A “quiet storm” threatens the District’s efforts to reduce opioid deaths

Despite efforts to combat addiction and overdose throughout Washington, the numbers aren’t going down like Mayor Bowser’s administration had hoped.

This article was originally handed in as a class assignment on Dec. 11, 2019.

Mayor Muriel Bowser’s multimillion-dollar plan to reduce opioid overdoses in Washington in 2020 has hit a major roadblock. Despite educational initiatives, Narcan distribution programs and increased efforts to combat fentanyl trafficking throughout the DMV, overdose deaths have not decreased this year, according to a report from the D.C. office of the chief medical examiner.

The D.C. government is fighting “a quiet storm,” said Chikarlo Leak, who tracks opioid overdose deaths for the medical examiner.

In a phone interview, Leak said the key factor contributing to the District’s continuing opioid crisis is a lack of trust in government institutions, leading to a high rate of death specifically in historically marginalized black communities in Washington. Although the city is working to sustain partnerships with local organizations, the rate of overdose deaths is stagnating.

The newest opioid overdose mortality report is not currently available online, but Leak said it shows overdoses are not declining despite the $24 million spent on reducing deaths in the District. The initiatives in place revolve around expanding education and awareness while also providing access to life-saving opioid reversal drugs like Narcan. 

According to the 2019 second-quarter report produced by Leak Office of the chief medical examiner report, there are 14 fatal overdoses in the District every month. As of July 31, there were 98 opioid-related overdose deaths confirmed by the chief medical examiner compared to 109 deaths at the same time in 2018.

The Mayor’s plan

In order to address the increasing epidemic within the district, Mayor Bowser initiated the Live Long D.C. campaign in January 2018. The plan was implemented with the goal to cut opioid overdoses in half by 2020. The information provided by Leak casts doubt on whether or not this goal will be met by the end of next year.

“The District’s multi-stakeholder, public health approach has yielded progress in saving lives and reducing fatal overdoses,” the Mayor wrote in the strategic plan’s opening letter. “But there is still work to be done to reduce the impact of the epidemic on our city.”

The successes of the plan so far, according to Mayor Bowser’s letter, included reversing over a thousand opioid overdoses by distributing Narcan to community organizations, as well as monitoring synthetic opioids and providing educational materials on opioid addiction.

Between 2014 and 2018, 81 percent of all overdose deaths were African Americans, and 88 percent of all people who overdosed had been using for more than 10 years. This population provides a stark contrast to the average opioid user nationally, who are 18-29-year-old white men.

Live Long D.C. focuses on 7 goals, which include educating pharmacists and D.C. residents on opioid use, increasing access to harm reduction services and reducing barriers that might prevent or deter people from seeking out services.

Although the rate of overdose deaths dropped by 31 percent between 2017 and 2018, according to Leak the number of deaths has not dropped between last year and this year.

Leak’s role includes looking for trends in mortality rates, assessing causes of death and creating special reports for the Mayor’s office. He also serves on the oversight board of the Live Long D.C. initiative. He uses this data to provide policy suggestions to the various government programs designed to reduce opioid overdose deaths.

In addition to producing mortality reports, Leak also participates in meetings with government officials to discuss ways to improve access to care services within D.C. The quarterly meetings allow Leak to discuss and review his reports in a way to address opioid use and addiction with the city’s government.

He said that building on community partnerships has been essential to reaching users who would not normally interact with government-operated care facilities.

Organizations like Bread for the City and HIPS, which provide a number of legal and health support services within Washington, are the center point for this goal. They provide Narcan to residents, offer syringe exchange programs to reduce the transference of disease and offer buprenorphine, which reduces withdrawal symptoms in individuals who are trying to stop using opioids.

The Mayor’s office did not respond to requests for comment on this story.

Deaths in the District

The 2019 report on overdose-related deaths shows Wards 5, 7 and 8 having the highest rate of overdose deaths. These neighborhoods are all predominantly black. African-American men between the ages of 50 to 59 are the most at-risk population for opioid-related fatal overdoses in the District, constituting nearly a third of all deaths in 2018.

Michael Kharfen, senior deputy director of the HIV/AIDS, Hepatitis, STD and TB administration for the D.C. Department of Health is in charge of the city’s Narcan distribution program, which was introduced earlier this year.

In a phone interview, Kharfen said that because the opioid-using population in the District is so different, the city’s response has been unique in the way it approaches providing services for substance users.

“Our first intervention effort was partnering with our needle exchange providers who have very long-standing relationships and rapport with people who have a longer-term use of drugs,” said Kharfen. “We were not necessarily applying the same toolkit that may have been applied in place that’s more rural, that has the younger users … or are using prescription drugs.”

