This post originally appeared at WeStandUp.org back in April; since the site folded, I’m reposting it here.
More than 115 Americans die every day as a result of opioid overdoses. But as is often the case, the attention paid to the opioid epidemic most often focuses on abuses of prescription pain medication by otherwise stable middle- or upper-class individuals. Less visible in this narrative are marginalized populations like the homeless, for whom opioid addiction is not a new phenomenon, but an ongoing crisis.
New York City is no exception. In 2016, overdose deaths — primarily from opioids — rose 46% from the previous year, prompting Mayor Bill De Blasio to increase spending to $36 million to address opioid addiction through the city’s Healing NYC program. The New York Times recently reported that city officials are cautiously optimistic about the program’s success, citing a “leveling off” in opioid-related deaths following a sharp increase in 2016.
This optimism is certainly well-founded. However, it overlooks data which suggests that opioid overdoses among the city’s homeless population are not falling. Quite the opposite, in fact: opioid overdoses among the homeless are rising at an alarming rate. The New York Daily News recently reported that there have been 81 opioid overdoses in the first four months of fiscal year 2018; compared to the same time period last year, when the shelter system reported just 12 overdoses, that represents a 575% increase.
The Healing NYC program is aimed at treating opioid overdoses, preventing opioid addiction and offering counseling to opioid users following an overdose. So why are overdoses skyrocketing among the homeless and not the housed population? Because the city’s approach to the middle-class opioid crisis is dramatically different from the approach employed with its homeless denizens.
When it comes to the homeless, the approach is entirely reactive. The city has mandated that all homeless shelters carry Narcan — a nasal spray used to reverse the effects of an overdose — and that at least one shelter employee is trained in the use of Narcan at all times. At a recent New York City Council meeting, city officials also proposed distributing Narcan to homeless opioid addicts who use syringe exchanges.
While these efforts doubtless save lives, they only treat the effect of opioid addiction among the homeless; the underlying conditions that precipitate them remain largely unacknowledged. It is time for a different approach.
Studies have shown that when it comes to addiction recovery, stability – particularly in housing – is vital to successful outcomes. Recovering from an opioid addiction is difficult enough under the best of circumstances; attempting to do so without a guarantee of shelter borders on impossible. The most obvious remedy, therefore, would be to focus on giving the homeless stable housing and access to proper medical care.
The most viable option for long-term shelter is public housing. However, the New York City Housing Authority (NYCHA) has notoriously strict restrictions that in many cases bar individuals with a history of drug abuse from living in public housing.
Another option would be to establish more housing or shelters specifically for homeless individuals with prior convictions for violent, drug- or sex-related offenses. These shelters do exist; however, they are often (intentionally) located in remote, hard-to-access areas of the city. There are simply not enough centrally-located areas in New York City where a shelter for homeless individuals with prior felony convictions or ongoing substance-abuse issues could exist without provoking significant backlash from residents, landlords and property owners.
So if housing is not a feasible option, then what is? A medical provider who works in clinics throughout the New York City shelter system offered their assessment of the opioid crisis, on condition of anonymity. (This provider’s organization prohibits employees from giving public interviews.)
The provider praised the city for making Narcan readily available to shelters, police officers, and even members of the homeless population. However, the provider cautioned, Narcan has a narrow range of applications, and the focus should be more on prevention of overdoses instead of simple treatment.
“A user knows their limit,” the provider said. “There’s a common myth of [opioid] addicts ‘chasing the dragon,’ but a majority are only using to avoid withdrawal symptoms.” According to this provider, a key contributor to opioid overdoses is a lack of access to prescribed drug treatments like methadone and Suboxone (a combination of the drugs buprenorphine and naloxone).
Without access to these treatments, homeless opioid addicts often resort to buying black-market methadone or heroin. Unfortunately, the street versions of these drugs are commonly laced with fentanyl, a synthetic opioid that’s 50 to 100 times more powerful than morphine and a key cause of the respiratory failure responsible for most overdose deaths.
That, says the provider, is the biggest driver of opioid overdoses among the homeless. “90% of the patients I have whose deaths are directly caused by opioids are not current regular heroin users. They’re cold-turkey relapse cases or people who can’t access their methadone or suboxone.”
Still, the provider suggested, eliminating the bureaucratic red tape surrounding opioid treatment is no more feasible than building enough shelters to house all the homeless in New York City. According to the provider, there is a solution that could have an immediate and significant impact: reassess the existing treatment options.
Methadone is still widely-used as a treatment for opioid addiction. “Methadone is a huge part of the problem,” the provider said. “It’s an amazing pain management drug, but it’s antiquated as an addiction treatment — people are more limited in their day-to-day lives on methadone than they are on heroin.”
By federal law, methadone must be taken under a doctor’s supervision. Homeless individuals prescribed methadone are forced to go to their assigned clinic every day to pick it up; among the homeless population, this creates a massive barrier to successful outcomes. Said the provider, “If you get moved to [a shelter on] the outskirts of Queens and your methadone clinic is in Harlem, you either have to disrupt your entire day to get up to Harlem, or find heroin from a dealer in your area.”
While Suboxone is — like methadone — an opiate, it is a far more effective treatment for opioid addiction than its predecessor. Suboxone also has less of the euphoric effect found in methadone, allowing users to manage their cravings while still remaining able to function and live normal lives. Most importantly, doctors can prescribe a month’s worth of Suboxone, which lowers the risk of a homeless individual missing a dose because they were unable to reach a clinic.
“An easy fix is to increase access to Suboxone in the shelters and encourage the treatment of opioid addiction with Suboxone rather than methadone,” the provider said. The provider’s suggestion was echoed in the New York Times by Dr. Andrew Kolodny, a director of opioid policy research at Brandeis University. “We already have an effective treatment that people aren’t getting access to. The primary challenge is getting it to people.”
Recently, the FDA introduced a new approach to combating the opioid crisis. According to the Times, “Noting federal data showing that only one-third of specialty substance abuse treatment programs offer medication-assisted treatment, [Health and Human Services Secretary Alex] Azar said, ‘We want to raise that number — in fact, it will be nigh impossible to turn the tide on this epidemic without doing so.’”
Later in the Times piece, a senior FDA official was quoted as saying “’We will permit an endpoint that shows substantial reductions [in opioid use] but does not require the patient to be totally clean at every visit if the measurements are fairly frequent.’” These new initiatives, coupled with the changing attitudes regarding opioid abuse, offer a glimmer of hope for homeless or sheltered individuals currently battling addiction.
Using Narcan to treat opioid overdoses saves lives, but it can’t stop there. A more comprehensive approach to homeless opioid addiction is required; without it, we are only treating the symptom, not the disease.