Restoring HopeFighting the Opioid Crisis in Buffalo
Tagline Meet Ben Francis Subtitle
Tagline Meet Ben Francis Subtitle
Ben Francis was a high school senior when his insides betrayed him.
Ben says he was one of those “straight-edge” kids. He’d avoided
drugs and alcohol through his teens, and in his spare time, played soccer
and hung out with his friends. He was a promising artist and aspiring art
teacher; photography, in particular, inspired him. His life seemed to be
following a trajectory familiar to most of the kids who attended his large
high school in suburban Western New York, just outside of
Buffalo.
But after one high school soccer injury and three refills of
Vicodin—a powerful prescription opioid—Ben was teetering on the edge of a
new world. “I knew I liked the feeling,” he says. Although, when the
prescriptions ran out, he says he “figured that was over.”
It wasn’t
over, as Ben found ways to buy more pills and, subsequently, heroin—anything
that would induce in his body the same sensations brought on by the Vicodin.
While taking classes at SUNY Potsdam, every cent he earned went toward
feeding his addiction, toward calming the beast inside of him. “I would go
so far as to jump in the car at 5 a.m. with some friends and go to the
closest place to buy anything like that.”
“It became my life.”— Ben Francis
Ben Francis' descent
Ben Francis' descent
Ben managed to make it through a few weeks of classes during his first
semester of sophomore year at Potsdam. Then he started disappearing for days
and eventually dropped out. Ben planned to come back the following fall, but
he never did. His descent continued.
What’s misunderstood about
addiction, Ben says, is that no one wants to be that way. No one wants to
feel that way. Once the brain crosses that powerful threshold—between
recreational use and addiction—every day is a struggle just to feel normal.
Every day is a brush with death, a race to find a dealer, a plan to outsmart
the cops and the people who love you.
At this point, for Ben, it was
no longer about getting high. Rather, it was “about being able to
function—about being not sick.”
"The euphoria was gone"
Ben's story is common
Ben's story is common
Ben continued to use. “I figured I was resigned to that life until it
killed me,” he says.
Ben’s story is common.According
to the American Society of Addiction medicine,20.5 million
Americans age 12 or older had a substance use disorder in 2015. Of those, 2
million used prescription pain relievers and 591,000 used heroin.
Nearlya
thirdof those who use heroin develop opioid addiction.
Easy access to drugs like heroin, fentanyl, and even prescription
medications like OxyContin has fueled an epidemic of addiction—the deadliest
in U.S. history. Now, science is revealing how addiction affects the brain,
and experts are gathering evidence to determine how we can best address our
drug problem, from embracing evidence-based treatments to rethinking public
policies.
As a whole, the U.S. is making some progress toward
untangling the web of factors fueling the opioid crisis. But drug use is
still on the rise. In 2017, it's estimated thatmore
than 72,000 Americans died from drug overdoses,including
illicit drugs and prescription opioids. That’s more than triple the number
of deaths that occurred from drug overdoses in 2002. Life expectancy in the
U.S. is dropping because of this crisis.
“We have 4.5% of the
world’s population in the United States,” says Cheryll Moore, medical care
administrator at the Erie County Health Department in Buffalo, NY. To put
that in perspective, the U.S. consumes 30% of the world’s opioid supply. “In
the United States of America, we do a quick fix and we got in big trouble.
We are getting out of it
slowly.”
A nation in crisis
Opioid-Related Deaths in Buffalo
Opioid-Related Deaths in Buffalo
From 2009 to 2016, opioid overdose deaths doubled in New York
State.
However, a few areas have begun to see a decrease in
fatalities, including the city of Buffalo and surrounding Erie County.
What's behind the decline?
New York's I-STOP law
Back in 2013, New York State’s I-STOP law was put into
effect, requiring prescribers to consult a Prescription Monitoring Program
Registry when writing prescriptions for certain controlled substances. This
provided practitioners with secure access to prescription histories for
their patients. Officials and medical experts in Buffalo thought this would
help curb the crisis.
It did not.
"The opioids...here are exponentially potent"
The Erie County Opiate Epidemic Task Force
The Erie County Opiate Epidemic Task Force
A new response was necessary in Buffalo.
Cheryll Moore and her
colleagues started the Erie County Opiate Epidemic Task Force in 2017, which
is made up of seven working groups, including law enforcement, community
members, families affected by the crisis, medical providers, health
department officials, and more. “All of the efforts of all of the work
groups together, in synergy, are starting to make inroads. We’re trying all
different programs—anything that we can,” Moore says. “What’s working, we
keep. What isn’t working, we get rid of.”
