With overdose deaths up, what's ahead? We ask experts on the front lines of the epidemic

With overdose deaths pummeling our communities, including Hamilton County with its 31 percent jump last year, you might be left wondering, "what's ahead?"

It's an exhausting epidemic that started in the late 1990s with rising prescription painkiller overdose deaths. By 2011, a heroin epidemic of overdose deaths was evident in Ohio and Kentucky. Around 2014, that began to morph into skyrocketing deaths due to a new synthetic opiate, stronger than the rest. Fentanyl, another opioid, was slipped into heroin, or sold straight on the streets.

Since 1999, overdose deaths have risen nationwide, to more than 63,600 in the United States. In 2016. Opioids were involved in 42,249 of fatal overdoses in 2016, according to the Centers for Disease Control and Prevention.

Collateral damage includes infants born in withdrawal from opioids, children removed from heroin-addicted parents, increases in diseases spread through sharing contaminated needles or getting stuck by just such a needle that was discarded improperly and overcrowded jails.

We asked national experts and local, front-line soldiers in the opioid fight, what to expect from now on. Here's what they said.

Has the opioid epidemic peaked?

Probably not, experts say. 

"We're simply not there yet," said Dr. Adam Bisaga, addiction research scientist and professor of psychiatry at Columbia University Medical Center. "It's actually accelerating the last two years."

That's because of mega-potent, illegally made fentanyl and its analogues that have been streaming into the drug supply for about four years now, experts said.

Hamilton County began seeing the rogue street drug in 2014 and still, in 2017, experienced a 30 percent rise in overdose deaths from 2016, at 529.

"I think it's going to be a while before we see significant changes," said Dr. Lakshmi Sammarco, the county coroner. "In my office, we take things one day at a time – sometimes it's one weekend at a time."

Other locals on the front line believe a peak in deaths is nearing.

Newtown Police Chief Tom Synan believes overdoses have already peaked. He's looking at August through October of 2016 when overdose deaths shot up with illegally manufactured carfentanil (the elephant opioid) hitting the streets of Hamilton County and then, Northern Kentucky.

In 2016, the overdose count (survivors included) was about 50 to 75 per week in Hamilton County, Synan notes. Now? It's in the "low 50s."

But public health officials attribute that drop to medics and police officers carrying the lifesaving opiate overdose antidote naloxone. Users also are becoming more adept at managing their fentanyl intake, leaving fewer overdosing, says Northern Kentucky addiction and family physician Dr. Jeremy Engel.

What have we learned: What works, what doesn’t 

Abstinence does not work for most people with opioid addiction. Medication – whether given inpatient or outpatient, as long as the patients are in a safe environment and follow directions of physicians and therapists – does; research confirms this.

The FDA has approved the use of methadone, buprenorphine (an opioid) and naltrexone (a non-narcotic known by its brand name, Vivitrol) to treat opioid addiction. Best practices combine these medications with psychosocial therapy.

Experts in addiction and the World Health Organization say the chronic-disease medical model is the gold standard treatment for opioid addiction.

Is enough medication-assisted treatment available?

No.

Only 2 percent to 3 percent of physicians nationwide are approved to prescribe buprenorphine (the take-home medication used for treating people from a doctor's office). Most of these doctors can only prescribe to 30 patients, Bisaga said.

"We need to make this treatment available in every community," he said. 

"We are not close to treatment-on-demand ability," Sandi Kuehn, CEO of the West End-based Center for Addiction Treatment, told The Enquirer recently.

But things are improving in the Cincinnati region. Mercy Health-Cincinnati has created a collaborative that will launch in June, providing a full range of addiction services. Rather than reviving and releasing overdose patients, they will be more readily handed off to treatment.

Nan Franks, CEO and director of the Addiction Services Council, said treatment is more available now than ever to everyone who calls her agency's hotline, with minimal to no delays. Clinics that provide medication-assisted treatment have opened or expanded in the region.

The national Substance Abuse and Mental Health Services Administration notes that more physicians are becoming certified to prescribe buprenorphine, giving greater access to treatment.

In 2017, more than 10,700 doctors were added to the pool of those who could prescribe buprenorphine to as many as 30 patients. That compares to about 2,800 new docs certified to prescribe the medication in about 2014, when fentanyl burst out on the streets in Southwest Ohio.

