There are many different ways to quantify the opioid crisis. The obvious is the dramatic rise in deaths from overdoses. Let’s not overlook the number of overdoses themselves – often as recorded by calls to EMS and/or visits to an emergency room. The department of Health and Human Services (HHS) estimates that there were 2.1 million people who had an opioid use disorder in 2016. In today’s blog post, I share with you some of the harm reduction ideas and options for keeping our opioid addicts and society safe during the crisis.
Last week, I explained the science of addiction as a result of dopamine creation and the euphoric feeling from opioids affecting the reward circuit in the pleasure center of an addict’s brain. As it turns out – the mind’s association of opioids with dopamine is at the crux of addiction. Addiction is a disease. It is not an addict’s mental or moral weakness, lack of willpower or inability to make wise choices. It is based on how their brains have learned and changed through their experiences with opioids. Once we recognize this as a disease, we can find ways to keep addicts safe. We can also start looking at evidence-based treatment programs. While this is happening, we need to ensure the safety of the person suffering from “opioid use disorder”. Keeping addicts safe is the purpose of harm reduction.
Harm reduction is controversial because there is a cost to helping keep drug users (and those around them) safer. There is also a misconception that harm reduction encourages drug use. There are no studies that support that viewpoint – it is just a misconceived opinion.
While there are many different types of harm reduction, I’ve chosen to focus on some of the most impactful (and occasionally controversial) in this blog.
Syringe exchanges are important for the drug user and anyone they may have shared needles with. Diseases and infections such as HIV/AIDS, Endocarditis and Hepatitis C are easily and frequently transmitted through the use of dirty / shared needles. Now in recovery, Zach shared with me that before NYC had needle exchange programs, he would often make his way all the way to Lincoln Center where there was a drugstore that would swap a single needle. He was fortunate, and his caution kept him free of any harm from dirty needles. Today, there are many syringe exchange programs in New York and other cities. Almost all of them can be found on the North America Syringe Exchange Network’s web site (http://nasen.org). While there is a cost to an exchange program, a study in 2014 showed that for every $1 spent there is a savings of $6 simply based on the savings from HIV treatment costs alone. With that knowledge, even opponents of syringe exchanges recognize them as an investment – not simply a cost.
Today, more than ever, there is a need to be vigilant in knowing the active ingredients in drugs available on the street. The drug safety testing process (also known as “drug checking”) can range from simple to very complex. The presence of fentanyl has become so pervasive that in New York, dealers have started advertising “real dope not that fent(anyl) sh**”. The absence of regulation around illicit drugs means that any user must have a ‘buyer beware’ attitude. A nonprofit organization in the UK known as The Loop provides mobile test facilities (which they call “pop-up labs”) at concert events and is working on permanent locations where they will anonymously check any drugs that are brought in. An even more basic testing approach is to make test strips available. For example, fentanyl test strips can be ordered on the internet for about $1 each (I keep these in my backpack as well). Earlier this year Scientific American ran a story describing how the “$1 Fentanyl Test Strip Could Be a Major Weapon against Opioid ODs”. One of my personal favorite nonprofits – West Oakland Punks with Lunch – helps with drug checking, naloxone distribution and syringe exchanges – check them out - https://www.punkswithlunch.org.
Supervised Injection Facilities
With the incorporation of fentanyl into the drug supply the importance of supervised facilities is even more important. With approximately 100 supervised injection facilities operating in at least 66 cities around the world, it’s surprising that there are none in the United States. The first one in North America opened in Vancouver, Canada in 2003. The Vancouver facility is run by Insite – a nonprofit organization. Since 2003, there have been more than 3.6 million clients, nearly 40,000 clinical treatment visits (available, but never required) and 6,440 overdose interventions. It’s likely that the first facility in the United States will open this summer in San Francisco. Having lived in the Bay Area, I applaud the San Francisco Department of Public Health’s unanimous endorsement to open the site. Earlier this month, New York’s mayor Bill De Blasio announced his intention to open four injection centers. Seattle, Philadelphia and Baltimore have each declared their intention to open one. These sites have many benefits including reducing much of the visible activity associated with illicit drug use, including improper syringe disposal and public drug use. With trained staff and naloxone readily available, overdoses are much less likely to be fatal. The challenge with naloxone is that (according to an NDEWS HotSpot study), the majority of people when they overdose are male, 20-39 years old alone when they take their fatal dose. If a drug user has an opioid overdose, they are not going to be able to self-administer naloxone. This is one of the critical challenges overcome by supervised injection facilities.
While these facilities are crucial, there is often a public concern that they attract drug users and bring them into the community. Zach shared his perspective as a recovering addict – "When I was using, I broke into numerous buildings and fixed in people's hallways outside their apartment doors. on rooftops, in backyards where people's laundry was, alleys, & if I couldn't get into a building I gotta go to a public bathroom where I'm gonna take 20 minutes and cause a huge line outside, and I was one of the clean junkies so I always took my s*** with me and never left needles behind but many people do, some people enjoy spraying their own blood all over the wall after they've done a shot, so would you rather I and other people like me continue to do that or is it cool if we just go to one safe place that doesn't interfere with your public bathrooms and building lobbies and hallways?"
