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What’s missing from Philadelphia’s approach to opioid crisis? Experts from outside the city weigh in | Opinion

Experts recommend standardizing care, including the voices of drug users, and more.

Every day Jorge Rosario, 52, cleans the sidewalk along the 2700 block of Kensington Ave., Philadelphia. The city and community are working to bring the opioid crisis under control.
Every day Jorge Rosario, 52, cleans the sidewalk along the 2700 block of Kensington Ave., Philadelphia. The city and community are working to bring the opioid crisis under control.Read moreANTHONY PEZZOTTI / Staff Photographer

In 2018, Philadelphia saw a modest decrease in overdose deaths — from 1,217 in 2017 to 1,116. Unfortunately, the decrease didn’t start a downward trend. Preliminary estimates from the Department of Public Health suggest overdose deaths in 2019 will end up close to the 2018 number.

The Inquirer’s Aubrey Whelan reported last week on efforts in the city to reduce overdose deaths in 2020. These include expanding access to treatment, social services, and naloxone (the opioid “antidote”), continuing the police diversion program in North Philadelphia, creating a opioid pill tracking system, and — depending on court approval — opening a supervised injection site. The list is not exhaustive but gives a good overview of where the city’s focus lies.

While the city is expanding many services, most of these efforts are not new -- and did not significantly reduce overdose deaths in the last two years. The Inquirer’s Abraham Gutman asked experts on addiction and the overdose crisis to review Philadelphia’s efforts and tell us what’s missing.

Responses have been lightly edited for clarity and length.

Include voices of drug users

Philadelphia has laid out some good-sounding plans but is seemingly missing the voice of important experts: people who are actively using. These voices are natural harm reductionists, know what their community needs, and know how the system is failing them. With these voices, strategies would be more inclusive and extensive to reflect the whole crisis and address drug use beyond opioids. Meaningful, sustainable employment opportunities and supportive housing for active users should also be priorities. As a former injection drug user, a father who lost his son to overdose, and now a community specialist in harm reduction, my experience shows how robust peer programs and housing can offer stability and purpose, while at the same time meeting people where they are.

Shantae Owens is a community leader with VOCAL-NY’s User Union.

Standardize care

Treatment should be made available on demand, when people need it. ERs and primary-care settings are beginning to provide treatment. More can be done to support and standardize these efforts. In Baltimore, we emulated the work of Rhode Island to set up “Levels of Care” for every hospital to achieve best practices. Developed with active input from hospitals, the Levels of Care designate hospitals with a score of 3, 2, or 1 (1 being the most comprehensive), depending on whether they meet criteria such as providing treatment to patients with addiction and ensuring physicians are prescribing opioids judiciously.

Leana Wen is an emergency physician and a visiting professor at George Washington University’s Milken Institute School of Public Health. She served as Baltimore’s health commissioner and president/CEO of Planned Parenthood. @DrLeanaWen

» READ MORE: At Penn, people in recovery are helping more patients with addiction enter treatment

Have outsiders assess programs

Well-intentioned people often assume that the more services you provide, the better. But we have experiences all over the country of some services not being implemented well, some being poorly managed, and some not meeting needs. The only way to differentiate those services from effective ones is to have an outside, objective individual or team continually assess how the system is functioning and provide feedback to all care providers.

Keith Humphreys is a professor of psychiatry and behavioral sciences at Stanford University. He previously worked at the White House Office of National Drug Control Policy under Presidents George W. Bush and Barack Obama. @KeithNHumphreys

Increase focus on drugs beyond opioids

I’d love to see cities educating and addressing polysubstance use [the use of more than one drug], not solely focusing on opioids. We know that polysubstance use is the norm and that overdose deaths of stimulants including methamphetamines and cocaine are on the rise. How can we prevent these deaths, and encourage safer use?

We must expand harm-reduction efforts to routinely include safer smoking or snorting kits as well as injecting supplies. Safe consumption spaces should take into account all substances. Cities can support that in both the ways they authorize and zone these spaces. Cities should also promote leadership and employment of people who have used or do use drugs in getting more naloxone and harm-reduction supplies into the hands of those most likely to use them.

Kimberly Sue is the medical director of the Harm Reduction Coalition and author of “Getting Wrecked: Women, Incarceration, and the American Opioid Crisis.” @DrKimSue

» READ MORE: Cocaine and methamphetamine are on the rise in Philly, even as the opioid crisis continues

Expand methadone access

While expanding access to buprenorphine — a medication to treat opioid use disorder that can be prescribed at physicians’ offices — is critical, it should not come at the expense of methadone, the medication with the most evidence of increasing treatment retention and reducing mortality (and drug use, and crime) to date. Federally certified Opioid Treatment Programs — the only settings permitted to prescribe methadone for opioid use disorder — are scarce and tightly regulated, despite strong empirical support for the medication. Leaders would be wise to establish new, patient-centered methadone clinics to meet the needs of the people they serve with as few obstacles and requirements as possible. The lower the threshold to receive care, the more people helped, and the fewer lives lost.

Rachel Winograd is an associate research professor at the Missouri Institute of Mental Health at the University of Missouri St. Louis and a leader of Missouri’s State Opioid Response. @Rayraywino

» READ MORE: Using opioids to treat addiction is considered the gold standard. So why aren’t more doctors prescribing them?

Offer social assistance to move lives forward

Stopping a massive crisis requires more than “picking the right programs.” You have to take them to scale. Look at World War II. We didn’t just “build tanks.” We won by building four times more than the Germans did.

Philadelphia has to flood the zone with naloxone, addiction meds, and social help. For most communities, the toughest challenges are rolling out treatment on a large scale, and [offering] social assistance. I’m worried about that last part because national comparisons demonstrate that it’s tough to rent an apartment in Philadelphia. So once people get into treatment and stop using, they will require a lot of assistance to put their lives back together. It’s the prospect of a better life that helps people move forward.

Stefan Kertesz is a professor in addiction medicine and primary care at the University of Alabama at Birmingham School of Medicine and the Birmingham Veterans Affairs Medical Center. @StefanKertesz