A World of Hope: BOCO’s Opioid Crisis

With editing and contributions by De La Vaca

Original illustration by Irina Ratsek

Unless you’ve been abroad in a country without a drug problem, say the Netherlands or Portugal, you’ve likely heard about the opioid crisis happening here in the United States. 

While the world seems to be falling apart on a grand scale, we look to a more intimate war, to more immediate and local ravages: the opioid crisis. In 2015, a Coloradan died from an overdose every 36 hours. 259 people died of what the CDC terms “natural opioid” overdoses, with 495  total opiate deaths.

Colorado is middle of the pack in terms of national opiate deaths, but solving the crisis in our own backyard is as critical.

“I know that both nationally and in Colorado it’s a real immense public health crisis and we haven’t really cracked it yet,” says Colorado State Rep. Matt Gray.

Rep. Jared Polis offers statistics: “Every single day in the U.S., 91 lives are lost to opioid addiction. The problem has grown to epidemic proportions in the U.S., and we must actively and aggressively address it… We need new ideas and approaches to end the opioid crisis along with better access to mental health services, substance abuse treatment, and education about the dangers of drug abuse.”Polis is working with a bipartisan coalition of legislators to bring a package of six bills in 2018 to address the opiate crisis.

President Donald Trump declared the crisis a “national public health emergency” during a speech on CNN in October. “We can be the generation that ends the opioid epidemic,” Trump said. In the same speech Trump referred to drugs as “bad” and said a “wall” will keep heroin from coming into the States from Mexico.

What is an opioid?

The National Institute on Drug Abuse (NIDA) defines opioids as a drug used for pain relief; a more thorough definition from Medicine.net says they are, “A synthetic narcotic that resembles the naturally occurring opiates [or] any substance that binds to or otherwise affects the opiate receptors on the surface of the cell.” Opioids are abused because of their euphoric effects, which leads to addiction. Commonly prescribed opioids include OxyContin, Percocet, Vicodin, Adderall, Ritalin, Valium, and Xanax, as well as codeine, morphine, heroin, and fentanyl. It’s important to note that the claim that the vast majority of those who abuse opioids are initially prescribed opiates is false. In fact, reports Vice, “The research actually shows that people who developed new addictions in recent years were overwhelmingly not pain patients. Instead, they were mainly friends, relatives, and others to whom those pills were diverted—typically young people.”

Boulder County Statistics

Data from the Center for Disease Control and Prevention (CDC) from 2000 to 2014 showed one person died from a drug overdose every 10 hours in Colorado while one person died from a drug overdose every 11 minutes in the United States.

Mortality Data from Colorado Vital Statistics shows, since 2005, the leading cause of accidental deaths in Boulder County is drug overdose, exceeding motor vehicle deaths.

The 2016 Annual Report for the Boulder County’s Coroner Office showed there were 13 deaths due to opiates, out of 228 in Colorado overall. Four of these deaths were from the synthetic opioid fentanyl, which is 50 to 100 times stronger than heroin.

Reported this month, David Schiller of the Drug Enforcement Administration was ready to take the biggest opioid distribution case in U.S. to bring down the nation’s largest drug company: McKesson. They had evidence that they failed to report millions of suspicious orders of addictive painkillers, for years, including supplying drug rings.

The team, based out of the Denver DEA field office, wanted to revoke registrations to distribute controlled substances at some of McKesson’s 30 drug warehouses, to fine the company more than $1 billion (which wouldn’t be their first fine — in 2008, they paid a $13.25 million fine), and push criminal charges. However, it wasn’t enough for the U.S. attorney in Denver; criminal charges were never brought.

McKesson has been suspected of wrongdoing here in Colorado, as well. In 2012, Pharmacist Jeffrey Clawson, at Platte Valley Pharmacy in Brighton, Colorado, with a population of approximately 35,000, was selling as many as 2,000 pain pills per day.

