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We have life-saving treatments for the opioid overdose epidemic. Here's why they often don't get used - San Francisco Chronicle

Throughout history, the discovery of cures and treatments have led to fewer people dying from diseases. For epidemics, they tend to signal an end. But that hasn’t been the case for the decades-old opioid epidemic, for which effective treatments are available, but vastly underutilized across the U.S., including in San Francisco.

In recent years, the epidemic has escalated with the rise of the extra-lethal synthetic opioid fentanyl. More than 700 people died of drug overdoses in 2020 in San Francisco — more than three times as many as in 2017. The majority of those deaths involved fentanyl. San Francisco is on track to see approximately 650 overdose deaths in 2021.

Treatments, including potentially life-saving medications and support services, remain largely inaccessible to the people who are most adversely affected by the opioid epidemic, which disproportionately affects people of color, experts say. Both patients and providers face numerous barriers — regulatory, social or otherwise — in giving and receiving them.

“Stigma is a big reason that this doesn’t become a priority as something we should do consistently in the care for patients with opioid use disorder,” said Dr. Keith Kocher, a University of Michigan emergency doctor who was among the authors of a study that examined the underutilization of medications to treat opioid disorder.

That study revealed that just 7.4% of emergency department visits across the U.S. from August 2019 to April 2021 involving a nonfatal opioid overdose led to a prescription for naloxone, the fast-acting overdose reversal drug better known by its commercial name Narcan, within 30 days of the visit. For buprenorphine, an opioid-based drug widely regarded as the most effective medication for reducing opioid cravings and withdrawals, that figure is 8.5%.

In comparison, the researchers found that 49% of patients received a prescription for epinephrine, a drug to treat severe or life-threatening allergic reactions, following an anaphylactic shock. Their analysis is based on data from Symphony Health, one of the largest health data providers in the U.S.

Epinephrine, like naloxone and buprenorphine, is an “antidote” for a life-threatening event, Kocher said. People who experience overdoses and anaphylaxis are both at risk of repeat episodes, so it makes sense to equip patients with medications that can prevent them.

“But when it comes to overdose, we don’t think of it the same way,” he said. That results in missed opportunities to save more lives.

Those missed opportunities are also evident in San Francisco’s data on buprenorphine prescriptions, a metric health departments track widely because it’s a mainstay for treating opioid use disorder. Despite numerous targeted efforts to address the opioid crisis, there’s still a glaring gap between the soaring deaths and emergency department visits related to opioid use and the number of buprenorphine prescriptions.

These gaps in care are explained in part by the regulatory barriers healthcare professionals face in their ability to provide addiction care, said Dr. Kao-Ping Chua, an opioid researcher and a co-author of the University of Michigan study.

For opioid abuse medication treatments, there are stringent rules and requirements to prescribe them, Chua said. For instance, methadone, a medication used similarly to buprenorphine, can only be administered at federally certified treatment facilities. Also, doctors must obtain a waiver to prescribe buprenorphine, and even then can only prescribe the medication to just 30 patients in the first year after receiving that waiver. But no waiver is required to prescribe other opioids, which are often stronger.

“We treat these medications as if they're special in some way because we put addiction into a different category than other medical diseases,” Chua said. “But it really shouldn't be the case.”

That “different category” is one that stems from stigma, he and other researchers said. The opioid epidemic’s mounting death toll reflects how much of American society still views opioid addiction and other types of substance disorders not as a public health crisis fueled by structural problems like poverty and racism, but evidence of bad character and moral failure because of its association with illicit drugs.

That stigma continues to influence the response to the opioid epidemic, creating barriers to treatments. Experts say this ultimately pushes responsibility into the hands of law enforcement and emergency departments to manage the crisis, which costs the U.S. billions of dollars in extra spending on healthcare and public safety, as well as lost productivity, according to the National Institute on Drug Abuse.

“Our society for many years has treated addiction as somebody’s personal choice, their moral failure,” said Dr. Marlene Martin, a UCSF associate professor and hospitalist at San Francisco General Hospital. “That’s what we have seen propagated for many years, but what we see in the hospital and in the clinics is different.”

What she sees as a hospitalist, Martin said, are people in pain who, on top of any underlying trauma that drove them to addiction, suffer from a range of physical and psychological symptoms. “These are my patients in front of me. I need to do something better. If there are tools out there that I can help provide for them, why wouldn’t I?”

Many people with opioid use disorders end up in emergency departments.

Many people with opioid use disorders end up in emergency departments.

Scott Strazzante/The Chronicle

Opioid use disorder, or OUD, “causes alterations in receptor sensitivity, leading to medication tolerance and changes in pain perception,” according to the National Center for Biotechnology Information. At its core, it’s like a chronic relapsing brain disease, Martin of UCSF said, with symptoms ranging from the physical, such as infections, to the psychosocial.

“That's why we need a combined approach,” the UCSF hospitalist said. “We have to work on both [physical and psychosocial aspects] at the same time to take care of the individual and to prevent future substance use disorders from developing, and also address the root causes that are leading to the substance use.”

