Public perception is tough to overcome in battle against opioid addiction
Three years ago, Rhode Island expanded its treatment of inmates with drug abuse problems. They were given buprenorphine, methadone and naltrexone and counseling up to a year. When released, they were referred to therapy within the community.
"It was quite an expansion to what we had already been doing," said Lauranne Howard, substance abuse coordinator for the state Corrections Department. It was also the first time inmates in this country received such comprehensive treatment. The results were startling. Deaths from drug overdose in the prison system fell 61% over one year. Statewide, overdose deaths fell by 12%.
Despite evidence that such results were possible, Howard and Dr. Jennifer Clarke, the Corrections Department's medical programs officer, had to convince opponents who feared the program would propagate addiction or enable contraband sales.
Similar scenes are playing out across the nation, with public health officials forced to combat preconceived notions about what addiction is, and what it takes to address it.
"We treat addiction differently than virtually every other disease," said Dr. Joshua Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health. "People with addiction are often blamed and told it is their responsibility to 'fix it' themselves, and stigma colors people's thinking about what the right thing to do is."
New York City officials want to open the country's first sanctioned supervised injection site. At the facilities—Mayor Bill De Blasio wants four of them—people would be able to inject drugs while being monitored by medical professionals in an effort to reduce the risk of overdose or infection.
But efforts to launch similar programs in Denver, Philadelphia, San Francisco and Seattle all stalled over the past two years during the height of the opioid epidemic amid criticism that they would promote and increase drug use.
"The reality is, when you open a heroin injection site you're legalizing the use and possession of heroin," said Joshua Freed, chairman of Safe King County, a campaign looking to ban supervised injection sites in King County, which includes Seattle. The organization is fighting a legal battle to put an initiative on the November ballot to prohibit public funding of safe injection sites. A judge kept a previous referendum off the ballot, ruling the initiative would supersede the authority of the local county board of health, which supports opening a site.
Advocates say the facilities reduce overdose-relate deaths and the spread of disease.
A 2017 report used when Philadelphia was considering a site showed that one in Vancouver, British Columbia, led to a 35% reduction in overdose deaths within 500 meters of the facility just three years after it opened in 2003.
Sharfstein and others like him say they're tired of presenting evidence only to be shot down. More importantly, they believe the nation's skyrocketing overdose death rate will not fall until addiction is treated like a disease rather than a moral failure.
Despite opioid abuse having dominated headlines for nearly two years, Americans remain skeptical about categorizing drug misuse as a medical condition. The Associated Press-NORC Center for Public Affairs Research recently found that 44% of Americans surveyed said addiction indicated a lack of willpower, and 4 in 5 said they were unwilling to associate closely with someone with an opioid addiction.
"Stigma is the single largest reason why we don't have these programs everywhere where they are needed," said Laura Thomas, deputy state director for the Drug Policy Alliance in California. "There's really no other health condition where we either use the criminal justice system primarily to engage around the health condition, or where we ignore the science and the evidence around what works."
That would help explain why U.S. cities have only recently started considering such interventions as safe injection sites even though there about 100 in Australia, Canada and Europe. Studies of those facilities, as well as one secret unsanctioned site that has been operating under a heavy veil in the U.S. since 2014, show reduced rates of needle-sharing, which can spread HIV and hepatitis; fewer overdose-related deaths; and an increase in drug addiction treatment.
Public health advocates often speak with frustration about how stigma delays a response that can save lives. For example, in 2015 nearly 200 people in Indiana's Scott County contracted HIV over just a few months from drug users sharing contaminated needles. Needle exchange advocates pushed to lift a state ban on the facilities, but the governor at the time, current Vice President Mike Pence, said he morally objected to needle exchanges. He eventually signed an executive order lifting the ban in Scott County, but it came two months after the outbreak was first detected. Meanwhile, more than 20 new cases were diagnosed every week at the height of one of the biggest outbreaks the country had seen in decades.
After tens of thousands of needles were handed out, new HIV cases dropped.
In 2016, Congress lifted a nearly 30-year-old federal ban on needle exchanges. The prior year, more than 33,000 people died as a result of opioid overdoses.
"Stigma is the thing that makes someone not believe in evidence because it's that inconsistent with their underlying opinion about the situation," Sharfstein said. "So, I don't think it's enough to just present data in order to overcome stigma."
Public health officials dealing with the opioid crisis say there are lessons to be learned from how the stigma surrounding AIDS and HIV was blunted.
Programs like Horizon, which started in 1997, directly addressed stigma as contributing to the AIDS epidemic. Horizon educated people about the disease and found ways to properly measure stigma in different communities and catered responses to it. It also worked with the media to profile unlikely people affected by the disease—putting a face to the disease.
"So much of the early response to the HIV epidemic was to demonize and stigmatize people with AIDS and to portray them in all of these types of scary ways," said John Hamilton, clinical outreach officer at Mountainside Treatment Center, an integrated drug addiction recovery provider based in Connecticut. "I think we're seeing very similar things with those with addiction; there is so much fear that's completely misplaced."
Hamilton recalls that the federal government waited four years after HIV/AIDS was first detected in 1981 before committing resources. In that time, more than 15,000 cases occurred, resulting in more than 12,000 deaths.
Lawmakers have yet to appropriate funding to combat the opioid epidemic at a level public health advocates say would make a difference. Congress allocated $3 billion to fight the crisis for fiscal 2019 as part of the budget deal passed in February. The Trump administration's proposed budget calls for an additional $7 billion in funding for opioid abuse treatment, for a total of $10 billion. But it has not yet reached the level of funding for HIV/AIDS prevention, which totaled more than $20 billion for fiscal 2018 alone.
Howard said advocates need to continue to make the case for controversial approaches to address opioid abuse and underscore what's at stake.
"Sometimes I think you have to follow your conviction and do the best you can to try to get the resources and support that you need to put something in place," Howard said.
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