Hope and help amid opioid OD epidemic

2018 may break annual chain of death increases

Bill Kinkle hasn’t worked as a nurse in nearly a decade, but the Pennsylvania man never leaves home without emergency medical supplies. Always on his belt: naloxone, a medication that can reverse an opioid overdose and save a life. Kinkle, who lives in the Philadelphia suburb of Willow Grove, says his own life has been saved by naloxone more than once.

Nearly 15 months into recovery from heroin addiction, he carries a card telling others where they can get help. His message, he says, is that “people can recover, they do recover, and they are worth the effort.”

Kinkle handed out those cards at two Philadelphia libraries last month as they hosted what the Pennsylvania Health Department called the largest naloxone giveaway ever. About 80 sites participated statewide.

It was one effort among many, by governments, organizations and individuals, to fight a drug overdose epidemic that killed more than 52,000 Americans in 2015, 63,000 in 2016 and 70,000 in 2017.

But 2018 might have been a turning point.

“Every year for 23 years, we’ve set a new record for overdose deaths,”

says Andrew Kolodny, who researches opioid policy at Brandeis University in Massachusetts. If provisional data from the first half of 2018 hold up, he says, “it could be the first year in 23 years that deaths don’t increase.”

The latest update from the federal Centers for Disease Control and Prevention shows that deaths peaked at 72,775 in the 12 months that ended in October 2017. Opioids were responsible for nearly 50,000 of those deaths.

After that, the running 12-month total declined slightly each month through May 2018 before ticking up slightly to 70,652 in June 2018. Preliminary data from the second half of the year are not yet available.

“While we don’t yet know if 2018

“My biggest fear is that we are going to take our foot off the gas. Now is when we have to put our pedal to the floor.” Bill Kinkle, addiction survivor

is going to show a decrease, we’ve got a pretty good inkling that it’s at least not increasing as rapidly,” says Lauren Rossen, a statistician at the CDC’s National Center for Health Statistics.

If 2018 was a turning point, there’s still a long way to go.

The crisis began with a wave of prescription opioid overdose deaths in the late 1990s. A second wave emerged when heroin deaths surged in 2010. The third wave, still crashing over the country, started with a spike in deaths linked to powerful synthetic opioids, especially illicit fentanyl, in 2013, CDC data show.

Fentanyl deaths kept rising in the first half of 2018, provisional data show.

“The number of deaths is still huge,” says Daniel Ciccarone of the University of California-San Francisco, a physician who studies opioid use and supply.

What states have done

Progress is uneven. As of June 2018, provisional data show, deaths were falling in fewer than half of states while rising or holding steady in others.

Some of the states hit hardest by the epidemic have seen apparent declines – some sporadic, some sustained. Some of the programs and policies adopted in those states might offer a road map for others:

❚ Vermont: Five years ago, then-Gov. Peter Shumlin devoted his entire state of the state address to “a full-blown heroin crisis.” Since then, state Health Commissioner Mark Levine says, Vermont has eliminated waiting lists for opioid addiction treatment. The state pioneered a “hub and spoke” system of regional treatment centers linked to trained primary care providers. The mainstay is medication-assisted treatment, in which drug users get safe doses of narcotic medications such as methadone or buprenorphine, which reduce cravings and withdrawal symptoms. Or they might get naltrexone, which blocks the effects of opioids, reducing their appeal. The medications are paired with counseling and social support.

❚ Rhode Island: The small state was the first to broaden the use of medication-assisted treatment to all prisoners who might benefit. That includes those entering prison during treatment or withdrawal and those who have been opioid-free in prison but risk restarting the drugs upon release.

❚ Kentucky: Intravenous drug users can get clean needles – usually along with naloxone kits and information about treatment and other services – at about 50 “syringe service” sites operating under state guidelines passed in 2015. That makes Kentucky a leader in such efforts.

❚ Ohio: Ohio is among many states that use Medicaid expansion to get more people into treatment. It uses federal grants to train more providers. Ryan Hampton, a recovery advocate and author who lives in California, says he saw something more when he visited hardhit Dayton in late 2017: “A true disaster response” had taken hold, he says. Social workers and peer counselors knocked on the doors of overdose survivors to offer help as part of a program run by the sheriff’s office.

❚ Pennsylvania: Under a series of disaster declarations, officials from 15 agencies meet once a week to address the opioid crisis, says state Health Secretary Rachel Levine.

The state developed its own hub and spoke treatment system. Under orders Levine signed in 2015, anyone in the state can get naloxone without a prescription; the state gave away more than 6,100 kits of the drug in December. The state runs public service announcements aimed at lifting the stigma around addiction. “It’s a medical condition,” Levine says. “It’s not a moral failing.”

Looking for more answers

If overdose deaths did decline or level off in 2018, Kolodny cautions, it will be “impossible to draw a straight line” to any program or policy.

“The truth is we don’t know what factors are having the greatest impact,” he says. “It needs to be studied.”

Ciccarone, the researcher at the University of California-San Francisco, advises a broad approach.

“All good answers need to be on the table and be funded,” he says. “States that are doing better didn’t just use one monolithic answer.”

The Trump administration awarded states and communities $1 billion last year for treatment and prevention. The Obama administration spent $1 billion on such grants over the two previous years. Some states provided substantial additional funding.

Still, Ciccarone says, “we haven’t devoted enough money yet.”

Hampton, the California activist, has been in recovery himself for more than three years. He wants to see more long-term recovery services that address housing, jobs and social and medical needs.

“If we can get someone past year five of recovery,” he says, “they’ve got an 85 percent chance of sustaining their recovery.”

Whether the apparent slowdown in deaths can be sustained is another question. Vermont’s Levine says the challenges remain daunting.

“A lot of the underlying factors that produced this crisis haven’t changed very much,” he says.

One thing that has changed, Ciccarone says, is how many Americans view people with drug use disorders.

“Society has softened its stance on what it means to be dependent on a drug,” he says. “The fact is that it’s ubiquitous among the wealthy and unwealthy. … It’s an American problem.”

Kinkle, the Philadelphia recovery advocate, hopes his fellow Americans will keep trying to save people like him.

“My biggest fear is that we are going to take our foot off the gas,” he says. “Now is when we have to put our pedal to the floor.”

JASPER COLT/USA TODAY Bill Kinkle, holding his son Isaiah, has spent more than a year in recovery from heroin addiction. Now he helps others get help.