By Alex Mann
This article kicks off a Beltway Bulletin series showing the human side of the opioid epidemic. Beneath each set of eye-popping statistics and combative policy proposals, there is a series of stories of the people who experienced the epidemic first hand, one way or another. Beneath each scar is a story.
Gov. Larry Hogan has unveiled a plan to combat a resurgent heroin epidemic in the state of Maryland.
Announced on Jan. 24, the Heroin and Opioid Prevention, Treatment and Enforcement Initiative comes in response to the staggering increase of overdoses, many related to the emergence of the potent synthetic opioid drug fentanyl. Hogan’s plan aims to suppress the epidemic by coordinating resources more efficiently, expanding treatment and creating new law enforcement options.
Based on the Maryland Department of Health and Mental Hygiene’s preliminary 2016 data through quarter three (Jan. – Sept.), heroin-related deaths in the state reached 1,810, a 72 percent increase from the same period in 2015. Deaths related to fentanyl, which is up to 100 times more potent than morphine or street level heroin, skyrocketed to 738 in 2016, a 284 percent increase.
“The most substantial evolution in the last year has been the emergence of fentanyl and other synthetics that have really changed the game,” Anne Arundel County Executive Steve Schuh said. “They are incredibly inexpensive, they are incredibly easy to make, but they are incredibly dangerous.”
Anne Arundel County experienced a 123 percent increase in heroin-related deaths and a 392 percent increase in fentanyl-related deaths through the third quarter of 2016, based on the aforementioned data.
The substitution effect
“When there’s so much of a substitution effect, many people will just go to the next thing,” said Sally Satel, a staff psychiatrist at PIDARC, a methadone clinic in Washington D.C., and lecturer in psychiatry at the Yale University School of Medicine. “It’s paradoxical, but you almost have to wonder if curtailing access to the relatively safer drug is only making more dangerous drugs more prevalent or popular.”
Satel referred to the opioid drug OxyContin as an example. In 2010, pharmaceutical companies made the drug safer.
“People then started using Percocet and Vicodin, [for] the more immediate release forms, or turned to heroin,” she said.
Hogan’s multifaceted initiative can be broken down into four sub-components: establishing an Opioid Operation Command Center to coordinate local, state and federal efforts and resources; new funding for opioid addiction treatment services; a new law that allows for law enforcement to target kingpins prospering from opioid addiction; and two pieces of legislation designed to prevent the crisis from worsening.
The Opioid Operation Command Center will better facilitate the collaboration of state and local public health, human services and public safety units to quell the negative impact of opioid addiction on Maryland communities.
“Any time you have multiple agencies united around a cause and communicating better, that’s a good thing,” said Chris Garrett, communications director at the Maryland Department of Health and Mental Hygiene.
Substance abuse treatment
Hogan’s fiscal year 2018 budget includes $4 million in new funding to assist those caught in the grips of heroin or opioid addiction along with $1.3 billion for mental health and substance abuse disorders.
In addition, Maryland Medicaid will now be able to reimburse for residential substance use treatment.
According to Satel, treatment must vary from patient to patient, depending on the longevity of their drug use. Treatment could include helping patients rebuild socially and treating some of the underlying mental health conditions that fuel drug abuse. For many users, “these drugs serve a purpose.”
Persistent excessive drug use is “fundamentally driven by an effort to self-regulate [or] self-medicate,” Satel said. “I think it often makes sense to see abuse and addiction as a symptom, rather than the primary problem. Still, it can be a very dangerous symptom.”
Cracking down on opioids
On the enforcement front, the Distribution of Opioids Resulting in Death Act, designed for law enforcement to target kingpins, creates a new felony for individuals who distribute an opioid drug that results in another person’s death. The offense will be punishable with up to 30 years incarceration.
The legislation contains protections for those who sell drugs to support their own addiction.
“That is something that came from the general assembly and has been advanced by people like Delegate [Kathleen] Dumais,” Schuh said. “I think it’s preposterous. The second somebody hands heroin to another human being, in my book they have just committed an act of violence against that person.”
Dumais (D) said the Legislative Black Caucus brought up the provision originally, as they feared small-scale street dealers would take the brunt of the extended sentences. She said the bill’s original intent was taking down those manufacturing the drugs.
Seven days upon first consultation
The Prescriber Limits Act and the Overdose Prevention Act are preventative measures to keep the problem from deteriorating further. The former will prevent doctors from prescribing more than seven days worth of opioids upon first consultation.
“The substitution phenomenon certainly puts more emphasis on the importance of treatment, of trying to eradicate the desire to use,” as opposed to blocking access to drugs, Satel said. “I can understand why some states want to limit an initial prescription to seven days. It is not so much pain patients who abuse these drugs, but rather non-patients, so the fewer drugs in circulation, the better.”
Meanwhile, the Overdose Prevention Act will allow local fatality review teams to collect non-fatal overdose data to better recommend prevention strategies. In the past fatality review teams only gathered fatal overdose data. Also, the bill will permit more pharmacists to prescribe naloxone, an opioid blocker, by extending immunity provisions to pharmacists.
Addiction, a human process
“[Opioid addiction is] complicated. If you just think of it as a brain disease, which is the way it’s been ‘medicalized’ over the past two decades,” Satel Said. “You risk not seeing the other dimensions of this phenomenon. It includes the brain, of course, but goes way beyond neurobiology.”
“To me addiction is a very human process,” she added.