There’s no one easy answer for how to respond to the opioid epidemic. Cities, counties, and states across the country have tried to be innovative in their approach to the public health crisis ever since concern over opioid and heroin use began to grow. More than 150 realtors in San Diego knocked on doors this year to educate residents about prescription opioids and how to properly dispose of unneeded drugs. Philadelphia plans to open the United States’ first safe injection site for people who use drugs like heroin, despite the Justice Department having filed a lawsuit against it. Oklahoma settled a lawsuit against a company that manufactured drugs that have contributed to the epidemic, and is using some of the settlement money to fund their efforts against opioids.
Still, one of the most effective ways to treat opioid use disorder is through medication-assisted treatment (MAT), according to the National Institute on Drug Abuse. MAT suppresses opioid withdrawal and reduces cravings, making it easier for a person to progress in their recovery. Only about a quarter of people with opioid use disorder ever receive treatment, however. A recent study published in JAMA Psychiatry shows that the people who receive buprenorphine, which is MAT that can be prescribed in a primary care setting, are generally white people who have the cash or private insurance to pay for it.
The opioid epidemic has long been framed as a white, rural crisis, but that doesn’t begin to get at the full scope of the problem. It’s true that since data tracking began in 1999, white, non-Hispanic people have been dying at the highest rate from opioid overdose nationwide. It’s also true that there has been a particularly devastating rate of prescription opioid misuse in rural Appalachia. But opioid overdose deaths are surging among Hispanic and especially Black communities. A report published in JAMA Network Open earlier this year indicated that opioid-related deaths increased most sharply between 1999 and 2016 in the eastern half of the United States, with eight states, including Connecticut and Ohio, seeing opioid mortality rates double every three years. Washington, D.C., where nearly half of the population is Black, has seen its opioid mortality rates more than triple every single year since 2013.
Caleb Banta-Green, principal research scientist at the Alcohol and Drug Abuse Institute (ADAI) at the University of Washington, believes that accessing medication-assisted treatment should be as easy as getting a morning coffee.
“I can go to any Starbucks I want to get coffee,” he tells Bustle. “Why don't we set up the same thing for medication access?”
Bustle looked at how three metropolitan areas deeply feeling the effects of the opioid epidemic are approaching it in various settings. In New York City, we looked at primary health care; in Chicago, we looked at jails; and in Seattle, we looked at community networks. Getting people medication-assisted treatment was a consistent theme in each approach — but so was compassion.
When people who use opioids receive treatment, their sobriety is often short-lived. But in Chicago’s Cook County Jail, receiving treatment and being sober are not optional. Mary Addante and Kimberly Morehead, who are incarcerated there, are thankful for the treatment. “I don’t know any other jail or institution that has a program that helps inmates like this,” Addante tells Bustle.
The opioid epidemic is a significant health issue within Chicago. According to a report from the Chicago Department of Public Health, 796 people died from an overdose involving opioids in 2017, more than the number of people who died from either gun violence or car accidents that year. In Cook County Jail, at least 5,000 people detox from heroin each year.
“There is very little innovation that you find in jails and prisons across the country,” Cook County Sheriff Tom Dart tells Bustle. The number of women housed in correctional facilities has grown dramatically since 1970, according to a 2016 report by the Vera Institute of Justice and the Safety and Justice Challenge, and about two-thirds of them are women of color. Those who use opioids also face a variety of unique challenges, like an increased susceptibility to mental health issues and a high rate of trauma.
To address these gender-specific issues, Cook County Jail developed its 90-day Therapeutic Healing Recovery Initiative for Vitality and Empowerment (THRIVE) treatment program. The program makes Cook County one of the few jails in the United States to address the opioid epidemic specifically among women.
Over two-thirds of individuals released from jail return within three years, according to the Bureau of Justice Statistics. But Cook County Jail reduces the likelihood of its formerly incarcerated people returning to jail or relapsing after they’re released by prescribing them buprenorphine, often known by the brand name Suboxone.
Once a woman completes the THRIVE program and is released from jail, Cook County matches her with an outside treatment facility to ensure her Suboxone treatment continues.
“Whatever milligram you leave here on, when you are released, you already have a clinic picked out and your prescription is transferred to that clinic so you can continue it on the outside,” Morehead tells Bustle.
Administering Suboxone alone, however, would not be effective in setting women up for post-incarceration success. Supplemental mental health and career service programs also help them reintegrate into the community. Not having a thoughtful transition upon release is not really an option, Dart says.
