The newest strategies to curb overdose deaths: Prescription heroin, drug vending machines

DETROIT — From free needles to supervised injection sites where drug users can shoot up amid people trained to respond to overdoses to a vending machine that doles out Narcan, harm reduction — the newest strategy to stem the vast number of drug overdose deaths — is making headlines across the nation and in Michigan.

Reducing the harms associated with drug use in order to keep addicts alive long enough to get treatment — if they want it — is an official part of Michigan’s drug policy. Last year, the state spent six months and $900,000 in grant money on an advertising campaign to educate the public on where and how to get Narcan, the medication that reverses opioid overdoses, and where and how to find needle exchanges. The campaign’s bottom line: Drug users can change — at their own pace.

It is a sharp and, experts say, necessary contrast to the old Just Say No/abstinence only approach. “The strategy nationwide has focused mostly on prevention and treatment and abstinence and I think we’ve seen in our data nationally, in Michigan that that has not been working in terms of curbing the epidemic we have of fatal drug poisoning,” said Joe Coyle, director of infectious disease prevention for the Michigan Department of Health and Human Services.

“I think people reaching abstinence is not a bad thing,” he said. “People engaging with treatment is not a bad thing, and we should be encouraging that where we can, but we need to keep people alive long enough to get there.”

More than 100,000 people across the nation died from overdoses — 2,952 of them in Michigan — during the 12 months ending April 2021. Never before have so many overdose deaths been recorded during a 12-month period.

So what, exactly, is harm reduction? And what has been its impact so far?

What is harm reduction?

Rather than thinking of people who are addicted to drugs as criminals or moral failures, harm reduction recognizes that addiction is an illness and a public health crisis. Its goal is to reduce the harms associated with drug use in order to keep drug users alive by reducing the spread of diseases such as HIV and hepatitis and reducing the number of overdoses. Because illicit drugs aren’t going away.

Why is harm reduction being embraced now?

Drugs are deadlier than ever and what we’ve been doing to stem the overdose crisis isn’t working. The number of people dying from drug overdoses keeps increasing. In 2020, more people than ever — 93,000 — died from drug overdoses. And preliminary data shows that in the 12 months between April 2020 and April 2021, more than 100,000 people died from drug overdoses. Most of the deaths were related to fentanyl, an ultra potent synthetic opioid that is up to 100 times more powerful than morphine and up to 50 times more powerful than heroin, according to the U.S. Centers for Disease Control and Prevention. Sending drug users to jail or ordering them into rehab isn’t preventing overdose deaths any more than sending a cancer patient to jail or rehab would stop their disease. Harm reduction advocates, including the Drug Policy Alliance, which seeks to decriminalize drugs, say addiction is a health matter, not a criminal one and it’s necessary for the U.S. to change the way it thinks of addiction.

How does harm reduction keep people alive?

Harm reduction advocates believe in easy access to Narcan (generic: naloxone), which reverses opioid overdoses. They also support easy access to clean syringes to reduce transmission of hepatitis and HIV; both diseases are spread by contaminated needles. And they support the use of fentanyl test strips, which can determine whether fentanyl has been mixed into street drugs, to stop users from unknowingly consuming fentanyl. Another tenet of harm reduction: medication-assisted treatment, which uses opioids such as buprenorphine or methadone to prevent withdrawal symptoms and reduce cravings for other opioids such as pain relievers, heroin or fentanyl.

So this medication-assisted treatment trades one drug for another?

That’s the opinion of those who favor abstinence-based treatment. But the reality, according to harm reduction experts, is that buprenorphine and methadone soften withdrawal and keep people from craving drugs, which means they’re less likely to relapse.

Buprenorphine is a partial opioid agonist, which means it doesn’t fully engage the brain’s opioid receptors the way heroin or fentanyl does. The buprenorphine formula, known by the brand name Suboxone, contains naloxone. Naloxone is the generic name for Narcan. Suboxone is meant to be dissolved under one’s tongue. If someone tries to crush it to snort or melt it to inject, the naloxone in the formula activates and renders the buprenorphine useless.

And methadone doesn’t provide the euphoric rush of heroin, according to the National Institute on Drug Abuse.

In an ideal situation, buprenorphine and methadone use is heavily monitored. And the use of medication-assisted treatment involves counseling. Both buprenorphine and methadone need to be taken daily.

How successful is medication-assisted treatment?

Here’s an example: One study of 17,586 Massachusetts drug users who survived an overdose showed that subsequent treatment with methadone or buprenorphine greatly reduced their risk of dying from another overdose. Overdose deaths decreased 59% for those receiving methadone and 38% for those treated with buprenorphine, according to the study funded by the National Institutes of Health.

Is there other medication used to treat drug addiction?

Yes. Naltrexone (brand name: Vivitrol) is also used. It’s given as a monthly injection. Unlike buprenorphine and methadone, it is not an opioid. Those who favor the use of naltrexone point to its monthly injection as a convenience factor — Suboxone must be taken daily and in most cases, even with pandemic-related exceptions that allow some patients who are doing well in their treatment to take it home with them, methadone is usually administered daily at clinic sites. Fans of naltrexone as treatment also point to its lack of street value as another advantage over buprenorphine and methadone.

Starting naltrexone is more complicated, however. A person starting naltrexone needs to wait seven to 14 days after their last opioid use before they start treatment with it, whereas a person starting buprenorphine needs to wait 12 to 72 hours, depending on which opioids they last ingested. Waiting that number of days required to start naltrexone can be extremely difficult for someone who is dope sick from withdrawal and experiencing intense cravings.

