STORIES SULLIVAN from How a Rural Community Addresses the Opioid Crisis VOLUME 1 June 27, 2018 Patricia Strach Katie Zuber Elizabeth Pérez-Chiqués 1 ABOUT THE AUTHORS Patricia Strach is the deputy director for research at the Rockefeller Institute of Government Katie Zuber is the assistant director for policy and research at the Rockefeller Institute of Government Elizabeth Pérez-Chiqués is a research assistant at the Rockefeller Institute of Government 2 In rural communities like upstate New York’s Sullivan County, where the bus runs twice a week and cab fare is expensive, people who need substance abuse treatment often have a hard time getting to it. A few years ago, one public official in the county wanted to show state officials how vital transportation is to addressing access, especially in a county the size of Rhode Island. She started by inviting them to Sullivan County. Instead of meeting in a conference room, she took them for a drive. “I tried to really give them a visual,” she said. “They were shocked that it took an hour to get from one end of the county to the other, and that’s just straight.” It’s clear that America has an opioid problem. In conversations with people on the front-lines of the epidemic, however, it is not so clear that lawmakers in Albany or Washington, DC, understand the realities of the crisis — like the challenges of accessing services in remote rural communities. This disconnect between the communities fighting opioids on a day-to-day basis and lawmakers devising solutions in the state’s Capitol weakens the response to the opioid crisis. How can we expect state and federal officials to craft relevant solutions to a problem we don’t fully understand? In an effort to bridge this disconnect between local communities and lawmakers, the Rockefeller Institute of Government is conducting an in-depth study of the opioid crisis in Sullivan County, a rural community located 100 miles northwest of New York City. Readers will follow the project as it happens — what we call “research in real-time.” By talking to community members, public officials, medical experts, and activists, we seek a better understanding of the causes and effects of the opioid epidemic not just in Sullivan County, but in similar communities across the country. In short, we ask: + What does the opioid problem look like in a small, rural community? + How has the community responded? + What do people on the ground need from government to address it? In essence, this project looks at how government works by examining its response to a public health crisis. How do different levels of government — state, federal, and local — work together to address the situation? Are the policy solutions really addressing needs on the ground? How are governmental agencies and departments working or not working together in response? Our work combines aggregate data analysis with on-the-ground research in affected communities to provide insight into what the opioid problem looks like, how communities respond, and what kinds of policies have the best chances of making a difference. 3 PART 1 Fallsburg, New York Pathways to Addiction How the US Developed an or twice before. But does it really tell the Opioid Problem whole story? In an effort to answer that question, we How did opioids become a problem in the traveled to Sullivan County, which has one United States? It’s a question that many of the highest opioid death rates of any people are asking and that most newspapers county in New York State, to consult with purport to know the answer to, at least if community members, public health officials, you read the headlines. Opioids became and the families of people struggling with a problem in the early 1990s when big addiction. Although many people agreed that pharmaceutical companies tried to boost prescription drugs and the pharmaceutical profits by pushing the sale of painkillers. companies are largely to blame for the People eventually got hooked, but when current crisis, this narrow focus on they lost access to prescription medications painkillers ultimately obscures other parts they turned to heroin as a cheaper, more of the story we heard about legitimate accessible alternative. injuries, recreation, and self-medication. In This is a common story told about the short, it misses the broader sociocultural origins of America’s opioid epidemic, and and economic changes that have coalesced it is probably a story you’ve heard once alongside a shift in physicians’ prescribing 4 practices to lead America down the road to addiction. In this blog, we unpack the national narrative surrounding the opioid crisis in the United States, and then adjust it to account for what we heard on the ground in Sullivan County. How Did Opioids Become a Problem? The National Narrative Americans moved from prescription opioids to heroin and now fentanyl. Source: 2016 National Survey on Drug Use and Health. Note: Current use indicates those individuals who reported using heroin in the past Nearly every account of the opioid crisis month, whereas past year use represents any individual who reported using heroin within that year. in America begins in the early 