Dr. Rebecca Haffajee, an assistant professor of health management and policy at the University of Michigan whose research focuses on behavioral health and pharmaceutical policy, says Cook County’s is a very promising approach, adding that people have a vastly increased risk of fatal overdose when they transition out of jail. Research has shown that providing treatment for opioid use disorder while a person is incarcerated may lead to a significant drop in overdose deaths.
While Cook County Jail may be implementing innovative treatment to help fight opioid use disorder, Addante and Morehead feel their magnolia-colored cell is not an ideal place for recovery. “Cook County has provided us some great opportunity,” Addante says. “But at the flip of that we are still in jail. It’s not easy no matter how many times you’ve been in here.”
New York: Health Care
Prominently displayed in the New York City office of Dr. Mariely Fernandez, MD, is a large corkboard plastered with photos of newborn babies, smiling kindergarteners, and high schoolers at graduation. “This is my wall of love,” she says.
Three floors above Fernandez’s office is a methadone clinic, where the parents of some of those children may be receiving treatment. Or those parents may be down the hall, speaking to a therapist about how their recovery is going. Or perhaps they’re just bringing their child in for treatment for a cold that won’t go away. Fernandez, who is board certified in both pediatrics and addiction medicine, is the chief medical officer at the Center for Comprehensive Health Practice (CCHP), which offers primary care, behavioral health, and substance use treatment in East Harlem.
“Not every patient here has a history of substance use,” Fernandez says. But she finds it hard to believe that there’s anyone out there who doesn’t know someone who is struggling with a substance. So it’s important to her that CCHP offers all the various services that it does.
According to statistics from the NYC Chief Medical Examiner and the Department of Health and Mental Hygiene (DOHMH), someone dies of a drug overdose in the city every six hours. Overdose deaths have increased across New York City’s five boroughs over the last several years, and fentanyl, a synthetic opioid that has at least 50 times the strength of morphine and is sometimes mixed in with other substances, has played a role in approximately half of those deaths.
“The stakes of relapsing are higher in the context of fentanyl,” says Dr. Hillary Kunins, the acting executive deputy commissioner at DOHMH. If someone uses fentanyl or heroin, “their relapse becomes deadly,” Kunins says, which makes prevention, intervention, and treatment efforts in a primary health care context crucial.
Getting medication-assisted treatment into the doctor’s office is difficult, though. There aren’t enough providers who are capable — or willing — to provide the medications, Haffajee says. Providers must undergo training and receive a qualified physician waiver to prescribe buprenorphine, which can be a barrier. But some doctors also “just don’t want to take on these kinds of challenging patient populations,” as Haffajee puts it, without institutional support and resources that include a team of case managers and social workers to provide continuity of care for the patient.
CCHP serves people who have a substance use disorder, people who are experiencing homelessness, and people who are unable to pay for services. While a lot of CCHP’s patients come to the practice thanks to word of mouth, New York City also has a series of programs, like the Relay and CATCH programs, that connect people with substance use treatment like CCHP offers. These programs dispatch peer advocates to speak about opioid use disorder with a person who has been admitted to a hospital or emergency room, and then connect them via a “warm handoff” to treatment services and ongoing care.
"We're lucky to be living in the state that we do."
“A warm handoff is actually having someone there taking you by the hand and introducing you to another health care provider and saying, ‘Hey, this is my friend, so they're gonna help you with this,' and ensuring that connection happens,” says Noah Isaacs, director of health care planning and analysis in the Office of Behavioral Health for NYC Health + Hospitals, which oversees all of the public hospitals in the city. “Because, so often, the place where things break down is between that crisis and making it to that next appointment.”
It’s at those appointments where an organization like CCHP stands out. Beyond primary care, it offers a methadone clinic, doctors who can prescribe buprenorphine, on-site counseling, and child care for patients to be present at their appointments. Fernandez isn’t sure her practice could do that work in a place that isn’t as progressive as New York.
“We're lucky to be living in the state that we do,” Fernandez says. “Could there always be more funding for this kind of work? Of course, because everything like this really does need more money thrown [at it]. But I'm lucky to have the opportunity to be working in a place like this and that patients have access to services like ours.”
Seattle: Community Networks
For Bradley Finegood, a strategic advisor for the Department of Public Health in King County, Washington, one interaction really drove home the stigma that surrounds medication-assisted treatment. He met with a medical provider who was an early adopter of offering MAT, and when he asked about whether they gave out naloxone kits, the provider said they had mixed feelings on whether the overdose-reversing drug was “enabling.”
“And I'm like, ‘You have mixed thoughts about keeping somebody alive?’” he recalls.