Wait, these helper drugs have a street value?

Buprenorphine and methadone are sold illegally. Several published reports indicate the majority of the people who buy it illegally are doing so to stave off withdrawal when they are unable to find their drug of choice.

Naltrexone has no street value because it is not an opioid.

Are these medication-assisted treatments safe?

All treatments have been approved by the U.S. Food and Drug Administration. Methadone treatment has been used since the 1960s.

However, the babies born to women who use buprenorphine — which was approved for use in the U.S. in 2002 — or methadone during pregnancy may be born addicted to those drugs and have to go through withdrawal.

Despite that risk, most doctors believe it’s better to keep a pregnant woman on buprenorphine than run the risk of her relapsing and experiencing the harms that often accompany the use of street drugs — violence, crime, sexual assault, homelessness, overdose, death.

Is abstinence part of harm reduction?

Not necessarily. Not doing drugs is the only sure way to to wipe out the harms associated with drug use. But harm reduction advocates say it’s unrealistic to think drugs will suddenly disappear. In other words, drug addiction — like other illnesses such as cancer, heart disease, diabetes — is here to stay.

Harm reduction recognizes that recovery from addiction isn’t easy and that relapses occur. In addition, some harm reduction advocates point out that not everyone who uses drugs wants to or is ready to stop and that it’s much better to help those users stay alive and help them be productive members of society than expecting them to quit cold turkey.

Isn’t harm reduction — the needles, the Narcan — just making it easier for addicts to use drugs? Isn’t it just enabling them?

Some believe that is the case. “People think that focusing on harm reduction … we’re somehow taking away from treatment. I think what harm reduction advocates are saying is we need all the tools in our tool kit,” said Sheila Vakharia, deputy director of the department of research and academic engagement for the Drug Policy Alliance. “Adding harm reduction is not taking away from treatment, it’s supplementing treatment.”

Research shows that drug addicts who participate in harm reduction programs are more likely to stop drugs altogether than those who do not participate. A study of clients at a Seattle needle exchange showed that people who used the service were more likely to reduce their drug use or stop altogether. It also showed that new users of the program were five times more likely to enter treatment than those who never used the syringe services program. And once people are no longer using dirty needles, the infection rate for HIV and hepatitis declines.

As for Narcan, it helps keep people alive until they’re ready to receive treatment.

Why not just give out heroin?

Well, a clinic in Vancouver, British Columbia, offers pharmaceutical-grade heroin to patients who have not been successful on methadone. The dosage is enough to keep away the cravings and withdrawal so patients can hold jobs and keep their lives together. It is also safe from fentanyl.

And vending machines in four cities throughout Canada dispense prescription hydromorphone to certain users as a substitute for heroin. The hydromorphone (brand name: Dilaudid) is unadulterated, making the users safer from fentanyl.

So drugs are legal?

In some places, drugs are legal. Portugal decriminalized the use and possession of small quantities of drugs in 2001 and with the decriminalization, overdose deaths decreased. Same for Switzerland.

In 2021, the state of Oregon decriminalized possession of small quantities of heroin, cocaine, illicit pain medication, methamphetamines and other drugs. A person caught with small quantities for personal use of any of those drugs is to be issued a civil citation, though a report by National Public Radio indicates many, many people ignore their citations.

Late last year, New York opened its first supervised injection sites. Drug users shoot up at a safe location around staff members who have access to Narcan and can reverse overdoses, provide syringes and resources for treatment.

Where does Michigan fit in all of this?

With grants, Michigan has expanded its syringe exchange programs and continues to do so. During the first quarter of 2019, syringe services programs distributed 164,517 syringes, compared with 718,169 during the first quarter of 2021.

The state has a standing order for Narcan, which means it can be purchased at pharmacies without a prescription.

Michigan’s prisons have begun medication-assisted treatment. As of November 2021, 332 incarcerated people were receiving medication-assisted treatment and there is a waitlist with roughly 910 people on it. The prison population was roughly 32,100 at the end of last year, according to the Michigan Department of Corrections. The MDOC estimates that 70% of those who are incarcerated have substance use disorders, including 22% who have opioid use disorders. It anticipates medication-assisted treatment being offered at all of the state’s prisons by the end of 2023.

The MDHHS is expanding its Naloxone Leave Behind Program where EMS workers who respond to nonfatal overdoses leave a naloxone kit with the patient or family members or friends. Last year, they left behind more than 125 naloxone kits. So far all or part of 24 counties — including Macomb, Washtenaw and Livingston — are participating in the leave behind program.

The Oakland County Jail has installed a naloxone vending machine for people who are leaving jail. Drug users who leave incarceration are especially vulnerable to overdose. Abstaining from heroin/fentanyl for a period of time, say during a jail sentence, reduces a user’s tolerance for the drugs. Often, people who have been abstinent restart their habit using the same amount of drugs they used before they stopped. Doing so is overwhelming and causes overdose and, often, death. With the vending machine, anyone leaving jail has access to Narcan.

Will any of this harm reduction stuff make a difference?

We will have to wait and see. It’s clear to experts that abstinence-only isn’t working.

Sources: National Institute on Drug Abuse; U.S. Substance Abuse and Mental Health Services Administration; U.S. Centers for Disease Control and Prevention; National Institutes of Health.