By the time President Donald Trump declared the opioid crisis a public health emergency in 2017, abuse had gradually increased for two decades.

More than 47,600 Americans died from opioid-related overdoses in 2017 alone, according to the National Institute on Drug Abuse, bringing the total number of deaths to nearly 400,000 since 1999.

That number continues to climb.

While it took years for lawmakers, government officials and the press to truly grasp the scope of the problem, those on the front lines were seeing ramifications shortly after the introduction of a new wave of opioid painkillers in the late 1990s.

Melanie Brown-Woofter, president and CEO of the Florida Council for Community Mental Health, said the consequences were obvious early on, but were initially overlooked.

“There’s always a canary in the coal mine,” she said. “And our folks on the ground started expecting individuals with addictive behaviors and seeing the overdoses in the hospitals much earlier than it was officially recognized by our state leaders. We had seen this years ago with cocaine, and we saw it with meth. And now we’ve moved into the opioid world.”

As the number of deaths increased exponentially with prescription opioid overdoses into the late 2000s, state and local governments took notice and worked to identify solutions.

In Minnesota, State Rep. Shelly Christensen, D-Stillwater, said there’s “an appetite” on both sides of the aisle to address the opioid epidemic.

Two similar bills from the Minnesota House and Senate would acquire funds to respond to the crisis by increasing annual registration fees for opioid manufacturers and drug wholesalers.

The fees would bring in $20 million annually and be used for prevention, education and treatment, Christensen said. An advisory council would make recommendations to the state on how to spend the funds.

“It’ll be a huge project and it’s a huge problem,” Christensen said. “It’s going to take a while to really get a handle of it.”

Coordinating efforts and resources

Ken Martin, chairman of Ohio State University Extension, said former Ohio attorney general and current Gov. Mike DeWine created a drug czar to help lead efforts to combat and treat addiction. And Brown-Woofter praised the efforts of Florida Gov. Ron DeSantis in reinstituting that state’s drug czar, which had been cut eight years ago.

“We feel that a coordinated effort that’s led centrally to be able to address this issue is so important,” Brown-Woofter said. “Today, it’s opioids. A few years from now, there may be another product out there. We see it morph over time.”

That recognition prompted federal and state governments to allocate funding for prevention, treatment and recovery – highlighting why these efforts are so vital.

But there’s still work to be done.

A recent Bipartisan Policy Center analysis revealed that increased congressional funding reached states with some of the highest number of opioid deaths, such as West Virginia, Pennsylvania, Ohio and Kentucky, but found that rural areas were largely underserved.

The report identified 57 federal grant programs providing $3.3 billion in opioid funding in 2017 and $7.4 billion in 2018 – a 124 percent increase in spending.

From 2017 to 2018, funding targeted to opioid use disorder treatment and recovery increased by $1.5 billion, according to the analysis.

Congresswoman Betty McCollum, who represents the Stillwater-area as part of Minnesota’s fourth district, introduced the Community Action Opioid Response Act (CAORA) in February 2018, which allocated $250 million in federal grants to support efforts to help children and families affected by the opioid crisis.

However, McCollum’s health policy staffer, Patrick Maillet, said the act was never voted out of the Education and Labor Committee. This year, Maillet said via email that McCollum introduced an act that incorporates many provisions from the CAORA to help provide communities resources to address the opioid crisis.

“Our cities and counties cannot afford to take on these costs on their own,” Maillet said. “If the federal government does not step in to help with this fight, cities and counties across America will continue to have to divert precious public resources to combating the devastating effects of opioids rather than education, infrastructure, and other public initiatives.”

Funding a response to the crisis is imperative, Christensen added, because taxpayers have carried the burden of caring for families traumatized by the epidemic. The state spends millions of dollars responding to the crisis, Christensen said.

“There are costs in there that people don’t realize,” Christensen said. “There have been entire families that have been hurt.”

New state and federal funding in Wisconsin, which saw more than 900 opioid overdose deaths in 2017, has encouraged health-care officials to crack down on the crisis. U.S. Sen. Tammy Baldwin, D-Wisconsin, recently announced the state will receive an additional $6.25 million in federal grant funding for opioid abuse prevention, treatment and recovery.

Some recent initiatives include an addiction recovery helpline, funding for inmates leaving jail and public health alerts issued to areas with high numbers of opioid overdoses.

“We’ve continued to see a rise in opioid-related deaths since the early 2000s,” said Paul Krupski, director of opioid initiatives for the Wisconsin Department of Health Services. “We have a three-pronged approach to address the crisis, which, I’d guess, is fairly similar to what a lot of other states are doing. We firmly believe we will eventually get ahead of this.”

The department recently partnered with the University of Wisconsin School of Medicine and Public Health to launch an addiction consultation program, connecting providers in rural areas with addiction specialists for insight and resources.

Because Wisconsin is largely rural, counties are often the first line of defense when addressing substance abuse. The health department has awarded grant funding to more than 25 counties and tribal nations through its Unmet Opioid Treatment Needs program. In the first half of the program’s second year, more than 1,000 residents have received treatment or recovery support services.

