PracticePerspectivesFallI S S U E

2 0 1 9

Takia Richardson, L ICSW, LCSW

Sen ior P rac t i ce Assoc ia te

t r i chardson.nasw@soc ia lworkers .org

750 First Street NE, Suite 800 Washington, DC 20002-4241 SocialWorkers.org

The National Association of Social Workers

750 First Street NE

Suite 800

Washington, DC 20002-4241

SocialWorkers.org

©2019 National Association of Social Workers. All Rights Reserved.

Practice Perspectives Fall 2019

America’s Drug Crisis: Challenges and Successes in the Opioid Epidemic and Beyond

Introduction Fallout from the opioid epidemic has gripped the country. Rural and suburban communities have seen substance misuse at unprecedented levels. From OxyContin in medicine cabinets to mail-order fentanyl from China, increasingly potent opiates have infiltrated communities, producing more than 100 overdose deaths per day. In the 12-month period ending in November 2017, the number of drug overdose deaths reached a high of 70,723 (Ahmad et al., 2019). Finally, in 2018 researchers noticed the first decrease in the rates of opioid-related overdose deaths in almost 30 years. That same year, researchers also noticed an upward trend in the use of stimulants (that is, cocaine and methamphetamines) either alone or in tandem with other opiates. Federal health officials have identified this as the fourth wave, although it is far less widespread than previous iterations of the opioid crisis.

The epidemic has typically been discussed in three waves. Its roots can be traced back to the mid-1990s with a noted increase in prescription opiates for the treatment of pain. This quickly led to pill mills, misuse, and overdose deaths once users discovered they could alter the composition of the pills to obtain the highest levels of the narcotic. This is commonly referred to as the first wave. The second wave of the epidemic started around 2010. After federal prescribing restrictions, prescription opiates were much more difficult to obtain. Some users switched to heroin, which was cheaper and more widely available. There was a noted increase in heroin use and accidental overdoses. While seeking to address the growing heroin epidemic, health care providers, state and federal government agencies, and researches noted a significant increase in overdose deaths related to fentanyl, a manufactured opioid available from China and Mexico. Fentanyl, which is significantly stronger than OxyContin and heroin, has high abuse potential, profit margins, and overdose risk. The use of fentanyl and other synthetic opioids skyrocketed, marking the third wave. Although officials noticed an increase in the availability of and overdoses related to fentanyl starting around 2013, little was done to address use of this drug specifically in the early days. Officials have not yet identified an

Fallout from the

opioid epidemic

has gripped the

country. Rural

and suburban

communities have

seen substance

misuse at

unprecedented

levels.

effective approach in dealing with the various waves of the opioid crisis and are starting to express concern about a possible fourth wave. Substance misuse involving stimulants, such as cocaine and methamphetamines, used either alone or with opioids, is shifting the drug crisis landscape once again.

The First Wave: Prescription Opiates In the mid-1990s, the American Pain Society identified the undertreatment of pain as a major issue. It argued that pain management was insufficient in American medicine and pushed to have pain rebranded as the fifth vital sign. Physicians were urged to assess pain with increased regularity and to take the management of pain more seriously. As a result, physicians from primary care settings to hospitals and college health centers began prescribing opioid analgesics. Opioids were prescribed for a variety of ailments from invasive surgery to a sore throat (Cicero & Ellis, 2017). The risk for addiction to opioid analgesics, which were widely available, was significantly downplayed. Purdue Pharma developed and aggressively marketed OxyContin as a treatment for moderate to severe pain with low abuse potential. OxyContin was appealing to some because of the time-release mechanism that required the user to take the analgesic once or twice daily as opposed to every few hours. This time-release mechanism was an integral part of the marketing campaign, as it was touted as an important factor in reducing the likelihood of abuse and addiction. Purdue Pharma poured a considerable amount of money into marketing and had high expectations from the sales reps. Tactics used to bolster drug sales—including lucrative bonuses to sales reps; OxyContin “starter packs” for distribution to potential customers; and “all expenses paid” symposia, OxyContin-branded gifts, and free samples for physicians, pharmacists, and nurses—were remarkably effective. Prescriptions of OxyContin increased from 670,000 in 1997 to almost 6.2 million in 2002 (U.S. Government Accountability Office, 2003). The composition and mass distribution of the analgesic were problematic. Because of the time-release mechanism, OxyContin contained higher levels of narcotic. Patient package inserts advised against crushing or dissolving the pills, warning that tampering with the product could

