The War on Drugs: One Approach to Reduce Overdose Deaths in New York City

Introduction

It is estimated that over one thousand New Yorkers died of unintentional drug overdoses in 2016, more than three times the homicide rate in the city that same year.[1],[2] While a breakdown of the 2016 overdose data is not yet available, based on 2015 data we can expect the vast majority of these deaths were linked to the abuse of opioids—a broad category of drugs including prescription pills like OxyContin and illicit drugs like heroin.[3] As the use and abuse of opioids has increased, it has spread throughout the city, crossing race and class lines. No longer limited to stereotypical drug users of the 1970s and 1980s—generally men of color—the problem is starting to receive the attention it has long deserved from the media, the American public, and professionals in the field.

The response from law enforcement and health officials has been largely based on the belief that the “prescription pill to heroin pipeline” is the cause of the heroin epidemic. Yet this notion is a knee-jerk response based upon a simplification of the problem, largely ignoring the complex data and facts concerning widespread opioid addiction as a crisis in its own right. Recent studies help to provide a better understanding of the relationship between heroin and opioid use that can help us formulate a more comprehensive response.

The Rise in Overdose Deaths in New York City

In 2015, there were 937 unintentional overdose deaths in New York City, 16 percent of which involved fentanyl—a synthetic and short-acting opioid fifty to one hundred times more powerful than morphine.[4] This percentage appears to be rising: preliminary data from 2016 indicates this number may have reached over 40 percent in 2016.[5] Between 2013 and 2015, state and local laboratories experienced a 954 percent increase in fentanyl cases in forty-five of New York State’s sixty-two counties.[6] Making the problem more complicated—for health officials and law enforcement alike—is that of these fentanyl-involved overdose deaths in 2015, 70 percent also involved heroin.[7] And the Drug Enforcement Agency (DEA) hints that such a percentage could be even higher since “heroin metabolizes into morphine very quickly in the body, making it difficult to determine the presence of heroin” after death.[8]

High-poverty neighborhoods and White New Yorkers experienced the highest rate of unintentional overdose deaths involving heroin in 2015.[9] The steepest increases were driven largely by younger New Yorkers: among New Yorkers ages fifteen to thirty-four, the rate of heroin-involved overdose deaths more than tripled between 2010 and 2015, to 7.3 per 100,000.[10] There are likely multiple reasons for this sharp increase, including less stigmatization, an increase in purity and decrease in price of heroin, and the possibility of receiving drugs laced with fentanyl.

Neighborhoods in Brooklyn, Flushing, Washington Heights, and the Bronx experienced sharp rises in overdose deaths even as many have gentrified.[11],[12] Neighborhoods in Brooklyn alone saw a 170 percent increase in overdose deaths from 2014 to 2015.[13] Opioid painkillers like fentanyl and hydrocodone—which are costlier than street drugs like heroin—contributed to more overdose deaths in the city’s wealthier neighborhoods than in poorer neighborhoods.[14] During 2013 and again by 2015, opioid overdose deaths rates were highest among residents of Staten Island, New York’s borough with the highest median household income and a majority White population.[15],[16]

These climbing rates prompted the development of a naloxone pilot project on Staten Island in 2014. Naloxone is an opioid antagonist, a drug to treat incidents of overdose, now more widely used across New York City and nationwide. While using naloxone saves lives, this is only the tip of the iceberg: a fully functioning opioid response extends far beyond law enforcement offering naloxone, which does nothing to bridge the gap between an overdose incident and long-term treatment. Nevertheless, this pilot project is one public health response from local government. The Bronx—poorer and less White than Staten Island—had the highest rate of deaths by heroin in 2015 at 146 total, but did not receive the same kind of attention.[17],[18]

These data indicate the rise in overdose deaths cannot be attributed solely to traditional socioeconomic demographics and that changing racial and class makeups are finally bringing attention to the issue. The reported rise in overdose deaths across race and class has received extra attention due to the scale of the problem and its effects on a broader—namely, White and wealthy—segment of the American population.[19] The United States is now beginning to define this problem as a public health epidemic, in contrast to the criminal activity of the 1980s and 1990s. While our laws need to be enforced, those in the field are coalescing around the notion that response needs to come at this problem from every angle, rather than simply arresting our way out of it.

Structural Changes in the Drug Market Have Led Us to This Point

The relationship between nonmedical prescription-opioid use and heroin use is often misunderstood, and hasty conclusions are not always supported by empirical evidence. Despite the difficulty in proving statistical causation, industry experts agree decreases in the price of pure heroin in the United States are associated with increased heroin overdose-related hospital admissions. Heroin is significantly cheaper today than it was in the 1980s: the price per gram of pure heroin in 1981 averaged $3,260 (in 2012 US dollars), but by 1999, had decreased to $622 per gram.[20] Prices have remained low since 1999, and purity levels have only increased;[21] as heroin has become purer, it has become more useable by snorting. As heroin has become both cheaper and purer, we have seen an increase in hospital admissions, demonstrating that these increased hospital admissions are associated with structural changes in the heroin market.[22] In addition to price and purity, another driver for the increase in heroin abuse is recent chemical alterations to prescription opioids to make them more difficult to snort or inject, driving drug users to heroin in place of prescription drugs like OxyContin.[23]

