Public Health Innovator Leana Wen on Challenging Addiction Stigma

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After years of opposing common-sense policies or simply ignoring the issue, politicians in Washington and many state governments are finally supporting public health solutions to the challenges posed by opioid drug abuse, instead of relying solely on criminal law enforcement. Unfortunately, this political momentum is built on thousands of tragedies.

The number of opioid fatal drug overdoses in the United States has quadrupled in recent years while the number of prescriptions written for opioid drugs also increased fourfold, according to the Centers for Disease Control and Prevention. Law enforcement crackdowns on prescribers and drug traffickers have forced people living with opioid addiction to seek out street drugs, such as heroin cut with dangerous additives that increase the likelihood of an overdose.

The uptick in opioid-related deaths has busted the myth that addiction and the misuse of painkilling drugs are only problems in poor areas and communities of color. The mainstream media’s new attention to affluent white people who use heroin has pushed politicians to finally listen to public health experts who have said for years that the government should abandon its war on drugs and expand access to medical services that treat addiction as an illness.

With a vote of 94 to 1, the Senate recently passed the Comprehensive Addiction and Recovery Act (CARA), which promotes drug misuse prevention programs and would allow state health and law enforcement agencies to expand access to medical treatments for overdose and addiction. Republicans, whose predecessors routinely blocked the federal government from supporting basic health services for drug addicts, broadly supported the bill, although they were reluctant to appropriate extra funding for it.

The Obama administration has announced $94 million in Affordable Care Act funding for 271 public health centers in 45 states that will increase the availability of medication-assisted treatments, or MATs, for opioid dependency. These treatments include drugs like methadone and buprenorphine that ease the physical symptoms of opioid addiction and help patients lead normal lives as they recover. The White House has asked Congress for an additional $1.1 billion to combat the so-called “opioid epidemic.”

These efforts, along with initiatives in several states, also include provisions designed to put the opioid antidote naloxone into the hands of first responders, as well as drug users and their friends and family. Naloxone is extremely effective at reversing overdoses and saving lives, but for years the drug has only been available by prescription in many parts of the country. As Truthout has reported, activists and public health advocates have not waited for a blessing from Capitol Hill to distribute the drug and train people on how to use it.

In Baltimore, where officials estimate that nearly one in 10 residents is addicted to a drug, city health commissioner Dr. Leana Wen has launched an aggressive naloxone distribution campaign since she was appointed in January 2015. Wen recently testified before Congress and has received national recognition for the program, which makes naloxone available to every resident whether they use drugs or not. Truthout spoke with Wen about the naloxone campaign, treating addiction as a health issue instead of a criminal problem, and how public health departments can be important tools for social justice.

Mike Ludwig: Where did Baltimore’s naloxone programs come from? Were there any challenges as far as public perception of naloxone in the beginning, and how have the programs been received?

Dr. Leana Wen: Sure. Where the program came from is our increasing recognition that overdose is a national public health emergency. We have seen the number of people dying from overdose quadruple nationally and take away the lives of our citizens of Baltimore City. We have more people dying from overdose in our city than are dying from homicide. This is particularly tragic because naloxone is a complete antidote. Somebody who is dying from overdose can receive naloxone and their life will be saved within seconds, and so that’s where this idea came from. In the course of a year, we now have one of the most aggressive and efficient overdose prevention and treatment programs in the country that involves getting naloxone into the hands of every resident.

We believe that naloxone should be part of everyone’s medicine cabinet, part of everyone’s first aid kit. We have begun to train the police and have armed all of our paramedics with naloxone. We are also training family and friends with over 8,000 trainings … I issued a standing order in the city, which means that there is a blanket prescription available to 620,000 residents of our city. We also started a first of its kind online naloxone training, where you can watch a video and receive a prescription to be filled in our local pharmacies.

So, in terms of public perception, yes, there is stigma and misconception about overdose. There may be individuals who feel that [it] is a choice whether to be addicted to drugs. But we counter that with evidence to say, addiction is a disease. It is taking the lives of our residents, and we all have to save a life. There are people who said, wouldn’t making naloxone available increase the likelihood of someone using opioids? We counter that by saying [that] we would never make that argument about an individual who has a peanut allergy. You would never say to someone with a peanut allergy, “Sorry, but I am not going to give you epinephrine because it might make you eat peanuts next time.” We have to understand that our misconceptions are based on stigma and not science. And that that’s the work we have to do in this city.

