On this last episode, we look back on 23 years of joyous, difficult and always informative conversation.
The opioid crisis is ongoing in this region, and still very much an epidemic.
In D.C., Maryland and Virginia the number of opioid prescriptions being written has dropped in past years, and in D.C. and Maryland prescription overdoses have dropped too. But overall overdose deaths (including from synthetic opioids like fentanyl) are still on the rise across the region. While jurisdictions like D.C. are rolling out pilot programs to prevent and reverse overdoses it’s not clear how effective they’ll be.
Opiate addiction is not mutually exclusive with other health issues, mental or physical, and many patients deal with a unique combination. Particularly when coupled with socioeconomic disparities, the differences in who is addicted to what mean that coming up with a cookie-cutter solution to the crisis isn’t just difficult – it’s more or less impossible.
We’ll hear from three people whose organizations are working toward solutions to the opioid crisis.
Produced by Maura Currie
- Andy Robie Family Physician, Chief Medical Information Officer at Unity Health Care
- Faye Taxman Director of the Justice Community Opioid Innovation Network at George Mason University
- Quinton Askew President/CEO, Maryland 211
KOJO NNAMDIYou're tuned into The Kojo Nnamdi Show on WAMU 88.5. Later in the broadcast concerns about racism continue to plague a school district in Northern Virginia, but first the opioid epidemic is ongoing in our region. The latest data from the national institute on drug abuse says while overdose deaths are decreasing in D.C. and Maryland, they're increasing in Virginia and the spectrum of who battles addiction and to what opioid is vast, which means of course that there's no single solution that will work for every patient.
KOJO NNAMDIEnding the opioid crisis means ending individual addiction through long term care and management. But for many vulnerable groups that's easier said than done. Joining us to talk about the progress that's been made and the work that needs to be done is Andy Robie, a Family Physician and the Chief Medical Information Officer at Unity Health Care here in Washington D.C. Andy Robie, thank you so much for joining us.
ANDY ROBIEThank you for having me.
NNAMDIRemind us first, Andy Robie, opioids are not just prescription pain medications. When we talk about these drugs, what are we referring to?
ROBIESo, you know, certainly we're referring to prescription pain medications, but particularly in the District thinking about the opioid crisis we're referring to heroin and then also to this newer and really potent synthetic called fentanyl.
NNAMDIYour organization, Unity Health Care, is a general care provider in the District, but you also do a lot of work with addiction care and management. What happens when a patient walks in looking for help with opioid addiction?
ROBIEYeah. So, you know, over the past couple of years we've benefitted from a lot of funding from the D.C. Department of Health and from HAHSTA that's allowed us to greatly expand our capacity to provide treatment for patients with opioid use disorder. And so, you know, I guess we see patients coming in in a few different circumstances. So we see patients who perhaps are receiving primary care services at Unity, have a relationship with a primary care doctor who maybe isn't prepared or trained to treat opioid use disorder. And, you know, at some point that provider identifies, you know, the patient as using heroin or using fentanyl and needs help and submits a referral to our medication assisted treatment program, what we call the Opioid Recovery Program.
ROBIEWe see lots of patients who, you know, are familiar with Unity, because we have clinics in their community who self-refer. Call a phone number and get connected with one of our case managers and get an appointment to see a provider. And then also are starting to see patients who are being released from in-patient drug treatment programs or from the Department of Corrections, who have been engaged in treatment of those programs and need kind of continuity of care in the community that we're able to provide care for.
ROBIEAnd so, you know, what we are primarily focused on offering at Unity is treatment with medications. And so there are two primary medications that we offer. One is called Buprenorphine, you know, commonly referred to by the brand name Suboxone. And then more recently we've been able to offer an injectable medication called Naltrexone or Vivitrol and those medications help to -- you know, well in the case of Buprenorphine reduce withdrawal symptoms from opioids. But both of them really work to reduce opioid cravings and help people maintain abstinence for opioids as they kind of progress in their recovery.
NNAMDIWell, we've heard a lot about Naloxone. What about Naloxone?