It’s important to recognize the transition rate from opioid use to heroin use is actually small but, due to the large pool of opioid users, impacts a large number of people. According to a recent study in the New England Journal of Medicine (NEJM), the transition from oral use of prescription opioids to instead crushing and snorting the drug can, in fact, lead to heroin use.[24] However, the NEJM affirms a widely held opinion[25] that “heroin use among people who use prescription opioids for nonmedical reasons is rare, and the transition to heroin use appears to occur at a low rate.”[26]

The predictors of future heroin use—pharmaceutical opioid dependence, early age of use, pharmaceutical opioid use to get high, and non-oral drug use—are corroborated in multiple studies,[27] but hard associations are not as easy to prove statistically. It is critical to shift the conversation towards an empirically supported understanding of the complexity of drug abuse and successful options for victims requiring treatment.

Public policy must adapt to market changes that can affect drug concentration and price. Furthermore, understanding the nuances of this issue and the relationship between heroin and opioids is critical to formulating a response to what has become known as a public health crisis. Causation aside, the bottom line is that significant opioid dependence crosses racial and class lines. To address the opioid epidemic, it is critical to recognize the signs of addiction, support effective and quick treatment, and adjust legislation and enforcement to meet the needs of today’s opioid epidemic.

A Change in Approach to Response Has Led to a Decline in Opioid Use

Efforts to combat this epidemic have typically been conducted in silos. But solving this problem is far beyond the reach of any one government agency. So far, responsibility has yet to be determined, follow-up is lacking, and efforts beyond criminal sanctions have not been sufficiently developed.

Efforts to “crack down” on the overprescription of opioids in 2011 and 2012 by both law enforcement and the medical industry offer an example of what can happen when we work together. In 2000, the National Survey on Drug Use and Health (NSDUH) reported 2.78 million people in the United States admitted to misusing prescription painkillers, and by 2012, that number had almost doubled to 4.82 million users.[28] However, by 2014, following efforts by law enforcement to prosecute doctors for inappropriate prescriptions and increased professional development for doctors, numbers declined by roughly 500,000.[29] At the time, the director of the Johns Hopkins Center for Substance Abuse Treatment and Research attributed this decline to “some stabilization or even a decrease in prescription opioid misuse.”[30] In 2015, survey data reported another decline, down to 3.8 million current misusers of pain relievers ages twelve and older.[31]

While this decline could be attributed to individuals choosing not to report, such an overall decline may also be an indication that improvements within the medical industry are beginning to decrease, or stabilize, addiction trends. The medical industry has improved professional training standards to look for early warning indicators of painkiller abuse in an effort to curb overprescribing. Although only a small number (about 4 percent) of controlled prescription drug (CPD) abusers initiate heroin use, this represents a significant number of heroin users because the size of the CPD-abuser population is significantly larger than the heroin population.[32] In the law enforcement community, there is a belief that since painkiller use has declined, drug users are replacing their prescription opioids with heroin. Policy makers should be reminded of the low transition rate between prescription opioid use and heroin, and that correlation between the two does not suggest a firm causal linkage.

While opioid use on the whole has declined, we cannot misinterpret these results simply as a win against the epidemic. Too many people are still dying of overdoses. This example demonstrates the need for policy makers, health officials, law enforcement, and court systems to take a more critical look at the data. In particular, they should take care to:

1. Analyze trends and connections between overdose incidents
2. Eliminate gaps between agency responsibilities
3. Ensure aggressive follow-up that provides evidence-based treatment to victims
4. Develop a broader knowledge base among partners by viewing incidents side by side and combining multiple data sets from law enforcement agencies, health departments, hospitals, and treatment facilities

This gives stakeholders an improved view of this complex issue and a better understanding of how to solve a problem with this level of complexity. Data must guide policy discussions, and field activities and pilot programs should use empirical research as a foundation for positive change to address the opioid epidemic. It is the beginning of a new chapter in the war on drugs.

New Research Shows the Need for Better Treatment Options

Until recently there has been no empirical research studying illicit prescription opioid users and their use of heroin. A 2010 Ohio study of eighteen to twenty-three year olds by the National Institute on Drug Abuse (NIDA) concluded the strongest predictors of heroin use were non-oral use of prescription opioids—namely, crushing, sniffing, and snorting.[33] This kind of research allows stakeholders to design alternative approaches to reduce overdose incidents. Similarly, an unclassified DEA Intelligence Report includes recommendations for standardizing reporting for drug-related deaths in the United States. It gives suggestions for how to collect and report data and stresses the need for treatment and admission to publicly funded facilities.[34]

Government leadership must recognize there is a critical need to improve drug abuse treatment programs using empirical data. One successful example of an improved treatment regimen is Addiction Treatment Services (ATS), an innovative, personalized treatment program at Johns Hopkins Bayview Medical Center.[35] This therapy is successful because it is modified for each patient. The program is able to pivot from one level of addiction treatment to another, depending on the patient’s needs.[36] Failures within the program are not viewed as individual failures but rather the failure of the program to adapt to the individual needs of the patient. ATS is one of only a handful of programs that offer a combination of methadone, buprenorphine, and naltrexone maintenance therapy, in addition to a full complement of mandatory addiction counseling and group classes. Such treatment is only available at select centers across the United States.

