On the front lines

Opioids, including fentanyl, continue to take lives

Posted Thursday, November 14, 2024 11:33 am

‘Fentanyl took everyone by surprise'

Physician advocates for proven drugs for treatment

Snohomish County leads the state in per capita opioid overdoses, and Everett is ground zero.

That’s where Dr. Tom Robey comes in. He’s an emergency medicine physician at Providence Regional Medical Center Everett and principal investigator for emergency department-based substance use disorder trials. He works closely with local partners, including Swedish Edmonds.

Outside of Providence, you might spot Robey, or his team, on the streets in a white Ford Transit van. Washington Health Care Authority and opioid settlement funds administered through the City of Everett enable him to bring medication to those on the streets using drugs – it’s stuffed with boxes of Narcan, which can counter fentanyl overdoses – while also offering services and treatment options for the unhoused.

The program is called Emergency Mobile Opioid Team Everett (EMOTE), which Robey hopes to expand to other locations. It has two peer counselors with lived experience now in recovery to connect with people struggling with addiction and homelessness. The peers have real-time access to prescribers and other services and can transport clients to detox centers or help with telehealth appointments with local behavioral health agency Conquer Clinics.

Robey, whose calling is providing safety net services in the ER and beyond, notes that addiction has complicated causes that have genetic, physical, social, and economic factors. To him, opioid addiction is a disease affecting the brain and not an isolated fault of character. This has long been the prevailing scientific consensus regarding addiction, but as Jan Hoffman wrote in The New York Times in September, some behavioral scientists now see personal choice and that users must have some fault.

It’s healthy to talk about the causes of addiction, Robey said. “But focusing on culpability distracts from the brokenness of the disease and the way forward out of this epidemic. If we acknowledge it as a medical situation with medication that works, hopefully that can reduce the stigma and the lack of information out there about what’s going on.”

Although the Snohomish Medical Examiner’s Office tracks the number of overdose deaths, Robey said those numbers are a small number of the total. He is encouraged by the latest numbers showing opioid deaths – the majority from fentanyl – while very high, have decreased slightly in 2024 compared to a peak in summer 2023.

“Some of our efforts might be behind that. It might also be that the drug-using population may have more experience about what’s going on, too. Fentanyl took everyone by surprise, just in terms of its lethality and its potency. Now, what I’m really surprised by is fentanyl’s affordability. It is the cheapest deadly drug I think we’ve ever had.”

In addition, the easy flow of fentanyl from Mexican cartels overwhelmed the county in the 2020s, adding to the overdose increase.

Building tolerance

Because of fentanyl’s highly addictive properties, new users may initially feel a jolt of euphoria, but the way the drug interacts with the body over time changes such that people eventually don’t feel high. “They don’t feel that euphoria after they’ve been using for months. What people feel is the lack of withdrawal, and so they’re using it just to get back to that threshold where they can feel normal. It’s not unusual to see folks in the ER using 50 pills a day. They might need some pills just to get to a point where they can interact with people, so they can go get food, so they can arrange their shelter for the night.”

Robey advocates for those addicted. “There’s an element of brokenness in our community and the health-care system at large, and that’s what drives me to do the things that I’m doing. Very few of the people I take care of want to use drugs. It’s just that with fentanyl, it’s so hard.”

Robey is a strong supporter of immediate medication-assisted treatment for those addicted to fentanyl and other opioids, using drugs that work on “reward pathways” that remove withdrawal symptoms without generating euphoria. In addition to connecting patients who come to the ER to treatment programs, he will often begin buprenorphine (sometimes given as brand names Suboxone or Subutex) treatment while a patient is in the ER. Buprenorphine helps treat withdrawal and reduce cravings. Not everyone succeeds with a single medication; methadone and naltrexone are options that work for other patients.

Robey trained as an emergency medicine resident at Yale-New Haven Hospital with Dr. Gail D’Onofrio, known for research in medication-assisted treatment (MAT) introduction in the emergency department.

“Many are now championing increased access to MAT in Snohomish County, and my residency training at Yale helped me see how the ER could be a meaningful part of addiction treatment. We were giving buprenorphine to patients who came in who’d overdosed or who had an opioid-use disorder. We started their treatment in the ER because these are folks who don’t generally seek medical care anywhere else or have been turned away because of stigma. They’ll come to the ER for something else, and if you screen and find out they have an addiction, why not give them medicine for the addiction?”

Sublocade is another form of buprenorphine for treating addiction. It’s an injectable form of buprenorphine that lasts for a month. “It’s amazing, but we’re still battling the government and insurance to get it paid for in the hospital because it’s expensive. Some say that there’s not enough evidence it works. Well, how much evidence do you need? There’s plenty of very good evidence that it works.”

