Can Vermont look for new approaches?

Other countries, like Switzerland and Portugal, have successfully moved away from punitive measures to attack opioid demand. Here, the public approach to the opioid epidemic is slowly homing in on a model that includes treatment, with some promising indicators of success. But one thing is still in the way: stigma.

BRATTLEBORO — Since its official classification as a public health emergency in 2017 by the U.S. Department of Health and Human Services, overall numbers have begun to wane, if only a little.

The wheels are turning, but is it enough?

The question of how best to stem the tide of the substance addiction pandemic is daunting. Other nations, like Switzerland and Portugal, have attempted far more wide-ranging strategies, with evident success.

Might those more-radical steps work in the United States?

Switzerland once had one of the highest rates of opioid abuse in all of Western Europe and ultimately eased restrictions on sale and use of the drugs when law enforcement became overwhelmed in the early 1990s - a measure that initially did little to help the problem at hand.

But by decriminalizing use and sale of opioids in specific parks and other locations, coordinated with a free needle-exchange program, government officials were able to document users and get reliable reads on the depth of the problem.

That data ultimately helped shape the approach Switzerland took to address the problem.

More than 300 publicly funded addiction-support programs emerged there by the end of the 1990s, and a special Federal Commission for Drug Issues was formed. Fourteen individuals - mostly academic experts in the field of narcotic drugs, as opposed to law enforcement - provided advice on public policy decisions regarding the issue.

The benefits were long-awaited, but significant: between 1991 and 2010, overdose deaths were cut in half, with the number of new heroin users decreasing by 80 percent. The rate of of HIV infections also dropped by 65 percent, according to the Stanford Social Innovation Review.

Similarly, according to the American Psychological Association, Portugal was once in the throes of an opioid crisis so severe that its capitol, Lisbon, was popularly known as the “heroin capital of Europe” in the 1990s.

Employing a harm-reduction model in the early 2000s, the Portuguese were able to rein in the crisis through a new series of innovative laws and standard operating procedures to deal with members of their citizenry found to be abusing opioids.

By decriminalizing possession and use of up to “10 days' worth” of narcotics - an amount deemed suitable to assume that the user in question was not dealing - the authorities were able to achieve a paradigm shift in which health interventions, rather than judicial interventions, could be an alternative path awaiting such drug users.

Specifically, they were subject to assessment by a triad - usually a psychologist, a physician, and a social worker - who would then, using collective discretion, allow such individuals to avoid any legal penalty in exchange for their compliance in a drug-treatment process. By completing a six-month program, recovering addicts would have their cases closed.

Although perhaps more conservative than the Swiss approach, Portugal's measures also garnered substantial results, with heroin users in the country decreasing by 75 percent in some 17 years, and injection-related HIV diagnoses dropping by over 90 percent in the same time frame, according to The New York Times.

Can overseas approaches work in Vermont?

Are we employing the right tactics? Should we be emulating these countries known for their success in curbing crises similar to our own?

For those who only examine Windham County's staggering overdose body count - at least 39 have died since the start of 2020, about double the number of deaths here from COVID-19 in the same span - looking to other countries as models for our own way out of the woods is an attractive rabbit hole.

But specialists closer to home do not necessarily think this way.

“I think it's useful when different countries take different approaches,” said Kurt White, the senior director of patient care services at the Brattleboro Retreat.

“We can study what's done to learn what the best solutions might be,” he said. “At the same time, it's very difficult because not every country has the same setup and the same needs.”

White has worked at the Retreat for over 15 years and describes himself as having had a front row seat to the progression of the problem since he started in 2005.

Specifically, he oversees therapists in the hospital's department of inpatient social work and the different outpatient departments. Such work is both challenging and humbling, White said, but enough time in the field will turn you into an expert.

According to White, it is difficult to compare the United States to most other countries - especially the ones famous for kicking their opioid problems - because of several key factors that set this country apart.

“The United States is basically a nearly continent-sized country; it bridges two oceans,” said White. “And it has a very different sort of geography and setup and regional differences and different drug trafficking routes.”

White points out that he has followed the situation in Portugal for years, noting that some very smart people over there have commendably countered their opioid problem.

Still, he believes that specific strategies employed by countries like Switzerland and Portugal, such as decriminalization and safe dispensaries, are unlikely to be politically viable in the United States, and that it is questionable whether we have strong enough evidence to persuade people stateside to move in such directions.

Alternatively, White prefers to view and approach the situation as a manageable problem with a generational shelf life.

“Normally in a drug epidemic, it lasts a certain amount of time, and [we] try to treat the people that have the problem, get them into recovery, make sure treatment is easily available and accessible, and then you work on prevention in the next generation,” White said of the general methodologies being used in Vermont.

Acknowledging that COVID-19 has both exacerbated the opioid crisis and complicated treatment measures, White says that “this isn't really about Covid. The good news is that young people are not starting to try illicit opioids in the same way that they were 10 or 15 years ago.”

Drug use among young people in the state can be measured over time by results from the every-other-year Vermont Youth Risk Behavior Survey, developed by the national Centers for Disease Control and Prevention. New data will reflect the impact of the 2020 COVID-19 pandemic as students are surveyed this fall by the Vermont Department of Health.

As of 2019 - the last time the survey was conducted - opioid use among teenagers had declined significantly compared to 2009.

“Basically, 17 percent in 2009 to 12 percent in 2019,” White elaborated, noting that more vulnerable groups such as students of color and members of the LGBT communities tend be affected the most.