Denver DEA field found out that most of the drugs came from McKesson’s warehouse in Aurora, Colorado. McKesson filled 1.6 million orders from the Aurora warehouse and only reported 16 orders as suspicious between June 2008 and May 2013. Clawson is now serving a 15-year sentence.

Screenshot, NY Times

Fentanyl hits BOCO

Jamie Feld, MPH, an epidemiologist working at Boulder County Public Health and a member of the Boulder County Opioid Advisory Group, talks abou fentanyl in Boulder County. Fentanyl laced batches of heroin are prominent on the east coast, where the opioid crisis is more severe than in CO, but has found its way to the west.

“That’s really new,” says Feld. “Someone who’s using heroin, they don’t know fentanyl is in it, then they’re much more likely to overdose.” Just this past September, Fox News personality Eric Bolling’s son died here in Colorado from a combination of cocaine, marijuana, and fentanyl laced opioids, which was labeled an accidental overdose, according to the autopsy report.

Why the crisis?

Where do these high numbers of opioid use begin? An article from the October 17 issue of The New Yorker, The Family That Built an Empire of Pain, is about the Sackler family, one of the richest in America. Arthur Sackler, as a young man, got rich promoting pharmaceuticals.  In the ’60s he advertised Valium as a way to relax college freshmen upset about leaving home for the first time.

In 1995, Sackler’s company, Purdue Pharma, introduced OxyContin (oxycodone), a relative of heroin that is reportedly twice as powerful as morphine, to the market. Doctors had been cautious about prescribing opiates up to that point so the Slackers introduced OxyContin “with a marketing campaign that attempted to counter this attitude and change the prescribing habits of doctors. They funded research and paid doctors to make the case that concerns about opioid addiction were overblown.” Purdue Pharma has made $35 billion in sales since.

The New Yorker also reports, “Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids. Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin.” And here we are in Colorado with a spike in heroin use, as opioid use has dropped 5 percent while heroin use has spiked, according to reports.

We have gotten to this point due to prescription opioids, both targeting users and friends and family who find it available, but how? We already know that something as simple as a high school sports injury, getting your wisdom teeth or your tonsils out, or a strained lumbar can lead to abusing prescription painkillers. Anyone with a prescription and a desire can easily sell or give pills to friends. They’re in high demand. By the time a high school kid reaches college age, prescriptions can be too expensive and they discover through drug networks that heroin is cheaper.

According to the United Nations Office on Drugs and Crime, the price of heroin has gone down from over $300 a gram in the 90’s to $131 a gram in 2007.

An addict among us

Tony is a local working man and former heroin addict. He spoke to us about the world a recovering addict faces, a world he lives. His name has been changed to protect his identity.

“Everything you see in the media has been just facts and numbers,”Tony says. “A lot of it is completely impersonal.”

In February 2016, Tony got a DWAI (Driving While Ability Impaired). Tony had a prior and before sentencing he started methadone treatments, but he failed a drug test for pot and cocaine at the halfway house resulting in 30 days work release, which means he is free to go about his day but spends nights in county jail, in addition to completing work.

Tony’s drug use must be seen as coupled with untreated mental health issues. He suffers from Aspergers. While drug use and thrill seeking behaviors are not common on the spectrum, nor required for addiction, drug use can become highly problematic.

“A new study in Sweden,” according to the Atlantic, “suggests that people with autism who have average or above-average intelligence quotients (IQs) are more than twice as likely to become addicted to alcohol or other drugs as their peers are. The risk is even higher for people who also have ADHD. This study is the first to look at the general risk for addiction among people with autism.”

American Addiction Centers points out that, “For people on the autism spectrum, including those with Asperger’s syndrome, the ability to access treatment that is suited to their needs can present a barrier to treatment that is already a challenge to get.” The same holds true across the mental health spectrum. Rather than treating the whole person, medicine sees and treats these as separate.

Tony was denied his methadone inside Boulder County jail and says, “The nurse told me this would be the best thing to ever happen to me;” being forced to go cold turkey and endure the violence of withdrawals. Tony said he “was so sick I didn’t sleep for nine days straight.” In a place like a jail, enduring withdrawals without medical attention is a terrifying prospect.