ROBIEYeah, so Naloxone is a really important medication, you know, kind of from a harm reduction standpoint. Naloxone is what's called an opioid antagonist or an opioid blocker. It's a medication that's used to reverse opioid overdoses. And so, you know, what we know is that when somebody overdoses on opioids and often by the time EMS gets there to treat them it's too late. And so it's really critical to get that overdoes reversal medication in the hands of people who, you know, either themselves are prone to overdose or who have context family members or friends who are using opioids and might overdose. So they can get that overdose reversal as soon as possible when they do overdose. And so, you know, D.C. recently bought a very large number of doses of Naloxone. And they've really been working to get that out in the community and into the hands of people.
NNAMDIYes. Apparently there's a pilot program that's being run in the District. Tell us about that and what kind of impact it has so far because this is one approach the use of Naloxone, correct?
ROBIESure. Yeah, so the District purchased I think 60,000 is the number of doses of Naloxone. Naloxone can be, you know, it's an injectable medication. But also kind of more commonly in the hands of a lay person is used as in intranasal medication. So it's sprayed into the nose. And so, you know, the District Department of Health offers training to medical people, but also to people without any medical background about how to identify somebody who's overdosing and how to administer Naloxone to that person. And then have, you know, really gotten the medication into the hands of, you know, our medical clinics or really all of our clinics have Naloxone that we've gotten from the District to give to patients.
ROBIEBut also a lot of different community organizations where they've trained people to teach patients how to use it or teach, you know, family members how to use it. And so I personally, you know, treat a lot of patients with medication for their opioid use disorder. Many of those people continue to use opioids and are at risk for overdose I try to get Naloxone in the hands of all of patients. You know, with the hope that they won't need to use it. But I have had, you know, quite a few patients, who've used the Naloxone and have reversed either their own overdose or a friend that sort of reverse their own overdose or family member's overdose.
NNAMDIJoining us in studio is Faye Taxman, Director of the Justice Community Opioid Innovation Network at George Mason University. Faye Taxman, thank you for joining us.
FAYE TAXMANThank you for having me today.
NNAMDIYou're directing as I mentioned George Manson University chapter of the Justice Community Opioid Innovation Network or JCOIN. What aspects of the opioid crisis will JCOIN be researching?
TAXMANSo let me explain JCOIN first.
TAXMANJCOIN is an initiative that's funded by the National Institute on Drug Abuse that consists of -- recently just added a new one today. Of 13 research centers around the United States to basically look at the use -- how to address the use of opioids among people involved in the Justice System. So in this country we know we have one of the highest incarceration rates in the world. Little known fact that people don't like to talk about is that we also have a large proportion of almost six million people on probation and parole supervision. And people who are involved in the Justice System have almost a 400 times greater likelihood of lifetime us of some sort of opioid than the general population.
TAXMANSo NIDA is funding this collaborative, called JCOIN, to basically address the opioid crisis, and look at different innovative ways of trying to provide medication assisted treatments like Andy was just talking about throughout different segments of the Justice System, but also in the community. The center I'm running is Coordination and Translations Center and our goal is to really look at improving uptake throughout the justice and health communities in terms of acceptance of MAT medications as a treatment for people with opioid disorders.
NNAMDIWhat are MAT medications?
TAXMANSo MAT refers to Medication Assisted Treatment like Andy talked about, Buprenorphine, Vivitrol, Naltrexone. You know, those are the assortment of medications. And usually in the Justice System people don't think that you should treat one medication for a drug abuse problem or a substance use program. And so a lot of the work that we're going to be doing is about increasing the acceptability that we should be using medications either by themselves or as a supplement to behavioral therapy to really help people with opioid disorders. And also to improve recovery rates.
NNAMDIWe'll talk about some more about that later. But joining us by phone is Quinton Askew, President and CEO of Maryland 2-1-1. Quinton Askew, thank you for joining us.
QUINTON ASKEWNo problem. Thank you for inviting me.
NNAMDIFor those who have never called the line, what is Maryland 2-1-1?
