While the US has been in the throes of the Covid-19 pandemic, another public health crisis has surged past a tragic milestone. Over 100,000 people died from drug overdoses between May 2020 and April 2021, according to provisional data released by the US Centers for Disease Control and Prevention on Wednesday – a 28.5% increase from the 12 months prior and a record high for the US.
Though these statistics are new, the problem is not. Overdose deaths have been trending upward for years.
A key aspect of the issue, experts say, has been the rise of fentanyl, a synthetic opioid that can be up to 100 times more potent than morphine, is much cheaper to produce than traditional plant-based opioids and is often mixed with street drugs without the buyer’s knowledge, increasing the risk of a fatal overdose.
Combine the growing popularity of fentanyl with a pandemic that has forced people into isolation, and stripped them of the in-person relationships and support systems they depend on, and it’s easy to understand the spike in overdose deaths since lockdowns began.
But despite the macabre picture the trend lines paint, there is much that can be done to curb the overdose death rate, says CNN Medical Analyst Dr. Leana Wen, who served as the health commissioner of Baltimore from 2014 to 2018 during which time the city had some of the highest opioid overdose rates in the US, and who currently serves as advisory board chair of the Behavioral Health Group, a network of outpatient opioid treatment and recovery centers in the US.
Many of the programs Wen implemented in Baltimore – including promoting the widespread availability of naloxone, the fast-acting opioid antidote, piloting test strips that can alert users to the presence of fentanyl in street drugs and increasing treatment for opioid use disorders – she feels have the potential to curb overdose deaths across the nation.
To address the opioid crisis we must refocus on a single mission, says Wen, and remind ourselves that when it comes to public health, we are all striving for the same outcome: saving lives.
The following interview has been edited for length and clarity.
CNN: Experts have attributed the recent spike in overdose deaths to the pandemic and to the rise of fentanyl. Can you explain how those two factors impacted the overdose death rate?
Wen: Prior to the pandemic, we were already having an epidemic of opioid overdoses that was driven primarily by fentanyl, which is many times stronger than heroin and is often used to cut street drugs. So, if someone is taking their usual amount of heroin, for instance, but there’s something in there that’s many times stronger, they are much more likely to overdose and die.
And then the pandemic happened. Public health resources were already stretched to the limits, so the people working on the opioid crisis had to shift focus to addressing the pandemic. This was necessary, but it also left a gaping hole in the social safety net.
On top of that, we know that addiction is a disease of isolation, and recovery depends on relationships. Many people during the pandemic lost their health insurance and the ability to get treatment. Some may have lost other social resources like stable housing or faced food insecurity. Treating their disease of addiction may not have been top of mind. We also can’t forget that addiction and mental health issues are diseases of despair, and this pandemic has worsened mental health for so many people. I think that is yet another layered component of what was already a major problem that has lost attention and lost funding and lost people working to solve it.
CNN: How can overdose deaths be addressed while the pandemic is still ongoing and resources are still stretched thin?
Wen: We can save lives right now through harm reduction practices. That includes getting naloxone, the opioid antidote, to as many people as possible in communities. We should also look at other classic harm reduction practices like making fentanyl test strips widely available. This does not mean condoning or encouraging drug use, but rather if people are going to be using drugs, they need to know if there’s fentanyl in their supply so that they can reduce the risk of a fatal overdose. Then there are safe injection facilities, which in Portugal and the other countries have been shown to save lives. They are controversial, but if our focus is going to be on preventing deaths, then we should be looking at all strategies that are effective.
We also need to ensure that people have access to evidence-based treatment. For treating individuals with opioid use disorder, for instance, that means a combination of medications like buprenorphine or methadone, along with psychosocial support. There needs to be adequate insurance coverage for these treatments – and while telemedicine should be enabled and allowed, we also must also recognize that many patients need brick and mortar care. Ultimately, the treatment for individuals with addiction needs to be viewed the same as treatment for people with any other medical illness.
CNN: What about longer-term solutions that can be implemented?
Wen: Strengthening our public health infrastructure is critical. Covid-19 has laid bare the many problems, including the underinvestment in and undervaluing of our public health system. We have seen what happens when resources are diverted from existing critical priorities to Covid-19. We, of course, need to focus on this because this is an existential emergency, but these other crises have not gone away.
CNN: What are some of the barriers to implementing these policies and initiatives you just described?