result in the delivery of an uncontrolled, possibly fatal dose of oxycodone. “Purdue’s own testing in 1995 had demonstrated that 68% of the oxycodone could be extracted from an OxyContin tablet when crushed” (Van Zee, 2009, p. 223). Crushing the pills to snort or dissolving to inject produced a heroin-like high. This made it appealing on the black market and increased its popularity in the underground drug scene. A pill that may have cost, at most, five dollars from the pharmacy now demanded up to 15 times that on the street. Opioid-related overdoses and deaths began to increase due to the prevalence of natural and semisynthetic opioids (for example, oxycodone and hydrocodone). Over a 14-year period, from 2000 to 2014, almost 500,000 people died from drug overdoses (Rudd, Aleshire, Zibbell, & Gladden, 2016). Most of these overdose deaths involved prescription opioids or heroin. Federal and state governments started a crack-down to address overprescribing in an attempt to ebb the tide of current and newly addicted patients. Prescription drug monitoring programs were instituted to track patient prescription histories. In May 2007, Purdue Pharma paid $600 million in fines and payments to resolve criminal and civil lawsuits for “misbranding.” In 2010, Purdue Pharma reformulated OxyContin, making the pill harder to crush or dissolve. The Second Wave: Heroin The changes in the formulation of OxyContin had an impact on the use and abuse of opioids. Nonmedical pain reliever (NMPR) users were faced with a choice—use the new formulation as prescribed, stop use altogether, or find a cheaper alternative. A portion of those who had abused prescription opioids and were no longer able to obtain them due to federal and state restrictions transitioned to heroin, ushering in the second wave of the epidemic. Heroin was a cheaper alternative and it was easier to procure. It is important to note that not every NMPR user became addicted to or even used heroin, but there was a subset of users who transitioned to heroin to meet the continuing needs of their addiction. Data from a 2013 Substance Abuse and Mental Health Services Administration (SAMHSA) report show that while four out of five recent heroin users previously used prescription opioids, only about 4 percent of NMPR users

transitioned to using heroin within the five years following first NMPR use (Muhuri, Gfroerer, & Davies, 2013). In addition, multiple studies show that factors other than NMPR use played a role in the transition to heroin. Prior drug use (pills to heroin, cocaine to heroin), family or friends who used, and polydrug use are some of the more common pathways to heroin use, with poly- or prior drug use shown to be the most common path (Kane-Willis, Schmitz, Bazan, Narloch, & Wallace, n.d.; Muhuri et al., 2013). As heroin use rates increased, the medical, research, and criminal justice communities noticed that the users began to look different than those who used heroin in the 1960s and 1970s. Users were no longer predominately people of color who resided in urban areas. The demographics had shifted to affluent white men and women who resided in suburban or rural areas (Cicero, Ellis, Surratt, and Kurtz, 2014). Over the course of five years, from 2010 through 2014, heroin overdoses continually increased, tripling from 8 percent of all drug overdose deaths in 2010 to 23 percent in 2014 (Warner, Trinidad, Bastian, Miniño, & Hedegaard, 2016). The Third Wave: Fentanyl and Fentanyl Analogs An already complicated opioid landscape became deadlier with the introduction of fentanyl, the third wave of the opioid epidemic. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine. It was first developed in 1959 for use as an intravenous analgesic. The first formulation of fentanyl as a transdermal patch was introduced in 1990. Over the years, several iterations of the drug were produced in the form of lozenges, lollipops, and oral and nasal sprays. However, most fentanyl-related overdoses are not the result of misuse of pharmaceutical-grade fentanyl but rather illegally manufactured versions of the drug coming from cartels in Mexico or through direct order from China off the dark web. Dealers started mixing fentanyl into heroin to stretch the product and increase the potency. Some users were exposed to the drug without prior knowledge or consent and, at times, overdosed on a drug they never knew they had taken. Others sought out fentanyl-laced substances, aware of the possibility of a lethal dose but addicted to the high it produces and no longer able to obtain the same effect from straight heroin.

Prior to 2014, overdoses involving fentanyl had remained relatively stable (1,645 in 2010; 1,656, in 2001; 1,605 in 2012). Between 2013 and 2014, fentanyl-related overdoses more than doubled from 1,905 to 4,200 (Warner et al., 2016). By 2015, the number of people who died from fentanyl or other synthetic opioid overdoses had increased to 9,803, a number that would more than double the following year. Due to its potency, a few grains of fentanyl analogs are enough to cause a fatal overdose. Carfentanil, a drug used as a sedative for large animals that is 10,000 times more potent than morphine, poses a particularly dangerous threat to users and first responders. A fatal dose of fentanyl can be as low as 2 mg. A fatal dose of carfentanil can be as low as 0.02 mg. Law enforcement officials are advised to wear gloves and masks when handling the drug to avoid accidental overdose, as it can be absorbed into the skin or inhaled while breathing.