Kharfen said that a key part of the city’s response to overdose deaths is understanding the relationship between the District’s using population and government support systems.

“[Washington] is very different in terms of where people are willing to access, whom they trust,” said Kharfen. “The distinctive approach in the District has been … partnering with the organizations that have that kind of credibility and authenticity with a community of people who’ve used drugs for a long time and have been often marginalized or rejected by other traditional systems of care.”

He said that while his goal is to provide better access to Narcan for family members and friends of drug users, he also thinks about “adopting and adapting to the needs” of the city’s unique conditions.

https://infogram.com/deaths-in-the-district-1hkv2nnx9epp2x3?live

Rana Bou-Serhal, the top pharmacist at an Adams Morgan neighborhood CVS that participates in the program, said her pharmacy has only distributed seven or eight kits since the program began. In 2018, there were eight opioid-related overdose deaths in Ward 1, where the pharmacy is located.

Bou-Serhal said “there’s no limit, they can get as many [kits] as they want.”

She said that she will then fill out a form that includes the requestor’s information as well as the number of kits they were given, which she then will fax to the Washington D.C. Board of Pharmacy.

Aside from the standard questions that pharmacists are required to ask, some local healthcare providers in the District go beyond the specific requirements laid out by the board of pharmacy.

Sukriti Kaushal, a pharmacist at Grubb’s Pharmacy Southeast, said in an interview that the pharmacy will cross-check a requestor’s name with their own database to view which medications they are currently prescribed.

“Any patient that comes in with a prescription that has the potential for abuse with the ability for Narcan to resuscitate, we offer them the Narcan for free,” said Kaushal.

She said the pharmacy offers patients information on the pharmacies that distribute Narcan, what days they’re open, and how to get to them. The pharmacy will also offer Narcan kits to friends and family members that pick up these prescriptions.

Kimberly Henderson, the director of communications and community relations for the D.C. Department of Health, said in an email that 1565 kits have been distributed since Aug. 31.

Purity and potency

Fentanyl is a highly potent synthetic opioid that is often cut into heroin in order to pack a more powerful punch in a smaller dose, making it easier to transport and distribute. This means that people who have been using opioids for decades are now facing an increased risk because it is nearly impossible to distinguish between heroin that is pure and heroin that contains fentanyl.

“You see a white powder, you don’t know the concentration” or purity of the substance, said Leak.

Leak said that his role on the Live Long D.C. advisory board includes making suggestions for policies that could reduce the number of overdose deaths involving fentanyl specifically.

“Handing out fentanyl test strips, getting Naloxone, and harm reduction” are all goals of the Mayor’s initiative, according to Leak.

In 2018, there were 213 total overdose deaths, with fentanyl contributing to 86 percent of fatalities. In the second quarter of 2019, 98 percent of all opioid-related overdose deaths in the District involved some amount of fentanyl.

Leak said that this trend remains the same for the unpublished third-quarter report.

Since the Office of the chief medical examiner first started testing for fentanyl in 2014, 873 of the 1,018 people who died from opioid-related overdose tested positive for the drug.

Despite this information, in the 24-page Live Long D.C. report published in March, fentanyl is only mentioned seven times despite accounting for well over 90 percent of all opioid-related overdose deaths. While the report mentions the prevalence of fentanyl-laced opioids, there is no specific plan to reduce fentanyl-related overdoses.

The only plan outlined in the report is to “develop effective law enforcement strategies that reduce the supply of illegal opioids in the District of Columbia.”

Leak said that continuing to focus on “implementing educational campaigns” will be the major factor in reducing opioid overdose deaths. In the coming months, bus stops and homeless shelters will have advertisements with information on how to get Narcan and begin addiction treatment at local facilities.

He said that “reducing regulatory barriers, creating a robust and comprehensive surveillance system, … supporting behavioral health programs and providing immediate access to intervention and care” are all key to reducing overdose deaths.

“We want to make sure residents and users are aware that there are services in the city,” said Leak.

Harm reduction advocate emphasizes seeing substance users as “people first”

Frederick, MD – John Dittmann leans against the wall while sitting at his Starbucks table, with a kind smile on his face and a coffee steaming by his left hand. He speaks with an accent that’s hard place, which makes sense considering he grew up bouncing between California and West Virginia before settling in Maryland as an adult.

His baseball cap casts a slight shadow over his eyes, but passion lights up his face the moment he begins to discuss his work as an advocate for people in recovery from opioid addiction. 

“Being in recovery myself, my goal is to blend my advocacy work and to teach people about the medical aspects [of addiction] to correct misconceptions,” said Dittmann. “I will educate anyone who needs educating … where I see a need, I speak up.” 

Aside from running his Facebook group, Dittmann is a paramedic and also works as a member of the national group Advocates for Opioid Recovery as a member of their survivor’s council. He provides consultation for people in legal struggles with clinics as well as providing support systems for their recovery. 

