Localizing the opioid epidemic

This story is one of a three-part collaborative report on the opioid epidemic by Melissa McCarthy, Rahwa Hailemariam and Katie Meier. They collectively obtained and analyzed data, and interviewed sources.

Editor’s note: Names of individuals suffering or recovering from drug addiction have been changed to respect their privacy and protect them from any possible legal ramifications.

By Melissa McCarthy

Infographic by Sophia Greif

He can’t remember, but has since been told that he’d turned a violent shade of blue as he lay unconscious in the car on the side of a Bellingham road.

Moments before, he had used heroin for the first time in weeks, but had adjusted his intake for his reduced tolerance. Something else must have been cut with the drug. All he remembers is being extremely disoriented and realizing something was wrong.

The next thing he knew, he was surrounded by paramedics. He had just received four shots of naloxone, an emergency treatment in cases of opioid overdose, to bring him back from the brink of death. Chase, now age 32, had just overdosed on heroin cut with fentanyl.

Not all individuals are as lucky as Chase. His girlfriend at the time had dialed 911 and first responders had arrived before Chase was too far gone.

Overdose deaths in Whatcom County have been on an upward trend in recent years. Data from the Whatcom County Medical Examiner shows that drug overdose deaths have been up by approximately nine percent each year for the past four years. In 2016, 59 percent of all accidental deaths investigated by the Whatcom County Medical Examiner were found to be drug overdoses, up from 50 percent the year prior.

From 2006 to 2016, the annual reports consistently showed that heroin and other opiates were the leading substances found in toxicology reports postmortem, except for 2007 and 2013 which did not specify the prevalence of different types of drugs.

This only includes drug overdoses found to be accidental. Accidental deaths include drug overdoses, motor vehicle accidents, fires, falls, etc. The Medical Examiner also investigates suicides, homicides and other suspicious circumstances of death.

Whatcom County Drug Court coordinators prepare to conduct a urinalysis of a Drug Court client. // Photo courtesy of Melissa McCarthy.

In Bellingham, opiate abuse differs from the national narrative. The prevalence of heroin on death certificates illustrates that this is the leading drug of choice in Bellingham and Whatcom County at large. Experts said the drive to eliminate prescription opioid abuse has led individuals to seek illicit alternatives like heroin.

Overdose deaths illustrate that this problem is growing, but they only begin to show the scope of the opioid crisis manifesting in the Bellingham community, which impacts every age, race, gender and socioeconomic demographic.

County Councilmember Todd Donovan said the impacts of opiate addiction are at the individual level, in the criminal justice system, in emergency medical responses, along with many other implications. On April 10, the Whatcom County Council voted unanimously to enter into a contract to file a lawsuit against Purdue Pharma, Endo Pharmaceuticals and Janssen Pharmaceuticals for their damage to public health.

“A lot of this is a result of not just the opioid addictions, but the heroin addictions that came from the opioid addictions,” Donovan said. “Hopefully we’ll get financial resources to fund programs in response to the addiction crisis that these companies, we think, are responsible for.”

The lawsuit is being drafted by a Seattle based-firm, Keller Rohrback L.L.C., and aims to hold these companies accountable for the public health crisis that is accused of being a direct result of their marketing strategies which led to misinformation and overprescription.

Donovan hopes the public dollars spent on services to help treat this crisis will be compensated by these companies.

In the meantime, funding toward services and treatment options are present, but far from meeting the need, Brian Wilson,  manager of emergency services at St. Joseph Medical Center, said.

“It’s going to get a lot bigger before it gets better,” he speculated.

 

Opioid addiction manifests locally

National headlines characterize opioid use in American as an epidemic, but that characterization from the mouth of a struggling addict makes one truly realize the magnitude of the problem.

“It’s an epidemic out here. It’s a full-blown epidemic,” said Suzanne, a 25-year-old female who regularly uses both heroin and methamphetamine. She is just entering Whatcom Drug Court, where she will be directed to treatment and long-term strategies for coping with substance abuse disorder. She will also have her drug-related felony charges absolved upon completion of this program.

“Some of us are lucky,” Suzanne said. “We get to go to Drug Court and get help. Ending up in jail over and over, that doesn’t help anyone.”

Suzanne started using as a coping method after the death of her boyfriend.

Yvonne Prouty, spoke care navigator at Cascade Medical Advantage and counselor at Whatcom Community Detox, said the majority of individuals she encounters struggling or recovering from drug addiction use heroin in combination with another drug.

Washington State Department of Health death reports shows that the combination of opiates and methamphetamine is extremely common, as is the combination of opiates and benzodiazepines, a class of drug often prescribed for treating anxiety, insomnia and epilepsy. Some common benzodiazepines include Xanax or Valium.

Prescription opioids include drugs like oxycodone, codeine, morphine and others. Heroin is an illegal opioid. Opioids are considered “downers” or depressants. Methamphetamine and benzodiazepines are “uppers” or stimulants. The combination of these types of drugs can often be lethal.

