The crowd was overflowing at a nondescript convention center in suburban Maryland, a few miles from the Baltimore airport. The event had originally been capped at 350, but organizers had to make plans for an overflow room, seating an additional 150 people. Despite that, registration still maxed out days before the conference took place. Any event that brings together three regional leaders in the same room -- in this case, Maryland Gov. Larry Hogan, Virginia Gov. Terry McAuliffe and Washington, D.C., Mayor Muriel Bowser -- is noteworthy. But that’s not why the overcapacity crowd had shown up on an unseasonably chilly day in May. It’s because they were all there to discuss the opioid epidemic.
Hogan, who issued a state of emergency for Maryland’s opioid overdose problem in March, told attendees at the conference that his state had been doing everything within its power to address the epidemic, without much success. He seemed almost to be pleading with the crowd when he said, “We’re throwing everything we have at this.”
But are we?
Cities and states have tried all sorts of solutions as America’s opioid crisis has worsened. But many public health officials say there are many options -- in some cases, approaches that have been proven effective in other countries -- that are still being left on the table. To really fight this epidemic, these experts say, governments must fully embrace every solution out there. And they may need to change the entire way they think about opioids.
Over the past few years, cities have equipped police officers with naloxone to reverse overdoses in emergency situations. Some health officials, including those in Baltimore and Houston, have written a blanket, jurisdiction-wide prescription for naloxone, making the antidote available to any resident who needs it. Many states have tried to limit the supply of addictive opioids by restricting the number of pain-relief pills a physician can prescribe. Every state (except Missouri) now has a prescription drug database intended to stop potential users from doctor-shopping to obtain more drugs. And last summer, 46 governors signed a compact to double down on policies that could curb the epidemic. Led by Massachusetts Gov. Charlie Baker, the compact outlines specific steps that governors pledge to follow. This includes changing prescription guidelines, establishing more public awareness campaigns and pursuing good Samaritan laws, which protect someone from arrest if they help at an overdose scene.
The deepening crisis has even caused some leaders to embrace more controversial approaches, such as needle exchange programs. In 2015, for example, when an HIV outbreak caused by injecting opioids decimated one south Indiana county, then-Gov. Mike Pence was reluctant to act on what public health advisers were telling him was necessary to curb the outbreak: allowing clean needles to be distributed and dirty needles to be safely disposed of. It took enormous political pressure from both parties, in Indiana and nationally, before Pence agreed to allow a needle exchange program. Even then, the governor said he was still “opposed to needle exchange as anti-drug policy. But this is a public health emergency.” Two years later, these programs are already far less controversial. Today, the American Civil Liberties Union estimates there are 185 needle exchange programs across the country.
Other leaders are also exploring approaches that seemed politically unthinkable just a short time ago, including safe injection sites, where addicts can shoot up heroin under the supervision of a health-care professional and without fear of being arrested. The idea is to prevent people from overdosing while also offering them information about treatment. Vancouver, British Columbia, established a site in 2003 and has prevented nearly 5,000 overdoses since then, according to the clinic’s website. For years, the notion of setting up a sanctioned safe injection facility in the U.S. was a nonstarter. But now, Seattle lawmakers have approved a site that they hope to start building on soon. The idea is also being considered by leaders in Boston and San Francisco, where Mayor Ed Lee only recently dropped his opposition to them. “I had to kind of force myself to be open to the idea,” he told a reporter in January, “because it doesn’t come as a natural thing.”
The future of such facilities, however, could be shaped by the federal government. Attorney General Jeff Sessions hasn’t commented on safe injection clinics specifically, but he has signaled a tough-on-drugs approach that would presumably not include such facilities. Leana Wen, Baltimore’s health commissioner, recently said that Sessions’ stance has given her pause on whether a safe injection site is even worth pursuing. She’s asked the federal government how it would respond if the city were to establish safe injection sites, but said she hasn’t heard back. “I’m not one to shy away from a fight,” she said, “but we need further guidance from the feds if we’re going to proceed with this.”
Still, there are other solutions that public officials in the U.S. have been less willing to embrace. One of those is medication-assisted treatment, in which a physician prescribes a controlled substance, most commonly methadone and buprenorphine, to help an addict transition safely from opioid dependence. The idea is still controversial. Health and Human Services Secretary Tom Price criticized the practice, warning that it could just be replacing one opioid for another. But it’s an approach that has already proven effective elsewhere: After France allowed all doctors to prescribe buprenorphine, for example, opioid overdose deaths dropped by 69 percent. Here in the U.S., Melinda Campopiano, medical officer with the Substance Abuse and Mental Health Services Administration, says that medication-assisted treatment cuts the mortality rate for drug users in half. But she acknowledges that it can seem counterintuitive. “Giving an opioid to an opiate user doesn’t click really well, but it’s the truth: If you want someone to not overdose, this is the definitive overdose strategy,” she says. “Detox is not treatment.”