In Hamilton County, nearly 140 doctors are certified, a federal doctor-finder shows. The agency provides a treatment-locator link as well.

How will this epidemic continue to hit home?

More kids in foster care: If the opioid epidemic continues at its current pace, Ohio will have more than 20,000 children in custody by 2020, a December 2017 report from the Public Children Services Association of Ohio says. That's up nearly 59 percent from 2013. While the epidemic isn't the only thing pulling kids into care, it's a significant trigger. In 2015, the same report shows, half the children taken into custody had parents who were using drugs.

Newborns exposed to drugs or drug-dependent: Babies exposed to opioids in utero will continue to be born as long as pregnant women use the drugs or are treated with them. But their outcomes likely will improve, said Dr. Scott Wexelblatt, medical director of regional newborn services, Cincinnati Children’s Hospital Medical Center.

In part, that's because Greater Cincinnati has provided universal testing for opioids for pregnant women, a non-punitive system that helps identify children born with opioid exposure. The plan is to track these children and be available to care for them, Wexelblatt said.

Already, infants in Ohio who are born with neonatal abstinence syndrome, or withdrawal symptoms from a dependency to opioids, are having shorter hospital stays thanks to standardized care. And Cincinnati Children's is watching these infants' development closely through a specialized clinic for babies and toddlers who were born with the syndrome.

And, there's more positive news: The number of newborns with Neonatal Abstinence Syndrome or exposed to opioids in utero in the Greater Cincinnati area has stabilized, Wexelblatt notes.

In 2017, 37.1 infants per 1,000 newborns had been exposed to opioids before birth, and 12.9 had Neonatal Abstinence Syndrome. That's virtually the same as in 2014.

More need for needle exchange: "Worst-case scenario, without more support for syringe exchange programs, communities will see more discarded syringes and people struggling with opioids will have fewer places to get help – and this will ultimately show up as more HIV, hepatitis C and overdose," said Daniel Raymond, policy director for the National Harm Reduction Coalition in New York.

"But that’s not inevitable," he said. "Syringe exchange and harm reduction programs are taking root, and we’re seeing some success stories. With support, we’re likely to see programs expand services."

Jails potentially gain empty cells: Addiction experts believe that addiction should be "decriminalized." That is, give people evidence-based treatment, don't lock them up.

More jails, including most in the Cincinnati region, are providing at least one form of medication-assisted treatment and some evidence-based programming to inmates with addiction. 

Jail space can grow if people get the best treatment, and incarceration costs go down as recovery rates – without recidivism – go up. The National Institute on Drug Abuse says that conservative estimates show that "every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft." 

What next steps should be taken?

"Look at this from a much higher perch" while continuing current programs on the ground, suggested Jason Merrick, Addiction Services director for Kenton County Detention Center and a longtime treatment advocate in Kentucky.

Here's how that will look in Northern Kentucky: Kenton County's Detention Center, with Northern Kentucky University as an independent research partner, will track progress of programs that keep addicted people out of jail and get them into treatment. The program, paid for with a $300,000, three-year U.S. Department of Justice grant, includes an Alexandria Angel program, where people can drop off their drugs at the police station and get funneled into treatment in return.

They will then standardize the programs and get them established throughout the region. 

Joseph J. Plumeri, executive chair of the National Center on Addiction and Substance Abuse, said the future needs to look like this:

“Every child needs evidence-based prevention in his or her school or community, and every person with substance use disorder needs access to effective treatment. We need to be guided by compassion and science."

So, are we there yet?

No.

"All of the initiatives being launched in cities and states across the country, such as Cincinnati, are highly important, but they don’t represent the widespread adoption of evidence-based practices that this epidemic calls for," Plumeri said. "We continue to take half-measures and under-invest in fixing the problem, then wonder why we’re not getting better results. Reaching a few thousand people is just a drop in the bucket – there are millions of people in need of treatment and support."

More Enquirer coverage on the opioid epidemic

Hamilton County sees 31 percent jump in OD deaths

Heroin overdoses soar 30 percent in NKY

Pulitzer Prize-winning Seven days of heroin