that about methamphetamine,” Banta-Green says.

So why haven’t you read about this emerging epidemic? One of the reasons may be simply that, unlike for opiates, there aren’t any particularly effective medical interventions for meth overdoses or addiction. When someone overdoses on heroin, for example, emergency responders, or even a lay person with the right equipment, can quickly reverse the overdose by giving the victim a shot of Narcan, a drug that restores heart function and breathing. There is no similar drug for meth ODs, which overload the cardiovascular system with adrenalin and can lead to heart failure, stroke, seizures and hyperthermia (overheating). A stimulant overdose “definitely requires medical attention,” Sayre says. “It’s not something that a layperson or even a medically trained person without the proper resources can appropriately manage.”

 

So why haven’t you read about this emerging epidemic? One of the reasons may be simply that, unlike for opiates, there aren’t any particularly effective medical interventions for meth overdoses or addiction.

 

Methamphetamine addicts seeking treatment face a similar dearth of medical (as opposed to behavioral) treatment options as those with other addictions. While heroin addicts have the option of medication-assisted treatment with methadone or buprenorphine (Suboxone), two prescription opiates that serve as replacements for more harmful drugs like heroin, there is still no medication-assisted treatment for stimulants like meth. Drug replacement therapy with other stimulants like Adderal (a drug that’s very closely related to meth) doesn’t appear to work and can be dangerous to users who already have high blood pressure and enlarged hearts; and although two antidepressants, buproprion (Wellbutrin) and mirtazapine (Remeron) have shown some promise in reducing meth use in chronic users, neither has been widely tested or shown impressive results.

“I’m not very optimistic that we’re going to get a good medication any time soon,” says Dr. Andy Saxon, who directs the Center of Excellence in Substance Abuse Treatment and Education at the Veterans Administration in Seattle.

Instead, Saxon says that the best treatment he’s found for meth addiction is a behavioral approach called contingency management, where users are given rewards with some monetary value if they stop or reduce their use. The VA, for example, uses what Saxon calls the “fishbowl technique.” Veterans who pass a drug test get to pull a card from a fishbowl (or more than one card if they’ve passed several tests in a row); the reward on the card could be anything from verbal reinforcement (“Nice work”) to a $100 gift card for the VA store. The idea is to replace the hit of dopamine produced when a user takes a drink or a hit with a monetary reward, since both rewards act on the same pleasure center in the brain. Other moderately effective treatments include cognitive behavioral therapy, relapse prevention, and motivational interviewing, all mainstays of traditional treatment programs.

None of those treatments is particularly effective (according to Saxon, about half the people who are in the VA’s behavioral treatment programs manage to reduce their use), and all are significantly more expensive than medication-assisted treatment for opiates, which may consist of nothing more than a prescription for a replacement drug. Nor is it easy to reach meth addicts, particularly those who are homeless or living in marginal housing; unless they are injection users or use other injection drugs like heroin, meth users aren’t coming in to needle exchanges, and they typically leave emergency rooms with little more than a recommendation to seek further treatment and a “good luck.”

Sayre suggests a few solutions that could help meth users in the immediate and long term. First, he says, the state needs to do everything it can to ensure that users in crisis feel safe seeking help. Existing “Good Samaritan” laws, which shield people seeking medical help for an overdose from prosecution, should be expanded to cover people who are on parole, on probation, or who have outstanding warrants. Second, existing outreach programs, such as needle exchanges, should provide incentives for meth users to come in and access their services, such as providing new, unbroken meth pipes. (The People’s Harm Reduction Alliance, which runs a needle exchange in the University District, already does this.) And third, “maybe we need to think more seriously about offering safe spaces and more help for people who are tweaking”— overstimulated on meth—where they can get access to treatment and other services.

As it happens, the county has already proposed creating such a space. It’s called a community health engagement location (colloquially known as a safe consumption site). But it’s generated significant controversy, and is currently the subject of an initiative designed to ban all such facilities across the county.

Morning Crank: A New Line of Business

1. When Mayor Ed Murray announced his $275 million homelessness ballot measure last week, he noted several times that the measure included “5,000 new treatment slots” for homeless people struggling with addiction, accounting for about $20 million over the five-year life of the levy. If the image that pops into your mind is beds in a residential treatment facility like the Betty Ford Center, think again: The treatment in the levy proposal consists primarily of programs that expand access to buprenorphine, also known as Suboxone—a prescription opioid that reduces cravings in people who are addicted to heroin and other opioids—and “housing with intensive outpatient substance use disorder treatment,” also focused on expanding buprenorphine distribution.