The success of ATS points toward an even more glaring issue: the low number of effective multiple-treatment type centers, inconsistent insurance coverage for treatment in general, and, most importantly, the ineffectiveness of current programs universally covered by insurance. Many programs are short and ineffective, with less than sixty days of treatment covered by insurance. With short spans of treatment, victims leave without the skills needed to avoid future relapse. Adding to the problem, when an individual undergoes treatment, their body’s tolerance for the drug lowers significantly. When they relapse, they often inappropriately estimate how much of the drug they need to get high, which can lead to overdose and, ultimately, death.[37] Current government programs are insufficient and do not follow up with victims of serious addiction who require longer treatment.

Law Enforcement Cannot Shoulder the Responsibility Alone

Which agency should shoulder the responsibility for follow-up on drug overdose incidents? Some suggest it is a health problem while others argue that the burden falls to police departments, which have the most daily contact with the public. Laws must be enforced; at the same time, all stakeholders carry a responsibility to help those who need treatment. The complexity of the opioid epidemic requires increased coordination between prosecutors, investigators, and the criminal justice system. This does not require agencies to take on new responsibilities but only to broaden their view of how to approach the issue.

For police, this response would cultivate a dual role: first, on enforcement and investigation, and second, on follow-up for delivery of treatment and social services for the victim of drug abuse. We already see these approaches within the framework of domestic violence reporting, investigation, and follow-up. Domestic violence incidents require reporting by doctors, teachers, and other mandated reporters. Consequently, domestic violence incidents receive careful attention from the criminal justice system, including relentless follow-up to ensure appropriate intervention and tracking. With this as a model, an improved response to drug abuse incidents can ensure accountability from many actors. Mandated reporting and persistent follow-up can lead victims towards successful treatment. In this approach, law enforcement agencies will continue to have multiple roles, most of which involve enforcing drug trafficking, sales, and distribution violations. But police departments should define success as an overall reduction of overdose or drug incidents within a household, as they do in domestic violence, rather than single police-involved incidents.

Yet law enforcement cannot be the only guardians of this problem. Policy makers must hold key stakeholders in health care and criminal justice accountable. Doctors, emergency medical technicians, judges, prosecutors, defense attorneys, and others all have an important role to play in managing the response to this crisis. Systemic collaboration can help reduce drug-involved fatalities and can get victims of drug abuse the treatment they need.

Stakeholders should have an understanding of how to guide drug abusers toward treatment while prosecuting criminal violations appropriately. Policy makers must introduce legislation to close legal loopholes regarding altered synthetic opioids. Currently, it is difficult for states to prosecute drug dealers who have synthetically altered the chemical properties of opioids, which can essentially free them on a legal technicality if the drug has not been defined within the state’s penal law. State penal law must mirror federal criminal law so that synthetic opioids, regardless of chemical composition, are adequately defined in the state’s code. States should be able to prosecute any illicit drug, chemically altered or not, to ensure dealers can be successfully prosecuted if their drugs lead to a person’s overdose and death.

The Path Forward

In recent years, experts have championed opioid antagonists that, when administered, neutralize the pharmacological effects of an opioid in the body during an overdose. Currently, many police departments, including the NYPD, provide antagonists like naloxone through programs alongside the state Department of Health and the NYC Department of Health and Mental Hygiene. While these efforts do save lives, this is only an initial step, does not contribute to prevention, and does not bridge the gap between treatment and criminal sanctions. To lower the number of overdose deaths, stakeholders must create systemic partnerships to forge new problem-solving approaches.

To begin addressing this issue, state attorney general (AG) offices should adopt a Drug Monitoring Initiative, as used successfully by the New Jersey State Police (NJSP). This methodology uses technology to collect and share huge amounts of data across agencies, analyzing the relationships between overdoses. Furthermore, ownership by AG offices allows this agency to own legislative problems surrounding this issue. The AG is the most appropriate owner, as it liaises with all relative agencies and partners in their reporting stream, including law enforcement and health departments. By combining this model with the effective use of real-time data, stakeholders have a better understanding of the problem and can immediately implement strategic solutions across multiple agencies.

Proper use of data remains the best way to address the problem, but with the exception of the NJSP, most agencies are in infantile stages in their approach to overdose incidents. Ownership of this program by the AG office, instead of by one agency like the Health Department or law enforcement, allows a state to take full ownership and apply resources appropriately, engaging other agencies as needed. This keeps stakeholders accountable, and ensures laws and regulations are crafted and executed uniformly towards one end goal. This approach addresses both health treatment and appropriate use of law enforcement.

Agencies must pool resources to reach the collective goal of reducing overdose incidents. Shoulder to shoulder, standing together, agencies must form an unbreakable wall for those who need assistance in the fight against the horrors of drug abuse, addiction, and the unnecessary loss of life.