This is how a lot of
regions in the U.S. are operating: on informed experimentation. Because the
opioid crisis is extremely complicated and varies county by county, medical
experts and policymakers are working to get on the same page and make their
process more effective given limited resources.
One of the task
force’s programs that seems to be working is a new response from police
officers whenever they encounter an
overdose.
All hands on deck
Just outside Buffalo is the socioeconomically
diverse and historically blue-collar town of Cheektowaga, the city’s second
largest suburb. The Cheektowaga Police Department’s attitude toward the
opioid crisis is all hands on deck. Officers are tightly integrated with
Cheryll Moore’s task force; officers communicate with the health department
and other parts of the network directly after responding to an
overdose.
Lieutenant Brian Gould says when his team arrives on the
scene, the sight is a scary one. The victim—sometimes collapsed on a
bathroom floor in the mall, sometimes slumped over against a building—isn’t
breathing. “They’re unresponsive,” Lt. Gould says.
Take a look at the science behind opioid addiction:
Take a look at the science behind opioid addiction:
Normal brain activity
Opioid drugs and the brain
What happens during an overdose
Breathing life back into the breathless
In the event of an overdose, a compound called naloxone can
revive someone on the brink of death. Sold under the brand name Narcan and
administered either by injection or in the form of a nasal spray, naloxone
can literally breathe life back into the breathless.
Naloxoneblocks
the effects of opioidsby binding to opioid
receptors—proteins that drive the body’s response to these compounds by
serving as docking sites for opioid molecules. If there’s an opioid already
present on the receptor, naloxone kicks it off. Then, when naloxone binds to
the receptor, it blocks that receptor’s activity but doesn’t activate
it—meaning a person can recover from his or her overdose.
Though
naloxone can bind to every kind of opioid receptor, it has a particular
affinity for mu opioid receptors. Mu receptors can be bound by drugs like
morphine, fentanyl, and heroin. Their activity is responsible for the
euphoric, sedative, and pain-relieving effects attributed to these drugs.
The exact way in which naloxone interacts with mu receptors to
displace opioids and restore breathing remains unclear. The effectiveness of
the drug, however, is no mystery. Within minutes of receiving naloxone, an
overdose victim can regain consciousness and may even experience sudden
withdrawal symptoms.
A drug so powerful in reversing an overdose
has little to no effect on people without opioids in their system. “You
can’t mess it up,” Lt. Brian Gould says. “If you administer naloxone to
somebody who’s not having an overdose situation, it has no negative effects.
They end up with a wet nose—that’s all.”
In Cheektowaga, police
officers are equipped with Narcan nasal spray kits. This is unusual—the
number of police forces carrying Narcan is changing rapidly. But records
suggest that the majority of law enforcement officials do not carry Narcan,
though it’s extremely effective in saving lives. Since law enforcement
officials are typically the first people on the scene after an overdose, and
because time is of the essence when a person isn’t breathing, a police
officer’s ability to administer Narcan can be the difference between life
and death.
"We were saving lives"
Kickstarting a process
In Cheektowaga, after a person has overdosed and received Narcan, his or her information is quickly entered intoODMAP,an app created by the Washington/Baltimore High Intensity Drug Trafficking Areas (HIDTA) program. This database is used in various ways across the country, but in Cheektowaga, it kickstarts a process: The officer enters certain data into ODMAP (for example, location of the overdose, how many doses of Narcan were administered, whether the overdose was fatal or not); then Moore’s team dispatches someone to connect with the individual.
YOUR LIFE WAS SAVED THIS TIME
Meanwhile, law enforcement gives the person who has
overdosed a small but alarming package. It’s a bright orange envelope with
the words “YOUR LIFE WAS SAVED THIS TIME” written in large bold
letters.
“It’s [an] envelope full of information on how to get help,”
Lt. Gould says. “We have a 24-hour opiate addiction hotline—there’s a card
in there for that. There’s information on how to get naloxone. There’s
information on how to get people into treatment.” The orange packet is a way
for law enforcement to get this critical information into the hands of
overdose victims and their loved ones.
“I scan this map three times a day.”— Cheryll Moore
Every dot and diamond corresponds to an overdose.
The power of a peer
Cheryll Moore checks ODMAP in the morning, at lunch, and at
night. If there are any new overdoses, Moore identifies the police
department that was involved and reaches out to their records clerk for a
report. If the person who has overdosed hasn’t called the health department,
then within 24 to 72 hours after the overdose, Moore’s team deploys a
peer—someone in recovery who’s been trained to support those still
struggling with addiction—to talk to them and let them know that they’re not
alone. Most of the time, the peer goes to the person’s home to see if
they’re around; as a backup plan, the peer will try reaching the person by
phone.
