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Fighting the Opioid Addiction Crisis in Buffalo

Logo https://stories.wgbh.org/fighting-the-opioid-addiction-crisis-in-buffalo

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Ben Francis was a high school senior when his insides betrayed him.

Ben says he was one of those “straight-edge” kids. He’d avoided drugs and alcohol through his teens, and in his spare time, played soccer and hung out with his friends. He was a promising artist and aspiring art teacher; photography, in particular, inspired him. His life seemed to be following a trajectory familiar to most of the kids who attended his large high school in suburban Western New York, just outside of Buffalo.

But after one high school soccer injury and three refills of Vicodin—a powerful prescription opioid—Ben was teetering on the edge of a new world. “I knew I liked the feeling,” he says. Although, when the prescriptions ran out, he says he “figured that was over.”

It wasn’t over, as Ben found ways to buy more pills and, subsequently, heroin—anything that would induce in his body the same sensations brought on by the Vicodin. While taking classes at SUNY Potsdam, every cent he earned went toward feeding his addiction, toward calming the beast inside of him. “I would go so far as to jump in the car at 5 a.m. with some friends and go to the closest place to buy anything like that.”

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Photo by Ben Francis

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Ben managed to make it through a few weeks of classes during his first semester of sophomore year at Potsdam. Then he started disappearing for days and eventually dropped out. Ben planned to come back the following fall, but he never did. His descent continued.

What’s misunderstood about addiction, Ben says, is that no one wants to be that way. No one wants to feel that way. Once the brain crosses that powerful threshold—between recreational use and addiction—every day is a struggle just to feel normal. Every day is a brush with death, a race to find a dealer, a plan to outsmart the cops and the people who love you.

At this point, for Ben, it was no longer about getting high. Rather, it was “about being able to function—about being not sick.”

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Ben continued to use. “I figured I was resigned to that life until it killed me,” he says.

Ben’s story is common.According to the American Society of Addiction medicine,20.5 million Americans age 12 or older had a substance use disorder in 2015. Of those, 2 million used prescription pain relievers and 591,000 used heroin. Nearlya thirdof those who use heroin develop opioid addiction.

Easy access to drugs like heroin, fentanyl, and even prescription medications like OxyContin has fueled an epidemic of addiction—the deadliest in U.S. history. Now, science is revealing how addiction affects the brain, and experts are gathering evidence to determine how we can best address our drug problem, from embracing evidence-based treatments to rethinking public policies.

As a whole, the U.S. is making some progress toward untangling the web of factors fueling the opioid crisis. But drug use is still on the rise. In 2017, it's estimated thatmore than 72,000 Americans died from drug overdoses,including illicit drugs and prescription opioids. That’s more than triple the number of deaths that occurred from drug overdoses in 2002. Life expectancy in the U.S. is dropping because of this crisis.

“We have 4.5% of the world’s population in the United States,” says Cheryll Moore, medical care administrator at the Erie County Health Department in Buffalo, NY. To put that in perspective, the U.S. consumes 30% of the world’s opioid supply. “In the United States of America, we do a quick fix and we got in big trouble. We are getting out of it slowly.”


























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From 2009 to 2016, opioid overdose deaths doubled in New York State.

However, a few areas have begun to see a decrease in fatalities, including the city of Buffalo and surrounding Erie County. What's behind the decline?

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Back in 2013, New York State’s I-STOP law was put into effect, requiring prescribers to consult a Prescription Monitoring Program Registry when writing prescriptions for certain controlled substances. This provided practitioners with secure access to prescription histories for their patients. Officials and medical experts in Buffalo thought this would help curb the crisis.

It did not.

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A new response was necessary in Buffalo.

Cheryll Moore and her colleagues started the Erie County Opiate Epidemic Task Force in 2017, which is made up of seven working groups, including law enforcement, community members, families affected by the crisis, medical providers, health department officials, and more. “All of the efforts of all of the work groups together, in synergy, are starting to make inroads. We’re trying all different programs—anything that we can,” Moore says. “What’s working, we keep. What isn’t working, we get rid of.”