Have you seen any impacts so far?

Just in several months in training the police, police have saved 21 lives [since receiving naloxone training in September 2015]. Elsewhere in the city, ever since April of 2015, we’ve had 129 naloxone reports through our poison control reporting system, which is a significant underreporting of the number of times that people are actually using naloxone. And as I mentioned, we’ve had over 8,000 trainings in 2015 alone. So we are seeing an impact. We are also seeing the impact throughout the city because the perception of stigma is changing.

Does Maryland have a Good Samaritan law to go along with this? (In general, Good Samaritan laws protect those who call 911 to report an overdose from arrest for drug use or possession.)

Yes.

Great.

That Good Samaritan law was passed at the same time as our standing order, and the Good Samaritan law, just to be clear about who it protects — it protects the individual who is calling to report an overdose. So, that’s a friend or a family member, and there is also liability protection in the state of Maryland for providers for prescribing naloxone, which is important to me too, because I am now the single prescriber for 620,000 residents.

Right. And you know, that is one of the provisions of CARA [the Comprehensive Addiction and Recovery Act], to get this kind of federal liability protection [for health care providers writing prescriptions for naloxone]. I want to ask you what you think about this recent legislation that finally passed [in the Senate]. There has been some criticism that there is not enough money behind it, and I know that some of that money would end up going to health departments like yours. So, I wanted to get your feeling about CARA.

Sure. We support CARA; we applaud its bipartisan passage through the Senate. I believe it passed 94 to 1, and it’s an important step in the right direction for recognizing that addiction is a disease and should be treated as [a] public health emergency, not only as a criminal justice issue. So, it is one step in the right direction. We also agree that much more funding is needed, especially to provide evidence-based treatment. Naloxone will save someone’s life at the moment they are dying, but it will not keep someone from relapsing, and it is not a long-term solution. We need evidence-based treatment that includes medication-assisted treatment and psychosocial support and other wraparound services. And that is what we need to have more resources for, not only in Baltimore City, but around the country. However, CARA is one step in the right direction.

OK, let’s talk about those treatments for a second. I’ll tell you a little story about what just happened to me. Every once in a while I’ll help distribute naloxone to people informally. I live in Louisiana where the laws are just starting to loosen up around it, so there’s already been a lot of informal distribution. Someone heard I had naloxone, but they thought the person who told them this said “Suboxone” [otherwise known as buprenorphine, a drug that assists users in withdrawing from opioids], and they came to me and asked if I could get Suboxone off the street. I said no, but told him that it is a prescription drug, and if he could afford to see a doctor, he might be able to get a prescription. And this blew his mind, and I thought there were so many issues wrapped up in just that moment. Barriers to access to health care, stigma around addiction — there were so many things going on in that moment.

Right, and one of the issues around Suboxone or buprenorphine is that only doctors who are certified to prescribe it are able too. And that’s … a very small fraction, like 3 percent or something, of all doctors … and they can only prescribe Suboxone to 100 patients at a time. There’s a federal limit … that does not exist for any other medication. So, that is an area … that we continue to do advocacy around. There is no limitation on how many opioids that a doctor can prescribe. Why is there a limitation on the number of treatment slots, the number of patients that a doctor can provide treatment to?

Yeah. While we are on the subject of medication-assisted treatment, there is provision in CARA to expand MAT in prisons and holding facilities, and that could send a signal to jails and prisons across the country. Do you know anything about those provisions?

I don’t know the specifics about them but I will tell you two things that may be related. One of them [is that] President Obama asked for the secretary of health and human services, Secretary Burwell, to come to Baltimore last Friday. She wasn’t able to at the very last minute, but the surgeon general came to Baltimore to make the announcement about the president’s $94 million investment in medication-assisted treatment in general through federally qualified health centers. Now, we are very glad that they did it in Baltimore. It’s in recognition of our work in preventing overdose and treating addiction.