Over the decades since the opioid crisis was declared an epidemic in the U.S. in the 1990s, healthcare experts from across disciplines have come up with several different approaches to treating opioid disorder — pharmacological, behavioral or otherwise — with varying degrees of success.

Among the most effective clinical options, according to various research, involve medications like buprenorphine that help people reduce cravings and withdrawals, or reverse the effects of an opioid, like naloxone.

Naloxone is a short-acting “antagonist,” meaning its effect counters that of opioids. Another antagonist, naltrexone, is used to treat OUD over a longer term.

Buprenorphine and methadone are the most widely prescribed and accepted pharmacological treatments for OUD and have shown high efficacy, including in trials. Research has shown that these treatments increase the likelihood that a person would remain in treatment, which also leads to lower risk of a fatal overdose, disease transmission and criminal justice involvement.

Both buprenorphine and methadone are “agonists,” which means their effects closely mimic those of morphine or heroin. That has been the basis for some people’s concern over misuse and diversion.

Researchers say those concerns are misplaced. “Methadone and buprenorphine DO NOT substitute one addiction for another,” according to the National Institute on Drug Abuse. “When someone is treated for an opioid addiction, the dosage of medication used does not get them high - it helps reduce opioid cravings and withdrawal. These medications restore balance to the brain circuits affected by addiction, allowing the patient’s brain to heal while working toward recovery.”

But misconceptions like these have played in part in creating the extra scrutiny and regulations that create a “red tape” around addiction care, UCSF’s Martin said.

She also said many medical professionals aren’t trained to provide addiction care, because it’s seen as optional, rather than necessary. The extra steps needed to provide these treatments mean that there’s no real incentive for providers to offer them, she said. In California, federal data shows less than half of substance abuse treatment facilities offered any kind of pharmacological (medication-assisted) therapy, as of 2019.

But the number of facilities across the country offering medication treatments is slowly increasing as more doctors become aware of their efficacy. Data from the Substance Abuse and Mental Health Services Administration shows the share of facilities with medication treatments rose from 9% in 2010 to 11% in 2020.

San Francisco’s public health department has incorporated buprenorphine in its response programs, including the city’s Street Overdose Response Team (SORT), which connects patients, many of whom are unsheltered, directly to providers on the city’s streets. SORT offers, among other services, naloxone kits and buprenorphine prescriptions. Data shows 23% of the people SORT engaged between August this year when it first launched to the end of November either received a refill or new start of buprenorphine.

But buprenorphine — or any other drug — is not a magical cure-all, said Kristen Marshall, manager of the Drug Overdose Prevention and Education, or DOPE, Project, which partners with the city’s health department to distribute the opioid reversal drug Narcan in San Francisco.

There are many reasons why people with addiction disorders would not want such treatment, said Marshall. Getting the needed multi-faceted and consistent treatment can be cost-prohibitive and simply not an option for unhoused peopled. Some people experience tremendous pain while undergoing medication-assisted treatments. Many also fear repercussions that hinder them from seeking a life away from addiction, including a permanent record of substance abuse treatment history that could affect job-seeking or insurance rates.

Marshall said those who are addicted often don’t want to engage with the healthcare system at all, due to distrust stemming from negative experiences while seeking help. The pervasive stigma surrounding addiction also exists within the medical and emergency care fields, and that can result in abrasive, judgmental and coercive tactics that further traumatize already traumatized people, she added.

And more often than not, the treatments do little to tackle root causes, she said. “There’s a reason these people use drugs. If we don’t address them, that deepens their hopelessness and helplessness.”

That’s not to say treatments like buprenorphine shouldn’t be widely available to people who want and need it, she said. They can save lives, but providers must first build trust. “It’s going to take them a minute for them to trust these interventions,” she added. “When they see it works, that’s it. They can take it and make it their own.”

Community-based programs in San Francisco have worked to boost Narcan access.

Community-based programs in San Francisco have worked to boost Narcan access.

Scott Strazzante/The Chronicle

The opioid epidemic is the result of complex problems requiring complex solutions — one that has been brewing for decades, Marshall said. “We’re talking about generations of trauma that led us to this moment.”

For meaningful change to occur, she and others said communities must show empathy and the willingness to tackle the social issues that fuel the epidemic. “The first thing for our community in San Francisco is for people who live here to understand that these aren’t criminals,” the harm reduction expert said. “They’re in pain, utilizing the things they have access to numb that pain.”

Change is already in motion — albeit slowly, Marshall and others said. There is momentum to build greater access to holistic treatment and services.

But the work to save lives and to end the opioid epidemic should not just rest on specialists, frontline providers or emergency personnel, she and others said. Martin of UCSF said, “We need all hands on deck. This cannot be left only to the specialists.”

That includes everybody, she said. “People who don't use substances need as much education as people who do use substances, so that we can all understand why this is a crisis and how we can all band together to take care of it to improve the health of our community.”

Yoohyun Jung is a San Francisco Chronicle staff writer. Email: [email protected] Twitter: @yoohyun_jung