“Every case is unique,” Moore says. “That’s the beauty of the
peer asking someone, ‘What is it that you’re looking for?’ The key is not
what I want, but what you want for you.”
The optimal goal of this
relationship is to connect the person with long-term treatment. A peer also
sits down with family members to determine how best to support the
individual.
“We’ve interacted with 58 people since September [2017],
and since then, more than 60% are still connected to treatment,” Moore
says.
This is all possible because of ODMAP, which connects people to
recovery options in near real time. Historically, the health department
received reports from law enforcement about their use of Narcan, but it
wasn’t necessarily same-day information. These individuals are usually “sick
and tired of feeling sick and tired,” says Antonio Estrada, one of the
peers. They’re more open in that vulnerable state to exploring treatment
options, he says. It’s important to note, though, that this window of time
is extremely fleeting; if the opportunity passes, patients could end up in
severe withdrawal and go back to using.
As a peer, Estrada knows what
it’s like. He’s been in recovery for 18 years, and can describe to overdose
victims what the journey feels
like.
"Hey, we're here for you"
Medication-assisted treatment
Historically, diseases of addiction like opiate use
disorder were treated with abstinence-based programs that included
behavioral interventions, but no prescription medications. However, without
chemical assistance to reduce the brain’s cravings, patients on these types
of treatments are muchmore
prone to relapse,with failure rates estimated between 80 to
90%. Today, so much of the opioid drug supply is tainted with unpredictable
amounts of potent fentanyl. Every time a person uses, the risk of death is
extremely high.
As a result, more and more addiction specialists are
advocating for medication-assisted treatment or M.A.T. This combines social
and behavioral interventions with drugs like methadone or buprenorphine that
mimic the body’s own pain relievers, reduce cravings, and help regulate the
production of dopamine.
"The treatment of choice"
"The treatment of choice"
For Dr. Paul Updike, the medical director for Substance Use Services for the
Catholic Health System in Buffalo, NY, this approach is the “treatment of
choice.” But he notes that different treatments should be “complementary,
not exclusive of one another.”
There’s a growing consensus that
emergency departments should work aggressively to offer medication-assisted
treatment to every overdose victim immediately—at the moment when they are
most vulnerable to relapse.According
to the Recovery Research Institute,the window of time
between referring a person to treatment and his or her actual appointment,
if too long, could result in loss of motivation. Many addiction specialists
fear that after 24 to 72 hours, a patient might already be in acute opioid
withdrawal, and at increased risk to use—and overdose—yet again.
“If
you have a diabetic patient whose blood pressure is too high, and a few
weeks later, the blood pressure got too high again, you don't kick him out
of the diabetic clinic,” says Dr. John Aldis, an addiction medicine
specialist in the Eastern Panhandle of West Virginia. “You welcome them back
in, you get them back on treatment, as often as is needed. And that isn't
being done in addiction medicine.”
At Massachusetts General Hospital
in Boston, people who have overdosed are sent home with a prescription for a
drug that combines buprenorphine and naloxone (sold under the brand name
Suboxone). Unlike methadone, which is a Schedule II drug and requires a DEA
license to prescribe, buprenorphine can be prescribed and given to
individuals right in a doctor’s office. According to the Drug Addiction
Treatment Act of 2000, doctors can prescribe buprenorphine in a variety of
settings including community hospitals, health departments, and prisons. On
the other hand, methadone maintenance treatment can only be performed in a
Substance Abuse and Mental Health Services Administration (SAMHSA)-certified
clinic.
In Western New York, many hospitals are connected with
Cheryll Moore’s task force. “Each case is slightly different,” Moore says.
In general, overdose victims are transported to the local emergency
department after overdoses occur; at 13 of those emergency departments,
staff are trained and registered to provide and prescribe Suboxone. Moore’s
task force is responsible for having trained 150 of those providers in the
past few years. Additionally, the individual is given an appointment with a
nearby long-term treatment provider within two to seven days after the ER
visit if the individual so chooses to pursue long-term care.
“We
currently have a network of 27 community-based substance use disorder
providers that have allocated more than 60 slots weekly for immediate
appointments and continuation of medication-assisted treatment,” Moore says.
This is necessary because the initial prescription from the ED is only valid
for a week—then the patient is advised to follow through with the arranged
long-term treatment. If a client is uninsured, the task force has set up a
process with a local Congressional Budget Office to accept donations to pay
for the first week of medication for the individual.