1990s, when large pharmaceutical companies sought to boost profits by increasing the sale of prescription opioids. Indeed, while many doctors feared the addictive properties of drugs designed to minimize pain, companies like Purdue Pharma set out to change physicians’ prescribing habits by aggressively marketing and promoting their drugs. As early as 1995, the Food and Drug Administration approved Purdue Pharma’s pain reliever OxyContin, and other opioids like it, for the purpose of treating moderate-to- Source: 2016 National Survey on Drug Use and Health. severe pain lasting over extended periods Note: Current use indicates those individuals who reported using heroin in the past month, whereas past year use represents any individual who reported using heroin of time.1 Although organizations like within that year. the Agency for Health Care Policy and Research believed that such drugs could be used to improve long-term treatment back pain.2 Their efforts paid off. By of cancer pain, companies like Purdue 2001, sales of OxyContin exceeded $1 hired hundreds, if not thousands, of billion annually, and the drug became sales representatives to push the drug “the most frequently prescribed brand- on primary care physicians — physicians name narcotic medication for treating who treated conditions other than cancer moderate-to-severe pain in the United including arthritis, injuries, and chronic States.”3 1 Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem, 2 Patrick Radden Keefe, “The Family That Built Report to Congressional Requesters GAO-04- an Empire of Pain,” New Yorker, October 110 (Washington, DC: United States General 30, 2017, https://www.newyorker.com/ Accounting Office, December 2003), https:// magazine/2017/10/30/the-family-that-built-an- www.gpo.gov/fdsys/pkg/GAOREPORTS- empire-of-pain. GAO-04-110/pdf/GAOREPORTS-GAO-04-110. 3 Prescription Drugs: OxyContin Abuse and pdf. Diversion and Efforts to Address the Problem. 5 Consistent with what has been described According to research as a “coordinated, sophisticated, and highly deceptive marketing campaign,” published in Addictive designed to convince “doctors, patients, and others that the benefits of using Behaviors, an increasing opioids to treat chronic pain outweighed number of people are the risks,” the sale of prescription opioids skyrocketed in the United States.4 experimenting with Between 1999 and 2010, sales of opioid pain relievers nearly quadrupled, fueling heroin as their first an increase in the number of opioid- related deaths.5 During the same eleven- opioid, rather than year period, opioid-related deaths climbed steadily from 8,050 in 1999 to 21,089 in transitioning from 2010 and beyond. By 2016, estimates from the Centers for Disease Control and painkillers to heroin, as Prevention indicate that between 1999 and 2016 opioids claimed the lives of the dominant narrative more than 350,000 Americans.6 would suggest. Alarmed by the growing number of deaths, state and federal officials sought to restrict access to painkillers, or so the narrative continues. In 2016, Massachusetts became one of the first states to limit the duration of first-time little over a year, the National Conference opioid prescriptions to seven days.7 In of State Legislatures found that twenty- three states enacted similar legislation, 4 County of Sullivan vs. Purdue Pharma L.P., et with prescribing limits ranging anywhere al., Supreme Court of the State of New York, Sullivan County, Index No. 2017-961, June 7, from three to fourteen days. Prescription 2017, http://webapps.co.sullivan.ny.us/docs/ drug monitoring programs (which seek cmgr/pr/y_2017_m_06_d_08-Summons-and- Complaint.pdf. to improve opioid prescribing) and 5 “Vital Signs: Overdoses of Prescription Opioid dosage limits (which penalize healthcare Pain Relievers — United States, 1999-2008, providers who prescribe patients more Morbidity and Mortality Weekly Report (MMWR) 60, 43 (2011): 1487-92, https://www.cdc.gov/ than a certain amount of opiates) are mmwr/preview/mmwrhtml/mm6043a4.htm?s_ two additional examples of state-level cid=mm6043a4_w%20-%20fig2. interventions designed to control the 6 “Data table for Figure 1. Age-adjusted drug overdose death rates: United States supply of opiates. For its part, the federal 1999-2016,” https://www.cdc.gov/nchs/ Drug Enforcement Administration (DEA) data/databriefs/db294_table.pdf, in Holly announced in October 2016 that it would Hedegaard, Margaret Warner, and Arialdi M. Miniño, Drug Overdose Deaths in the United reduce the manufacture of almost every States, 1999-2016, NCHS Data Brief No. 294 opioid pain medication in the United (Washington, DC: National Center for Health Statistics, December 2017), https://www.cdc. gov/nchs/data/databriefs/db294.pdf. 7 Office of the Massachusetts Governor, baker-signs-landmark-opioid-legislation-into- “Governor Baker Signs Landmark Opioid law. Legislation into Law,” press release, March 14, 2016, https://www.mass.gov/news/governor- 6 States by a minimum of 25 percent.8 Although many people celebrated these supply-reduction efforts as a necessary first step in the war against opioids, others warned about their effects on people already struggling with addiction. Indeed, for the men, women, and teenagers already dependent on prescription opiates, limited access to painkillers created a new problem — finding more money to buy more expensive pain pills on the street, or tracking down a cheaper, more accessible alternative. For many, Monticello, New York the solution was heroin.9 A rise in the use of heroin seems to bear number of heroin-related deaths has also this out. According to The National Survey climbed. “Between 2002 and 2013, the on Drug Use and Health, heroin use in rate of heroin-related overdose deaths the United States has steadily increased nearly quadrupled,” with more than since 2007, with only a few exceptions. 