Suboxone is a drug that allows people who are severely addicted to heroin or other opiates to stabilize on a less-harmful opioid drug under the supervision of a medical professional, without having to go to a clinic to receive medication every day, as methadone patients do. Increasingly, health departments and addiction experts are recommending long-term buprenorphine use for people with severe addictions, because it reduces cravings for street drugs like heroin that can lead to overdoses and dangerous lifestyle choices. (Suboxone itself has been shown to be addictive). However, no prescription alone can address the many factors that lead a person to start abusing drugs in the first place, such as trauma, abuse, depression, mental illness, and despair. And buprenorphine doesn’t address addictions to non-opiate substances at all, including alcohol addiction, which kills about 88,000 people each year (compared to about 33,000 deaths from opioid abuse) and is endemic among people experiencing homelessness.

Curious about the precise breakdown of those 5,000 “treatment slots,” I asked the levy campaign for more detailed information. Here’s the breakdown they provided. Of the 5,000 slots over five years, 3,600 would consist of expanded access to buprenorphine, through new clinics, transportation to and from buprenorphine providers, and a new access point for people seeking treatment to find a provider in their area. That accounts for about $1.6 million of the approximately $4 million in new annual spending.

Another $540,000 a year would subsidize rent for about 300 formerly homeless people in “Oxford-style” sober housing—self-managed houses where people with substance use disorders live together in a sober, supportive environment. It’s unclear at this point what measures the city would take to monitor the quality of the sober housing it subsidizes, but Kaushik says the city will take steps to ensure the providers are legitimate.

The remainder—about $2 million—would pay for two programs: A low-barrier, residential inpatient treatment center serving 16 people a year, and an intensive outpatient program, with case management, serving about 300 formerly homeless people who would receive housing subsidies from the city. (The treatment would not be located in or tied to the housing itself).

When I asked about the relatively small amount of money for treatment in his levy proposal last week, Murray pointed out that treatment was “a new line of business” for the city and is typically funded by King County. Given that millions of people seeking treatment are likely to lose health care coverage under Trump’s health care “reform,” the city might need to get used to being in the treatment business.

2. Another question that nagged me about the mayor’s levy proposal had to do with the “landlord liaison” program that will be funded through the levy. I wondered if the city still needed a program to match landlords with tenants just coming out of homelessness, given that the city now has a law banning housing discrimination based on a tenant’s source of income.  (A tenant paying with one of the short-term rent vouchers funded by the levy, for example, could not be turned away because he had a voucher). City council member Sally Bagshaw, perhaps the most vocal elected proponent of the program, told me the landlord liaison program would go much further than helping renters get access to housing; it would also provide landlords with a financial “backstop” by promising to pay for any damages tenants cause, to provide case management, and to respond quickly to emergencies or landlord concerns.

“Let’s say we put Bob in [a unit], and we know Bob has some bipolar issues. If he’s stabilized, he’s fine’ if he goes off his meds, he’s not,” Bagshaw says. “Let’s pretend, for the sake of argument, that Bob does trash the place. We will have an insurance pool and we will say to the landlord, when Bob leaves, if he has trashed the place, if he puts his hand through a wall or puts a stick of dynamite down the toilet, we will come in and pay to fix the place back up.” Bagshaw says the goal of the program would be to identify 1,000 units around the city whose landlords would agree to participate in the program.

 

An Expert Gives the Prognosis—and Makes the Case—for Medication-Assisted Addiction Treatment

Caleb Banta-Green

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The King County Heroin and Prescription Opiate Task Force wrapped up its work in September with a 101-page report recommending policy changes in three key areas: Prevention, treatment, and user health/overdose prevention. Two months have passed, and the task force has more or less gone dormant, but some of the recommendations–which include opening two new supervised drug-consumption facilities, one in Seattle and one in a still-TBD King County city–are happening behind the scenes. Some recommendations, including a new buprenorphine clinic providing medication-assisted treatment for opiate addiction at the downtown public health center, are already underway, while others are still on hold pending cost estimates, funding, and neighborhood buy-in.

Although the most controversial element of the recommendations, by far, has been the supervised consumption sites (one state lawmaker, Republican Sen. Mark Miloscia, has vowed to pass legislation that would preclude the city and county from opening any safe-consumption sites, along with legislation that would ban sanctioned homeless encampments), expanding access to medication-assisted treatment is also harder than it looks. Currently, federal drug law only allows doctors to provide buprenorphine (brand name: Suboxone) to a maximum of 100 patients at a time; doctors who want to prescribe buprenorphine have to go through special training and certification. Currently, according to the task force report, “Treatment capacity for buprenorphine is limited and far exceeded by demand.”