ASKEWSo Maryland 2-1-1 by law is the Health and Human Service referral number for the state. It's been around since 2006 a little over 13 years. And any individual who lives within the State of Maryland can call 2-1-1 for a Health and Human Service need. Whether that's understanding, I don't know how to pay my bill. I can't afford to pay my rent or I'm looking for any mental health or substance abuse services. Individuals dial 2-1-1. They are connected to one of our four regional call centers. We have a call center that's looked in Baltimore. One that's in Frederick. One that's located on the lower eastern shore as well. And so they answer calls throughout the State of Maryland for any of our residents.
NNAMDIAnd so if someone calls in looking for resources for opioid addiction, what kinds of resources do you offer them?
ASKEWSo we -- last year we developed -- 2007 Governor Hogan declares state of emergency, and what that did was that triggers a rapid response of coordination throughout the state. And just last year we partnered with Maryland Department of Health and Behavior Health Administration to take over their Maryland Crisis Hotline. And so any of our residents who are suffering from any opioid or substance abuse they would dial 2-1-1 and press one. And they would be automatically connected to one of our call centers for treatment incidents, counseling referral or any emergency crisis needs.
ASKEWSo someone can call 24 hours a day, 365 days a year. Also we have technology where individuals are also able to text and chat with us. So individuals who may not have an interest in speaking to someone over the phone they can also text and chat. But all of our call centers are nationally accredited through American Association of Suicidology or information and referral. And so in 2-1-1 Maryland we have a robust data base of over 6,000 resources is able to connect someone to services immediately within their community.
NNAMDIThis is not solely an addiction help line, though. Many of the people who call you are grappling with issues other than addiction. What is the helpline equipped to do?
ASKEWYes. That is correct. And so by law we are an information service referral line. So individuals can call us for anything related to understanding where a food bank is, wanting to understand how they can volunteer in their community, or they're looking for a job or a cold weather shelter. So we can provide information on any particular health and human service need in the closest zip code or community that they're in. There have been individuals who are specifically in crisis or need specific substance abuse services, those folks are immediately connected with one of our call specialists in which they would dial 2-1-1, press one.
ASKEWBut folks can contact us for any health and human service need that they might have. And oftentimes we find that individuals that there might be a substance abuse need. That there's also some other financial or support that the individual's needs. And so with 2-1-1 we take that holistic approach that, you know, let us be able to help find you supports that you need in order for you to become self-sufficient. And so it may not just be one entity. But we want to ensure that they have all the resources and information they need.
NNAMDIAndy Robie, Doug in Potomac couldn't stay on the line, but writes, "I just wanted to make a quick comment, 25 to 30 years ago I used to take a drug that had Naloxone in it. Why don't they put that in OxyContin?"
ROBIEWell, so I'm not sure what drug that was 25 or 30 years ago, but, you know, Naloxone is an opioid blocker. It would actually counteract the effect of OxyContin. So it would make that, you know, not an effective pain medication. I'm not sure that would be a good approach.
NNAMDIAnd here now is Roman in southern Maryland. Roman, you're on the air. Go ahead, please.
ROMANHi. How are you today, Kojo?
ROMANGood. I'm also doing very well. I was born addicted to heroin and to methadone. In the 1960s and I spent a large part of my life struggling with opioid addiction and I tried everything, you know. From cold turkey to abstinence only programs and I tried -- at some point I did try Suboxone, but I found it very difficult. It gave me horrible headaches. And it did not make me feel like I wanted to not do drugs. It made me -- I still wanted to do drugs on it. Some people it works wonderfully for. I finally found methadone, which you haven't mentioned on the show. And I believe it's the gold standard. But it's so heavily stigmatized that a lot of communities will not allow a methadone clinic in their area, because they believe that it will bring crime and it will bring other problems when in reality the crime is already there.
ROMANThe addicts are already there. They just need help. And some of the programs are punitive. It's difficult to get into them. You have to go every single day until you're stable, but then you're still -- you know, you have to continue going. I think eventually it needs to be something that is provided through a primary care doctor who is, you know, properly trained after someone has stayed --
NNAMDIGet rid of some of the stigma that's associated with it. I do take your point, Roman. But I would like to have Faye Taxman respond.