Tony believes addicts can die in withdrawal situations like the one he went through, but also right after. “Your tolerance goes down and you get right out of jail and think you can do the same amount [of heroin] and you overdose,” Tony says. Luckily he got back on methadone and got clean.

Methadone is used to reduce withdrawal symptoms in addicts without causing the “high” associated with addiction. It is also a pain reliever but, “There’s a stigma around that it’s a crutch,” Tony says. “Everybody I told, everybody in my family, my girlfriend, close personal friends… said do not get on methadone. Now a year and half later they’re all urging me to stay on it.” 

“Once you have tolerance you do not get high off of methadone,” Tony says. “It just keeps you level and it lets you get your life back together, deal with your issue of why you became addicted in the first place, and then worry about the withdrawals and coming off of it slowly and in a medical setting,” rather than a jail cell.

Tony moved to Colorado from out of state several years ago and feels things are worse for addicts here.

“If you’re an addict and want to go to rehab or something you can walk into [a treatment center] and they’ll find you a bed,” Tony says about back home. “[Boulder County] does not have the services they do back there. Here it feels like it’s all privatized. It feels like there’s way more red tape and so they love to say that they’re real progressive, and they are on some issues, like marijuana, but really conservative on other issues…”

Tony hasn’t used since August of 2016 and takes 26 mg of methadone everyday, but smokes pot as well. “Once I smoke I don’t want to do anything else,” Tony says, implying that the marijuna high also helps mitigate opioid cravings.

Fight drugs with drugs

A better world, a world with less overdose, is available because of a drug called Naloxone. Known best by its most popular brand name, Narcan, it is preventing heroin overdoses because it is an “opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids,” according to drugabuse.gov.

It comes in many forms, include pills and sprays. You can literally spray into one nostril with a pump to save the life of someone overdosing. It can also be administered through an auto-injector called Evzio, which has voice instructions on the device explaining how to inject into the thigh.

Jamie Feld of Boulder County Public Health says they’ve trained all law enforcement in the area on Narcan. “There’s 375 kits that were given out,” says Jamie. “If they get to a scene where someone might have overdosed then they can respond.” Narcan kits can be picked up through their syringe access program, but you can also find it in pharmacies.

Could legal medical marijuana (MMJ) be used in recovery? Could it help prevent opioid dependence in the first place? Rep. Jared Polis says MMJ can be used as a safer and more effective alternative for pain management than addictive prescription opioids. He compares MMJ to Kratom, which is another naturally-occuring alternative. State Representative Jonathan Singer is looking into more ways to incorporate MMJ. He wants physicians to be able to prescribe MMJ for acute and chronic pain.

Legislative solutions

Screenshot, NYT

Legislative solutions are the only robust way to solve this crisis. The good news is we don’t have to reinvent a wheel; we have models on which to draw. Portugal, for example, decriminalized all drugs at their federal level nearly 16 years ago.  More critically,  but part and parcel, they redirected the funding for their “war on drugs” to prevention and treatment efforts, changing their national perspective on drug abuse from crime crisis to health crisis.

Portugal’s drug decriminalization meant that “authorities [didn’t] arrest anyone found holding … less than a 10-day supply of an illicit drug” according to Vice. After a decade of positive results (reduced drug use, reduced drug crimes, etc), they moved to fully legalize drugs. The monies saved were diverted from coordinated action with the US DEA and their own drug task forces and were put into education, prevention, and rehabilitation.

Portuguese officials claim that “It was the combination of the law and…services that made it a success. It’s very difficult to find people in Portugal who disagree with this model.” It’s hard to disagree with evidence on hand from nearly two decades of work.

What are the practical effects of their legislative solution to a drug crisis? Vice reports, “The rate of new HIV infections in Portugal has fallen precipitously since 2001, the year its law took effect, declining from 1,016 cases to only 56 in 2012. Overdose deaths decreased from 80 the year that decriminalization was enacted to only 16 in 2012, after legalization.