Drug cartels have seen the impact of fentanyl on the drug market and their bottom line. Fentanyl and fentanyl analogs are being added to counterfeit prescription pills, cocaine, and methamphetamines. Illegal fentanyl analogs are easily ordered from the dark web and sent through the U.S. Postal Service. Some communities, such as Montgomery County, Ohio, report that upward of 60 percent to 70 percent of all deaths are fentanyl overdose deaths. The availability, potency, and impact of fentanyl across all demographics requires new approaches to deal with the fallout. The Fourth Wave: Stimulants and Polysubstance Use In the early 2000s, domestic meth labs were popping up across the country. To address the scourge of exploding labs and hazardous exposure for law enforcement, officials instituted limitations on purchases of pseudoephedrine, which was used to make homemade methamphetamines. These restrictions helped and there was a temporary drop in rates of meth production and use. This hiatus was short-lived. Mexican drug cartels took over production of meth, producing mass quantities and trafficking the drug into the United States. The cartels have been able to produce a product that is almost 100 percent pure and cheaper than most other drugs on the market. At a recent Centers for Medicaid and

As heroin use rates

increased, the

medical, research,

and criminal justice

communities noticed

that the users began

to look different than

those who used

heroin in the 1960s

and 1970s. Users

were no longer

predominately people

of color who resided

in urban areas. The

demographics had

shifted to affluent

white men and

women who resided

in suburban or rural

areas (Cicero, Ellis,

Surratt, and Kurtz,

2014).

Fallout from the

opioid epidemic

has gripped the

country. Rural

and suburban

communities have

seen substance

misuse at

unprecedented

levels.

effective approach in dealing with the various waves of the opioid crisis and are starting to express concern about a possible fourth wave. Substance misuse involving stimulants, such as cocaine and methamphetamines, used either alone or with opioids, is shifting the drug crisis landscape once again.

The First Wave: Prescription Opiates In the mid-1990s, the American Pain Society identified the undertreatment of pain as a major issue. It argued that pain management was insufficient in American medicine and pushed to have pain rebranded as the fifth vital sign. Physicians were urged to assess pain with increased regularity and to take the management of pain more seriously. As a result, physicians from primary care settings to hospitals and college health centers began prescribing opioid analgesics. Opioids were prescribed for a variety of ailments from invasive surgery to a sore throat (Cicero & Ellis, 2017). The risk for addiction to opioid analgesics, which were widely available, was significantly downplayed. Purdue Pharma developed and aggressively marketed OxyContin as a treatment for moderate to severe pain with low abuse potential. OxyContin was appealing to some because of the time-release mechanism that required the user to take the analgesic once or twice daily as opposed to every few hours. This time-release mechanism was an integral part of the marketing campaign, as it was touted as an important factor in reducing the likelihood of abuse and addiction. Purdue Pharma poured a considerable amount of money into marketing and had high expectations from the sales reps. Tactics used to bolster drug sales—including lucrative bonuses to sales reps; OxyContin “starter packs” for distribution to potential customers; and “all expenses paid” symposia, OxyContin-branded gifts, and free samples for physicians, pharmacists, and nurses—were remarkably effective. Prescriptions of OxyContin increased from 670,000 in 1997 to almost 6.2 million in 2002 (U.S. Government Accountability Office, 2003). The composition and mass distribution of the analgesic were problematic. Because of the time-release mechanism, OxyContin contained higher levels of narcotic. Patient package inserts advised against crushing or dissolving the pills, warning that tampering with the product could

result in the delivery of an uncontrolled, possibly fatal dose of oxycodone. “Purdue’s own testing in 1995 had demonstrated that 68% of the oxycodone could be extracted from an OxyContin tablet when crushed” (Van Zee, 2009, p. 223). Crushing the pills to snort or dissolving to inject produced a heroin-like high. This made it appealing on the black market and increased its popularity in the underground drug scene. A pill that may have cost, at most, five dollars from the pharmacy now demanded up to 15 times that on the street. Opioid-related overdoses and deaths began to increase due to the prevalence of natural and semisynthetic opioids (for example, oxycodone and hydrocodone). Over a 14-year period, from 2000 to 2014, almost 500,000 people died from drug overdoses (Rudd, Aleshire, Zibbell, & Gladden, 2016). Most of these overdose deaths involved prescription opioids or heroin. Federal and state governments started a crack-down to address overprescribing in an attempt to ebb the tide of current and newly addicted patients. Prescription drug monitoring programs were instituted to track patient prescription histories. In May 2007, Purdue Pharma paid $600 million in fines and payments to resolve criminal and civil lawsuits for “misbranding.” In 2010, Purdue Pharma reformulated OxyContin, making the pill harder to crush or dissolve. The Second Wave: Heroin The changes in the formulation of OxyContin had an impact on the use and abuse of opioids. Nonmedical pain reliever (NMPR) users were faced with a choice—use the new formulation as prescribed, stop use altogether, or find a cheaper alternative. A portion of those who had abused prescription opioids and were no longer able to obtain them due to federal and state restrictions transitioned to heroin, ushering in the second wave of the epidemic. Heroin was a cheaper alternative and it was easier to procure. It is important to note that not every NMPR user became addicted to or even used heroin, but there was a subset of users who transitioned to heroin to meet the continuing needs of their addiction. Data from a 2013 Substance Abuse and Mental Health Services Administration (SAMHSA) report show that while four out of five recent heroin users previously used prescription opioids, only about 4 percent of NMPR users