TAXMANSo Roman raises a good point about the regulation of methadone. So the way in which we regulate methadone, which is actually through the DEA is it has to be provided at clinics and those clinics have certain hours. Plus the person who's on methadone even if they've been on methadone for 10 years they have to participate in counseling. So it's a very heavily regulated medication. It's one area in which a lot of folks like Roman have commented that we need to revisit these medications. In Europe, methadone is provided at pharmacists. And people can go in and get their daily doses. And they just go in and they leave and go about their business. There's some take-home methadone programs that also exist. All of those are basically changes we need in our regulations to be perfectly honest, if we want to expand the use of methadone.
TAXMANAnd, you know, for some people methadone is the wonder drug, other people Buprenorphine; you know, every individual is different. So we really do need to offer a wider variety. But dealing with the stigma issue is one of the most critical factors if we want to expand how we address the opioid crisis in this country. We have to, you know, get rid of this notion that people in recovery basically are different than the rest of the population. And looking at our regulations and practices for our clinics is really an important component of that.
NNAMDIGot to take a short break, when we come back we will continue this conversation giving you an update on the opioid crisis and the innovative attempts being made to help people to recover from it. I'm Kojo Nnamdi.
NNAMDIWelcome back, we're discussing the opioid crisis in this region and the innovative measures that are being taken to help people to recover. We're talking with Quinton Askew, President and CEO of Maryland 2-1-1. He joins us by phone. Andy Robie is a Family Physician and the Chief Medical Information Officer at Unity Health Care here in D.C. And Faye Taxman is Director of the Justice Community Opioid Innovation Network at George Mason University. Andy Robie, late last week the D.C. Department of Behavioral Health announced that it's expanding the community response team initiative which handles addiction crisis as well as mental health crisis. Do you see a lot of overlap like that in your line of work?
ROBIEAn overlap between mental health crisis and addiction crisis, absolutely, so, you know, a very large portion of folks who are struggling with addiction are also struggling with other mental health disorders like depression, anxiety. In fact, you know, sometimes people are using opioids to, you know, to treat anxiety or initially start using them to address some mental health issues that haven't been treated otherwise.
NNAMDIHere is Jackie in Columbia, Maryland. Jackie, you're on the air. Go ahead, please.
JACKIEHi. This is Jackie McCoy. Hi, Quinton from Howard County days. I just had kind of statement or a question. I noticed that whenever people of low income or people who are struggling have to access some sort of support they have to prove that they're poor. Every place they go, it's a scholarship. It's an opportunity. You got to prove that you're poor. Is there some kind of way to standardize things so that people are not first of all humiliated every time they have to ask for help or, you know, having to pull up paperwork and go through all these changes, which is probably why people don't access the help that's available.
NNAMDIOkay. Two questions for you with regard to that. Andy Robie, what demographic are you mostly seeing come in for treatment?
ROBIEYeah, so, you know, in the District we're seeing mostly men in their 40s, 50s, 60s and even 70s. You know, the opioid crisis in D.C. really is focused in Ward 7 and 8. So these mostly are low income men who often have been using heroin since they were teenagers or in their 20s. So for many years.
NNAMDIBeyond the general practice setting, Unity Health Care is also doing some work with specific populations. Talk about that.
ROBIESo, you know, I guess one specific population that we do work with is folks in the correction setting. So I'm happy to be here with Faye talking about the opioid abuse disorder in that setting. So Unity provides all the care in the D.C. Department of Corrections or the D.C. jail. And we've really been expanding our efforts to identify folks, who are struggling with opioid use disorder in that setting and provide them with a couple of full range of treatment options, and then really working to connect them with care in the community after they get released.
NNAMDIAnd Quinton Askew, our caller who seems to know you is concerned about low income individuals and their ability to access resources.
