Abstract
The scope of the current opioid epidemic striking the nation is likely far greater than most of us can appreciate. As the health officer for Snohomish County, Washington, I am required to take actions to maintain the health of the residents in the jurisdiction I serve. Part of this work involves controlling and preventing the spread of diseases in the county, including opioid use disorder. I joined the Snohomish Health District as health officer in August 2017 and knew from the beginning that substance abuse would be one of my highest priorities. Public health is an essential partner in the ongoing efforts to address this crisis, but government agencies, community partners, and individuals working together with a shared purpose are also important in addressing the epidemic.
Background
In the summer of 2017, the Snohomish Health District embarked on a first-of-its-kind data collection effort with local partners to capture a snapshot of the opioid epidemic. At the request of the district, representatives from across the county voluntarily collected real-time data on opioid overdose cases encountered during 1 week. The result: 37 overdoses in Snohomish County in 7 days; 3 were fatal.
This point-in-time study was repeated in July 2018. 1 There were 57 overdoses, representing a nearly 55% increase in just 1 year; 2 people died. Reasons for the increase may include an increasing trend in the use of heroin in place of prescription opioids. As healthcare providers became more cautious about prescribing opioids, people with an opioid use disorder turned to heroin. In 2017, the number of overdose deaths in the county associated with heroin overtook those associated with prescription opioids for the first time. In addition, deaths linked to fentanyl—the synthetic opioid that is far more lethal than heroin—more than doubled in just a few years. We have also recently seen a surge in counterfeit “Perc 30” pills laced with fentanyl being sold on the street. At least 1 overdose reported during the 7-day count in 2018 can be attributed to these Perc 30s.
There are a few other items of note during the 2018 count. The oldest person who overdosed was 73 years old; the youngest was 17. We partnered with the Snohomish County sheriff's office to collect other opioid-related data. During that 7-day period, roughly 32% of new bookings at the jail were people under opioid withdrawal watches.
The opioid epidemic is not unique to Snohomish County, but what sets this community apart is the cross-agency collaboration and the decision by multiple key players, including the health district, to treat this as an emergency.
Public Health in a Multi-agency Response
On November 8, 2017, the Board of Health of the Snohomish Health District joined the Snohomish county executive, the sheriff, and the county council in adopting a joint resolution committing to a focused and collaborative approach to addressing the opioid epidemic. 2 The county's Department of Emergency Management was partially activated to support this effort.
While there was no formal declaration of emergency in the county, like a natural disaster would require, a partial activation provides staff resources for better coordination and communication across agencies and service providers. On November 29, 2018, the county executive signed a directive that extended the activation of the emergency management system to address the opioid crisis through November 30, 2019. The partner agencies also formed an Opioid Response Multi-agency Coordination (MAC) Group. The group's goals are to:
Reduce opioid misuse and abuse Lessen the availability of opioids Reduce criminal activity associated with opioids Use data to detect, monitor, evaluate, and respond Reduce collateral damage to communities Provide information about the response in a timely and coordinated manner Ensure the availability of resources that efficiently and effectively support response efforts
The Snohomish Health District's role includes providing data and analysis of the epidemic's scope and impact, along with evidence-based approaches to addressing opioid use disorder. The MAC Group completed 63% of its objectives in its first year. Accomplishments include:
Reducing the wait time for toxicology results in fatal overdoses from an average of 15 weeks to 12 days Increasing the number of medical providers who prescribe buprenorphine/naloxone for medication-assisted treatment by 10% Distributing more than 1,000 needle clean-up kits to community members and 500 lock bags designed to keep prescriptions secure Training older adults at 14 senior centers on the appropriate use, storage, and disposal of prescription opioids
The Health District also produced an online resource that is used by the MAC Group: www.snohomishoverdoseprevention.com. The website is designed as a 1-stop clearinghouse for information on prevention, treatment, and support of people with opioid use disorder.
Challenge 1: A Comprehensive Look at the Crisis
The health district required current data on the epidemic, but the fact that opioid use disorder was not a notifiable disease presented a problem. Until 2017, the only primary data the district collected was the number of associated deaths reported by the county medical examiner. At the time, it could take up to 18 months to complete investigations, largely because of the time needed to receive results of drug testing. Moreover, deaths associated with opioid misuse leveled off, likely due to efforts to increase the availability of naloxone, making opioid-associated deaths a poor indicator of the severity of the epidemic in the county. As a result, we pursued multiple avenues to build a more robust data pipeline.
Through the MAC Group, hospitals, law enforcement, fire departments, emergency medical services, the syringe exchange, and other partners determined what was available that could be accessed and developed new methods of data collection. The key was to directly access the data in real-time. The data sources include first responder calls, emergency department visits, hospitalizations for overdoses, neonatal abstinence syndrome cases, and the incidence of hepatitis C, each of which was already used and had an electronic database that was accessible online. Even the syndromic surveillance system, BioSense, was tapped to better define the epidemic. More importantly, these sources could be accessed under a health officer's authority and provide more robust data sooner than making overdoses a notifiable disease—an idea that was not popular with community partners because it would be an unfunded initiative.