In the US, by comparison, more than 14,000 people died in 2014 from prescription opioid overdoses alone. Portugal’s current drug-induced death rate, three per million residents, is more than five times lower than the European Union’s average of 17.3, according to EU figures.”

“Long story short, I think we can learn a lot of lessons from Portugal,” Rep. Singer told us, “We need to really look and see how their system works and they’ve got a lot of things going on in Portugal that we don’t; for example, universal healthcare.”

Singer has already talked to a number of sheriffs around Colorado about Portugal. “They have all basically said that their job is to enforce the law and that if state lawmakers have new ideas about how they should enforce the law they’ll continue to enforce the law, which is a pretty positive statement in my mind because it means that they’re just not outright opposed to finding new solutions to this crisis,” Singer says.

Netflix & Criminal Justice

13th, Promo image

When it comes to the subject of criminal justice reform a good place to start may very well be a documentary called 13th by the brilliant African American filmmaker, Ana DuVernay.

13th is about the 13th Amendment to the Constitution, which was ratified as the conclusion to the Civil War and the purported goals of Abraham Lincoln to free slaves. In actuality, the amendment outlawed slavery, “except as a punishment for crime whereof the party shall have been duly convicted,” which resulted in an explosion of African American incarceration vis-a-vis the Black Codes, which later became the infamous Jim Crow laws.

People of color began being criminalized then, and it continued up through history, up through the War on Drugs, which is the major cause of the rise of prison inmates in the U.S.   The US Bureau of Justice Statistics (BJS), reports that “2,220,300 adults were incarcerated in US federal and state prisons, and county jails in 2013.” Of those, FiveThirtyEight reports that, “there are 207,847 people incarcerated in federal prisons. Roughly half [46.3 percent in 2017] are in for drug offenses.” Time wrote a piece called, “39% of Prisoners should not be in Prison.” We have an overly punitive perspective on criminal justice.

The War on Drugs officially began in June 1971, according to DrugPolicy.org. It was started by President Richard Nixon.

Crack cocaine, a smokeable version of cocaine, was sold in small doses and was inexpensive like heroin is today. Seen as an affliction and vice of the poor Black community, Congress implemented harsh penalties and mandatory minimum prison sentences for crack cocaine dealers and users, as well as imposing draconian police state mechanism for entire communities where the drug flourished. At the same time, powdered cocaine flourished in White communities but was largely ignored. That is, someone arrested for 1 oz of crack cocaine got the same sentence as someone in possession of 100 oz of powdered cocaine.

Some politicians later realized these policies weren’t working and were, instead, targeting specific communities in racist ways. 13th shows former president Bill Clinton admitting this in a speech years later.

13th suggests drug decriminalization is the answer when it comes to the nation’s current crisis, just as Portugal, both as a remedy to the affliction of drugs and as a vindication of the communities of color who were the victims of Nixon’s War on Drugs.

Restorative Justice

Restorative Justice (RJ) is a philosophy that views crime as harmful to people but criminalization of people as equally harmful. It is an approach to problem solving that is based around three basic concepts, according to Restorative Practices International: When crime (or wrongdoing) occurs, the focus is on the harm that has been done to people and relationships; when harm has been done, it creates obligations and liabilities; and that the way forward involves wrongdoers, victims, and the community in efforts to heal the harm and put things right.

For example, instead of labeling a former drug addict like Tony a criminal, RJ aims to encourage accountability, participation, and communication between victim, offender, and community. Law enforcement is also included in this philosophy.

District Attorney for the Twentieth Judicial District Stanley Garnett has worked for Boulder County since being elected in 2008. He began by tackling marijuana legalization, but turned his attention to opioids.

“We go after drug dealers very hard,” he says. “However, people who are arrested or have contact merely for drug use or possession, we try very hard to keep them out of custody to minimize the impact.”   

He even went through a real life example of what this scenario might look like.