ASKEWYeah, and so with one of the things that is unique about 2-1-1 is that we have a variety of resources that fit sort of any particular income level. Of course, most of folks who may call may be low income or just trying to survive, but if individuals who are calling 2-1-1, you know, with our robust database of resources we are usually able to connect them with something fits within their income means.
TAXMANSo, Kojo, I wanted to add.
NNAMDIPlease go ahead Faye.
TAXMANWhen Quinton was talking about 2-1-1 services, so in Montgomery County they actually started with a crisis center. If they get someone who overdoses or has an opioid problem they actually have peer navigators that they call. And those peer navigators then make connection with that individual and or their families. They'll go to the hospitals. They'll begin the process of trying to help people look at their use patterns or their housing situations to try and encourage people to get treatment for their opioid disorders. This model of taking the crisis interventions -- crisis centers and equipping them with peer navigators is something that other jurisdictions have looked at.
TAXMANIn fact in some places they actually have, you know, fire departments when EMS goes out to actually bring information about treatment, and then go back and see people after an incident occurs. That's some of the innovations that are really going on around this country. And I think they recognize that it doesn't matter what class or status you are. You know, the people when they are in this crisis situations of overdoses we need to really help them navigate through these systems and really begin the process of thinking about what are some of the options.
NNAMDIHere now is Nathan in southeast Washington. Nathan, you're on the air. Go ahead, please.
NATHANHey, Kojo. Thanks for having me on. I'm a social worker at Anacostia High School. And the thing that I think about is so a lot of the students that get into opioids usually start with prescription painkillers like Percocet or Vicodin. And so I guess for me I'm wondering -- it becomes very difficult because these drugs are manufactured by the pharmaceutical industry. And they, you know, get out by one way or another. And they end up in our communities.
NATHANSo are we doing enough on a federal level to be aggressive towards the pharmaceutical industry? And one thing comes to mind is for an example, Steny Hoyer over in Maryland. He accepted -- I don't know -- thousands of dollars from opioid distributors. Some of the biggest opioid distributors in Maryland and has not been aggressive enough in my opinion on holding them accountable and kind of stopping it at the federal level so it becomes more difficult for the pills to get into our communities. And then on the ground level it becomes an epidemic.
NNAMDIWell, Virginia, D.C. and Maryland have all taken legal action against Purdue Pharma, the company that manufactures OxyContin. At what level do you think, Andy Robie, the drug manufacturers are responsible for this crisis?
ROBIEThat's a tough question. But, you know, I think, you know, there certainly has been kind of a -- or was a concerted effort to, you know, convince physicians and patients that these were safe medications. You know, and when I was early in my training the message that I got was, you know, as long as somebody has pain and they're taking these medications as prescribed, you know, they're not going to become addicted. That's not going to be an issue. And, you know, my understanding is a lot of that originated from the pharmaceutical industry. And so, you know, I think they do play a significant role and bare a skin of responsibility.
NNAMDIWell, healthcare providers across the country are looking at cracking down on opioids by prescribing less and for shorter periods of time. But aren't there any unintended consequences of that approach?
ROBIESure. Yeah. So, you know, there are many patients in this country who've been on opioids. You know, taking them as prescribed for pain for, you know, many years at this point. And so a few years ago, I think in 2016, the CDC released some guidelines, you know, around opioid prescribing that really suggested limiting the duration of prescribing, limiting the amount that's prescribed. And I think these were all good things, but some of the unintended consequences were, you know, physicians looked at these guidelines and started to get embarrassed or perhaps angry that maybe we'd been misled or fed, you know, bad information about the efficacy and safety of opioids.
ROBIEStarted to look at our patients and worry that, you know, we were doing harm to them by continuing to prescribe opioids. And then also, you know, like a lot of us got worried about regulatory scrutiny from boards of medicine, from the DEA, from pharmacies and, you know, different places like that. And then the other thing we saw is that payers started to implement a lot of controls over opioid prescribing. So requiring, you know, prior authorizations for patients to be able to get the opioids that maybe they'd been on for a decade to treat their pain or just limiting access generally making it impossible for patients to continue to fill the prescriptions that they'd been relying on for a lot of time.
