Confronting America’s opioid epidemic
If someone was doing the work Kimberly Blake is doing now just a year or so ago, she said, her son might still be alive.
Blake, an OB-GYN in Burlington, Vermont, is taking on a new experiment to expand addiction treatment and fight the opioid epidemic. Typically, needle exchanges give people who use drugs new, sterile syringes (to avoid infection from reused needles), and may refer people to treatment and provide other health care services. But the needle exchange run by the Howard Center in Burlington, where Blake now works, is doing something above that: offering addiction treatment — specifically, prescribing buprenorphine, a medication for opioid addiction — on the spot.
Blake said she was motivated to join the program as its staff doctor in large part due to her son’s death last year from an overdose involving alcohol and fentanyl, a synthetic opioid that’s increasingly supplanted heroin in the illicit market. She was already involved in addiction treatment and advocacy as she saw her son struggle with drug use over the years, but his death was yet another push to do more to combat the drug overdose crisis — particularly after she realized that her son had used the needle exchange for help.
“Some people are good at writing. Some people are good at public speaking,” Blake said. “I’m a good doctor. And I feel like that’s where I can fill a role to help with this epidemic.”
Before her current job, Blake was already working half-time at an OB-GYN clinic that helps pregnant women get into addiction care. She also had the credentials to prescribe buprenorphine — which, under federal law, requires a special training course. So when the new opportunity opened up at the needle exchange, Blake jumped at it.
“I was able to quickly move into the role,” she said. “And I felt really compelled to try and do something.”
The program exemplifies the kind of innovative steps that Vermont, which has already done a lot to confront the opioid crisis, is pursuing as it continues its expansion of addiction care. While many states — and parts of Vermont — are still working to expand basic addiction treatment, the Burlington needle exchange shows that there are other possibilities to make addiction treatment as accessible as possible to those most in need of it.
All of this goes toward a big problem: In 2017, drug overdose deaths hit yet another record — with more than 72,000 people dying from drug overdoses in the US that year, based on preliminary federal data. New England is one of the regions hardest hit by the crisis, which makes Vermont’s steps and successes all the more relevant.
Vermont has done a lot of work, but there are still gaps
Over the past few years, Vermont has built a “hub and spoke” system that has integrated addiction treatment into the broader health care system. In doing this, the state has not only expanded addiction treatment but also managed to sharply cut waiting periods for treatment. Perhaps as a result, Vermont had the lowest drug overdose death rates in New England in 2017, and it was one of the few states across the country that saw a decline in drug overdose deaths last year.
Grace Keller, a program coordinator for the Howard Center’s needle exchange, saw firsthand how bad access to treatment was before. “People would come to the really scary conclusion that they needed help,” she told me. “I would have to put them on a waiting list, and try to help them mitigate their risk and bear witness to the horrible things that happen to them while they’re waiting. In the last 10 years, I’ve seen people die, go to jail, and lose custody of their children — all while asking for help.”
Things are much better now, Keller said, but Vermont’s work is far from done. Case in point: John Brooklyn, one of the architects of Vermont’s hub and spoke system, estimated that around 35 to 40 percent of people in the state who need care for an opioid use disorder have gotten into treatment. That leaves more than half without care they need.
The Howard Center’s needle exchange, known as the Safe Recovery Program, is offering treatment on site — particularly buprenorphine — to help reach the remaining untreated population.
Buprenorphine has very strong evidence behind it. By subduing cravings and withdrawal, the medication addresses some of the core causes of addiction. Although it’s an opioid, it has a ceiling on its effect — so it can’t cause a high when used as prescribed, and it’s very unlikely to cause an overdose. Studies show buprenorphine, as well as methadone, reduces all-cause mortality among opioid addiction patients by half or more and does a much better job keeping people in treatment than non-medication approaches.
The Howard Center’s needle exchange program has been around since 2000, currently serving about 5,000 clients. It does the kinds of things you would expect from a modern syringe exchange program: It provides not just needles but also the opioid overdose antidote naloxone, fentanyl testing strips, HIV and hepatitis C testing, and referrals to addiction treatment elsewhere. Keller described it as “a comprehensive harm reduction program for people who use drugs.”
There is a ton of research showing that needle exchanges work to combat the spread of infectious diseases like hepatitis C and HIV, cut down on the number of needles thrown out in public spaces, and connect more people to treatment — all without enabling more drug use. This is an exhaustive body of research, backed by independent academic researchers, the World Health Organization, and the Centers for Disease Control and Prevention.