Wen: For the most part, thankfully, there has been bipartisan agreement that this is an urgent issue and needs to be a top priority. There are partisan differences around certain key elements – criminalizing of drug use, for example. Many of us in public health would say that it is far past time for addiction to be treated as a disease, and not as a crime.
The harm reduction practices that I mentioned earlier are also not universally accepted by policymakers at this point. Most people of various political ideologies would support naloxone, because it’s hard to be against the idea that if somebody’s overdosing in front of you, you should save their lives. But syringe exchange programs, which are often sites where naloxone is distributed, are controversial. Many parts of the country still do not allow them for fear that they condone drug use, when what they actually do is to prevent the transmission of HIV and hepatitis, and provide outreach to individuals who could be susceptible to overdose.
In addition, there is a major issue around treatment. The concern here is not even so much political as in a partisan divide, but rather political as in what resources we are willing to devote to this issue. There are solutions we could tap into, but do we have the political will to devote the resources to finally solving this crisis?
I understand that there are many funding priorities in front of the Biden administration and in front of Congress. The question is: where does addiction fall in their list of priorities?
CNN: When you were health commissioner of Baltimore, you focused heavily on implementing specific measures such as widespread access to naloxone and increased access to treatment as part of your initiative to combat the opioid crisis in the city. Do you think it’s possible to implement a similar initiative on a national scale, or is this problem something that needs individualized approaches specific to each locality?
Wen: There are general guiding principles that are necessary for addressing addiction in every community. And those principles include harm reduction, increasing access to treatment and strengthening public health infrastructure. Those are the three pillars that are uniform across all parts of the country. When I was the health commissioner in Baltimore, I worked closely with my colleagues in public health around the country, including Dr. Rahul Gupta, who at the time was the commissioner of health in West Virginia. He primarily oversaw a rural constituency and I oversaw an urban one, but together we wrote about how the programs that we implemented are similar. They were tailored to the specific constituencies we represented and the hospitals, nonprofits and community organizations that we worked with. And while there are different methods of reaching people in urban areas versus rural ones, the principles and the guiding values are the same. So, I think there is a way to scale up what we know works.
CNN: Do you see this as an issue that should be primarily addressed at the federal, state or local level of government?
Wen: It needs to be a combination. The funding has to come from the federal government and then must be distributed to communities based on level of need. The communities then are best positioned to understand how to use that funding for specific programs or resources in their area.
The federal government, though, is not going to give money and say, “Do whatever you want with it.” There are very clear guidelines on how that money should be spent. And in this regard, the federal government has a major role to play in defining the evidence-based treatment that the funds can be used for. We don’t want federal money, for instance, going toward rapid detox programs, which can be harmful and increase the rate of overdoses.
At the same time, states have to do their part. Those that have not expanded Medicaid need to. We need to have policies that treat addiction as we do all other medical illnesses.
CNN: What advice would you have for people who are facing addiction and don’t know how to seek help or what resources are available to them?
Wen: If somebody struggling with addiction has a primary care provider that they trust and go to regularly, their doctor is the best person to seek help from because that person will know them, will understand their history, and will know what resources are available in their community. Additionally, the Substance Abuse and Mental Health Services Administration website has a list of providers in different parts of the country and a person’s local health department may be able to refer them to treatment options depending on the part of the country they live in. In some parts of the country, hotlines exist for people to call if they are seeking help.
CNN: Are you optimistic that we will be able to turn around this trend?
Wen: Public health is now right in the crosshairs of the ideological and culture wars in a way that it should not be. It’s not helpful when masks and vaccinations are seen as political issues, and public health has now been largely equated with Covid-19. So, if Covid-19 is seen as a partisan issue, public health by default becomes partisan as well.
Fighting drug overdose deaths is one of the issues where there is very clear bipartisan agreement that we have a problem, unlike the issue of Covid-19. Not everyone agrees that Covid is even a crisis. Addressing the opioid crisis is a way to get back to a bipartisan consensus on public health.
I’m not saying that is the reason why we should be addressing the overdose crisis. We should be addressing it because it killed over a 100,000 people in America last year; we should be addressing it because it was a crisis before the pandemic and then it became largely forgotten.
But, as an added benefit, addressing the opioid crisis could get us back to the heart of the matter: how public health can unite rather than divide.