Finegood’s brother died of an opioid overdose on New Year’s Day in 2005. In Seattle, around two-thirds of all drug overdose deaths involve opioids in some form, with 19% attributed to opioids only and 49% attributed to opioids combined with another drug. Heroin overdose rates have tripled between 2002 and 2018, according to research from the ADAI.
Seattle also has a significant population of people who are homeless, which presents unique challenges in responding to the opioid epidemic. King County, which encompasses Seattle, has the third-largest population of people who are experiencing homelessness in the United States. Between 2012 and 2017, overdose was the cause of death for about one-third of people who were homeless when they died, according to data from the King County medical examiner.
To identify what might work for King County, the mayors of Seattle and nearby Renton and Auburn convened the Heroin and Prescription Opiate Addiction Task Force in 2016. The task force came up with eight recommendations, and now various people around the county, like Finegood and Banta-Green, the University of Washington research scientist, are tasked with overseeing their implementation.
Those recommendations fall into three “buckets”: prevention, treatment, and user health. A big part of the task force also has been building a network of providers, care navigators, and community-facing agencies. Having this network gives the people involved the ability to easily refer someone to agencies that provide housing services or mental health treatment, or agencies that specialize in serving a specific population, like women, people who are transgender, or people who are homeless. It’s all still a work in progress, but having the community involved is key.
Elizabeth Gregory Home (EGH) in Seattle offers services for women who are experiencing homelessness or a substance use disorder. In the front of the center, which is tucked in the basement of a church, women charge their phones or rest on recliners. Along with providing a place for women who are experiencing homelessness to safely spend their days, EGH offers a transitional housing program and case management services.
“Our whole thing is to provide this refuge of compassionate care for anyone who identifies as female who is homeless and to help them get the tools and support they need to hopefully get towards an independent way of life,” Ruth Herold, the executive director, says.
Shannon Graves first found EGH as part of her community service obligation after being jailed on drug charges. She was prescribed opioids after breaking her arm horseback riding when she was 12 years old, and she says that one prescription led to 10 years of struggling with opioid use disorder and homelessness.
Graves estimates her recovery began around the 12th time she ended up in jail. She then opened up to the idea of inpatient treatment, which she received at American Behavioral Health Systems in Spokane, Washington.
“I always said, ‘Oh yeah, that might be a good idea,’” Graves says. “But like, maybe tomorrow, maybe next month, or ‘Oh, I just want to get in one last good high before I have to go in and seal the deal.’ It is more like a closure thing, because opioids literally were like the love in my life. It’s like a toxic, abusive relationship.”
After volunteering at Elizabeth Gregory Home, Graves realized it was what she wanted to do full time. She recently started working there, and she says she thinks the sense of community there will help her recovery.
“Once I started feeling what it was like to be loved and valued and honored, then I could start to see the good things in myself,” Graves says.
What About The Rest Of The U.S.?
While there are proposals that lay out a federal response to the problem, like President Trump’s Initiative to Stop Opioid Abuse and Democratic presidential candidate Elizabeth Warren’s policy plan, there hasn't been much in the way of national opioid efforts. Instead, the lion’s share of work to reduce the rate of opioid overdose deaths and prevent people from developing an opioid use disorder is taking place on the state or local level.
According to the National Conference of State Legislatures, 45 states considered more than 480 opioid-related bills in 2018, ranging from limiting opioid prescriptions to continuing education for health care providers to expanding access to the overdose-reversing medication Naloxone. Around 70 of those bills became law.
Haffajee also points out certain strategies that are successful in one city can’t necessarily be picked up and applied to any other city in the nation. These efforts are all based in urban areas, and might not work in a rural area or a city that isn’t facing the exact same problems. For rural towns with less access to inpatient care, or areas where prescription opioid misuse is more prevalent, Haffajee notes that offering telemedicine services or giving people Naloxone when they're prescribed opioid painkillers is probably “going to be a more effective strategy.”
Still, experts say making medication-assisted treatment more accessible and ending the stigma of opioid misuse is universally necessary to reverse spiking overdose rates.
“There's this whole NIMBY, not-in-my-backyard, idea,” Finegood tells Bustle. NIMBY is a concept where homeowners don’t want certain things they find objectionable — like shelters or substance use treatment services — in their neighborhood.
“We need people to stand up and say, ‘Yes in my backyard,’ right? We need people to say, ‘Yes, please bring services to my community,’ because my brother could still be alive today.”
Kaisha Young and Jamie Spain contributed to this report, which was produced in partnership with the Social Justice News Nexus at the Medill School of Journalism, Media, Integrated Marketing Communications at Northwestern University.
If you or someone you know is seeking help for substance use, call the SAMHSA National Helpline at 1-800-662-HELP(4357).