transitioned to using heroin within the five years following first NMPR use (Muhuri, Gfroerer, & Davies, 2013). In addition, multiple studies show that factors other than NMPR use played a role in the transition to heroin. Prior drug use (pills to heroin, cocaine to heroin), family or friends who used, and polydrug use are some of the more common pathways to heroin use, with poly- or prior drug use shown to be the most common path (Kane-Willis, Schmitz, Bazan, Narloch, & Wallace, n.d.; Muhuri et al., 2013). As heroin use rates increased, the medical, research, and criminal justice communities noticed that the users began to look different than those who used heroin in the 1960s and 1970s. Users were no longer predominately people of color who resided in urban areas. The demographics had shifted to affluent white men and women who resided in suburban or rural areas (Cicero, Ellis, Surratt, and Kurtz, 2014). Over the course of five years, from 2010 through 2014, heroin overdoses continually increased, tripling from 8 percent of all drug overdose deaths in 2010 to 23 percent in 2014 (Warner, Trinidad, Bastian, Miniño, & Hedegaard, 2016). The Third Wave: Fentanyl and Fentanyl Analogs An already complicated opioid landscape became deadlier with the introduction of fentanyl, the third wave of the opioid epidemic. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine. It was first developed in 1959 for use as an intravenous analgesic. The first formulation of fentanyl as a transdermal patch was introduced in 1990. Over the years, several iterations of the drug were produced in the form of lozenges, lollipops, and oral and nasal sprays. However, most fentanyl-related overdoses are not the result of misuse of pharmaceutical-grade fentanyl but rather illegally manufactured versions of the drug coming from cartels in Mexico or through direct order from China off the dark web. Dealers started mixing fentanyl into heroin to stretch the product and increase the potency. Some users were exposed to the drug without prior knowledge or consent and, at times, overdosed on a drug they never knew they had taken. Others sought out fentanyl-laced substances, aware of the possibility of a lethal dose but addicted to the high it produces and no longer able to obtain the same effect from straight heroin.

Prior to 2014, overdoses involving fentanyl had remained relatively stable (1,645 in 2010; 1,656, in 2001; 1,605 in 2012). Between 2013 and 2014, fentanyl-related overdoses more than doubled from 1,905 to 4,200 (Warner et al., 2016). By 2015, the number of people who died from fentanyl or other synthetic opioid overdoses had increased to 9,803, a number that would more than double the following year. Due to its potency, a few grains of fentanyl analogs are enough to cause a fatal overdose. Carfentanil, a drug used as a sedative for large animals that is 10,000 times more potent than morphine, poses a particularly dangerous threat to users and first responders. A fatal dose of fentanyl can be as low as 2 mg. A fatal dose of carfentanil can be as low as 0.02 mg. Law enforcement officials are advised to wear gloves and masks when handling the drug to avoid accidental overdose, as it can be absorbed into the skin or inhaled while breathing.

Drug cartels have seen the impact of fentanyl on the drug market and their bottom line. Fentanyl and fentanyl analogs are being added to counterfeit prescription pills, cocaine, and methamphetamines. Illegal fentanyl analogs are easily ordered from the dark web and sent through the U.S. Postal Service. Some communities, such as Montgomery County, Ohio, report that upward of 60 percent to 70 percent of all deaths are fentanyl overdose deaths. The availability, potency, and impact of fentanyl across all demographics requires new approaches to deal with the fallout. The Fourth Wave: Stimulants and Polysubstance Use In the early 2000s, domestic meth labs were popping up across the country. To address the scourge of exploding labs and hazardous exposure for law enforcement, officials instituted limitations on purchases of pseudoephedrine, which was used to make homemade methamphetamines. These restrictions helped and there was a temporary drop in rates of meth production and use. This hiatus was short-lived. Mexican drug cartels took over production of meth, producing mass quantities and trafficking the drug into the United States. The cartels have been able to produce a product that is almost 100 percent pure and cheaper than most other drugs on the market. At a recent Centers for Medicaid and

As heroin use rates

increased, the

medical, research,

and criminal justice

communities noticed

that the users began

to look different than

those who used

heroin in the 1960s

and 1970s. Users

were no longer

predominately people

of color who resided

in urban areas. The

demographics had

shifted to affluent

white men and

women who resided

in suburban or rural

areas (Cicero, Ellis,

Surratt, and Kurtz,

2014).

An already

complicated opioid

landscape became

deadlier with the

introduction of

fentanyl, the third

wave of the opioid

epidemic. Fentanyl

is a synthetic

opioid that is 50 to

100 times more

potent than

morphine.

Medicare Services meeting, U.S. Department of Health and Human Services assistant secretary of health Dr. Brett Giroir identified methamphetamine use as the fourth wave and recommended that it is viewed as a public health issue.