What’s distinct about the Howard Center program is it’s not just referring people to treatment but actually starting them on opioid addiction treatment on site. Although it’s not the first needle exchange to do this (with Prevention Point Philadelphia, among others, having a similar program), the practice is far from standard. But with the help of a recent $525,000 federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Howard Center has jump-started its new approach.
“It’s just another layer of availability,” Blake, the program’s doctor, said. “It’s really meeting people where they’re at and trying to add an additional access point.”
Needle exchanges could be another entry point to addiction treatment
Since it’s a relatively new approach, the research on the concept is early and limited — though some more rigorous studies are underway. That makes it hard to gauge just how much of an impact this kind of approach will ultimately have, particularly at a population level.
But given the evidence on buprenorphine, the approach seems, at least in theory, sound.
Keller said the program aims to solve a persistent problem in addiction care: The decision to seek help can be fleeting — given that addiction does, after all, have a powerful hold over people’s brains.
Keller, for one, has seen people not show up to appointments, set up with the help of the needle exchange, scheduled for the very next day. “I’ve seen those moments pass us by,” she said. “We don’t want any of those moments to pass us by anymore.”
One big advantage for the needle exchange is that people are already present. “Sometimes, when people are thinking about using, it’s kind of a sudden decision,” Blake said. “If you can catch that person in that moment, you might be able to convince them that this isn’t a great idea today. It might be a good idea to use a medication instead of using a needle today.”
Needle exchanges can also tap into the trust that they’ve built with people who use drugs. Since these are programs that are inherently built around not judging those who use drugs, the clients — who often have terrible experiences with other public programs or parts of the health care system — feel like they can be more open with staff at needle exchanges.
Indeed, a 2015 survey published in Substance Abuse found that the majority of clients at a harm reduction agency in New York City would prefer starting buprenorphine treatment at a harm reduction agency, such as a needle exchange, over starting at a general medical clinic or drug addiction treatment program. These findings, though, may not be generalizable to populations at other needle exchanges, since they’re based on a survey of one community.
Still, this suggests an opportunity for needle exchanges: They could get people on buprenorphine and then link them to a traditional treatment program to sustain their recovery. Or perhaps with the right resources, needle exchanges could provide long-term treatment on their own.
Short of that, providing buprenorphine for just a few days could help. “If you’re going to be using something today, use something that’s not as likely to kill you,” Blake said, drawing a contrast between buprenorphine, which is very unlikely to cause an overdose, and heroin or fentanyl.
Ultimately, the research will show how this all works out and which approach is best.
As of last week, Blake said things were going well. She had seen 30 patients since she began her work in late October, and all but three had followed up with her for continuing care, as planned. Blake said that patients were “so grateful.” Two of them had recently gone through overdoses — before treatment — and were, finally, “so happy to be taken care of.”
America needs to expand access to addiction treatment
Much of the US is not Vermont, and still lags far behind in offering even the most basic access to addiction treatment.
A 2016 surgeon general report found that about 10 percent of people in the US with a drug use disorder get specialty treatment — attributing the low rate largely to a lack of access. Even when treatment is available, other federal data suggests that fewer than half of treatment facilities offer opioid addiction medications like methadone and buprenorphine, even though such medications are considered the gold standard for opioid addiction care.
The big problem behind the opioid crisis, as Brandeis University opioid policy expert Andrew Kolodny has explained, is it’s generally easier in the US to get high than it is to get help, because people with opioid addiction have an easier time obtaining drugs like opioid painkillers, heroin, or fentanyl than they do getting effective treatments like methadone and buprenorphine. Until that dynamic flips, Kolodny argues, the opioid epidemic will continue.
Part of solving this will require a long-term investment in addiction treatment. Kolodny and other experts say that the federal government needs to invest tens of billions of dollars above what it’s already investing to accomplish this. And the funding can’t just be one-off, temporary grants — which have been the standard federal response so far — but sustained, long-term funding, like the Ryan White Act that Congress enacted to combat HIV and AIDS.
Vermont’s hub and spoke system, sustained largely by the Obamacare-funded Medicaid expansion, shows the kind of change such an investment can result in. And the needle exchange’s buprenorphine program provides another example of the kind of innovative work, although on a smaller scale, that states can take on to expand treatment along with more traditional approaches.
For Blake, taking part in this work is personal.
“As a parent going through this for 10 years or so, I felt the thing that seemed to me the most helpful in dealing with my son was the harm reduction focus,” she said. “And I know that Sean, my son, received not just syringes at the needle exchange; I know he also felt a lot of compassion there. I wanted to be a part of that.”