Another important data source was focus groups, with stakeholders including pharmacists, dentists, veterinarians, pain specialists, and other allied health professionals, to get their unique perspectives on the epidemic. With that information, we developed interventions such as grand rounds with providers to raise awareness of the status of the epidemic in the county and local continuing education courses on opioid prescribing.
Challenge 2: Heroin and Fentanyl
Considerable effort to reduce the number, strength, and duration of opioid prescriptions being given has had a clear impact. However, for those already struggling with substance use disorder, tighter guidelines on prescriptions may push them to try heroin. At least 61% of individuals recorded in the 2018 7-day count overdosed on heroin. 1 Fentanyl, which is up to 100 times more lethal than prescription opioids or heroin, is another growing concern.
Efforts to address this concern showcase the strength of a multi-agency approach. We have partnered with a local hospital for a Centers for Disease Control and Prevention (CDC)–funded program to not only collect data on overdose and withdrawal patients in the emergency department, but also to perform some limited outreach to those patients. Through that partnership, we were alerted to several patients who overdosed and who commented that the pills they overdosed on tasted different. Law enforcement also shared information from the streets about counterfeit Perc 30s laced with fentanyl, and we contacted the local syringe exchange. A client at the AIDS Outreach Project/Snohomish County Syringe Exchange provided a photograph of the counterfeit pills, which we shared with the drug task force and used to create a warning postcard that was shared with hospitals, first responders, syringe exchange clients, and the public. The exchange has also been distributing personal-use fentanyl drug tests provided by the Washington State Department of Health, so clients could check their own supply.
Challenge 3: Public Perception
Since opioid use disorder is 100% preventable, there is a common misconception that it is a choice and that abstinence is simply a matter of willpower. However, there is considerable medical research showing that chronic misuse of opioids leads to pathophysiologic changes in brain chemistry, proving it is indeed a disease. Like other chronic diseases such as diabetes and asthma, it may require long-term medical treatment, and relapses could occur, but attentive nonjudgmental support may hasten return to treatment.
Opioid use disorder is also 100% treatable. Since some people have different requirements to maintain their recovery, we are working to ensure that a full complement of treatment options is available to improve chances of sustained recovery: the full receptor agonists (eg, methadone), the partial receptor agonist (eg, buprenorphine), and the antagonists (eg, extended-release naltrexone). Medication-assisted treatment also has the added benefit of harm reduction, including a 50% reduction in opioid-related deaths.
However, it can be difficult to gain support for key intervention and treatment programs when the public does not view opioid use disorder as a treatable disease. People with an opioid use disorder are also less likely to reach out to get any kind of treatment due to the same perceptions among health professionals.
Challenge 4: Other Health Issues
This epidemic has led to an increase in secondary impacts in local communities. The number of hepatitis C cases countywide in 2017 was almost 53% higher than in 2016. In fact, nationally, the primary demographic for newly identified hepatitis C infections has shifted from people born before 1965 to people using syringes to inject illicit drugs.
People engaging in drug use also have a higher risk of acquiring sexually transmitted infections as a result of exchanging sex for drugs. Therefore, the epidemic may also partially account for rising rates of syphilis, gonorrhea, chlamydia, and other similarly transmitted diseases. Snohomish County had 101.1 gonorrhea infections per 100,000 residents in 2017, which is nearly 3 times the 2008 rate. Syphilis rates have also increased in the county and in Washington State, from 1.1 cases per 100,000 people in 2008 to 6.6 cases per 100,000 in 2017. 3
Finally, used needles create an environmental hazard when not disposed of properly. The syringe exchange located in Everett collected about 2.2 million used syringes in 2017, an all-time high. Since a local ordinance prohibits the discarding of syringes in the trash, the health district began providing needle clean-up kits free of charge in 2017. Through MAC Group efforts, the program was expanded, in partnership with the county's solid waste program, in sponsoring a number of free drop-off locations for the sharps containers when full. Partnering with local law enforcement, community groups have organized mass safe collection days in problem areas. Further, law enforcement, code enforcement, and the health district have teamed up to deal with the rising problem of nuisance properties that have become havens for illicit drugs.
Next Steps
The collaborative efforts in Snohomish County are bringing together agencies and partners to make data collection more automated. The health district and other agencies are working to build a pipeline so data monitoring will be simpler and more reliable, while also developing a public facing dashboard.
Health district staff will continue to analyze information from different angles to develop evidence-based prevention and intervention strategies while also implementing methods to monitor the impact of new programs. One innovative approach is to use the capture-recapture method to estimate the disease burden of the epidemic in the county so that we can determine where the gaps in treatment and supportive services are. 4 Another is expanding drug testing at the medical examiner's office beyond cases where evidence of drug use is found at the scene to other situations like car accidents to further explore how opioids are affecting the community.
The goal is to develop a more comprehensive look at the opioid epidemic, rather than a 1-week snapshot. Our collective work must provide treatment and resource pathways that can meet people where they are, when they are ready.
Footnotes
Acknowledgments
Some of the work highlighted in this article was supported by the Grant or Cooperative Agreement Number, U17 CE002734, funded by the Centers for Disease Control and Prevention. The article's contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the US Department of Health and Human Services.