The Drug Enforcement Agency reported recent seizures of cocaine and methamphetamines, indicating an increase in the supply of both drugs. Of note, Customs and Border Patrol found that these seizures did not typically contain traces of fentanyl or other opiates. This contamination seems to occur on the local level. In addition to fentanyl- contaminated stimulants, there is a subset of the drug-using population that willingly takes stimulants and opiates either concurrently or consecutively. A Centers for Disease Control and Prevention issued a report in 2017 that examined the “emerging drug pattern” of heroin and methamphetamine drug injection, noting that among 592 participants, 29.2 percent reported injecting only heroin, 20.8 percent reported injecting only methamphetamines, and 50 percent reported injecting both over the previous 12-month period (Al-Tayyib, Koester, Langegger & Raville, 2017). In addition, approximately half of methamphetamine users have an opioid use disorder. Ellis, Kasper, and Cicero (2018) explored the increases in methamphetamine use across regions and demographics from 2011 to 2017. Researchers found that use is the highest in the western part of the country, a trend that has remained consistent. Use increased among both men and women, but researchers noted that use among women almost doubled. Use was consistently higher in rural areas than both urban and suburban areas. Use by white people has increased and outpaced use by nonwhite people since 2015. The 35- to 44-year-old age group showed the most significant use rate increases. In addition, there was a two-fold increase in methamphetamine use among opioid users entering treatment. Users report combining the two drugs to create a roller coaster high or to balance the sedating effect of opiates, to deal with unavailability of opioids, lower price point, and not having to deal with the same restrictions opioid use presents. Interventions In a return to practices from the early 1900s, some police departments have begun employing licensed social workers to help them address the opioid

epidemic as they move away from criminalization of addiction and aim to treat it from a health perspective. How social work skills are implemented varies between municipalities. Some departments have social workers accompany officers in opiate outreach programs. Other departments have social workers accompany officers on every overdose call. In both instances, social workers are available to provide treatment and community resources to the user and their family. In New Hampshire, a state that ranks in the top five for fentanyl overdose deaths and at the bottom for treatment program availability, fire departments have implemented “safe station” programs where users can walk in to get connected with drug treatment. Law Enforcement Assisted Diversion (LEAD) programs have seen a new push in popularity as the nation seeks to identify long-term solutions (for example, treatment and wraparound services) as opposed to short-term fixes (for example, arrests). Programs and communities have seen that arrests are ineffectual and, at times, increase the overdose rates. People with an opioid use disorder who are arrested and have not made the choice to abstain from the drug face painful withdrawals while behind bars and an increased risk of overdose if they use upon release due to decreased tolerance. LEAD programs offer a warm handoff to a treatment or social services organization for screening and assessment for people who come in contact with law enforcement or for those who want help to transition to a sober lifestyle. Office-based opioid treatment (OBOT) is a form of integrated behavioral health care that allows users to access medication-assisted treatment (MAT) in primary care physicians’ offices with waivers. Social workers can perform the necessary OBOT services, including psychosocial assessments, counseling or therapy, and monitoring treatment adherence and progress with the added benefit of being able to connect consumers with community resources such as housing or provide assistance with other psychosocial factors that may contribute to substance use issues. Some jurisdictions, particularly rural areas, prefer OBOT programs to opioid treatment programs, which require the user to report to a treatment program daily to receive methadone. The time and transportation costs and requirements are not ideal in many situations. The National Rural Health Association has listed several policy recommendations to address the opioid epidemic in rural communities

where access to psychiatrists, nurse practitioners, social workers, and psychologists is significantly lower than in urban communities (Hancock et al., 2017). On a larger scale, the University of Texas–Austin College of Pharmacy, Steve Hicks School of Social Work, and Texas Overdose Naloxone Initiative developed Operation Naloxone. Operation Naloxone is a SAMHSA grant-funded initiative developed to increase access to treatment, reduce unmet treatment needs, and reduce overall opioid overdose deaths through prevention, recovery activities, and MAT. Operation Naloxone offers resources for patients and professionals. For patients, they offer a naloxone fact sheet, an interactive map identifying pharmacies and organizations that offer naloxone, how to administer naloxone, and information on how to test for the presence of fentanyl. For clinicians, they offer live and Web-based trainings and resources on risk evaluation, prescribing practices, and naloxone administration. The Council on Social Work Education (CSWE, n.d.) has developed recommendations for addressing the opioid epidemic for federal policymakers and highlighted the role that social workers can and should play in addressing this issue. CSWE advocates for the expansion of integrated behavioral health care and the inclusion of social workers in those settings. They support including social workers in federal education and training programs dedicated to reducing the shortage of substance use professionals. CSWE has developed the Social Work and Integrated Care Project, an initiative to implement integrated behavioral health education into MSW programs. To date, 30 schools of social work have accepted and added the curriculum, which offers tracts in clinical practice and policy. Addressing the psychostimulant crisis poses a more challenging issue. There is no MAT for stimulants, as there is for opioids. Further complicating the landscape, combining stimulants with opioids not only alters the signs of an overdose (that is, shallow breathing, unresponsiveness, pinpoint pupils, choking or gurgling sounds) but decreases the effectiveness of naloxone. At the present time, detoxification and behavioral therapy are considered the most effective techniques to treat a methamphetamine addiction.

