Opioids: progress, but still lots of work to do

[ P A R T  O N E ]

By Vanessa della Bitta — Short of living isolated and unplugged for the last few years, feigning ignorance about our nation’s opioid epidemic would be difficult. The evidence is everywhere—broadcast by major and local news sources and hiding in plain sight.

According to the Centers for Disease Control and Prevention (CDC), opioids were involved in 61 percent of drug overdose deaths nationally in 2014. The same year, drug overdose deaths outnumbered those from motor vehicle crashes by a factor of 1.5.

A friend tells me she drove through Pennsylvania recently and saw city billboards talking about opioid overdose prevention. On the bus in Madison, I’ve seen used wrappers of Suboxone (buprenorphine-naloxone)—a substance prescribed for medication-assisted treatment (MAT) of opioid dependence. The slick packets are built like Crest whitening strips, containing the medication in filmstrip form—different color packaging for different strengths.

I wonder if other Metro riders on their way to work or class or home recognize the wrappers, or if to them it’s just a scrap of litter that missed the trash. Whether we register the evidence or not—understand it or not—it’s a reality among us.
Here in Wisconsin, overdose deaths have exceeded motor vehicle and traffic-related deaths yearly since 2008, and have climbed steadily since. In 2014 (the last year for major research on the subject), there were 267 heroin–related deaths, surpassing the peak mortality of the HIV/AIDS epidemic in our state, which was a toll of 259 lives in 1993.

On the individual level, these losses are inconceivably traumatic and painful. Considered on a larger scale, this nasty (and—in many cases—preventable) onslaught of fatal opiate use is a symbol of the deeper and more complex issue of opioid use disorder, and has prompted a call to action.

Richard Kilmer, RPH, who was one of the original volunteers for the Madison AIDS Support Network and who serves as a Dane County Board Supervisor for District 4, says, “I think overdose deaths, especially among white suburban young adults, has raised awareness of this issue. This is very similar to the HIV epidemic, as young men waiting to die in their family homes returned to their hometowns from the big cities; it told people that it affects everyone, no family seemed immune.”

We’ve been here before

Similar to the response to the HIV/AIDS crisis in the 1980s and ’90s in the United States, many policymakers, public health officials and other advocates are calling for major harm-reduction and prevention strategies. For the past 31 years Kilmer has been a pharmacist with Community Pharmacy, which has been giving clean, free needles since 2007 and has been distributing a life-saving substance called naloxone in either nasal or injectable form since 2013. “First we need to keep people alive from overdoses, and then we need to find treatment options that work, or at the minimum maintain their addiction until better treatments are available. We need to stop judging people, and get out there and save lives.”

Naloxone (also known as Narcan) can effectively reverse an opioid overdose; naturally, increasing access to it is chief among harm-reduction initiatives. When opioids like heroin cause a lethal overdose it is because they suppress a person’s respiratory functioning. Naloxone binds to the same brain receptors as opioids like heroin or OxyContin, but it does not produce the same body- and mind-altering effects, such as euphoria, nor does it interfere with breathing. However, the strength with which naloxone binds to the receptors is far more powerful, allowing it to displace other opioid action on the brain.

This means that even when potentially fatal symptoms of drug poisoning are already occurring, naloxone can interrupt them by rushing in and boxing out, like an airtight defensive move. Thus, naloxone is a vital tool for saving lives when carried by first responders and when accessible to the public.

Naloxone without a prescription

Wisconsin Governor Scott Walker recently signed a statewide standing order allowing pharmacists to dispense naloxone to individuals without a prescription. Kilmer says, “My opinion is that naloxone and treatment should be free to anyone who asks for it.” He believes nobody should be charged “to save their child or a friend from an overdose.”

The first piece of legislation in Wisconsin regarding naloxone was proposed as Assembly Bill 446 in 2013, which authorized all first responders to carry and be trained in the administration of the drug. This bill, along with six others, comprised a package of new laws advanced by the State Council on Alcohol and Other Drug Abuse (SCAODA), dedicated ad-hoc committees and other advocates, and championed by Representative John Nygren. It is known as the HOPE (Heroin, Opioid Prevention and Education) Agenda.