Citing coordination with law enforcement and current practices of making treatment as accessible as possible, White seemed to articulate a general satisfaction with current practices and the trends they appear to be producing.

When asked if there was anything that could be changed to improve the situation, he stated that approaching opioid dependency as a medical issue, rather than a criminal one, would better serve the populace.

Pushing back against the stance that criminalizing things will help the problem - which he dismisses as a fantasy - Kurt White cites the rhetoric of author William L. White (no relation), who emphasizes medical treatment reforms over penal approaches in his 1998 book Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

'A health condition, not a moral failing'

These sentiments were largely echoed by Susan Walker, the executive director of Turning Point, a peer recovery center in Brattleboro for people in or seeking recovery for substance abuse. The center is one of 12 of its kind in Vermont.

“We embrace the idea that substance use disorder is a health condition, not a moral failing,” said Walker, a self-disclosed person in recovery of some 23 years.

She said she has observed positive changes in approach to substance abuse treatment over the course of her own recovery and subsequent involvement in treatment programming.

“There's a lot more options for people over the last couple of decades,” Walker observed. “It has been gradual in some areas, but more and more, we recognize that this is a health issue.”

Walker expressed exasperation about the stigma of addiction.

“If this is a health issue, what's the deal with stigma?” she said. “It gets in the way so much, and stigma is just a form of discrimination or oppression!”

“We could be the change in the world by helping people to become well, because people become well when we don't shun them and when we don't fail them,” Walker added.

Like White, Walker described the opioid crisis as a cycle that can be interrupted.

“If we help [people with substance use problems] find access to the supports they need, then they can become better parents and better employees and better community members,” she said.

Reframing the problem so that it can be thought of as more of a health condition than anything else is a key step in the right direction, according to the Turning Point director.

“Part of the message is we don't say, 'I'm an alcoholic,' because that defines the individual as a problem; rather, 'I'm a person in recovery,' said Walker. “And that means that I've achieved wellness.”

In contrast to popular narratives that the United States is mishandling the situation or that resources are sparse (Turning Point is sustained by ample state funding and grants), Walker points to the negative social stigma as the one factor she believes would improve the entire situation if it were to change.

“When we categorize something as a moral failing or a legal problem, we stigmatize people,” Walker said. “And then people don't want to seek help, because it casts them in a very negative light.”

On the other hand, Walker said that Covid caused backsliding across the board, as the support groups she normally runs were derailed by the virus.

“Isolation is the worst thing for people who struggle with substance use,” she said, “[because] connection and community are such an important part of the healing process.”

The pandemic also drove away most of her workers - many of whom were volunteers - which ultimately turned out to be a blessing in disguise, as Turning Point was able to restructure itself to better serve the community.

Walker recounted the experience of saying to herself, “If I'm going to open a recovery center, what should it look like?”

Rebuilding the program from scratch required over a year of hiring to re-attain previous staffing levels, but it has spawned new organizational capacity with a full-time program director, and two volunteer coordinators, among others, all of whom are well trained and with appropriate skill sets. Ironically, Walker said, she sometimes thanks Covid for forcing Turning Point to reinvent itself.

More outreach and collaboration

Like White, Walker credits coordination with law enforcement and noted a positive change in their approach.

This evolution of local law enforcement's approach to a more outreach-based, harm-reduction model took place under previous Police Chief Michael Fitzgerald, according to Walker, and has since grown into a local network of recovery-oriented programs such as Project CARE.

The outreach program aims to connect those suffering from substance abuse and trains police officers to facilitate such connections. This program is spearheaded by Lt. Adam Petlock of the Brattleboro Police Department, who, in a separate interview, offered some more detailed insight into how he and his colleagues are handling opioid troubles on the streets.

“People suffering from mental health issues are referred to HCRS [Health Care & Rehabilitation Services of Vermont],” said Petlock. “We have a social worker on staff that works with us directly here.”

Petlock went on to say that when police encounter a situation that relates to substance use, the person involved is referred to the official Project CARE liaison, Justin Johnsto, who is also affiliated with Turning Point.

According to Petlock, people who are more accurately defined as victims of opioid abuse are treated by law enforcement as having a medical condition that requires immediate attention and intervention, whereas those who have an obvious hand in distribution of drugs are treated as having allegedly violated a law. Officers are trained to use discretion and treat each situation on a case-by-case basis.

Despite years of outreach efforts, Petlock noted that there remains a certain level of distrust for law enforcement when it comes to possession and use. This is especially prevalent in the case of Good Samaritan immunity - a law granting legal immunity to anyone reporting an overdose, which has been in place for some time, but public fear stubbornly remains of legal consequences of sounding a medical emergency.

Although he declined to specify whether obvious dealers protected by the Good Samaritan law would subsequently find themselves on law enforcement's radar, Petlock was adamant that overdose responses by Brattleboro Police Department would be entirely within the context of a public health emergency.

Petlock said that he knew of several instances where distrust in Good Samaritan immunity led to fatal hesitation to call for help in emergency situations. It seems clear that this approach to enforcing the law can potentially save more lives(4).

The experts who spoke to The Commons exhibited professional opinions that a combination of stigma, fear, and shame could potentially be the most prominent factors currently obstructing progress that is already in stride.

Although more resources could help - Walker recently put out a general plea for more beds - according to these experts, our major impediments are sociological in nature.

“Compassion and empathy are just so important for not othering each other,” said Walker. “If we shame people to the fringes, then they don't get help until it becomes really bad.”

“What other health condition requires you to hit rock bottom before you get help?” she said.

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