D’Onofrio agrees. “There is no controversy. It is evidence-based practice,” she said, referring to the American College of Emergency Physicians’ consensus report in the Annals of Emergency Medicine. “It is not an option. It is a requirement. Both the emergency department and van community service are good options.”

‘Warm handoff’

In addition to administering medication while a patient is in the ER, Robey supports what he calls the “warm handoff,” which introduces a patient to the next provider in the health-care system. It can emphasize to patients that they’re being cared for and that their life matters, he said. “It’s great to be able to refer patients with next-day appointments to other local providers directly from the ER, like Ideal Option or Conquer Clinics. I believe addiction is an emergency. Most people don’t want to be addicted, and they don’t know how, or they’re not ready to engage in how to treat that addiction.

That’s where having an ER doc or nurse who is willing to have that conversation comes in. All you have to do is be willing to have the conversation: ‘Hey, do you want to talk to me about your addiction? We might have some things that could help here.’”

While Robey helps save lives in the ER and the EMOTE van, those not in the medical profession can do one simple thing to possibly save neighbors from overdosing on fentanyl.

“Narcan is the best way for people to look out for their neighbors. I recommend that people carry it in their car or purse. You’re much more likely to see someone who needs it when you’re out in the community, rather than when you’re in your home. Even I am more likely to use Narcan in the community than in the hospital.”

By Brian Soergel
Edmondseditor@yourbeacon.net

To learn about the stats and locations of drug overdoses in Snohomish County, all you have to do is look at the county’s Opioid Overdose and Prevention Data Dashboard. The Snohomish Health District maintains the dashboard as part of ongoing efforts by the Snohomish County Opioid Response Multi-Agency Coordination Group, a countywide effort to improve outcomes for those who use and abuse drugs. It shows that all opioid-related overdoses have continued to rise since 2017, with easy-to-obtain fentanyl the major culprit. When used properly, the prescription synthetic drug can aid in surgery, long-term pain relief, and end-of-life hospice care. But outside of those uses, the drug – much more potent than heroin – can cause dramatic respiratory depression, leading to death.

According to a report released in March, Snohomish County ranked highest in the state for fentanyl deaths. The Snohomish County Medical Examiner’s Office reported in August that 255 of the 327 overdoses it saw in 2023 involved fentanyl.

Behind all the numbers and dire warnings, of course, are individual stories. A top executive who lost his brother to an overdose. The county sheriff, who says a change in law has led to more arrests. A local caseworker, who saved a life with Narcan, which can reverse an opioid overdose. Two mothers who lost sons to overdoses, who decided to help others gain information and resources. Another woman, who herself faced addiction, now offers hope through her nonprofit. In addition, what steps are local school districts taking?

The life-saver

On her way to pick up some items from Walgreens, Erika Farris spied a group of people hovering over an unconscious woman on the pavement. Farris, a caseworker in Everett working with those struggling with addiction, moved in to take a look.

“I immediately sensed it was an overdose,” she said. Thankfully, she carries Narcan in her car. Farris retrieved the Narcan, sprayed two doses into the woman’s nose, began CPR, and told a bystander to call 911. The woman woke up. “A woman who worked at the Walgreens said she was glad I was there because the store was out of Narcan.” Farris had never had to administer Narcan, but had been trained many times. Although she wasn’t positive the woman was overdosing, she remembered in her training that Narcan can’t harm someone if administered properly. “I think at the moment I didn’t even realize it, but a bystander told me, hey, you just saved this woman’s life. Oh my gosh, it was awesome.”

The schools

The rise of fentanyl has caused school districts to update website policies, invite guest speakers, and – of course – train staff on the proper use of Narcan for a suspected overdose.

Diane Bradford, Mukilteo School District’s director of communications and public relations, said she is not aware of any fentanyl overdoses at the district’s schools. “We have shared information with families in the past from the district,” she said. “Schools also provide information and resources to students and families.” The district’s high school health curriculum does cover preventing and treating substance abuse, but it is more broadly focused than just fentanyl. A few years ago, the Kamiak High School visual communications class made a video that included interviews with parents who had lost children to fentanyl.

“As a precaution, we have expanded Narcan from high schools to all schools – even middle and elementary schools – which is above the state’s requirement to have it in each high school. Since we put those in place two years ago, we are not aware of any usage.”

In 2023, the Edmonds School District invited Snohomish Health District to speak with staff leadership at their respective leadership meetings on drug use in Snohomish County, opioid concerns, and Narcan. “We also had evening sessions for staff and families last fall on the topic, as well,” said Curtis Campbell, ESD communications director. “Our nursing staff completes training for the school administrators and any other designated staff that the administrator identifies on the use of Narcan in schools. We currently have it in all school buildings.”