Historical Criminalization of Illicit Drugs
There is no doubt that the non-discriminatory nature of the current opioid crisis and its impact has brought the drug crisis into the mainstream. Lawmakers, for example have been historically buffered by resources to treat and support family members with addictions shielding them from the social impact of the drug crisis. However, the opioid crisis refuses to be contained. Now even lawmakers from prominent families have friends or family members who have been impacted by opioids; therefore, the stigma for addressing the issue is evolving. One example is the movement to address behavioral health, a frequent root cause for addiction. We believe that these trends and efforts will continually contribute to reducing the stigma associated with drug addiction.
In the U.S., the criminalization of drug use has been the dominant social norm of professional society. There is considerable evidence and reporting on the benefits of regulating drugs to help ensure a consistent quality and potency. Along with world leaders such as George P. Shultz, Kofi Annan and Sir Richard Branson, the Global Commission on Drug Policy recommends decriminalizing and regulating drugs. It would still be illegal to sell drugs (trafficking) or to possess more than a few days worth of drugs in this context. The benefits are also economic. The intent is to use money that would have been consumed by the criminal justice system to help with counseling and treatment options. Portugal is often used as a real-life example for this. For this week’s media suggestion, check out this Australian video on Portugal’s experience - https://www.youtube.com/watch?v=6S4M-oreia8 In a joint statement by the World Health Organization and the United Nations, they urged focusing on rehabilitation rather than over spending on criminalization. This would entail putting in place law, policies and regulations by “Reviewing and repealing punitive laws that have been proven to have negative health outcomes and that counter established public health evidence”.
Trying to find non-opioid effective pain relief is difficult. However, there are an increasing number of studies and reports about the effectiveness of cannabidiol (CBD) – the non -psychoactive component of cannabis (tetrahydrocannabinol or ”THC” is the psychoactive component) as a replacement for opioids for chronic pain. A study released in 2014 in the Journal of the American Medicine Association reported that “Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates”. I’ve actually seen this in action with my mother-in-law. She’s in her late 70s and has suffered from chronic back pain for decades. Her doctor’s pain management was based on incrementally larger doses of fentanyl through a transdermal patch. As the lifestyle impact of the high dose of fentanyl took its toll on her and her family, she considered trying to replace some of the fentanyl with a CBD tincture. She had to overcome cultural, generational and personal biases about the stigma of marijuana use. Within a few months, she has reduced her fentanyl dose by 75%! As the fentanyl level in her system decreased, her quality of life has increased in kind. She is ready to cut the remaining fentanyl dose in half again, bringing her dosage to just 1/8 of what it was a year ago. I’m glad I was able to discuss CBD use and answer her many questions, so she was comfortable trying it. Currently, CBD is legal in 46 states with a prescription for medicinal usage.
There are a number of moments where harm reduction and treatment merge – typically supervised injection facilities, emergency rooms and prisons. Adequate education, treatment – including medication assisted treatment (“MAT”) options as well as psychiatric help are important. Many leading emergency departments provide ‘warm handoffs’ to help ensure drug users are able to get in to a treatment program. Next week, we’ll discuss treatment options and the long road to recovery.
By: Dean Shold VP, Technology at Medigram
Dean Shold is the VP of Technology for Medigram. Before his current role, Dean was the VP of Infrastructure and Chief Technology Officer for Stanford Health Care, and was previously the VP of Global Data Operations for Zephyr Health. With a degree in computing science and a passion for social good, real time data analysis and mobile computing, he brings a unique background and perspective to the healthcare industry. At Medigram, Dean drives enterprise customer complete solution development, implementation, support, and customer success. At Stanford Health Care, he led a global team of 180+ personnel at 24x7 support to 50+ locations including multiple hospitals. He managed the technology and support budgets and built and reorganized teams to drive performance and reliability. He built a command center based on FEMA's (Federal Emergency Management Agency Guidelines) and oversaw data center performance and builds.
Dean also has deep passion for practically addressing the opioid crisis. His interests are in the scientific and the social sides of the opioid crisis bridging the addict with the researcher and the lawmaker. He is fascinated by how the worlds of legal and illegal opioids intertwine and how our societal biases impact treatment and recovery. In his work, he brings a vision of how Health IT can be leveraged to better understand and address the crisis. This includes examining the following key dimensions in addition to Health IT such as fentanyl, naloxone, harm reduction, detox, treatment and recovery.
Outside of the office, Dean also co-founded a non-profit organization to create novel ways to donate to charities. Dean is an instrument rated pilot and avid music lover. He and his wife, Pauline recharge by exploring harm-reduction organizations, the arts, craft beer and music scenes.
Links to check out:
Substance Abuse and Mental Health Services Administration (SAMHSA) - Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health
The Opioid Epidemic by The Numbers – HHS
Syringe Exchange in the United States: A National Level Economic Evaluation of Hypothetical Increases in Investment
The Loop – drug testing
Highlights from the NDEWS New Hampshire HotSpot Study
De Blasio Moves to Bring Safe Injection Sites to New York City – The New York Times
SF Safe injection sites expected to be first in nation open around July 1 – San Francisco Chronicle
Supervised Injection Facilities - Drug Policy Alliance
Global Commission on Drug Policy: The World Drug Perception Problem
Joint United Nations and World Health Organization statement on ending discrimination in health care settings.
It’s Time for the U.S. to Decriminalize Drug Use and Possession
Legal weed: An accidental solution to the opioid crisis? – Maclean’s
Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010
Opiate Crisis Leads to More Young Addicts Needing Heart Surgery
North American Syringe Exchange Network – New York
Insite (supervised injection facility) statistics
Is CBD Legal? The Legal Status of CBD in 2018