Conclusion The National Survey on Drug Use and Health (NSDUH) distributed by SAMHSA (2018) is a survey of substance use, mental health, and treatment services collected in face-to-face field interviews. The 2018 NSDUH reported an overall decrease in opioid use disorders, from 2.1 million in 2017 to 2 million that year. Opioid overdoses dropped by 5 percent; the first decrease since the 1990s. The NSDUH identified stronger prescribing restriction, expanded access to treatment (including MAT), widespread availability of and access to naloxone, and increased awareness of the presence and dangers of fentanyl as reasons for the decline. The social work response to this epidemic should encourage novel approaches (for example, use of technology in identifying naloxone distribution sites, getting trained in naloxone administration, distributing fentanyl testing strips) while staying true to the foundation on which our profession was built. However, many jurisdictions note that traditional methods (for example, partnering with law enforcement, using the person-in-environment framework, educating family, and addressing social determinants) have proven successful and should continue to be implemented. With many communities continuing to see the effects of fentanyl in illicit substances beyond heroin and the growing concern over the increased prevalence of methamphetamines, the challenge to identify and implement programs and interventions to address this epidemic is far from over. References Ahmad, F. B., Escobedo, L. A., Rossen, L. M., Spencer, M. R., Warner, M., & Sutton, P. (2019). Provisional drug overdose death in the United States. Hyattsville, MD: National Center for Health Statistics. Al-Tayyib, A., Koester, S., Langegger, S., & Raville, L. (2017). Heroin and methamphetamine injection: An emerging drug use pattern. Substance Use & Misuse, 52, 1051–1058. doi:10.1080/10826084. 2016.1271432 Cicero, T. J., & Ellis, M. S. (2017). The prescription opioid epidemic: A review of qualitative studies on the progression from initial use to abuse. Dialogues in Clinical Neuroscience, 19, 259–269. Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry, 71, 821–826. doi:10.1001/jamapsychiatry.2014.366

In a return to

practices from the

early 1900s, some

police departments

have begun

employing licensed

social workers to help

them address the

opioid epidemic as

they move away from

criminalization of

addiction and aim to

treat it from a health

perspective.

An already

complicated opioid

landscape became

deadlier with the

introduction of

fentanyl, the third

wave of the opioid

epidemic. Fentanyl

is a synthetic

opioid that is 50 to

100 times more

potent than

morphine.

Medicare Services meeting, U.S. Department of Health and Human Services assistant secretary of health Dr. Brett Giroir identified methamphetamine use as the fourth wave and recommended that it is viewed as a public health issue.

The Drug Enforcement Agency reported recent seizures of cocaine and methamphetamines, indicating an increase in the supply of both drugs. Of note, Customs and Border Patrol found that these seizures did not typically contain traces of fentanyl or other opiates. This contamination seems to occur on the local level. In addition to fentanyl- contaminated stimulants, there is a subset of the drug-using population that willingly takes stimulants and opiates either concurrently or consecutively. A Centers for Disease Control and Prevention issued a report in 2017 that examined the “emerging drug pattern” of heroin and methamphetamine drug injection, noting that among 592 participants, 29.2 percent reported injecting only heroin, 20.8 percent reported injecting only methamphetamines, and 50 percent reported injecting both over the previous 12-month period (Al-Tayyib, Koester, Langegger & Raville, 2017). In addition, approximately half of methamphetamine users have an opioid use disorder. Ellis, Kasper, and Cicero (2018) explored the increases in methamphetamine use across regions and demographics from 2011 to 2017. Researchers found that use is the highest in the western part of the country, a trend that has remained consistent. Use increased among both men and women, but researchers noted that use among women almost doubled. Use was consistently higher in rural areas than both urban and suburban areas. Use by white people has increased and outpaced use by nonwhite people since 2015. The 35- to 44-year-old age group showed the most significant use rate increases. In addition, there was a two-fold increase in methamphetamine use among opioid users entering treatment. Users report combining the two drugs to create a roller coaster high or to balance the sedating effect of opiates, to deal with unavailability of opioids, lower price point, and not having to deal with the same restrictions opioid use presents. Interventions In a return to practices from the early 1900s, some police departments have begun employing licensed social workers to help them address the opioid