This is how a lot of regions in the U.S. are operating: on informed experimentation. Because the opioid crisis is extremely complicated and varies county by county, medical experts and policymakers are working to get on the same page and make their process more effective given limited resources.

One of the task force’s programs that seems to be working is a new response from police officers whenever they encounter an overdose.















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Just outside Buffalo is the socioeconomically diverse and historically blue-collar town of Cheektowaga, the city’s second largest suburb. The Cheektowaga Police Department’s attitude toward the opioid crisis is all hands on deck. Officers are tightly integrated with Cheryll Moore’s task force; officers communicate with the health department and other parts of the network directly after responding to an overdose.

Lieutenant Brian Gould says when his team arrives on the scene, the sight is a scary one. The victim—sometimes collapsed on a bathroom floor in the mall, sometimes slumped over against a building—isn’t breathing. “They’re unresponsive,” Lt. Gould says.

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In the event of an overdose, a compound called naloxone can revive someone on the brink of death. Sold under the brand name Narcan and administered either by injection or in the form of a nasal spray, naloxone can literally breathe life back into the breathless.

Naloxoneblocks the effects of opioidsby binding to opioid receptors—proteins that drive the body’s response to these compounds by serving as docking sites for opioid molecules. If there’s an opioid already present on the receptor, naloxone kicks it off. Then, when naloxone binds to the receptor, it blocks that receptor’s activity but doesn’t activate it—meaning a person can recover from his or her overdose.

Though naloxone can bind to every kind of opioid receptor, it has a particular affinity for mu opioid receptors. Mu receptors can be bound by drugs like morphine, fentanyl, and heroin. Their activity is responsible for the euphoric, sedative, and pain-relieving effects attributed to these drugs.

The exact way in which naloxone interacts with mu receptors to displace opioids and restore breathing remains unclear. The effectiveness of the drug, however, is no mystery. Within minutes of receiving naloxone, an overdose victim can regain consciousness and may even experience sudden withdrawal symptoms.

A drug so powerful in reversing an overdose has little to no effect on people without opioids in their system. “You can’t mess it up,” Lt. Brian Gould says. “If you administer naloxone to somebody who’s not having an overdose situation, it has no negative effects. They end up with a wet nose—that’s all.”

In Cheektowaga, police officers are equipped with Narcan nasal spray kits. This is unusual—the number of police forces carrying Narcan is changing rapidly. But records suggest that the majority of law enforcement officials do not carry Narcan, though it’s extremely effective in saving lives. Since law enforcement officials are typically the first people on the scene after an overdose, and because time is of the essence when a person isn’t breathing, a police officer’s ability to administer Narcan can be the difference between life and death.














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In Cheektowaga, after a person has overdosed and received Narcan, his or her information is quickly entered intoODMAP,an app created by the Washington/Baltimore High Intensity Drug Trafficking Areas (HIDTA) program. This database is used in various ways across the country, but in Cheektowaga, it kickstarts a process: The officer enters certain data into ODMAP (for example, location of the overdose, how many doses of Narcan were administered, whether the overdose was fatal or not); then Moore’s team dispatches someone to connect with the individual.

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Meanwhile, law enforcement gives the person who has overdosed a small but alarming package. It’s a bright orange envelope with the words “YOUR LIFE WAS SAVED THIS TIME” written in large bold letters.

“It’s [an] envelope full of information on how to get help,” Lt. Gould says. “We have a 24-hour opiate addiction hotline—there’s a card in there for that. There’s information on how to get naloxone. There’s information on how to get people into treatment.” The orange packet is a way for law enforcement to get this critical information into the hands of overdose victims and their loved ones.

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Every dot and diamond corresponds to an overdose.

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Cheryll Moore checks ODMAP in the morning, at lunch, and at night. If there are any new overdoses, Moore identifies the police department that was involved and reaches out to their records clerk for a report. If the person who has overdosed hasn’t called the health department, then within 24 to 72 hours after the overdose, Moore’s team deploys a peer—someone in recovery who’s been trained to support those still struggling with addiction—to talk to them and let them know that they’re not alone. Most of the time, the peer goes to the person’s home to see if they’re around; as a backup plan, the peer will try reaching the person by phone.