It’s hard to get comprehensive information on medication-assisted treatment, but it’s estimated that there are now around 1,000 programs in the U.S. For example, Tennessee, which lost more than 1,400 residents in 2015 to drug overdoses, now counts nearly 6,000 active patients in its methadone treatment program. Those kinds of numbers may sound like a lot, but health experts say they’re actually low. One reason for that may be a nationwide lack of doctors, since physicians must complete a specialized course before they become certified in medication-assisted treatment.
Other countries have used wastewater testing to find hot spots of drug abuse. It can take months or years to get community-level data on drug use. But wastewater hot-spotting is usually reportable within a day, and it’s typically more reliable than medical records and patient surveys. For an epidemic that varies in severity from one ZIP code to the next, having real-time, hyper-local data is necessary to distribute resources properly. But the idea has yet to take hold in the U.S., likely because it’s still a relatively new concept that requires coordination across agencies. Aparna Keshaviah, a statistician from the firm Mathematica Policy Research, says she’s aware of recent interest among policymakers, but there are still lots of questions, including which agencies would fund and oversee wastewater testing, that still haven’t been hashed out.
Even if officials in the U.S. were to pursue every available solution to the opioid crisis, however, the approaches can seem frustratingly piecemeal, like plugging a hole in a dike only to see two leaks spring up elsewhere. Naloxone can reverse overdoses in an emergency, but it doesn’t reduce addiction rates. Prescription databases prevent people from doctor-shopping for more pills, but those users often just start buying their drugs illegally. Limiting the supply of prescription opioids like Oxycontin has only led to a surge in fentanyl, an opioid that’s 50 times stronger than heroin and 100 times more potent than morphine. Fentanyl is so powerful that an Ohio police officer accidentally overdosed on the substance while searching the car of a suspected drug dealer. He passed out after brushing some of the powder off his shirt; other officers had to administer four doses of naloxone to revive him. Another emerging opioid, carfentanil, is an elephant tranquilizer that’s 10,000 times stronger than morphine and has been blamed for hundreds of recent overdoses. These new, increasingly potent substances continue to make the epidemic a moving target.
Part of the challenge for public officials is that “the opioid epidemic” is really a fight on two very separate fronts: the increased use of heroin in young adults in urban and suburban areas, and older adults abusing prescription drugs like Oxycontin in more rural areas. “You can cut the state of Virginia in half,” Gov. McAuliffe said at the Maryland conference. “On the East Coast, around Virginia Beach, it’s all heroin and now the more potent fentanyl. Then I can drive eight hours to Abingdon in the southwest corner of the state, and I can tell you there are no heroin problems there. It’s all prescription drugs.”
That makes the current crisis different from previous drug epidemics involving methamphetamines or crack cocaine. And it’s why some health experts say that cities and states need to reframe the whole way they think about the opioid outbreak. It’s not simply about the rise of a new class of addictive drugs that now take the lives of some 91 Americans every day. The opioid crisis is a jobs crisis; it’s an affordable housing crisis. The same forces that have reshaped the economy over the past decade have left a void that’s been filled, in many places, by opioids. A University of Pennsylvania study after last November’s election found that President Trump had overperformed in counties with the highest rates of “deaths of despair,” which include suicide, drug overdose and alcohol poisoning. It supports the fact that there are many Americans who feel left behind by the changing economy, and who fundamentally don’t believe the current political and policy framework is helping them. “Those [people] are hard hit by unemployment, uncertain futures,” says Baltimore’s Wen. “They look out the window and they don’t think that tomorrow will be any different than today. That’s something we have to address -- the demand for drugs to treat something other than physical pain.”
The opioid crisis is also a mental health crisis. In America’s patchy behavioral health system, stigma and a siloed care model prevent many people from seeking and receiving mental health care, which can exacerbate an opioid dependence. The Affordable Care Act attempted to address this with a parity law that required insurance plans to cover mental health on par with primary care services. But that measure has been weakly enforced.
Addressing those broader issues is, of course, vastly more difficult and would require a much more cohesive, coordinated approach. Public health officials can’t bring back middle-class jobs or make housing more affordable. But what they can do is push for safe housing, equitable access to care, and comprehensive addiction education in primary schools. And when the next drug epidemic does occur, public health officials have the responsibility to push for scientifically proven harm reduction tactics that might be politically controversial in the moment, says Wen. “Unlike many other diseases where we have very little information, we actually know what works [with addiction]. We just need the resources.”
Many local officials are optimistic that such a shift is finally happening, that there’s a genuine realization that addressing the opioid crisis requires leadership from all sectors of government. “I’ve had a lot of people complaining to me that when it was crack cocaine we didn’t have all of this kumbaya, come-together stuff,” says Phyllis Randall, the chair of the Board of Supervisors for Loudoun County, Va. “That’s true, but it is what it is. So let’s take what we’ve learned and apply it to every other drug.”