Caleb Banta-Green is a task force member and researcher at the University of Washington’s Alcohol and Drug Abuse Initiative who has studied the impact of the opiate epidemic and advocates for expanded access to medication-assisted treatment with suboxone or methadone. I sat down with him in his U District office the other day to ask some devil’s advocate questions about Suboxone, other addictions that can’t be treated by taking a pill, and the widespread belief that sometimes, you just have to force addicts into treatment.

The C Is for Crank (ECB): Listening to the task force and to city council members, like Sally Bagshaw, who have really dedicated themselves to working on the problem of opiate addiction, you’d think that buprenorphine treatment is the be-all, end-all of addiction treatment. That worries me a little. For one thing, it’s treating an epidemic largely caused by pharmaceutical companies with drugs prescribed by pharmaceutical companies, and they can and do jack up prices (and lie about side effects, as they did with Oxycontin). For another, it might take away pressure to provide funding for things like counseling and other supports that people need to live better lives without drugs. Should I be concerned?

Caleb Banta-Green (CBG): My analogy is always Starbucks. If you think about how so many people are coffee drinkers, well, there’s a lot of opiate users too, and they’re going to want their fix in a bunch of different ways and settings, just like coffee. Some people like espresso, some people like drip. We don’t just have one type of coffee that everyone has to drink in one setting and one way of paying for it. That’s not the way you get customers, and repeat customers, which is what we want when it comes to treatment. But that’s not what we do. We say, “Here it is, come get, and it if it doesn’t work, you’re failing treatment.” It’s like saying, “We’re making a shitty cup of coffee and you’re not drinking it. What’s wrong with you?”

My favorite, most disturbing, inspiring, frustrating thing in that Frontline piece [“Chasing Heroin“] is the woman [Kristina Block]—she was something like 20—and she said to her dad, “don’t want to use, but I’m not ready for treatment.” And I think treatment with a capital T is what she’s thinking about. Not like, “I don’t want to use and I [would like to] take buprenorphine, which I can take by mouth every 24 hours and not go into withdrawal and not get high.” She’s saying, “I don’t want to deal with the bureaucracy and the counseling and the hassle and the humiliation and the stigma.” That’s a different thing.

ECB: Assuming the county figures out a way to site and fund two supervised consumption sites on a pilot basis, is two years [the length of the proposed pilot program] long enough? I can see a scenario where a facility goes into a neighborhood and has just enough time to piss everyone off and scare them, but not enough time to show meaningful results, which obviously would be less than ideal.

CBG:  I think in two years, if you’re destroying a neighborhood or revitalizing a neighborhood, I think you can have a whiff of it pretty quick. There’s an example in Hamburg or Berlin where they put a [supervised injection facility] next to a park and basically the park looked totally different almost instantaneously, and in fact, drug dealing changed almost instantly because the only people left in the park were the drug dealers. No one was using anymore. So it changed the drug market as well. It can be very dramatic and very sudden.

“When Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible.”

ECB: Leaving aside all the public health measures like emergency room utilization, overdose prevention, and money saved, is there any good way to quantify subjective quality-of-life improvements for the people who use these programs?

CBG:  Do they return to a life that’s worth living? It’s great to keep people alive, but what’s going to make them want to stay alive and have a valuable, meaningful life? And if part of that is a sense of self and identity and worth, I don’t think those are weak outcomes. What is your sense of self? Do you feel valued and respected by other human beings? Those are kind of important things. In fact, they are essential. And it is a public health outcome, because that whole sense of self is related to a person’s mental health and health care and caring for themselves.

ECB: I’ve mentioned some of my reservations about heavy reliance on Suboxone as treatment before: As an opiate drug, it can be both habit-forming and addictive, it puts users’ fate in the hands of drug companies who don’t have a good record being honest with patients about their products, and I’m skeptical of treatments that sound like magic pills because policymakers zero in on the pill as the only solution, abandoning things like long-term therapy and social supports. Can you put my mind at ease about any of that?

CBG: I’m a researcher, not an addiction medicine doctor, but every single addiction medicine doctor who I know is really clear that in their practice with Suboxone, the majority of people who have long-term opiate use disorder do the best being on Suboxone for many years. Suboxone’s only been around for 14 years, so I can’t tell you that it’s 50 years, but I can tell you that the longer the better. And I can tell you that because when Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible. We wasted 10 years of research on that, even though we knew that on methadone maintenance, on average, the longer the better. So we wasted ten years and now we know the same thing’s true for Suboxone. To me, that’s not saying that a person has to be on it for 50 years. The point is, how’s the person functioning? The calendar shouldn’t be the guide for when or whether a person gets off Suboxone. It should be whether they’re functioning.

