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The other epidemic killing Americans

People are dying at record rates from opioid overdoses, and harm reduction advocates are asking the Biden administration to overhaul how it deals with the crisis.
 
by Michelle ChenTwitt 

Part 1

When North Carolina was besieged by Covid-19, Louise Vincent nearly died—but it wasn’t the virus that got almost her. She spent months shuffling in and out of clinics, struggling to get appropriate medical treatment, and eventually was poisoned when she attempted to medicate herself in desperation. The medicine she needed was methadone, which is used to help people manage opioid use disorder. She should have been able to access it easily; Vincent helps run the North Carolina Urban Survivors Union, a drug users’ advocacy and harm reduction group. 

But Vincent ran into trouble with her usual methadone clinic, in part because she had missed appointments because of traveling for work.

They wouldn’t let me come back and said I had failed at their program,” she told me.

She tried to switch to another local methadone provider, but she said it limited her to inadequate doses because of other medications she was taking. During her months-long struggle to get the drug she needed to function, she ended up going back to street heroin.

I was trying to use as little as possible just to get through the day,” she recalled. But even her limited exposure to the street supply led to frightening side effects. “[The drug] caused skin lesions, all sorts of stuff.… It was horrible. I didn’t know what was wrong with me. And the end result was that I was almost dead with a hemoglobin of 2.9”—a dangerously low level caused by the substance she later discovered had been mixed in: a horse tranquilizer called Xylazine. 

The preventable crisis that befell Vincent, which ended with a hospitalization that she described as traumatic, reflects a public health crisis that has quietly metastasized. While much of the attention of public health authorities last year was on the rising infection rates and death toll of Covid-19, another disturbing trend—a spike in overdose deaths during the first months of the pandemic—revealed a health crisis unfolding in the pandemic’s shadow: People are dying at record rates from an epidemic that has claimed about 450,000 lives over the past two decades.

While the pandemic shut down swaths of the economy and put millions out of work, people with opioid use disorder—including both users of prescription painkillers and people who inject street heroin—were bombarded with social stressors from social isolation to barriers to treatment as providers shut their doors. Harm reduction advocates are now asking the Biden administration to overhaul how the government deals with the opioid overdose crisis. 

According to the Centers for Disease Control and Prevention, from October 2019 to September 2020 drug overdose deaths nationwide rose 29 percent over the previous year, the vast majority from opioids, which killed an estimated 66,813 people. In the initial months of lockdown, according to the Commonwealth Fund, monthly opioid overdose deaths soared to more than 7,200 last May, up from just over 4,000 deaths a year earlier. Racial disparities have persisted through the pandemic: From 2018 to 2020, overdose deaths rose many times faster for Black and Latinx people than for white users.

The increase is fueled in part by the growing prevalence of fentanyl, a particularly lethal synthetic opioid that is often mixed in with other drugs. The federal government has reported a geographic expansion of the fentanyl market, moving west of the Missouri River, where it was not prevalent prior to 2018.

Some harm reduction organizations provide fentanyl test strips to help screen unregulated drugs—and the Biden administration recently lifted a ban on using federal funds to purchase the testing system. But fentanyl is already spreading much faster than users or service providers can handle. According to a recent study by Stanford researchers, available data for 2020 showed a 63 percent spike in fentanyl mortality over the previous year. 

The pandemic did bring some limited improvements in access to medication-assisted treatment (MAT), or treatment drugs prescribed through a regulated program designed to keep people off illicit drugs like heroin, usually in the form of buprenorphine and methadone. Shortly after the onset of the pandemic, the Trump administration lifted a requirement that an in-person doctor’s visit would be needed to prescribe buprenorphine, allowing people to use telehealth appointments instead. It also issued a guidance to methadone providers, advising them to provide up to a month’s supply of MAT doses at a time to stable users, avoiding the usual mandatory daily check-in at the clinic. 

Nonetheless, many providers have not followed the new take-home guidelines, according to Urban Survivors Union’s surveys of treatment providers. One respondent in Kentucky said, “They asked me to come in on a day when I was sick with possible COVID-19. They suspended all my 3-weeks COVID-19 take homes and made me come to the clinic daily when I was too sick to come in. They have very little regard for my health. I am [over 60] years old.” 

Silvana Mazzella, associate director of the public health and social services nonprofit Prevention Point Philadelphia, said that while the ability to access treatment remotely was a breakthrough, videoconferencing did not work as well for another critical service for vulnerable clients: mental health care. Since many clinics have closed their normal meeting spaces, she said, “for people who are unsheltered or transient, or don’t have [mobile phone access] all the time, this is a real problem. And all of these things contribute to a real change in the landscape and in risk of mortality and disconnection from services.” 

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