This first wave of HOPE Agenda legislation, enacted in 2014, received unanimous support in both the Assembly and the Senate, allowing for funding to supply Narcan to trained first responders, such as police officers and EMTs. Of note, the Good Samaritan Law was also passed as part of the initial round of the HOPE agenda (Assembly Bill 447), granting limited immunity to those who seek assistance from the police or medical professionals on behalf of another person who has overdosed.

According to Skye Tikkanen, who chaired the committee on Good Samaritan legislation in 2013, following the first seven laws there have been some amazing changes. Access to Naloxone has been much higher, there is more protection for doctors prescribing it, and more money for deferred prosecution units, which provide a way for those in the cycle of active use to avoid criminal convictions for things like felony possession charges.

During the most recent legislative cycle in 2016, nine new bills have been passed and signed by Governor Walker, setting in motion the second round of the HOPE agenda and advancing the statewide standing order for Naloxone. The newest bills focus heavily on prescription opioids.

In 2013 it was found that while heroin contributed to 27 percent of overdose deaths, prescription opioids were a factor in 45 percent. The new laws tighten the regulations of Wisconsin’s Prescription Drug Monitoring Program (PDMP), calling for increased accountability for doctors and pain management clinics prescribing opioid painkillers. They also charged the Department of Safety and Professional Services (DSPS) with drafting a guideline for best practices to curb overprescribing, and initiate further research on methadone clinics’ staffing ratios and facility accessibility for patients.

Tikkanen says, “Representative Nygren’s next is focusing on treatment, and that’s exciting.” Tikkanen has been a substance use and mental health therapist at Connections Counseling in Madison for the past 12 years, and is a powerhouse of recovery advocacy, as well as a person in long-term recovery.

She says that when she first began speaking out about the opioid epidemic, her ideas about harm-reduction were not mainstream, but that has changed. “In the past two to three years I would say law enforcement are my biggest advocates…. They’ll echo exactly the same sentiments that I say and talk about how we can’t arrest our way out of this problem, and how we need to treat this as the public health crisis and the personal health crisis that it is.”

Decriminalizing addiction

On the national level, the Comprehensive Addiction and Recovery Act of 2016 (CARA) is the first piece of major addiction legislation to make it through Congress in close to 40 years. Advocates have been pushing for policy changes aimed at decriminalizing the chronic disease, enacting harm-reduction strategies, increasing access to treatment and building up community recovery interventions for years.

The finalized act, ultimately passed and signed by President Obama this July 22, focuses heavily on prevention and harm reduction through awareness campaigns, prescription drug take-back programs, increased training for and access to naloxone, and better access to MAT like buprenorphine.  CARA also pushes for the development of more treatment-based alternatives to incarceration programs, more accessible and sophisticated recovery services for women, families and veterans, and investment in communities of recovery backed by nonprofits and other community organizations.

While CARA authorizes over $181 million each year in various grants to substantiate its objectives, funding still must be allocated through an appropriations committee each year, and it is up in the air how much money will actually materialize.
“That process is going to take about a year,” says Caroline Miller, Outreach Specialist with the University of Wisconsin-Madison and Consultant for Wisconsin Voices for Recovery. “Now’s the time when everyone is basically vying for pieces of this bill.”

Richard Kilmer notes that CARA is a great idea, but that “without sufficient funding, it is no more than a Band-Aid.”

Looking beyond overdoses

Fatal overdoses account for a big chunk of the conversation about opioids in the public eye, and rightly so—but along with efforts to save lives is a need for long-term treatment and recovery maintenance support.

“Addiction is a chronic health condition,” says Tikkanen. “This idea that this is an acute disease that happens once and then you get treatment and it’s done has so permeated the culture for so long that it really has been an upwards battle in order to teach people that…. The changes with making Naloxone more available, with changing the regulations around limited amnesty for people that do call 911 in cases of overdose, those are low budget or no budget items, and treatment is so expensive.”

Part Two will follow up with more on the landscape of treatment and recovery: the barriers and the essentials.