“We’ll sometimes get cases off the Pearl St. Mall,” he says, “where somebody gets in a fight and the cop will pull him aside and pat them down and find a little bit of cocaine in their pocket. We can charge that as possession of cocaine or we could give them a deferred prosecution and put them in a treatment program and simply charge them for the fight.”

This is in line with RJ thinking to a degree. RJ programs are characterized by four key values: Encounter: creating opportunities for victims, offenders (wrongdoers), their families and community members who want to do so to meet to discuss the crime (incident) and its impact on them. Amends: expecting wrongdoers to take steps to repair the harm they have caused. Reintegration: seeking to restore victims and offenders to wholeness, to become contributing members of society. And Inclusion: providing opportunities for parties with a stake in a specific crime or incident to participate in its resolution.

One RJ system in law enforcement is LEAD, the Law Enforcement Assisted Diversion, which is a program to educate and empower officers to keep low level offenders out of the system. Garnett thinks we need more programs like this to make an impact. 

“A cop on the street, particularly in big cities, they will deal with addicts and get to know them pretty well, and a lot of times they know if you arrest them and take them into custody, that doesn’t do anything,” Garnett explained. “What they really need is housing or they need a shot at getting a job or whatever, so LEAD trains the cops to size up the addicts in the particular area whom they know and then empowers them to make the decision not to charge or arrest, but instead to get them into treatment or to find other things that the addict needs.”   

The only problem is cities are forced to compete for the grant money they need because without it they can’t train cops in LEAD. Colorado Chiefs of Police announced in June the implemntation of LEAD and Law Enforcement and Behavioral Health Partnerships (Co-Responder) Programs. The Office of Behavioral Health (OBH) received a $5,200,000 grant effective July 1, 2017 to implement four LEAD pilot programs and five to eight law enforcement and behavioral health Co-Responder partnership programs.

Colorado’s legislative fix

Rep. Singer and his supporters have detailed  a “6 Bill Package” to introduce in 2018 to address the opioid epidemic. One of the bills addresses the need for a safe injection site in Denver.

Lisa Raville, Executive Director of the Harm Reduction Action Center, told us no one has ever died at a safe injection site and also says that the bill “has bipartisan support. Until it is introduced on Jan. 10, it is hard to know who will be neutral and oppose it.”

Tony agrees with the idea of a safe injection site. He says, “I’d rather see people using a safe area… Right now you go to a needle exchange place and they give you everything you need and then send you out into an alley to shoot up…  If there’s a safe injection site in Denver would you decide to go down and become a heroin addict? It doesn’t work that way.”

Another bill in the package details a seven day prescription plan to prevent misuse. “There’s a whole list of other exceptions to this rule,” Singer told us, “but if you haven’t had an opioid in the last twelve months and you don’t have one of these exceptions you would be limited on your first prescription for seven days with an option for one more seven day refill… After that you’d have to go back in and be reevaluated by your doctor.”

Medical and insurance lobbies could hinder this bill from being passed, but Singer is hopeful.

“This is an all hands on deck thing,” he says. “As a former social worker this is a really exciting thing…People for better or for worse are convinced that there’s a problem and they’re ready to talk about solutions.”

Where do we go from here?

When it comes our local opioid crisis, in order for the “solutions” we’ve looked at to have an impact, we need to end the “drug addicts are criminals” stigma.

It’s worth noting that recovering addicts on methadone can live fully functional lives, with the proper financial, familial, and emotional supports; a tall order in an America that seeks criminalization over support. We’ve all walked past an addict in the store, waved hi at a light, or smiled on a sidewalk. These are our parents, our children, our friends, and our community members.

A “wait and see” approach is not the answer when it comes to crisis and we are lucky to have elected officials in Colorado like Rep Singer who are being proactive in tackling this. These lawmakers, aided and spurred on by activists who fight for restorative justice, those who fight for drug decriminalization, who demand the release of those predominantly people of color who are incarcerated for petty drug crimes, are the chance we have to solve Colorado’s epidemic. In the end, though, federal laws have to change to see the light at the end of this long, dark tunnel, to be able to imagine an end to the crisis  here in Colorado and nationwide.