15,000 deaths occurring in 2016 alone.11 Because heroin consumption is not as common as the use of other illicit drugs, Although heroin claimed the lives of the survey includes estimates for both more people in 2016 than in any of the current (past month) and past year use. previous fifteen years, fentanyl — which Throughout 2016, an estimated 948,000 is a powerful synthetic opioid that is “fifty people aged twelve or older used heroin to one hundred times more potent than (see figure below). Although this figure morphine” — proved even more deadly.12 was comparable to the estimates reported Over the past several years, the rate of in 2014 and 2015, it was still higher than overdose deaths involving fentanyl and the estimates reported each year between other synthetic opioids doubled from 2002 and 2013.10 Not surprisingly, the 9,580 deaths in 2015 to roughly 19,400 in 2016, making fentanyl the deadliest opioid 8 United States Drug Enforcement now available in the United States (see Administration, “DEA Reduces Amount “Number of Drug Overdose Deaths in the of Opioid Controlled Substances to be United States, 1999 - 2016” on page 5). Manufactured in 2017,” press release, October 4, 2016, https://www.dea.gov/divisions/ So what explains this move from hq/2016/hq100416.shtml. 9 Theodore J. Cicero, Matthew S. Ellis, Zachary prescription painkillers to heroin and A. Kasper, “Increased use of heroin as an now fentanyl? The common explanation initiating opioid of abuse,” Addictive Behaviors 74 (November 2017): 63-6, https://www. researchgate.net/publication/317131906_ files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/ Increased_use_of_heroin_as_an_initiating_ NSDUH-FFR1-2015.pdf. opioid_of_abuse. 11 “Today’s Heroin Epidemic,” Centers for 10 Rebecca Ahrnsbrak, et al., Key Substance Disease Control and Prevention, Last Updated Use and Mental Health Indicators in the July 7, 2015, https://www.cdc.gov/vitalsigns/ United States: Results from the 2016 National heroin/index.html. Survey on Drug Use and Health (Rockville: 12 “What is fentanyl?,” Centers for Disease Substance Abuse and Mental Health Services Control and Prevention, Last Updated August Administration (SAMHSA), September 2017), 29, 2017, https://www.cdc.gov/drugoverdose/ https://www.samhsa.gov/data/sites/default/ opioids/fentanyl.html. 7 outlined above is that cracking down If you were to drive on prescription opiates has shifted the over Route 52 to go market to more dangerous drugs like fentanyl. As one senior Vox news reporter to ShopRite, it’s not put it: “If you go after opioid painkillers, people will eventually go to heroin. If uncommon — if you keep you go after heroin, they’ll eventually go to fentanyl. And if you go after fentanyl, your eyes open — to see they might resort to some of its analogs, people walking over that like carfentanil.”13 Admittedly, this logic makes sense. It assumes that whenever overpass with a baby individuals lose access to prescription painkillers they are forced into the streets carriage, holding the to buy stronger, cheaper alternatives. baby in their arms, with However, this explanation is too simplistic for understanding the complexities of everything they own in the current opioid crisis. Although the increasing number of deaths does raise the carriage.… Now put it questions about the utility of supply- this way. I’m going to be reduction efforts, this common narrative concerning the transition from painkillers brutally honest with you. to heroin and now fentanyl fails to account for a variety of other factors that have If I was in that position, contributed to the current opioid crisis. These include rapid increases in heroin I’d probably shoot dope production; changes in the distribution too. I would boot up and strategies of drug traffickers; and broader patterns of drug addiction throughout the bang off in a heartbeat if United States. I felt that hopeless. Cheap Heroin Floods the Market With respect to the supply-side economics of addiction, a substantial increase in the availability of heroin has created new increase was driven in part by reduced opportunities to abuse it. As the DEA poppy eradication in Mexico and Mexican observed in its 2017 National Drug Threat organizations’ shift to increased heroin Assessment: “Rapid increases in heroin trafficking.”14 What this means in the production in Mexico since 2015 have context of the United States is that more ensured a reliable supply of low-cost people have access to heroin than ever heroin, even in the face of significant before. According to research published increases in user numbers.