Suzanne is an example of this simultaneous usage, reporting both methamphetamine and heroin use.

“That’s a really common combination,” Prouty said. “Based on what I see, there’s a lot of overlap and a lot of deadly combinations.”

The vast majority of drug deaths from the Whatcom County Medical Examiner’s office show multiple substances in an individual’s system at the time of death. The annual report for 2017 is still being processed, but has shown all heroin use to be in conjunction with another substance on death reports.

Another observation made in the 2017 report was the number of deaths where fentanyl was found in the system had increased since 2016. Fentanyl was found in only one death report in 2016, and was found in five death reports in 2017. It was found in combination with another drug in three out of five cases.

It is possible some drugs may no longer be in an individual’s system at time of death, so there is a possibility that these numbers could be understating the prevalence of specific drugs.

Fentanyl is a synthetic opiate that is exceptionally potent and addictive. It may be prescribed in small doses after a severe injury, but is more commonly administered in a hospital setting. Only recently has it become sought after in the illicit drug market. It enhances the effects of drugs like heroin and cocaine, but also makes them much more dangerous.

Fentanyl is something that Chris Furman, therapeutic courts coordinator, is now screening for in urinary analysis reports of her clients at Whatcom County Drug Court. Drug Court is an alternative system for addressing drug related crimes, the goal being to stop criminal behavior by pointing drug abusers to services and treatment, instead of sending them to jail and perpetuating a cycle of criminality. About four or five months ago, Drug Court started screening for this substance.

Furman said she hasn’t had clients come in who report actively using fentanyl, but that multiple clients had told her they suspected a drug they were using had been cut with the substance and that they had likely overdosed because of it, like Chase had.

Terry Foulke, emergency room nurse at St. Joseph Medical Center, said that fentanyl is still very new in the area, but that she has received reports of it being combined with other opiates and causing overdoses.

Fentanyl is extremely potent. In Bellingham, first responders initially began carrying naloxone because they could overdose by coming into contact with fentanyl, Bellingham Police Sgt. Dennis James said.

When naloxone was first developed, it was used to stabilize hospital surgery patients. Wilson said it used to be used only for sedated patients on the operating table, in case of emergency during surgery and always administered by a professional in the medical field. Today, naloxone is extremely accessible. An individual can even buy the name-brand nasal spray, Narcan, at their local Walgreens.

“I don’t think anyone ever imagined we’d be using Narcan for overdoses,” Wilson said.
But today, it is used for exactly that. Foulke called the use of naloxone to combat overdoses “imperative” in today’s opioid-addicted community.

 

Demographics affected show no discrimination

The most common trend in individuals affected by opioid addiction is that there is no specific population affected.

Death reports from the Department of Health indicate an age range of 16 to 77 in Whatcom County overdose deaths in 2015. About 51 percent of the death reports were male and 49 percent were female the same year.

The same is reflected in Whatcom County Drug Court. The youngest person in court right now is 19 and the oldest is 65, Furman said. At the moment, they have more women than men, but Furman said that fluctuates regularly.

“Addiction does not discriminate,” Furman said. “Opioid use is all across the board.”

Furman isn’t the only one to use this term. Wilson and Prouty also described individuals facing opioid abuse problems as “all across the board.”

In terms of race, the demographics closely reflect those of Whatcom County as a whole. The Cascade Medical Advantage Report from July 2017 to February 2018, which records all individuals currently seeking services through Cascade Medical and other Whatcom County service providers, showed 75 percent of people in recovery as Caucasian. As a whole, Whatcom County is 79 percent Caucasian, according to the 2016 American Community Survey Census. The Cascade Medical Advantage Report didn’t distinctly classify minority groups.

Socioeconomic status is harder to measure. Based on testimonies from those dealing directly with these individuals, it seems as though there is a large number of low-income or homeless individuals who struggle with opioid addiction.

“There are a lot of disadvantaged populations who seek services or medical help, but you have to ask yourself, ‘What’s the cart and what’s the horse?’” Foulke said, stating it is not necessarily true that more homeless individuals abuse opioids, but that more opioid addicts may find themselves in situations of homelessness.

She explained that many people who are relatively well-off and begin abusing opioids can quickly find themselves in situations where they lose their jobs or their homes.

This was true for Chase. He began using heroin at age 29, which was also the year he first ended up in jail. He had a good job as an electrician, but his drug use made him unreliable at work and he soon lost his job.

Shortly after, with all of his available savings going to support his heroin addiction, he lost his home. He stopped contacting his children and began living on the street.

“Looking back, that was my lowest point,” Chase said. “My girlfriend and I were living on the streets. She had abscesses all over her body and was days away from dying. Thankfully, she got arrested. I had scars all over my neck and arms. I was stealing to support my drug addiction. But most of all, I was choosing drugs over seeing my kids.”

Chase said he always knew it was a problem, and wanted to want to stop. But it was not until he reached that point of desperation that he became willing to change. Chase is now a client at

Whatcom County Drug Court and is in treatment.