“Every case is unique,” Moore says. “That’s the beauty of the peer asking someone, ‘What is it that you’re looking for?’ The key is not what I want, but what you want for you.”

The optimal goal of this relationship is to connect the person with long-term treatment. A peer also sits down with family members to determine how best to support the individual.

“We’ve interacted with 58 people since September [2017], and since then, more than 60% are still connected to treatment,” Moore says.

This is all possible because of ODMAP, which connects people to recovery options in near real time. Historically, the health department received reports from law enforcement about their use of Narcan, but it wasn’t necessarily same-day information. These individuals are usually “sick and tired of feeling sick and tired,” says Antonio Estrada, one of the peers. They’re more open in that vulnerable state to exploring treatment options, he says. It’s important to note, though, that this window of time is extremely fleeting; if the opportunity passes, patients could end up in severe withdrawal and go back to using.

As a peer, Estrada knows what it’s like. He’s been in recovery for 18 years, and can describe to overdose victims what the journey feels like.


















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Historically, diseases of addiction like opiate use disorder were treated with abstinence-based programs that included behavioral interventions, but no prescription medications. However, without chemical assistance to reduce the brain’s cravings, patients on these types of treatments are muchmore prone to relapse,with failure rates estimated between 80 to 90%. Today, so much of the opioid drug supply is tainted with unpredictable amounts of potent fentanyl. Every time a person uses, the risk of death is extremely high.

As a result, more and more addiction specialists are advocating for medication-assisted treatment or M.A.T. This combines social and behavioral interventions with drugs like methadone or buprenorphine that mimic the body’s own pain relievers, reduce cravings, and help regulate the production of dopamine.

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For Dr. Paul Updike, the medical director for Substance Use Services for the Catholic Health System in Buffalo, NY, this approach is the “treatment of choice.” But he notes that different treatments should be “complementary, not exclusive of one another.”

There’s a growing consensus that emergency departments should work aggressively to offer medication-assisted treatment to every overdose victim immediately—at the moment when they are most vulnerable to relapse.According to the Recovery Research Institute,the window of time between referring a person to treatment and his or her actual appointment, if too long, could result in loss of motivation. Many addiction specialists fear that after 24 to 72 hours, a patient might already be in acute opioid withdrawal, and at increased risk to use—and overdose—yet again.

“If you have a diabetic patient whose blood pressure is too high, and a few weeks later, the blood pressure got too high again, you don't kick him out of the diabetic clinic,” says Dr. John Aldis, an addiction medicine specialist in the Eastern Panhandle of West Virginia. “You welcome them back in, you get them back on treatment, as often as is needed. And that isn't being done in addiction medicine.”

At Massachusetts General Hospital in Boston, people who have overdosed are sent home with a prescription for a drug that combines buprenorphine and naloxone (sold under the brand name Suboxone). Unlike methadone, which is a Schedule II drug and requires a DEA license to prescribe, buprenorphine can be prescribed and given to individuals right in a doctor’s office. According to the Drug Addiction Treatment Act of 2000, doctors can prescribe buprenorphine in a variety of settings including community hospitals, health departments, and prisons. On the other hand, methadone maintenance treatment can only be performed in a Substance Abuse and Mental Health Services Administration (SAMHSA)-certified clinic.

In Western New York, many hospitals are connected with Cheryll Moore’s task force. “Each case is slightly different,” Moore says. In general, overdose victims are transported to the local emergency department after overdoses occur; at 13 of those emergency departments, staff are trained and registered to provide and prescribe Suboxone. Moore’s task force is responsible for having trained 150 of those providers in the past few years. Additionally, the individual is given an appointment with a nearby long-term treatment provider within two to seven days after the ER visit if the individual so chooses to pursue long-term care.

“We currently have a network of 27 community-based substance use disorder providers that have allocated more than 60 slots weekly for immediate appointments and continuation of medication-assisted treatment,” Moore says. This is necessary because the initial prescription from the ED is only valid for a week—then the patient is advised to follow through with the arranged long-term treatment. If a client is uninsured, the task force has set up a process with a local Congressional Budget Office to accept donations to pay for the first week of medication for the individual.