The district has policies and a procedure related to drug abuse and opioid overdose. It offers online resources to support families and students on the dangers of fentanyl and other drug abuse. This includes the district’s comprehensive safety plan, particularly the preventive measures section. In addition, resources are available on a newly revamped website that the district heavily promotes, Report/Family Support. Campbell said there were two instances of naloxone (Narcan) being administered at schools last year for opioid overdoses, although he noted he did not know the type of opioids those may have resulted from.

Everett Public Schools is also taking steps to address the danger of opioid use – including fentanyl – communications director Harmony Weinberg said. “We understand the importance of addressing the fentanyl and opioid issue and are committed to ensuring the health and safety of our students. In partnership with the Snohomish County Health Department, we have ensured that each of our elementary and middle schools are equipped with at least one dose of Narcan, and our high schools have multiple doses of this life-saving opioid reversal medication.”

In addition, the district has designated responders at its schools trained to distribute or administer opioid reversal medication. “We are also continuing to raise awareness of the dangers of fentanyl through our substance use Intervention specialists, who work closely with students in our high schools,” Weinberg said. “We collaborate regularly with local law enforcement to address prevention efforts, and we remain vigilant and committed to educating our students and staff on this critical issue.”

The sheriff

The Snohomish County Sheriff’s Office was one of the first agencies in the state to train its deputies in administering Narcan. Today, police officers are also trained, including those in Mukilteo, Edmonds, and Mill Creek. “In the early days, we had a network for tracking the uses of fentanyl so we could see where it was around the county,” said Sheriff Susanna Johnson. “I still remember thinking, what is this fentanyl? So yes, even at our jail, deputies carry Narcan on their person.”

When arriving at the jail, officers test inmates to determine what drugs they may have in their systems. The Snohomish County Health Department and the county’s federal partners use the data to gain insight into drug usage trends. “Today, the best way to know what’s going on on the street is seeing what’s coming to the jail. It’s fascinating because we know the diagnostic rate, it’s fascinating because we’re seeing fentanyl drop and methamphetamine increase.”

According to the journal Addiction, fentanyl is indeed increasingly mixed with stimulants like methamphetamine, as well as the sedative xylazine, approved for veterinary use and known by its street name, “tranq.” “People who are trying to stay away from fentanyl will purchase meth, and there’s fentanyl in it as well,” Johnson said. “And that creates that addiction component. Some are just not getting what they’re looking for.”

Johnson points out that it’s not true those taking fentanyl, or any other opioid, are immune from arrest even if seen using it on the streets. She said part of the prior state Supreme Court’s State v. Blake decision ruled that felony drug possession was unconstitutional, citing due process. Last year, however, the Legislature recriminalized drug possession as a misdemeanor but added that diversion services must be offered twice before prosecution.

“When we see people using, we’re making those arrests. In this state, we don’t have possession by consumption. So we would actually have to see you using it and possessing it. So now we’ll make an arrest for that possession that used to be a felony. Now in Washington, it’s a gross misdemeanor. So they’ll be booked, but the very first time they’re charged with that, they’re offered diversion, and the diversion is treatment. But if they decline that, the next time they could be prosecuted.” Like most law enforcement in the county, fentanyl use has only increased the amount of time that police have to deal with drug issues – whether it’s somebody under the influence, assault, or property crime.

“It affects our neighborhood,” Johnson said, “and there is a contributing factor (fentanyl, alcohol, and drugs in general) that makes behavioral health worse.”

The executive

Snohomish County Executive Dave Somers is intimately aware of the dangers of fentanyl. His younger brother, Alan Paulsen, struggled with addiction and contracted HIV and hepatitis. “He wanted to be clean. But the thing with addiction – it never leaves you. It’s every day. When he passed away last year, he had fentanyl in his system.”

Paulsen died from an overdose in March 2023. He struggled through life and turned to drugs to numb his pain, Somers said. “I loved him dearly; we had a good relationship. He was funny, smart, and good with his hands. He called me a few days before he passed. It was my birthday, and he wanted to wish me a happy birthday.”

It can be easy to objectify those who fall under the grip of addiction, Somers said. “You can say these are people who just made bad choices – they just need to clean up. There are bad actors out there, but it’s not that simple. We have to keep our streets safe and the rest of it, but every person is an individual and you have to get to the underlying causes. Many are really good people who are self-medicating for physical pain.”

In 2022, Somers announced that Snohomish County, using ARPA funds, would purchase America’s Best Value Inn in Edmonds and Days Inn in Everett to convert them to time-limited “bridge” housing, including mental health and substance use disorder services. Both needed extensive cleaning due to drug exposure. Somers said they plan to open in 2025.

In April, Somers and Snohomish County awarded $77,800 to 11 organizations providing recovery services for people experiencing opioid use disorder in Snohomish County. Supporting community-based organizations is one of the strategies developed by the Multi-Agency Coordination (MAC) Group. The County is using funding received from the One Washington opioid settlements.