As the crisis continues to evolve, states must evolve with it, Krupski said, especially as states see a rise in fentanyl and illicit opioid use.

The department contracted with the AIDS Resource Center of Wisconsin to pilot a program using fentanyl testing strips.

“When individuals come in for syringe exchange, the staff is giving them the strips with direction,” Krupski said. “Our hope is it will help active drug users change their behavior; they’re testing the drugs beforehand and deciding not to use if fentanyl is detected. It’s, in essence, saving lives.”

Tackling the evolving epidemic

Most states implemented prescription drug monitoring programs (PDMPs) after realizing how significant the problem was.

PDMPs are designed to crack down on two major contributing factors to the opioid crisis – patients collecting opioid prescriptions from multiple doctors and unscrupulous doctors who operate “pill mills,” prescribing as many pain pills as possible.

While there is no federal standard for how PDMPs operate, they act as a way to ensure patients can’t receive multiple prescriptions for the same physical ailment, and that doctors who are overprescribing pain pills can be easily identified by authorities.

Many states have also limited the amount of opioid-based medication a patient can be prescribed. Wyoming’s legislature earlier this year limited the amount of opioids for first-time patients to a seven-day supply. Florida insurance companies put a cap on opioid prescriptions, as well, Brown-Woofter said.

Federal prosecutors are also threatening criminal action against those prescribing more pills than average. Wisconsin’s drug monitoring system revealed a 29 percent decrease in the number of prescriptions dispensed from 2015 to 2018.

Some of the county’s largest drug distributors continue to face civil lawsuits in several states, which could lead to billions of dollars in damages. Governments want companies such as Purdue Pharma and Walmart to reimburse them for the cost of combating the epidemic, arguing these companies misled communities about the risks.

In March, owners of Purdue Pharma, maker of OxyContin, agreed to pay Oklahoma $270 million for the company’s role in the crisis. Oklahoma Attorney General Mike Hunter said the settlement would help establish a national addiction research center at Oklahoma State University and support local efforts.

Minnesota communities are hiring coaches for recovering addicts, decriminalizing drug testing strips and treating inmates jailed for drug crimes. Minneapolis recently equipped police officers with Narcan, too. Washington County Sheriff’s Deputies began carrying Narcan in 2016.

Access to opioid-overdose drugs like Narcan is a vital component in keeping people alive and giving them the chance to seek recovery. But with increased access hasn’t always come a willingness to increase its usage.

Martin said too often law enforcement officers were reluctant to use drugs to help bring people out of an overdose because “they’ll keep coming back for more.” It was a prevalent sentiment throughout the country as this crisis grew. To combat it, experts say it will take a serious conversation and culture change to understand not only this crisis, but addiction as a whole.

But because drug problems can start and end in a medical facility, hospitals are now implementing emergency department intervention programs.

Another major step in helping save lives is making sure those seeking treatment are being served well. Brown-Woofter said Florida recently cracked down on some providers who ran “sober homes,” which provided those with opioid addiction places to recover. She said there were multiple cases of providers setting up shop to make a profit off of the crisis without producing any supports for those in recovery. Sometimes heroin dealers would wait outside the homes to try to entice people into relapse.

There were even cases where providers would kick people out when their insurance money ran out, connect them with drug dealers to get them to relapse, then readmit them in order to receive a new round of insurance dollars.

“There were some bad apples taking advantage of the system,” Brown-Woofter said.

What’s next?

While Christensen said Minnesota legislators want to solve the issue, they still need to come to a compromise on how to do it.

Christensen said the primary difference between the House and Senate bills is that the Minnesota Senate’s bill “sunsets” or drops the registration fees in the case of a legal settlement between drug manufacturers and the state.

Additionally, those opposed to the long-term fees say they will trickle down to consumers and increase the cost for drugs. Christensen said the House’s bill includes protections for people who use opioids for long-term pain management.

Minnesota legislators are in final negotiations over the bills and should come to a resolution before the session adjourns in May.

Experts in the mental health and substance abuse treatment fields believe there are immediate steps that can help keep more on the path to recovery. More funding for substance abuse treatment, increases in the mental health workforce, and increasing the time government and private insurance will fund rehabilitation stays are all on the wish list.

“Addiction is a brain disorder. And once you enter into addiction recovery, you’re in recovery for the rest of your life,” Brown-Woofter said. “People don’t choose this. Anything we can do to enhance service provision and increase capacity so anyone who needs it can seek services and keep them in recovery is what we’re interested in.”

Another area could have a significant impact on improving the odds of a sustained recovery for those with an opioid addiction.

“Expanding access to medication-assisted treatment is the most effective way to reduce overdose deaths and curb the opioid crisis,” said Beth Connolly, project director of the substance use prevention and treatment initiative at The Pew Charitable Trusts.

Connolly believes policymakers should focus on how treatment is delivered and build up the capacity of the mental health sector to deal with an increased need.

“(They should) support coverage and reimbursement policies that ensure access to care, and help underserved populations – such as pregnant women or individuals involved with the criminal justice system – access effective care,” Connolly said.

Contact Kim Schneider at kim.schneider@ecm-inc.com

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