Thank you for the opportunity to talk to you all. I very much appreciate coming after my colleague in British Columbia, because many of the points she brought up are things I wanted to talk about as well.
To start off, one of the really important things to understand is the importance of data. We've been tracking overdose deaths for quite a while. In Oregon we started to see an increase specifically in methamphetamine deaths from the mid-1990s up until 2000. At that time most of our methamphetamine was “cooked”—that's the expression—made locally from Sudafed or pseudoephedrine. At that time there were a number of laws put into place, including that you needed to have identification for purchasing Sudafed, and then it became prescription only. We thus saw a decrease in the local production of methamphetamine, which was good news, and we started to see less use.
At the same time, though, the methamphetamine then began being imported from elsewhere, and while that helped with the meth lab issues around environmental contamination and injuries, our meth use then started to increase again.
I'm an epidemiologist by training and so I like to categorize things and count, but I would also agree with my colleague that many of these deaths involve multi-substance use. If you take apart methamphetamine and then only look at opioids, or if you look at the contamination, or even alcohol.... Many people are polysubstance users and may have chronic medical conditions on top of that. It's therefore a bit hard to say how much of this problem is specific to one drug or specific to another. Again, I would echo the concern about doing a multi-substance use approach.
One thing we've seen in Oregon that I think is a little different from what has been seen in Canada is that we have had in the United States a problem specifically related to prescription opioid overdose. We started to see it in the late 1990s and up through 2000. We were really seeing a lot of opioids being prescribed for pain. People would take them and would die of overdoses from prescription opioids or would use prescription opioids in conjunction with illicit opioids.
Of course, there has been a huge effort in the United States to tamp down on prescribing of opioids for chronic pain, and so we started to see a decline in prescription opioid overdose deaths. At the same time, we are very concerned about heroin deaths and then fentanyl, as another opioid.
In Oregon, for better or worse, we have not yet seen the same problems with fentanyl overdose that other parts of the country have seen. Nonetheless, we've had a very sharp increase in fentanyl deaths from 2016 to now. Again, the incidence is still much lower than that from prescription opioids.
A minute ago I said I don't like to categorize, and I'm categorizing here. It's important to understand that these are polysubstances. There are multiple drugs on board, and because of that we have to see where the interventions can occur.
Looking, then, at what's happening within the health care system, no one is prescribing methamphetamine per se, but they are prescribing stimulant drugs such as Ritalin or Adderall. for ADHD—attention deficit disorder—just as an example. We're saying that we don't want those to be prescribed. At the same time, we're very concerned about illicit use. We need to work within the health care system to look at what's being prescribed.
Many of these patients are chronic pain patients, and so, if we're taking away opioids or other drugs, we want to be sure that people have access to non-pharmaceutical therapies. That's another thing we've been working very hard on within our health care system: to look at what other things might address a person's chronic pain.
We need to support people with medication-assisted treatment and get them into care. Of course, specifically for opioids, naloxone is a rescue drug. We still need to get people into care, even if they're rescued from an overdose. That's a sort of ”death prevention”, if you will, and we really want the upstream substance use prevention to happen as well.
Then getting the data to inform policies is really important.
We in Oregon are quite happy, if you will, that we've started to see progress in prescription opioid overdose deaths. Specifically, we've seen prescribing of opioids decline, and that's by 28% over the last couple of years.
That is going, then, in the right direction: we're working with health care systems. The challenge with some of these other drugs is that while you can look at what's happening in the health care system, you really need to look at what's happening with illicit substances as well.
One of the things we did in Oregon was to pull together a group of stakeholders to help advise us around the prescription opioid overdose and then to broaden that to look at all illicit substances. We called it our opioid initiative, and that included many of the health care partners from the health care system, the prescribers themselves. It also included substance use disorder treatment folks, as well as law enforcement.
It is important to make sure that law enforcement is on board both in terms of the immediate response and when we're talking about the criminal justice system. At least here in the United States, it's important that people who are on treatment for substance use disorder continue that, that if they're in and out of jail or prison, there isn't a sudden stop. We know that one of the riskiest times is when people who are in prison for drug-related causes, or even if it's for something else but they are addicted—and they may get off it while in prison—get discharged or released from prison. They're back into the same environment they left and at an extremely high risk of overdose.
One of the things my colleague from British Columbia did not mention is that many of these people who are using drugs, and who might be injection drug users, are at risk for a number of other adverse health outcomes. We look at overdose, but among people who inject drugs, Oregon has one of the highest rates of death from hepatitis C anywhere in the United States. We see HIV infection related to that. Hospital stays for heart, bone, blood, soft tissue and skin infections are all much higher among injection drug users.
The altered mental status that happens increases the risk of injury. We're of course concerned about pregnant women who use this and what the effects might be on their unborn babies. Recently there have been studies to show that opioids and many of these drugs increase the risk of suicide. We call this a “syndemic”, a number of these various epidemics that are combined. Really, we can't do HIV prevention without considering how many people are injection drug users, and of those, how many are using opioids or methamphetamine and so on.
The challenge for this, of course, is to look at what we would consider the upstream factors: Why are people using these drugs? I mentioned physical pain, but we know a number of these people also have adverse childhood experiences. They're experiencing social problems as well. They have unemployment. They might have problems with housing. We need to look at those upstream factors where we can be more supportive in terms of the community and how these folks can have a number of issues dealt with before they start using drugs. Again, if they have been using drugs, they need not only to be in recovery specifically from substance use disorder but making sure that they have access to housing and employment and those kinds of things so that they aren't necessarily tempted to be using drugs again.
As just very few examples of some of the activities we're doing, we've developed some specific provider training related to a psychosocial approach to pain. That is again broader than just the physical, but understanding that some of the psychological input, how people react to pain, is just as important.
I mentioned the prescribing guidelines. We've done those for opioids. We're considering doing them now for tapering off opioids. That's an important thing. Again, that's done in a compassionate manner.
Another example is harm reduction, things such as needle exchange. I know in British Columbia there are both needle exchanges and supervised injection sites. That's something that's a little controversial in the United States. It's the idea that you want people off drugs, but if people are going to use them, really this harm reduction and death prevention is extremely important.
I mentioned naloxone distribution. One of the other things we're doing is looking at who shows up in an emergency department with an overdose, and can we do a fast track to treatment? Can we have peer support to get those folks into treatment? It's a teachable moment.