This means that there are essentially two paths for a person who has overdosed in Buffalo: If a person enters an M.A.T.-participating emergency room, he or she can find long-term care immediately. If the person overdoses in Cheektowaga, he or she might still receive the same treatment at the ER (if that particular hospital has Suboxone providers), but that person will also have received the orange packet from law enforcement containing information about peer support and M.A.T.

Until all emergency rooms can provide Suboxone or methadone on demand, community providers are doing the best they can to engage people in treatment. In Buffalo, the task force and peer system seem to be making a difference.

At the Catholic Health System Methadone Clinic, the first of its kind in Buffalo, Dr. Updike is focusing on making sure people with opiate use disorder are stabilized with medication-assisted treatment so they can get back on track.

“When patients aren’t having to deal with the demand of their addiction every day, then things change dramatically,” he says. “There’s concurrent care here—a counselor, nursing staff…medication is an important piece of the treatment, though.”

In general, medication-assisted treatment works because opiate use disorder is a chronic, life-threatening illness characterized by changes in the brain. According to Dr. Updike, these changes drive the stigmatizing behaviors often associated with addiction—like criminality and joblessness—and medication is necessary for a successful recovery. “If we don't address that underlying problem, then patients will struggle,” he explains.
























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Many communities across the country have all but neglected their opiate-dependent populations. Others—those with sufficient resources—are trying to construct ideal pathways and permanent solutions. Ultimately, experts say that the best way forward is to make sure all emergency departments are equipped with on-demand methadone and Suboxone.

“We need just as many spots open for addiction medicine as we have for diabetic medicine or any other chronic, relapsing, and potentially fatal disease,” Dr. John Aldis says.

Given their limited resources, Buffalo officials are devising an ambitious plan that remains a work in progress.

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Cheryll Moore knows there’s more work to be done. “We have a long road ahead of us,” she says. “It’s going to take a long time to get out.” In October 2018, Erie Countyreceivedtwo grants from the Bureau of Justice Assistance for a total of $1.8 million to fight the opioid epidemic. Moore says that over the next three years, one million will fund an Opioid Mortality Review Board to help shape future public health practices and policies related to opioid addiction. The remaining funds will be used to develop a peer support unit for people suffering from opiate use disorder and who are in the Erie County probation system.

Additionally, Erie County received $3.2 million of funding from SAMHSA and the New York Department of Health to increase peer services, increase access to naloxone, and provide training to first responders in the eight counties of Western New York over the next four years.

Working out the kinks in systems like Buffalo’s will require taking a hard look at the delicate time frame between an overdose and a person’s next use of opioids. Dr. John Aldis says that medications with a long half-life (that is, medications that remain in the bloodstream for a longer period of time) are the most promising, and that medical care providers need to administer the first dose of methadone or Suboxone once a person is in withdrawal and after the effects of other opioids in the system have subsided. Before that, these medications can make a person very sick.

And once initiated, many people are able to hold down a job, avoid street crime and violence, and reduce exposure to HIV due to injections only because they’re taking methadone or Suboxone. Treatment, while a sacrifice, is much better than its opposite.

More than anything, the stigma around addiction needs to erode, says Dr. Aldis.







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Senior Writer: Allison Eck
Senior Digital Producer: Ari Daniel
Director of Photography: Arlo Perez

Deputy Executive Producer: Julia Cort
Production Assistance: Tim De Chant, Nafisa Syed, Vincent Pham
Animator: Ekin Akalin
Designers: Amelia Leason and Ken Kimball
Developers: Hilary Emmons, Tim Kinnel, Carl Lindberg
Additional Photography: Stephen McCarthy and Rob Lyall
Associate Researcher: Robin Kazmier
Producer/writer/director of NOVA Addiction: Sarah Holt
Scientific Advisor: John Aldis, MD
Digital Managing Producer: Kristine Allington
Additional Footage: Shutterstock, Getty, Freesound

Special thanks to everyone in Buffalo we spoke with.

Watch NOVA's filmAddictionwhere you'll also find a set of resource links.

© WGBH Educational Foundation 2018

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