ROBIEAnd so, you know, like what we saw is a lot of physicians pretty abruptly stopping opioids for patients who had been taking them, you know, as safely as possible for a lot of years. And, you know, quite a few of those patients turned to illicit avenues to obtain opioids. Often turning to heroin and other, you know, more potent and dangerous opioids to help alleviate the withdrawal that they were experiencing and to help treat their pain.
NNAMDIThat's the unintended consequences.
NNAMDIFaye Taxman, one might assume that people, who might have been in and out of the Justice System have gotten ahold of opioids illegally on the street, for example. Why is that not necessarily accurate?
TAXMANWell, you know, actually Buprenorphine is available and is used oftentimes by people to address cravings and they can acquire them illegally on the streets. So it is a concern in terms of, you know, it's called diversion of these medications. So it is a concern, but part of that concern is how easy access can we make it for people to get medications? Right now we have a lot of barriers. I mean, for example, there's limitations for physicians like Andy. You know, how many patients that he can actually prescribe to. Putting that kind of limitations means that, you know, it's harder for doctors and or LPNs who do some of the prescriptions also to be able to have, you know, robust patient load.
TAXMANSo, you know, the diversion is an issue. But I think more of the issue is, you know, helping people who have opioid disorders learn how to manage their disease. Much like we teach people with diabetes or cardiac problems.
NNAMDILet's start with a person who's in jail. If you're incarcerated while using opioids it's likely you'll have to quit without medical intervention. How could that affect the patient's addiction recovery?
TAXMANWell, withdrawal is a very painful process. It's not a pleasant process and so, you know, that actually sets people up for failure. That's why a lot of jails are moving and prisons are moving to a process where they begin people on medication before they leave. And therefore continue in the community afterwards. Since we don't treat an opioid disorder as a medical issue, we treat more as, you know, moral failing usually of an individual, jails and prisons aren't really setup the way we should in terms of trying to help them learn to deal with their disorder.
TAXMANYou know, very few people get access to treatment whether it's behavioral health or medication treatment in jails and prisons. There are some states like Massachusetts that actually just, you know, started to require that every jail, if someone comes in on a medication they have to continue on the medication. That's not true here. In Maryland and Virginia, if you come in on a medication it's not necessarily that the jail will continue you on that medication. So all those things are very disruptive and it also makes the person much more vulnerable.
NNAMDIAnother piece of the puzzle that you focus on is the role of probation and probation officers. How common is opioid use among probationers?
TAXMANOh, it's extremely common. I mean, you know, like I said earlier they statistics are the probationers have 300 to 400 times greater use of opioids than the general population. An average probation officer is going to have a good portion of their -- depending on where they are in the State of Maryland, Virginia or D.C. on opioids. They're ill prepared to deal with a substance use disorder. I mean, typically probation, you know, does referral. There's new methods now about thinking about what's the new role of probation, how can they connect better with treatment services, how do we encourage, you know. There is some places where -- actually not in this area where the local clinic like Unity would actually have health providers at a probation office so you would create more one stop shops. Those are some of the innovations.
NNAMDIAlmost out of time. Quinton Askew, but are addiction resources spread out evenly across Maryland or are there areas with more pronounced need?
ASKEWThe resources that we have with 2-1-1 are spread out across the state. And so especially within our rural communities that individuals are able to contact us with 2-1-1 press 1 and be able to connect to those resources that are close directly in their community. That they're able to reach to for when need help. Again, you know, 24 hours a day, 365 days a weeks, individuals are able to get the service that they do need.
NNAMDIAnd I'm afraid that's all the time we have. Quinton Askew is the President and CEO of Maryland 2-1-1. Faye Taxman is Director of the Justice Community Opioid Innovations Network at George Mason University. And Andy Robie is a Family Physician and the Chief Medical Information Officer at Unity Health Care here in Washington. Thank you all for joining us. We're going to take a short break. When we come back, concerns about racism continue to plague a school district in Northern Virginia. I'm Kojo Nnamdi.
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