This means that
there are essentially two paths for a person who has overdosed in Buffalo:
If a person enters an M.A.T.-participating emergency room, he or she can
find long-term care immediately. If the person overdoses in Cheektowaga, he
or she might still receive the same treatment at the ER (if that particular
hospital has Suboxone providers), but that person will also have received
the orange packet from law enforcement containing information about peer
support and M.A.T.
Until all emergency rooms can provide Suboxone or
methadone on demand, community providers are doing the best they can to
engage people in treatment. In Buffalo, the task force and peer system seem
to be making a difference.
At the Catholic Health System Methadone
Clinic, the first of its kind in Buffalo, Dr. Updike is focusing on making
sure people with opiate use disorder are stabilized with medication-assisted
treatment so they can get back on track.
“When patients aren’t having
to deal with the demand of their addiction every day, then things change
dramatically,” he says. “There’s concurrent care here—a counselor, nursing
staff…medication is an important piece of the treatment, though.”
In
general, medication-assisted treatment works because opiate use disorder is
a chronic, life-threatening illness characterized by changes in the brain.
According to Dr. Updike, these changes drive the stigmatizing behaviors
often associated with addiction—like criminality and joblessness—and
medication is necessary for a successful recovery. “If we don't address that
underlying problem, then patients will struggle,” he explains.
"We want to get people...to move forward again"
This is how methadone and Suboxone work in the brain.
Methadone
Suboxone
A work in progress
Many communities across the country have all but neglected
their opiate-dependent populations. Others—those with sufficient
resources—are trying to construct ideal pathways and permanent solutions.
Ultimately, experts say that the best way forward is to make sure all
emergency departments are equipped with on-demand methadone and Suboxone.
“We need just as many spots open for addiction medicine as we have
for diabetic medicine or any other chronic, relapsing, and potentially fatal
disease,” Dr. John Aldis says.
Given their limited resources, Buffalo
officials are devising an ambitious plan that remains a work in
progress.
"A huge difference"
"We have a long road ahead of us"
"We have a long road ahead of us"
Cheryll Moore knows there’s more work to be done. “We have a long road ahead
of us,” she says. “It’s going to take a long time to get out.” In October
2018, Erie Countyreceivedtwo
grants from the Bureau of Justice Assistance for a total of $1.8 million to
fight the opioid epidemic. Moore says that over the next three years, one
million will fund an Opioid Mortality Review Board to help shape future
public health practices and policies related to opioid addiction. The
remaining funds will be used to develop a peer support unit for people
suffering from opiate use disorder and who are in the Erie County probation
system.
Additionally, Erie County received $3.2 million of funding
from SAMHSA and the New York Department of Health to increase peer services,
increase access to naloxone, and provide training to first responders in the
eight counties of Western New York over the next four years.
Working
out the kinks in systems like Buffalo’s will require taking a hard look at
the delicate time frame between an overdose and a person’s next use of
opioids. Dr. John Aldis says that medications with a long half-life (that
is, medications that remain in the bloodstream for a longer period of time)
are the most promising, and that medical care providers need to administer
the first dose of methadone or Suboxone once a person is in withdrawal and
after the effects of other opioids in the system have subsided. Before that,
these medications can make a person very sick.
And once initiated,
many people are able to hold down a job, avoid street crime and violence,
and reduce exposure to HIV due to injections only because they’re taking
methadone or Suboxone. Treatment, while a sacrifice, is much better than its
opposite.
More than anything, the stigma around addiction needs to
erode, says Dr. Aldis.
"Everybody's worth something"
"Everybody has the capacity to climb out"
Credits
Credits
Senior Writer: Allison Eck
Senior Digital Producer: Ari
Daniel
Director of Photography: Arlo Perez
Deputy
Executive Producer: Julia Cort
Production Assistance: Tim
De Chant, Nafisa Syed, Vincent Pham
Animator: Ekin
Akalin
Designers: Amelia Leason and Ken
Kimball
Developers: Hilary Emmons, Tim Kinnel, Carl
Lindberg
Additional Photography: Stephen McCarthy and Rob
Lyall
Associate Researcher: Robin
Kazmier
Producer/writer/director of NOVA Addiction: Sarah
Holt
Scientific Advisor: John Aldis, MD
Digital Managing
Producer: Kristine Allington
Additional Footage:
Shutterstock, Getty, Freesound
Special thanks to everyone in Buffalo
we spoke with.
Watch NOVA's filmAddictionwhere
you'll also find a set of resource links.
© WGBH Educational
Foundation 2018