We very much believe that individuals should continue to receive medical care while they are incarcerated. We would not punish them for HIV, for heart disease, so therefore, people who have an addiction [should] also receive treatment for addiction while they are in jail or prison too. That is something that we very much want to continue to advocate for, and not only to advocate that they receive some type of treatment, but they receive the right treatment for them.

In Maryland, and I suspect in other places across the country, people who enter prison who are on buprenorphine are switched to methadone. We would never do that for any other disease. We would never say to somebody, “Well, you are on insulin, but now you are incarcerated so we are going to switch you to a pill.” That is not acceptable for other diseases, and that should not be acceptable for addiction either.

Thinking about incarceration and also the issues around incarceration, you’ve drawn a lot of connections between poverty, barriers to health care access and social struggles in Baltimore around employment and racial justice, and I’m wondering what lessons has Baltimore learned about approaching addiction as a public health issue.

For us, it’s about changing the conversation. A conversation that we might hear initially is “Let’s get these methadone clinics out of our backyard.” But for us, we had to change the conversation to that of “addiction is something that affects all of us.” In terms of sheer numbers, there are 60,000 people in our population of 620,000 who have an addiction, and so it’s something that affects, if not you, your family member or your friend or your neighbor, so we have to change the conversation to that of saving lives. And to change the conversation to that of one of science, instead of stigma — that addiction is a disease and that treatment is possible. So, it’s about shifting the paradigm that we’re able to focus on the public health approach, and that’s why our naloxone distribution has not only saved lives, [but] it’s also changed the conversation to one that is science-based.

In Baltimore City, as well as other places, we also struggle with funding, too. But, when you look at the sheer cost per life saved, we’ll see that saving lives with overdose prevention is a no-brainer. In multiple states across the country, there are more people dying from overdose than there are dying from homicide, suicide or car accidents. How much money do we spend on saving lives for individuals dying of these other causes? That’s an issue of parity; it’s an issue of fairness; it’s also an issue of just sheer numbers when we are trying to save lives of our citizens. So we are happy to share the lessons that we have learned in Baltimore with other places. We know that we have been able to make tremendous progress in the last year. We … are glad to continue to be innovators in this space to save lives and to treat addiction as a disease.

Health departments across the country are now going to have some extra money here and some discretion in how to use it. What are some specific things that we can look at beyond naloxone to treat addiction as a disease that you can do as a public health department?

Naloxone is only the first step, as I mentioned. It’s certainly not the only solution. Providing treatment is absolutely critical, so health departments across the country can continue to support their local providers in delivering evidence-based treatment. Health departments can be involved in public education. We launched the public education campaign called DontDie.org that provides information about what is the nature of addiction, what people should know, how we can all save lives. And health departments across the country can learn from our approach doing “hot spotting.” We look at data at where people are dying of overdose, what people are dying from, and target those areas [for naloxone distribution] and those are certain lessons that we are happy to share with other places, too.

There were a lot of protests over law enforcement in Baltimore not too long ago, and there has been some criticism of the Obama administration’s plan for tackling the “opioid epidemic” around the fact that there is still a lot of money going toward law enforcement and that money is going to cracking down essentially on drug dealers. One of the criticisms of that is that it continues to criminalize a lot of poor people and exacerbate conditions that lead to incarceration, addiction and poverty. I’m wondering if you have any perspective on that being in Baltimore.

Addiction ties into every aspect of our city. You cannot talk about law enforcement or the criminal justice system or unemployment or anything without addressing addiction. In our city of 620,000, there are more than 73,000 arrests made per year, and the most common reason for arrest is drug offense. We have four out of 10 people in our jails who have a mental health disorder, eight of 10 who use illegal substances. You cannot separate these two issues, and so for us, it’s about saving lives, treating addiction and changing the conversation.

And luckily we are starting to see that conversation change, even in the Beltway, so hopefully progress is being made.

Yeah, I think just from our standpoint, the reason why the health departments lead [the conversation] in this city and across the country is that we strongly believe that public health can be a tool for social justice, that it not only saves lives and works toward better health, but it also is part of the conversation that must occur in order for us to address underlying root problems, including addiction, unemployment and crime.

Note: This interview has been edited for clarity and length.