 

Prescription opiate abuse leads to illicit drug use

Although heroin is the most prevalent drug used in Whatcom County, this is not to say that prescription opiate abuse does not exist as well. Four out of every five illicit drug abusers began with prescription drugs, according to Whatcom Hope, an advocacy group to educate the community on opiate addiction.

“The unintended consequence of cracking down on over-prescription was that it drove people to seek pain relief drugs on the street,” public defender Shoshana Paige said.

The regression from prescription opiates to heroin is based on supply and demand, Wilson said. He gave an example of an individual stealing prescriptions from their grandmother’s medical cabinet. If she moves away or starts keeping those pills locked up, that individual needs to find their supply elsewhere. The same is true if someone has a chronic pain condition. If their doctor stops prescribing them their pain relief, the may turn to an illicit substance to treat their pain.

Furman said, in her experience, prescription drugs are the jumping off point for a lot of people.

“You just don’t give people opiates unless it’s absolutely necessary,” Furman said. “It’s like playing Russian roulette of who has a predisposition to abuse drugs.”

Foulke and Wilson remembered trainings, often hosted by big pharmaceutical companies, which taught them that opioids were not addictive if someone was experiencing chronic pain.

One conference specifically presented opioids as a drug to eradicate pain entirely.

“Even at the time, I remember thinking, ‘This seems too good to be true,’” Foulke said.

Foulke’s intuition was correct, and lawsuits are popping up all over the country in response to the deceptive marketing practices from big pharmaceutical companies like Purdue Pharma, Endo Pharmaceuticals and Janssen Pharmaceuticals, County Councilmember Donovan said. Whatcom County’s lawsuit follows suit with similar cases from Tacoma and Everett.

“They aggressively marketed to physicians saying, ‘You should prescribe this, no one will get addicted to it,’” Donovan said. In a previous lawsuit, they even admitted to false marketing, which Donovan said the Whatcom County case will reference in their suit.

Since then, Washington state laws have changed so that prescription opiates are provided for seven instead of 30 days, and no automatic refills are given.

Even though the prescription methods have changed at St. Joseph Medical Center and across the state, opioids are still being overprescribed, Foulke said.

Foulke’s own mother was prescribed oxycodone for pain at the emergency department only weeks prior. Foulke advised her to take Ibuprofen instead.

Another factor is the accessibility of heroin. Heroin is much less expensive and much more available than prescription drugs. This alone can drive people to begin using illicit substances.

 

Grasping for solutions

Facilities like Drug Court and Whatcom Detox are promising, but there are still a lack of services for those attempting to get off of opiates, Furman said.

Whatcom Detox has only eight detox beds, which are constantly full, Furman said. They recently received funding to double the number of beds at the facility, but Furman said that still won’t be enough.

There are two outpatient facilities in Bellingham: Catholic Community Services and Sea Mar Community Health Center. Both are consistently overbooked, Furman said. Two more will be coming to town, Sunrise Services and Lifeline Connections, to help alleviate this pressure.

Clean and sober housing is likewise limited, as well as extremely costly, Furman said.

Drug Court has the capacity to be serving over double its current client count, Paige said. They currently facilitate the cases of 35 clients but could be serving up to 80.

Brad, a 47-year-old male recovering from meth abuse, said heroin doesn’t have the same taboo surrounding it that it did when he was young. He’s seen more and more, younger and younger, individuals using this extremely addictive substance.

“Kids today don’t know what they’re getting into until they’re into it,” he said.

Chase and Brad both said that their first time using drugs was at 13 years old.

“We have seen a huge increase in the younger population,” Sgt. James said. “When I started, heroin was never really seen in high schools. Now we are seeing it in middle schools.”

Nancy Poulin, a registered nurse and supervisor of the syringe services program at the Whatcom County Health Department, said a comprehensive approach to combating this issue is necessary. She said navigating HIPAA, the legal provision that protects the privacy of medical information, presents challenges to ensuring clients can be easily referred to additional health and social services. This is unusually complex because of the added confidentiality the program provides syringe services clients.
“If we’re going to combat this, we need to be talking to each other,” Poulin said. “And it has to happen fast, given the rising rates of [disease] and opioid use that we’re seeing nationally.”

Even though the future seems daunting in terms of combating this epidemic, individual success stories can offer hope.

Prouty actually was a patient at Whatcom Community Detox before she started working there.
“And I’m a Drug Court graduate,” she said proudly.

She wasn’t addicted to opioids, but is an example of how drug addiction can be overcome.

“Nobody gave up on me, so I’m not going to give up on them,” Prouty said. “And I’m going to try to give them encouragement not to give up on themselves.”

Prouty spends her Thursdays doing outreach at the syringe exchange, talking to participants about getting clean. She uses her own story as a way to encourage those currently addicted to opiates.

“If you would have told me when I was a client that nine years from now I’d be sitting here doing this, I would have thought you were crazy,” she laughed. “But now I know that anything is possible.”

 

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