NYU Meyers's Holly Hagan is applying her experience tracking HIV in cities to a new rural epidemic.
Every day, 115 people in the US die of an opioid overdose—a death toll so high that it’s caused the nation’s overall life expectancy to drop for two years in a row. In 2016, opioids claimed 63,600 American lives, more than died during the HIV/AIDS epidemic’s peak in 1995 and more than the total number of US soldiers killed during the entire Vietnam War. The CDC estimates the economic burden of the epidemic at $78.5 billion per year, and in the states where the death rate is highest—West Virginia, Ohio, New Hampshire, Pennsylvania, and Kentucky—there are tremendous social costs as well, including for the children of drug users, who often end up being raised by other relatives or entering the foster care system.
Drug addiction has often been thought of as a problem primarily affecting inner cities, but the current crisis is most visible in rural communities. So the race is on to adapt strategies that have been effective in curbing drug-related urban death rates to a new landscape.
That’s where researchers like NYU’s Holly Hagan, a co-director of the Center for Drug Use and HIV/HCV Research and professor at the Rory Meyers College of Nursing, come in. Hagan is a nurse and epidemiologist whose research has focused primarily on the infectious disease consequences of substance abuse, and she previously served as principal investigator in New York City on the National HIV Behavioral Surveillance Project. More recently, she was tapped to chair the Executive Steering Committee of the Rural Opioid Initiative, a collaborative project of the CDC, the NIH, the Substance Abuse Mental Health Services Administration, and the Appalachian Regional Commission that funds nine research projects in areas with some of the highest rates of overdose and hepatitis C infection.
We asked Hagan to help separate myth from fact regarding opioid addiction, and to talk about the small things we all could do to help end the epidemic.
How’d we get here? It’s complicated.
What we now call the opioid crisis didn’t appear overnight, and its causes are complex. But Hagan says that most experts date its origins to a change in thinking about pain management that took place during the 1990s. Whereas opioids had previously been used to treat acute, post-operative pain or to help alleviate the suffering of cancer patients at the end of their lives, when there was little risk of addiction, pharmaceutical companies began marketing the drugs to doctors as safe and effective for managing chronic conditions, such as back pain and sports and work injuries, as well.
“There was a concern that there was a lot of untreated pain in this country, which was a legitimate concern,” Hagan explains. “But there was also a lot of deceptive advertising, particularly on the part of a company called Purdue Pharma, that really downplayed the abuse potential and risk of addiction.” One Purdue Pharma ad campaign that used the slogan “I got my life back” featured patients speaking about how the drug Oxycontin—billed as a non-addictive opioid—had helped them alleviate chronic pain. “Many of those people are now dead from overdose,” Hagan says.
Several states—including Alaska, Louisiana, Missouri, New Hampshire, New Jersey, Ohio, Oklahoma, South Carolina and Washington—as well as New York City and other counties and municipalities have filed lawsuits against the company over the past year.
But at the time, the marketing push—which included cherry-picked and often flawed studies that seemed to show a low risk of addiction—was successful, and the number of prescriptions for opioids skyrocketed.
“The pendulum swung toward a very liberal attitude around these drugs. Kids would go to the dentist to have a wisdom tooth removed and they’d come home with a 14- or 28-day prescription, which was way beyond what they needed,” Hagan says. “People with legitimate pain were not adequately monitored and developed dependence on the medication over time, while people who didn’t have pain suddenly had easier access to these drugs.”
When officials finally began to try to limit the number of prescriptions and the drugs became more difficult to get, people who were already addicted—and facing the debilitating effects of withdrawal—were left to seek out illicit sources.
“Now, in much of the country, the opioid epidemic has shifted into a heroin epidemic,” Hagan explains. “That’s a huge concern, because once you start injecting you increase your risk for HIV, hepatitis C, and overdose.”
Rural areas are hit hardest for a variety of reasons—some of them economic.
Many of the communities being studied in the initiative Hagan is overseeing are the same ones that have seen high rates of unemployment and economic depression in recent years—and that’s probably not a coincidence. “In places like Ohio, West Virginia, Kentucky, and Illinois, factories have closed down, coal mines have laid people off, and people don’t have work,” Hagan says. “They don’t have any hope about the future.”
Those feelings of idleness and despair may already be risk factors for drug abuse, but add to that the fact that many people in rural areas are employed in manual labor—where injury risk is high—and you have a recipe for potential addiction.
