Deadly overdoses in King County continue to rise, with a new high-water mark of 409 in 2018, even as new research points to high rates of deadly overdoses being unique to America.

There are more signs that the opioid epidemic both locally and across the country has morphed into a heroin and fentanyl one, even as attention has remained focused on pharmaceuticals. Information from the King County Medical Examiner’s office showed that 409 people died from drug overdoses in 2018, up from 383 in 2017, which in turn was more than the 345 in 2016.

Opioids continued to be the driving factor behind the trend, with 275 people dying from opioid-related overdoses in 2018 compared to 259 in 2016. Overdoses involving fentanyl were highest in 2018 when compared to recent years. On the other coast, there was a 45-percent increase in fentanyl overdoses in New York City in recent years, leading one doctor quoted by the New York Times to call it a “heroin and synthetic opioid epidemic that is out of control.” Opioid deaths across the country are holding steady at best, and in many places continue to rise, according to Dr. Jessica Ho of the University of Southern California.

Ho released a study in February examining overdose trends in the U.S. and compared them with those found in other countries. Deaths from overdoses have reached unprecedented levels in the U.S., with overdoses more than tripling over the last two decades. It has become the leading cause of injury deaths in the country, ahead of car accidents and murder. More than 70,000 people died in 2017, a 16-percent increase from 2016.

“I do think that this just has the potential to keep going, and I think that a lot of that is because many of the efforts that have been put into place address opioid prescribing,” Ho said. “But we also know that the epidemic has moved beyond that to heroin and fentanyl.”

The U.S. has seen drug epidemics before stretching back to heroin in the 1970s, followed by cocaine during the 1980s, but the current epidemic is distinct in three ways, Ho argued in her study. First, the magnitude of the current opioid epidemic is far larger than previously seen. Earlier epidemics also started with illegal drugs like heroin instead of being birthed through prescription drugs. Finally, previous waves were concentrated in major cities, while the current opioid epidemic has flooded into communities large and small across the U.S.

On average, drug overdose mortality is 3.5 time higher in the U.S. than in its peer countries, the study found. The study looked at a range of other developed countries and found people in the U.S. were between 1.6 to 28 times more likely to die of an overdose, with only Canada, Australia and the UK coming close. Average life expectancy in the U.S. was around 2.6 years lower than in other high-income countries in 2013 for both men and women with overdoses playing a significant role.

Additionally, the age of those who are dying has shifted downwards. Opioid overdoses between 1999 and 2001 were highest for men aged 35 to 49, but now death rates are uniformly high between 25 and 59.

“In the United States, there was this impression that — especially in the early years — of having this epidemic that drug overdose was a background mortality,” Ho said. “Obviously, as we’ve seen, that’s not the case.”

While much of the effort domestically has been focused on reducing the amount and frequency of opioids which are prescribed by doctors, many other countries additionally focus on harm reduction programs like needle exchanges and injection sites.

“I think that there is evidence that more of a harm reduction approach can reduce risky behavior,” Ho said. “…I think that the U.S. takes quite a strict line on abstinence only. On the other end of the spectrum would be countries like Italy, Portugal, which have decriminalized illicit drug use.”

The study said in mid-2018, there were only 333 needle exchanges in the U.S. compared to 3,000 in Australia, which has a much smaller population. Many countries in Europe also have supervised drug consumption facilities, programs which have been fiercely opposed by many neighborhood groups in both Seattle and Philadelphia.

A new drug

The prescription opioid epidemic is largely attributed to a change of narrative beginning in the 1990s, which saw pharmaceutical companies push the idea that too many people suffered unnecessarily from untreated pain. This led to the rise of doctors prescribing painkillers for many non-cancer uses, the study said. In 1996, shortly after OxyContin was approved in the U.S., it pulled in $45 million annually. By 2002 it had reached $1.5 billion. Opioid painkiller prescriptions quadrupled between 1999 and 2013.

After there was a push around 2010 to limit the amount of opioids being prescribed, many people who were addicted switched to heroin. But the fact that overdose numbers continue to rise or stay flat indicates a new epidemic centered around heroin, and increasingly fentanyl, is already here.

In addition to being much more powerful than heroin, fentanyl is also bringing with it a cycle of hysteria and dehumanization of those suffering from addiction, said Dr. Caleb Banta-Green, interim director of the University of Washington’s Alcohol an Drug Abuse Institute.

“Opiate use disorder has been conflated with homelessness, which is not accurate,” Banta-Green said.

Law enforcement has even been affected by scares surrounding fentanyl, often passing along stories of officers overdosing from simply touching fentanyl, something which Banta-Green said has no documented evidence to support it.

“That hysteria about this drug essentially makes the drug scary, and it makes the people scary again,” he said.

Addressing it

In community presentations, Banta-Green said there has been a tone change with people becoming both frightened and angered, leading many to push for cutting addiction services and kicking users out of communities, or jailing them.

In order to take on the current epidemic, Banta-Green said clinics providing medications like buprenorphine and methadone should be expanded in King County. Over the last three years, there have been multiple low-barrier buprenorphine clinics created in the county when there were none before.

Ho agreed that these clinics are needed to combat the epidemic, and additionally suggested that needle exchange programs and supervised injection sites should be approved and expanded. For prescription opioids, Ho said prescription drug monitoring programs should be mandatory to better track where prescriptions are going and whether people are shopping around to receive multiple prescriptions.

Both harm reduction practices like supervised consumption sites and needle exchanges compliment other services like buprenorphine clinics, Banta-Green said. If fentanyl and heroin are successfully stigmatized, it could result in even less being done to address the current epidemic, even as death rates rise. So far, the West Coast hasn’t been hit by fentanyl as hard as other places of the country, Banta-Green said.

“Opioid use disorder is a treatable medical condition and we have a range of medical and public health intervention that improves the lives of the people affected by the disease and the community in which they live,” Banta-Green said.

King County has been expanding its services, including opening low-barrier clinics and encouraging doctors to receive training to prescribe buprenorphine in out-patient facilities. The programs require at least eight hours of training and are known as “X waivers,” said King County Public Health drug policy expert Brad Finegood. Additionally, the county has been trying to reach users at hospitals, needle exchanges and jails.

“These are places that unfortunately people with opiate use disorder already go,” Finegood said. “We’ve been able to sort of find this flexible model to get this treatment to those people.”

Increasing the number of doctors who are trained and prescribe buprenorphine could help get people more easily into treatment and other services. Lowering barriers to access is an important part of their strategy, with Finegood saying the goal is to make receiving treatment for someone with an opioid disorder as easy as calling their dealer.

“If it’s easier for them to go to the black market then that’s what they do, because people really don’t want to go to those withdrawal symptoms because they’re awful,” he said.

Another important part of the equation, and one which addiction efforts often stress, is the need to de-stigmatize and treat addiction as a health problem. Stigmas around drug use can often lead people to not seek help, Finegood said.

“That shame that is put on people with substance abuse is tremendous, and people don’t want to get service and don’t want to get treatment,” he said.