epidemic as they move away from criminalization of addiction and aim to treat it from a health perspective. How social work skills are implemented varies between municipalities. Some departments have social workers accompany officers in opiate outreach programs. Other departments have social workers accompany officers on every overdose call. In both instances, social workers are available to provide treatment and community resources to the user and their family. In New Hampshire, a state that ranks in the top five for fentanyl overdose deaths and at the bottom for treatment program availability, fire departments have implemented “safe station” programs where users can walk in to get connected with drug treatment. Law Enforcement Assisted Diversion (LEAD) programs have seen a new push in popularity as the nation seeks to identify long-term solutions (for example, treatment and wraparound services) as opposed to short-term fixes (for example, arrests). Programs and communities have seen that arrests are ineffectual and, at times, increase the overdose rates. People with an opioid use disorder who are arrested and have not made the choice to abstain from the drug face painful withdrawals while behind bars and an increased risk of overdose if they use upon release due to decreased tolerance. LEAD programs offer a warm handoff to a treatment or social services organization for screening and assessment for people who come in contact with law enforcement or for those who want help to transition to a sober lifestyle. Office-based opioid treatment (OBOT) is a form of integrated behavioral health care that allows users to access medication-assisted treatment (MAT) in primary care physicians’ offices with waivers. Social workers can perform the necessary OBOT services, including psychosocial assessments, counseling or therapy, and monitoring treatment adherence and progress with the added benefit of being able to connect consumers with community resources such as housing or provide assistance with other psychosocial factors that may contribute to substance use issues. Some jurisdictions, particularly rural areas, prefer OBOT programs to opioid treatment programs, which require the user to report to a treatment program daily to receive methadone. The time and transportation costs and requirements are not ideal in many situations. The National Rural Health Association has listed several policy recommendations to address the opioid epidemic in rural communities

where access to psychiatrists, nurse practitioners, social workers, and psychologists is significantly lower than in urban communities (Hancock et al., 2017). On a larger scale, the University of Texas–Austin College of Pharmacy, Steve Hicks School of Social Work, and Texas Overdose Naloxone Initiative developed Operation Naloxone. Operation Naloxone is a SAMHSA grant-funded initiative developed to increase access to treatment, reduce unmet treatment needs, and reduce overall opioid overdose deaths through prevention, recovery activities, and MAT. Operation Naloxone offers resources for patients and professionals. For patients, they offer a naloxone fact sheet, an interactive map identifying pharmacies and organizations that offer naloxone, how to administer naloxone, and information on how to test for the presence of fentanyl. For clinicians, they offer live and Web-based trainings and resources on risk evaluation, prescribing practices, and naloxone administration. The Council on Social Work Education (CSWE, n.d.) has developed recommendations for addressing the opioid epidemic for federal policymakers and highlighted the role that social workers can and should play in addressing this issue. CSWE advocates for the expansion of integrated behavioral health care and the inclusion of social workers in those settings. They support including social workers in federal education and training programs dedicated to reducing the shortage of substance use professionals. CSWE has developed the Social Work and Integrated Care Project, an initiative to implement integrated behavioral health education into MSW programs. To date, 30 schools of social work have accepted and added the curriculum, which offers tracts in clinical practice and policy. Addressing the psychostimulant crisis poses a more challenging issue. There is no MAT for stimulants, as there is for opioids. Further complicating the landscape, combining stimulants with opioids not only alters the signs of an overdose (that is, shallow breathing, unresponsiveness, pinpoint pupils, choking or gurgling sounds) but decreases the effectiveness of naloxone. At the present time, detoxification and behavioral therapy are considered the most effective techniques to treat a methamphetamine addiction.

Conclusion The National Survey on Drug Use and Health (NSDUH) distributed by SAMHSA (2018) is a survey of substance use, mental health, and treatment services collected in face-to-face field interviews. The 2018 NSDUH reported an overall decrease in opioid use disorders, from 2.1 million in 2017 to 2 million that year. Opioid overdoses dropped by 5 percent; the first decrease since the 1990s. The NSDUH identified stronger prescribing restriction, expanded access to treatment (including MAT), widespread availability of and access to naloxone, and increased awareness of the presence and dangers of fentanyl as reasons for the decline. The social work response to this epidemic should encourage novel approaches (for example, use of technology in identifying naloxone distribution sites, getting trained in naloxone administration, distributing fentanyl testing strips) while staying true to the foundation on which our profession was built. However, many jurisdictions note that traditional methods (for example, partnering with law enforcement, using the person-in-environment framework, educating family, and addressing social determinants) have proven successful and should continue to be implemented. With many communities continuing to see the effects of fentanyl in illicit substances beyond heroin and the growing concern over the increased prevalence of methamphetamines, the challenge to identify and implement programs and interventions to address this epidemic is far from over. References Ahmad, F. B., Escobedo, L. A., Rossen, L. M., Spencer, M. R., Warner, M., & Sutton, P. (2019). Provisional drug overdose death in the United States. Hyattsville, MD: National Center for Health Statistics. Al-Tayyib, A., Koester, S., Langegger, S., & Raville, L. (2017). Heroin and methamphetamine injection: An emerging drug use pattern. Substance Use & Misuse, 52, 1051–1058. doi:10.1080/10826084. 2016.1271432 Cicero, T. J., & Ellis, M. S. (2017). The prescription opioid epidemic: A review of qualitative studies on the progression from initial use to abuse. Dialogues in Clinical Neuroscience, 19, 259–269. Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry, 71, 821–826. doi:10.1001/jamapsychiatry.2014.366

In a return to

practices from the

early 1900s, some

police departments

have begun

employing licensed

social workers to help

them address the

opioid epidemic as

they move away from

criminalization of

addiction and aim to

treat it from a health

perspective.