… This in Addictive Behaviors, an increasing 13 German Lopez, “How fentanyl became America’s leading cause of overdose 14 2017 National Drug Threat Assessment deaths,” Vox, Updated December 21, (Washington, DC: U.S. Department of Justice, 2017, https://www.vox.com/science-and- Drug Enforcement Administration, October health/2017/5/8/15454832/fentanyl- 2017), https://www.dea.gov/docs/DIR-040- carfentanil-opioid-epidemic. 17_2017-NDTA.pdf. 8 Jared Levine is recovering from an opioid number of people are experimenting addiction. The hardest part, he said, is with heroin as their first opioid, rather aftercare. If you’re not on probation, it’s than transitioning from painkillers to more difficult because there is no one heroin, as the dominant narrative would watching you. suggest.15 In 2005, less than 10 percent of people who were dependent on opioids takes the form of patches or lozenges — used heroin first. However, a decade is sometimes diverted from healthcare later, that number increased to a third, facilities, it is more common for making heroin “the leading drug for new powdered forms of the drug to be illicitly opioid initiates.” As one observed, a manufactured in China and Mexico and dealer-driven increase in supply “gave then smuggled into the United States.16 more people new opportunities to try Once here, powdered fentanyl is mixed heroin even if they weren’t addicted to into heroin, oftentimes without the painkillers.” buyer’s knowledge, or pressed into counterfeit pills resembling Xanax, Changes in the way drug traffickers are Oxycodone, and other opioid medications. doing business have also contributed to When used as a cutting agent in heroin, the rising number of deaths, particularly fentanyl “looks like heroin, is packaged with respect to the sale of fentanyl. in the same baggies or wax envelopes While prescription fentanyl — which as heroin, and displays similar stamps or brands as heroin.”17 From a dealer’s 15 T.J. Cicero, M.S. Ellis, and Z.A. Kasper, “Increased use of heroin as an initiating opioid of abuse,” Addictive Behaviors 74 (November 16 2017 National Drug Threat Assessment. 2017): 63-6. 17 Ibid. 9 perspective, the logic is simple. By mixing fentanyl with other adulterants including sugar, dealers can sell less heroin for the same price and oftentimes with the same effect. In fact, the DEA has observed that an increasingly large amount of fentanyl is being sold as heroin, even when there is no heroin in the product. Although most people who are exposed to fentanyl are unaware that it was used to cut heroin, there is some anecdotal evidence to suggest that others actively seek the drug. When we asked folks in Sullivan County about whether people know they are being sold fentanyl, one retired probation officer told us that some During the day, a young man plays basketball and neighbors tend a new community garden. By night, the Evergreen Apartments complex in people go looking for it. When a death Monticello is known as a hotspot for drug deals and violence. occurs, rather than alert people to avoid a particular dealer, it signifies to buyers the drug’s potential potency. “If it does kill China was a county-level official who somebody they run down the road and get told us that the federal government was more,” he explained. The DEA alluded to failing in its responsibility to stop drugs a similar phenomenon in its 2017 National at the border. In describing the federal Drug Threat Assessment. According to government’s “lackluster response” to the federal government’s leading drug the opioid epidemic, he pointed out that agency, public health warnings intended opioids — unlike marijuana — cannot be to notify “the community that a particular grown legally in the United States. “The heroin stamp is known to contain fentanyl” great poppy fields of Sullivan County can actually cause “some users to go in aren’t fueling this issue,” he reassured us. search of it.” Still, the DEA believes that Still, the vast majority of people we spoke the vast majority of heroin users who to talked less about foreign drug markets are exposed to fentanyl actually have no than about the realities of why people in desire to take the drug.18 rural communities turn to opioids in the first place. Beyond the supply-side economics of drug addiction outlined by the DEA, we From a Bird’s-Eye View to a spoke to folks in Sullivan County about Worm’s-Eye View: Pathways to what they believed was driving the Addiction in Sullivan County epidemic. Surprisingly, their answers didn’t revolve around drug cartels in Although we spoke to a variety of Mexico or the profits to be made by selling people in the fields of public health, fentanyl. Instead, their responses were law enforcement, and even families rooted in the small, rural community in struggling with addiction, they pointed us which they lived. In fact, the only person to in the direction of three main pathways mention illegal drug markets in Mexico or to addiction — legitimate injuries, recreational use, and self-medication. 18 Ibid. 10