And in July, Somers proposed a public safety sales tax that would add 2 cents per $10 purchase. Among other things, it would help to hire more law enforcement officers to hold cartels, drug dealers, and criminals accountable and establish a secure withdrawal management facility in Snohomish County to provide more capacity for those who need to get clean.

The hope

Although her nonprofit organization is called Hope Soldiers, Lindsey Arrington wants to provide more than that. She wants results.

“One of the things that we do differently is we help people find their identity and purpose in life,” she said. “We help people find freedom from addiction and mental health struggles, and we help them figure out what their purpose is. People are looking for meaning in their lives; we help connect people to opportunities to find that.”

The former executive assistant for the City of Mukilteo has herself struggled with addiction, using pills and heroin. She became homeless at a young age.

After getting clean, she founded Hope Soldiers more than a decade ago. “There were several overdoses that happened at my high school, and nobody was talking about it,” said Arrington, who attended Jackson High School in Mill Creek. “Nobody was doing anything about it. So I started planning an awareness event, and the PTA at Jackson told me that I needed to turn it into a nonprofit. I knew that I wanted the name ‘hope’ in the title. Honestly, I woke up one morning and it just came to me. I wanted there to be some symbolism around the silent battle people face with addiction and mental health.”

When she spoke at local schools in Hope Soldiers’ early days, she focused on opioids such as OxyContin and heroin. These days, it’s fentanyl. “It has a really big hold on people. It’s so cheap.” A recent presentation at Everett Community College, “Facing Fentanyl Together,” focused on the drug.

“We help people find support and services, whether it’s housing, mental health, whatever it is. We provide this helping hand to people and stay with them throughout their entire journey. Most clients we work with have several years of recovery, living a successful life according to what success looks like for them. It’s incredible to be able to give hope to people, that they do have a purpose in life. And that’s what we’re about: giving people hope.”

Hope Soldiers gets most of its funding through merchandise sales and occasional fund-raising. Arrington recently applied for a Snohomish County grant for the first time in 13 years. “I know there is funding,” said Arrington, who has three children, “but it’s more about connecting with people, engaging with them, making sure that they have a person who helps them feel like they’re not alone. And so that’s really what it’s all about.”

The moms

Debbie Warfield and Cathi Lee are connected by their grief. But also by their determination to help others by sharing that grief. Warfield’s son, Spencer, died from an overdose 12 years ago. Lee’s son, Corey, died nine years ago the same way.

So they founded “A Night To Remember, A Time To Act,” bringing community members together around International Overdose Awareness Day each summer. It’s a time to honor the lives lost to overdose, advocate for change, defeat stigmas surrounding addiction, and offer hope and support to the community and those who are struggling. August was its eighth anniversary.

They held the first event at Silver Lake Park in Everett, but have since moved it to the Snohomish County Plaza in Everett.

“There was not a lot of information at the time to help,” Warfield said. “We felt very secluded, shameful. We didn’t know how to help our sons. We went to medical facilities, treatment facilities, and pretty much were always sent home to deal with it. And if our sons continued to use, they would be dead.”

Spencer never had a chance to try any type of treatment before his overdose. “It’s just so sad to think that there was treatment out there, but we weren’t aware of it. He was aware of methadone but felt like it was just trading one drug for another. So he wasn’t interested in trying anything like that. It’s been our goal for the past eight years to shed light on addiction, and that people who are addicted come from loving families. They’re no different than anyone else. This can affect anyone.”

Lee’s son died in 2015 in his college dorm room just before Thanksgiving. “We spent two weeks in a hospital,” she said, “and had to make the horrific decision that no parent ever wants to make. There were a lot of misconceptions and negative stigma around addiction and drug use. Our son was young. He was in high school when he first started using drugs and alcohol; he didn’t fit the stereotype of an addict. We were told he was just having fun. He would get out of it. He was just partying. He was experimenting. We fought his addiction alone. Many of our friends and family never even knew the extent of his addiction until he overdosed.”

Shortly after her son died, Lee met Debbie. “She was doing a forum on opioids with the Snohomish County Health District. I was fresh with my grief, and I remember hearing Debbie’s story about Spencer and literally started bawling. I knew I needed to meet Debbie because her story was almost identical to mine: good kid, good family, same desperate need for resources that just were not available.

“After going to a couple of dinners and lunches and, frankly, having some heated conversations about feeling like it just wasn’t fair that we didn’t have the resources that we desperately needed, we decided that we would start ‘A Night to Remember.’ Partly for healing, at least for me, but mostly so that others don’t have to go through the same grief and heartache and feeling of aloneness and hopelessness that we did.”

The most recent event featured plenty of resources and compassion for those either struggling with addiction or parents and friends who simply wanted more information. “We’ve hosted a lot of programs and speakers over the years,” Lee said at the August event. “My hope is that all of you leave tonight with the support and facts and hope for you and your loved ones navigating addiction and recovery.”