Dittmann was in college when he first used opioids. It started with recreational cocaine use with some friends, but one night when they didn’t have any coke, they decided to take some Oxycontin with a friend who had been prescribed the drug.

“It kind of just snuck up on me,” said Dittmann. “It actually took me a long time to realize that I was physically dependent and became addicted.”

In school, Dittmann studied microbiology and analytical chemistry, and was on track to go to medical school. The science behind addiction had always fascinated him. By the end of college, he moved in with friends who also used and had gone from snorting crushed Oxy to injecting heroin, which culminated in his arrest after graduation. 

Part of his probation included a requirement to seek professional recovery assistance. Lacking confidence in 12-step programs, Dittmann instead chose to begin treatment at a methadone clinic. 

But what drove Dittmann to become an advocate for other people in recovery was not his personal experience as a user, but, rather, the neglect and corruption he saw during his decade hopping form one methadone clinic to clinic. During a span of 10 years, he sought treatment at seven different rehab facilities, seeking one that provided him with adequate support.

“We’re never going to stop the overdose crisis until we start seeing people who use drugs as people first.”

–John dittmann

At one time, after raising questions about medical advice he received at a clinic, he was put on “administrative detox,” where a patient is weaned off of the drug over 10-21 days. This is the process of slowly reducing the amount of methadone given to a patient and allow them to leave the clinic without suffering the most serious side effects of detoxification.

“It’s cruel, it’s dangerous, it’s to get you out of the clinic,” said Dittmann. He saw detox used as a punishment when other people like him were unable to pay their bills, or questioned the decisions of the clinicians.

Dittmann began to question the power dynamic in clinics that the people he and other people in recovery were relying on for medication and support. He saw contradictory information, such as warning signs and threats of felony charges for failing to follow clinic protocols, despite his knowledge that those punishments themselves were against the law.

When Dittmann’s younger half-brother died from an overdose, Dittmann realized that addiction is often a response to trauma. 

Even more important, he said, is understanding that people experience addiction and trauma in different ways. Making the recovery process more personal, allowing for mistakes and educating former substance users became a goal for Dittmann. 

From contradictory advice from clinician to clinician, to threats of legal action if patients failed to follow the program entirely that were posted in clinics and had no basis in state or federal law, Dittmann saw a need for advocacy on the behalf of others in recovery that didn’t have the same background in medicine he does. 

“It breaks my heart … the way people are being treated, the way they’re looked down on” while trying to recover from addiction, said Dittmann. “We’re never going to stop the overdose crisis until we start seeing people who use drugs as people first.”

Stacy Lesko was three years sober when she decided to join a Facebook group dedicated to helping people in recovery from opioid addiction. She said the group broke down “myths” and biases about addiction that are held by doctors and patients alike. 

“When you’re in active addiction, your life becomes this non-reality,” said Lesko. “A part of recovery is coming back to reality, and that was one of my biggest struggles.” 

For her, it was John Dittmann, the creator of the group, who helped her regain her footing. 

“Every morning I would get on there, and just read through,” said Lesko. “Not even just the questions you ask, things you didn’t even think of, or you forgot about, people were asking.” 

John would dedicate hours of time to researching and responding to each individual group member’s questions. He would provide links to research and personal anecdotes as a way for people to understand their addiction, and their recovery. 

“During active addiction, you’re fighting to get out, and you’re also fighting to defend yourself,” said Lesko. “All these people that loved and cared for me … they didn’t understand so then it built a barrier.” 

“When you’re in certain situations, people don’t understand how quickly it is to relapse,” said Lesko. “By John sharing everything that he knows, or can find, it’s easier to understand everything that you’re going through and to make better decisions.” 

Dittmann is too humble to admit the direct role he played in Lesko’s recovery.

Lesko said that thanks to Dittmann, she was able to reconnect with her friends and family because she had an outlet to discuss her recovery.

“I’ve learned that when defending yourself, you also have to be understanding of where people are coming from, too,” said Lesko. “People feel a certain way or have opinions about you, for a reason. Everything that I’ve gone through, they’ve gone through as well. ”

Overdose deaths in Washington overwhelmingly linked to synthetic opioids

The third wave of the opioid epidemic shows steady rise in overdose deaths.

*This story was originally handed in for an in-class assignment on May 2, 2019.

Dr. Randi Abramson, the chief medical officer at Bread for the City, says opioid users in Washington talk about fentanyl all the time. Users tell her, and other doctors, that their friends are dying and that they are afraid. People who have been safely using heroin for decades are now fearful that their opioids could be tainted with fentanyl, marking a new and deadly phase of the national opioid epidemic.