Opiate use disorder is not the same as alcohol use disorder. The difference is that if you have opiate use disorder, you’ve had it for a long time, you have an endorphin system in your body that is potentially permanently changed. The only way for some people to feel normal—not high, but normal—is to have opiates on those receptors. Most people with opiate use disorder need opiates on the receptors to feel normal. They’re the people who, when they first took opiates, they didn’t get lethargic and nauseated and sleepy. They’re the ones that said, “Oh, I feel normal.” So where’s the issue? If the opiate makes you feel normal and it doesn’t cause euphoria and it doesn’t have side effects and it helps them function, what’s the downside of them being on it?

“If it were my kid who was addicted to opiates, even as an adolescent, I would say, ‘Let’s get this person on Suboxone, and I want them on it until they’re 25.'”

ECB: One downside might be the widely reported side effects.

CBG: Here’s the issue. The side effect of going off of it is that your mortality risk doubles. That’s the side effect I’m worried about—when you’re not on it, your mortality risk doubles. If it were my kid who was addicted to opiates, even as an adolescent, I would say, “Let’s get this person on Suboxone, and I want them on it until they’re 25.” Then we can figure out what’s going on and figure out how they’re doing physically and socially and psychologically. But the overdose risk is so high with opiates, and even more so now with who knows what the fuck’s out there, that pharma raising the price or having some liver side effect that actually has not been found, compared to your overdose risk doubling? For me personally or for a family member of mine, I’m comfortable with that.

ECB: The task force recommended safe consumption sites, rather than safe injection sites, specifically to create a space for users of many different types of drugs, who use them in different ways.  Do you think that aspect will get lost as the county and local jurisdictions hammer out the details of where these facilities are going to be?

CBG: Brad [Finegood, assistant director of King County’s behavioral health and recovery division] has been very clear about trying to make access to all types of drug treatment for everybody, and we need that. And we need to have safe and heathy places for people who are using methamphetamine. We also need to have good treatment, social support, counseling, and all of that. We’re also very  unfortunate in that the treatment solutions for alcohol, methamphetamine, and marijuana are not nearly as good as they are for opiates.

ECB: Why not?

CBG: It’s because we don’t have medications. Also, we have an antidote [for heroin overdoses, naloxone] that lay people can give. We don’t have that for any other drug. And we have treatment medications that work really well. Methamphetamine’s a bitch. If your’e using meth and heroin, it’s really a bitch. We’ve seen a huge increase in methamphetamine deaths over the last decade, mostly because people are starting to combine it with heroin.

ECB: How many people do you think could benefit from medication-assisted treatment in the state?

CBG: There’s about 10,000 people on methadone. There’s probably 15,000 on buprenorphine in the state, based on a state survey. I think we easily have need for 15,000 to 20,000 more people on treatment medications. So there’s a lot of pent-up demand out there, and I also think that the demand is not just for methadone. There’s actually not bad access to methadone right now, but I know there’s a huge unmet need for buprenrophine.

“Why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment?”

ECB: When I talked to Senator Mark Miloscia after our visit to Insite, a prescription-heroin clinic, and other harm reduction programs in Vancouver, he said he was unconvinced by what he saw there and still believed that forcing people into treatment will make them stop using drugs. What is your response to that?

CBG: That comes up all the time, and as a human being, I don’t like the idea of forcing a person to do that. People have free will. But forget that point—the real point is, we don’t have nearly enough treatment access for the people who do want it, and I’d love to deal with [people who don’t want treatment] after we deal with the problem of making sure we have treatment available to the people who do want it. And the way that we know that they want it is that in a state survey, at least 2/3 of people said they want help reducing their use. People don’t want to be using heroin.

But they also don’t want to access the current types of treatment that are available that may be dehumanizing, that may use behavior modification and yell at you, that may call you a bad person, that may tell you that if you don’t believe in God, then you are not trying hard enough. In what other aspect of our lives would we want to be treated that way? So why would a person with substance use disorder want to be told that they’re a lesser person and they get fewer choices? The majority of people who are using don’t want to be using, and they need the right kind of treatment to not use. So why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment? Let’s take care of those thousands and thousands and thousands of people before we go through a surely illegal process of eugenics and forcing people into treatment.