Isolation, low education levels, poverty, and lack of opportunity—problems often associated with inner cities, Hagan says—are also factors in many of the rural settings she’s studying now.
Childhood trauma is also a strong predictor of future opioid use.
In her recent New York State Department of Health-funded study of 18- to 29-year-old prescription opioid and heroin users in Broome County, New York, Hagan found that half of the 200 participants had been physically, sexually, or emotionally abused when they were children, with 40% of them having experienced neglect. Prescription users were more likely to switch to heroin if others in their social circles were already injecting.
The finding is important given that the stigma around addiction is often an impediment to treatment—so it’s important that those in affected communities, as well as policymakers, understand that drug use is about more than a simple failure of willpower.
“When indicators of household dysfunction are prevalent to such a high degree, it’s hard not to have sympathy for these people and what they experienced as children,” Hagan says.
“Sometimes I do think it touches people when they’re able to put a face on this, and realize it’s not all strangers or boogiemen who snuck into the community somehow. Maybe it’s your child or parent or pastor or high school coach who has a substance abuse problem. It’s heartwarming to see communities come together and try to take care of their own.”
Harm reduction programs such as needle exchanges have a long record of success in cities, but setting them up in rural areas can be slow going.
Thanks to organizations such as the Harm Reduction Coalition, which formed in 1993 at the height of the AIDS crisis, New York City currently has about 15 needle exchanges, which help to reduce HIV and hepatitis C infection rates among injection drug users, along with a host of other neighborhood programs to help people get into treatment. Now the task of researchers like Hagan is to apply what they’ve learned about harm reduction in urban settings to the areas hit hardest by the opioid epidemic today. But there are sometimes obstacles, including in the form of community or political resistance to programs that can be seen as condoning drug use.
In 2015, for example, there was an outbreak of HIV in the small community of Austin, Indiana, where there were an estimated 500 injection drug users living in a town of just 4,200. Over the course of about a year, about 215 contracted HIV. “The outbreak continued for some time before Governor Mike Pence allowed an emergency needle exchange program to be set up,” Hagan says. “It’s almost unbelievable that this could happen in 2015. It was a terrible lesson.”
Other affected communities in poor states with small tax bases may lack the resources to set up such programs, Hagan explains. And then there are sometimes barriers to access that are unique to rural settings. Whereas in a city, drug users might easily be able to walk or take public transit to a storefront needle exchange or methadone clinic, transportation can be more of a challenge in less dense areas. “Maybe they don’t have a car, or they don’t have gas, or they’re waiting to get a ride from a friend,” Hagan says.
The good news is that national attention and resources are now being focused on these local challenges. After the incident in Indiana, Hagan says, the CDC analyzed patterns of hepatitis C infection nationwide to identify 220 counties that could be vulnerable to HIV outbreaks. “It led to some real movement to address harm reduction in areas that have been neglected,” Hagan says.”
Bystanders may have an important role to play—even if it’s just in countering common myths about addiction.
Interested in doing what you can to help? Hagan suggests attending an overdose prevention training, where you’ll learn the signs of an overdose and how to administer the medication naxalone—which reverses the effects of opioids—and turn the person on their side and call 911. “That could save a life,” she says. “You can think of it like your civic duty as a bystander—the same way lots of people learn CPR.”
In addition to advocacy work on the benefits of safe injection and needle exchange programs, Hagan says concerned citizens can also help by gently correcting some misconceptions about such efforts. “There’s no conflict between harm reduction and drug treatment,” she explains. “Every needle exchange program I know of has very strong ties to drug treatment programs, along with systems for referring people and helping them to get on Medicaid, which will help them pay for substance abuse treatment. The goal of harm reduction is to keep them healthy until they’re ready to recover and stop using drugs.”
Finally, Hagan says, it’s helpful to resist the urge to moralize. “You have to remember that the effects of these drugs are so strong, that you don’t need to have a history of abuse and neglect to develop a substance use disorder,” she says. “It can be the result of simply being exposed for a long time, often when the drugs are coming from a doctor. There are cases where parents had no idea their son was still taking Oxycontin for a sports injury, and then one day went in his room and found him dead. How can you blame those parents? They trusted that health care professionals wouldn’t put their child in harm’s way. We have to keep talking to each other about these issues, even when the conversations are difficult.”