Described by health professionals and historians as the third wave of the opioid crisis, overdoses involving fentanyl – a highly potent synthetic opioid – now account for about 81 percent of current opioid-related overdose deaths in the District of Columbia as of November 2018, according to a report by the Office of the Chief Medical Examiner.

That same report said that the annual number of opioid-related overdose deaths in Washington more than tripled between 2014 and 2017, from 83 to 279. In the last four years, 337 people in Washington have died from fentanyl overdose.

Doctors like Abramson at Bread for the City, a nonprofit organization that offers services for opioid users in Washington, said that the recent flood of fentanyl into the District is creating a trauma within the community. Abramson said the fear is “visible,” in meetings with her patients, and that they wonder if they could be next.

“Before, they weren’t scared,” Abramson said.

Fentanyl is not a new drug, but according to Dr. Stephanie Peglow, who works with the Virginia Department of Behavioral Health and Developmental Services, its role in recent overdose deaths across the United States can be attributed to its potency, its cheap manufacturing costs and the difficulty in its detection.

In an interview, Peglow said that fentanyl is a highly potent opioid with fast-acting pain-relieving effects. Because it packs a more powerful effect in a smaller dose, it is often used as a cutting agent with heroin. This makes fentanyl useful for traffickers that want to reduce the volume of shipments without impacting the potency of their product.

“If you used to need a very large suitcase of heroin that would supply, let’s say, a thousand people, you could now supply those a thousand people with the same effect with a handbag size, or smaller, of fentanyl,” said Peglow.

According to Peglow, the problem with mixing fentanyl and heroin is not only that it increases in the number of opioids entering vulnerable communities, but also that it is virtually impossible to detect without proper testing equipment.

“Even the most trained user of opioids cannot detect the difference between fentanyl and heroin until it’s used. … It’s white and powdery, and it’s indistinguishable,” said Peglow. “Not only are they not aware if they’re taking fentanyl, they’re not aware how much fentanyl is in it.”

Matthew Pembleton, a historian and professor at American University who has written for the D.C. Policy Center on the history of opioid use in the District, said that the opioid crisis in Washington has a “much different character” than other parts of the United States.

“You’ve got this population of older black men who have been heroin users, steady heroin users for a long time … but had settled into, like, a rough equilibrium. It seems like most of them are working, most of them are housed. Then all of a sudden, you’ve got fentanyl, and they’re not prepared for it,” said Pembleton.

In fact, 82 percent of all overdose deaths in Washington are African-Americans, according to the 2018 medical examiner’s report. The deaths primarily occurred in the eastern part of the city, with Wards 5, 7 and 8 seeing the highest rates of overdoses.

Opioid overdoses in the District more than tripled between 2014 and 2017

“It’s not a white rural thing anymore, it’s very much something that’s happening to people of color and in cities,” said Pembleton.

Former user Jennifer Dorsey said that the main issue that must be addressed is addiction itself.

Dorsey was 16 when she went to a recovery center for alcohol and drug misuse. Although she said that she did not stop using immediately after her rehabilitation, the experience “planted a seed” that helped her on her road to recovery.

“We were really a broken family as a result of my addiction,” Dorsey said.

At the time that she was still using, Dorsey that she was lucky that opioids were not more readily accessible. She used them “when they were available,” but said that opioids were not available “in the way that they are now.”

Dorsey said that her time in residential treatment inspired her to not only overcome her addiction and “get clean,” but also to begin working at recovery centers to show users that anyone has the ability to recover. Dorsey is now the regional clinical director for Kolmac Outpatient Recovery Centers’ office in Washington, as well as the organization’s offices in Maryland cities Gaithersburg and Silver Spring.

In order to effectively address the opioid epidemic in Washington, nonprofit organizations like Bread for the City have implemented programs such as syringe exchanges and addiction recovery services. They are in the process of introducing a system to provide fentanyl testing strips to heroin users that are patients at their medical clinic to reduce overdoses.

Vanessa Peter, leader of Bread for the City’s syringe exchange, said an important facet of their initiative is developing a familiarity with clients who utilize clean needles and addiction recovery resources provided by the nonprofit.

By building a familiarity with their regular patients, Peter said Bread for the City emphasizes the intersection between medical issues and social stability.

Washington’s city government is addressing the epidemic through education and awareness, but also through increased policing.

Mayor Muriel Bowser has proposed a program aimed to halve opioid overdose deaths in Washington by 2020, with language citing the necessity of “effective law enforcement strategies” in combating opioid, and specifically fentanyl, overdoses.

Abramson at Bread for the City remains unconvinced:

“This is definitely a healthcare issue, it’s not a criminal issue. … It’s not locking people up, there are not laws we need to change this: you’re never going to change this through the legal system.”