With many

communities

continuing to see

the effects of

fentanyl in illicit

substances beyond

heroin and the

growing concern

over the increased

prevalence of

methamphetamines,

the challenge to

identify and

implement

programs and

interventions to

address this

epidemic is far

from over.

Council on Social Work Education. (n.d.). Social work: A vital workforce to address the opioid crisis. Retrieved from www.cswe.org/Advocacy-Policy/ Policy-Agenda/Articles/Social-Work-and-Opioid- Epidemic-Principles Ellis, M. S., Kasper, Z. A., & Cicero, T. J. (2018). Twin epidemics: The surging rise of methamphetamine use in chronic opioid users. Drug and Alcohol Dependence, 193, 14–20. doi:10.1016/j.drugalcdep.2018.08.029 Hancock, C., Mennenga, H., King, N., Andrilla, H., Larson, E., & Schou, P. (2017). Treating the rural opioid epidemic. National Rural Health Association. Retrieved from www.ruralhealthweb.org/NRHA/ media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf Kane-Willis, K., Schmitz, S. J., Bazan, M., Narloch, V. F., & Wallace, C.B. (n.d.). Understanding suburban heroin use. The Illinois Consortium on Drug Policy. Retrieved from www.robertcrown.org/files/ Understanding_suburban_heroin_use.pdf Muhuri, P. K., Gfroerer, J. C., & Davies, M. C. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality.

Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths: United States, 2000–2014. Morbidity and Mortality Weekly Report, 64, 1378–1382. Substance Abuse and Mental Health Services Administration. (2019). The National Survey on Drug Use and Health: 2018. Retrieved from www.samhsa.gov/data/nsduh/reports-detailed-tables-2018-NSDUH U.S. Government Accountability Office. (2003). Prescription drugs: Oxycontin abuse and diversion and efforts to address the problem (Publication GAO-04-110). Washington, DC.: Author. Van Zee, A. (2009). The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. American Journal of Public Health, 99, 221–227. doi:10.2105/AJPH.2007.131714 Warner, M., Trinidad, J. P., Bastian, B. A., Miniño, A. M., & Hedegaard, H. (2016). Drugs most frequently involved in drug overdose deaths: United States, 2010–2014 (National Vital Statistics Reports, vol. 65). Hyattsville, MD: National Center for Health Statistics.

PracticePerspectivesFallI S S U E

2 0 1 9

Takia Richardson, L ICSW, LCSW

Sen ior P rac t i ce Assoc ia te

t r i chardson.nasw@soc ia lworkers .org

750 First Street NE, Suite 800 Washington, DC 20002-4241 SocialWorkers.org

The National Association of Social Workers

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©2019 National Association of Social Workers. All Rights Reserved.

Practice Perspectives Fall 2019

America’s Drug Crisis: Challenges and Successes in the Opioid Epidemic and Beyond

Introduction Fallout from the opioid epidemic has gripped the country. Rural and suburban communities have seen substance misuse at unprecedented levels. From OxyContin in medicine cabinets to mail-order fentanyl from China, increasingly potent opiates have infiltrated communities, producing more than 100 overdose deaths per day. In the 12-month period ending in November 2017, the number of drug overdose deaths reached a high of 70,723 (Ahmad et al., 2019). Finally, in 2018 researchers noticed the first decrease in the rates of opioid-related overdose deaths in almost 30 years. That same year, researchers also noticed an upward trend in the use of stimulants (that is, cocaine and methamphetamines) either alone or in tandem with other opiates. Federal health officials have identified this as the fourth wave, although it is far less widespread than previous iterations of the opioid crisis.

The epidemic has typically been discussed in three waves. Its roots can be traced back to the mid-1990s with a noted increase in prescription opiates for the treatment of pain. This quickly led to pill mills, misuse, and overdose deaths once users discovered they could alter the composition of the pills to obtain the highest levels of the narcotic. This is commonly referred to as the first wave. The second wave of the epidemic started around 2010. After federal prescribing restrictions, prescription opiates were much more difficult to obtain. Some users switched to heroin, which was cheaper and more widely available. There was a noted increase in heroin use and accidental overdoses. While seeking to address the growing heroin epidemic, health care providers, state and federal government agencies, and researches noted a significant increase in overdose deaths related to fentanyl, a manufactured opioid available from China and Mexico. Fentanyl, which is significantly stronger than OxyContin and heroin, has high abuse potential, profit margins, and overdose risk. The use of fentanyl and other synthetic opioids skyrocketed, marking the third wave. Although officials noticed an increase in the availability of and overdoses related to fentanyl starting around 2013, little was done to address use of this drug specifically in the early days. Officials have not yet identified an