Ongoing support is crucial for counties tackling overdose rates

Key Takeaways

Opioid overdose rates are largely declining across the United States, but there’s been a rise in polysubstance overdoses — meaning more people are dying of using fentanyl mixed with other drugs, such as cocaine or methamphetamine, according to Dr. Joshua Sharfstein, Johns Hopkins Bloomberg School of Public Health’s vice dean for public health practice and community engagement. 

Polysubstance use creates a larger problem for treatment, because unlike fentanyl and opioids, there’s no medication approved to treat stimulant use, Sharfstein told county commissioners May 1 at the NACo Large Urban County Caucus fly-in in Washington, D.C.

The best treatment option for polysubstance use is “contingency management,” which is when someone with substance use disorder is given an incentive, such as money, for not using, Sharfstein said. While it might be a controversial approach, data shows that it’s effective and that a punitive approach to recovery programs — for example, someone getting kicked out of a program for missing a session or failing a drug test — only leads to more overdoses, Sharfstein said. 

Reduce stigma

Working to reduce the stigma of substance use and recovery is important, particularly when it comes to housing, he added. 

“Housing that says you can’t be on buprenorphine or methadone, that’s housing that’s making people choose between their recovery and having a roof over their heads,” Sharfstein said. “Transportation to be able to get around, particularly to treatment and to jobs, and employment, becomes extremely important for recovering, but treatment should continue well into recovery.”

Xylazine, a sedative commonly referred to as “tranq,” doesn’t cause overdoses, but people who use it often get wounds, which can cause serious health complications, so counties should build a wound program and teach those who manage drug treatment programs how to recognize and treat the wounds, in addition to offering xylazine test strips to users, Sharfstein said. 

Mobile nursing teams are also an effective way for counties to address xylazine wounds, according to Daniel Cao, healthcare policy aide for Santa Clara County, Calif. Supervisor Otto Lee. 

Secretary Akbar Hossain, who works in the Office of Policy and Planning for the Commonwealth of Pennsylvania, echoed that sentiment, adding that Pennsylvania works with the University of Pennsylvania to send out nursing teams across areas with high rates of substance use.

Wayne County, Mich. partnered with Wayne State University to launch its Narcan vending machines. While counties are at the center of overdose prevention efforts, they often operate with limited and narrowly scoped federal resources, needing long term, flexible funding, not just short-term pilots. Urban counties in particular need policies that reflect their complexity.

Target demographics

While overdoses are down overall, Native Americans and older Black men are experiencing rising rates of overdose deaths, according to Jenna Bluestein, Pew Charitable Trusts’ behavioral health officer of government relations. In Maryland, the highest rates are among young Hispanic men, according to Michael Coury, director of communications for the Maryland Office of Overdose Response. 

Counties should assess data on the demographic groups that are disproportionately suffering the effects of substance use and overdoses and perform outreach and incentivize treatment among that population, according to Sharfstein. 

“When you take a step back, you see a lot of the services, particularly the outreach services, are not necessarily directed to places where that population may be,” Sharfstein said. “Senior centers may not have an outreach worker who’s doing harm reduction or helping to get people to treatment or talking to people, so this is a population that if you haven’t looked at it in your jurisdiction, it’s probably a very good idea to do that and to really kick the tires of the response to see whether it’s reaching.”

Most people with substance use disorder still have trouble accessing treatment, Sharfstein said. In Pennsylvania, Black people are 2.5 times more likely than white people to die by overdose, but less than 13% of Black people with substance use disorder have any evidence of treatment, according to Hossain, who added that the state is working to provide more access to treatment in vulnerable communities. 

In some cases, state law precludes recovery programs from utilizing methadone, but maximizing access to the drug is “extraordinarily effective” in supporting recovery, according to Sharfstein. 

“The rules for how methadone programs work have totally changed at the federal level, and that provides a lot more flexibility,” Sharfstein said. “You can pretty much wipe out the lines that are outside methadone programs if they are embracing the new rules, if they’re doing more take-home therapy, if they’re using telemedicine, there are a whole bunch of things that can be done.”

During this presidential administration, there’s a “great opportunity to overlap with treatment,” but harm reduction isn’t going to be “the easiest conversation,” Sharfstein said. 

Sharfstein encouraged county emergency services to start treatment immediately in overdose response, administering Naloxone (also known as Narcan) and following it up with a high dose of buprenorphine (which is used to treat opioid use disorder). A study showed there’s a five-fold increase in substance users following up on treatment if they’re administered buprenorphine, he said. 

“Let’s say I’ve overdosed, and I’m then saved by Naloxone,” he said. “I’m thrown into the worst withdrawal right there. I wake up. Everyone’s staring at me. I probably have soiled myself. It’s not a great moment, and all I want is to get rid of that feeling of withdrawal, and I might go out and use right away. If you give buprenorphine, you actually calm that.”

Meet them

The three most effective places to engage people with substance use treatment are in ambulances, hospitals and the justice system, according to Sharfstein. 

“The old way of thinking about drug treatment is that when people are ready, they’ll show up,” he said. “But the new way is to say, ‘Everywhere you can possibly engage someone, you should engage people.’”

Counties should provide quicker treatment in jails and prisons, and offer it to everyone, Sharfstein said. 

“Jails, traditionally in the United States, have been overdose factories,” Sharfstein said. “People withdraw from opioids when they’re in there, they come out, they use drugs again, and they’ve lost their tolerance, and they die. If you can give people treatment, as many people coming through as you can, you are interrupting that … and then if you put resources at the transition from jail out into the community, you’re really using that arrest as an opportunity to help people.”

It’s important for counties to remember that declining overdose rates won’t just continue without sustained investment in treatment and recovery programming, Sharfstein said.

“We’re driving overdose rates down — overdose rates just aren’t falling,” Sharfstein said. “We shouldn’t assume that it’s like the weather, there are things that we’re doing to have that impact.”