Opioid Crisis: Social Work Solutions

By Alison Laurio

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Donald McDonald started using alcohol, tobacco and other drugs at age 11. After high school, service in the Navy, college and a few years of working, he entered recovery treatment in 2004.

Following treatment, he went back to school, first becoming a drug counselor, then earning an MSW and focusing full time on helping others in recovery. It was, he said, a path to which not everyone has access.

"I've been in sustained recovery for 14 years," McDonald said. "I had access to recovery treatment. I got better and got well. There was no criminal justice, nothing to prevent me from going to grad school and getting a good job. It was privilege and dumb luck."

Many people aren't as lucky. Our country is in a crisis caused by opioids that started in the late 1990s and now is responsible for the deaths of thousands of Americans every year. Social workers are involved in every aspect, from pushing for new policies to dealing with the impact.


Where We Are


"Every day, more than 115 people in the United states die after overdosing on opioids," the CDC states. "The misuse of and addiction to opioids-including prescription pain relievers, heroin and synthetic opioids such as fentanyl-is a serious national crisis that affects public health as well as social and economic welfare."

The agency puts the total "economic burden" of just opioid misuse at $78.5 billion a year, which includes health care, lost productivity, treatment and criminal justice involvement.

"This issue has become a public health crisis with devastating consequences," the CDC states.

On Oct. 24, President Donald Trump signed the SUPPORT for Patients and Communities Act into law. It provides $8 billion in funding for help in four areas, according to National Public Radio: treatment and recovery; prevention; helping law enforcement stop the flow of drugs; and attempting to stop trafficking of fentanyl.

The bill passed both houses of Congress with nearly unanimous support, although many said more funding is needed. Some claimed Trump did not go far enough.

"But even as he vowed to alleviate the scourge of drug addiction and abuse that has swept the country ... Mr. Trump fell short of fulfilling his promise in August to declare "a national emergency" on opioids, which would have prompted the rapid allocation of federal funding to address the issue," the New York Times wrote.

Dr. Andrew Kolodny, co-director of the Opioid Policy Research Collaboration at Brandeis University's Heller School, called Trump's October 2017 announcement of a public health emergency "very disappointing." Without funding for new addiction treatment, he said, declaring a public health emergency isn't enough.

"This is not a plan," Kolodny said. "The administration still has no plan for dealing with opioids."


Persistent Problem


"We saw the role that prescribing was playing," said McDonald, national field director for Faces and Voices of Recovery in Washington, D.C. "That was kind of phase one of the opioid epidemic."

Working in North Carolina at the time, he said, policies were made on prescriptions and information was given to providers, which led to a bit fewer prescriptions and more patient awareness-but soon mortalities began rising again.

"Now the rise in mortalities is due to fentanyl, and another increase factor is an inequity in access to health care," McDonald said.

He said one in seven Americans will experience a substance abuse disorder in their lifetime. It can be anyone at any age in any level of society. But many lack the resources for treatment. A total of 12.2 percent of all adults lack health insurance, an increase of 1.3 percent since the last quarter of 2016, according to the Gallup-Sharecare Well-Being Index.

Over the last few years, Alabama has seen what Dawn A. Ellis-Murray calls a serious increase in opioid abuse.

It's a prevalent problem, she said, particularly in the southeast part of the state.

Ellis-Murray, executive director of NASW-Alabama, said the chapter is working with the FBI to get out the word, and using some of their resources to let people know the implications of the crisis.

While she said it's hard to get a handle on why there is a lot of opioid misuse, the state has a lot of poverty, and opioids "are capable of zoning people out."

"If there is a lack of resources, a lack of socioeconomic capacity and someone gets hooked, they're just in a cycle and it continues," Ellis-Murray said. "From everything we've seen, it's rising. And it's multigenerational, so it's starting to impact our youth."

The schools are not addressing it because it's not in their budgets, she said. "There's a lot of opportunity to have an impact and reverse the cycle we're seeing."

Ellis-Murray said there are things that can be done on the front end, instead of just being reactive. But it will take many partners, holding people accountable, and pushing on legislative budgets.

The CDC National Center for Injury Prevention and Control's Annual Surveillance Report of Drug-Related Risks and Outcomes in 2017 lists information for each state that includes the rates of opioid prescriptions dispensed per 100 people.

In Alabama, 107.2 prescriptions for every 100 people were written-the most of any state. In Connecticut, it was 48 per 100 people; and it was 71.9 in North Carolina. Washington, D.C. had the fewest prescriptions per 100 people, at 28.5, and Southern states generally had many more prescriptions than Northern states.

Ellis-Murray said her chapter's partnership with the FBI includes collaborating on forums that bring together all discipline areas, community-based partners that provide community-level interventions, local law enforcement, and individuals, workers and families.

The forums are open to the community, the panelists are mental health professionals, and panel discussions go well, she said. There also is a prescription crackdown, a database to make sure prescriptions are not duplicates, and the state has launched a task force.

"We'll do anything that has impact potential for social justice and inequity," Ellis-Murray said. "Conversations have started across the state at all levels. People are aware there is a concern. People are aware there is a problem."


Challenges Abound


"The opioid misuse challenge is compounded by low adoption of evidence-based prescribing guidelines, the stigma surrounding substance use, lack of intra-agency collaboration and the economic challenges of developing sustainable services in low-volume environments," said David L. Albright, Hill Crest Foundation Endowed Chair in Mental Health, director of the Office for Military Families and Veterans, and associate professor at the University of Alabama School of Social Work in Tuscaloosa.

"Overdoses in Alabama have climbed 82 percent since 2006," he said. "Substance use really tears at the most vulnerable among us-veterans, those in rural areas, children, those in isolation and people without connections to others."

Opioids bind the body's natural opioid receptors to the reward center in the human brain, diminishing pain and simultaneously producing feelings of relaxation and comfort, Albright said. For those experiencing pain-physical, mental or a combination of the two-the ability to access nearly instant pain relief and emotional comfort are powerful draws.

The use of opioids has killed more Americans than the wars in Iraq, Afghanistan and Vietnam combined, he said.

"Care providers face the challenge of finding the right balance of solving for pain while keeping patients safe," Albright said. "Nearly any veteran who has carried 100-pound packs for hundreds of miles will face some level of chronic neck, back or knee pain. Veterans are twice as likely as non-veterans to die from accidental overdoses of highly addictive painkillers-a rate that reflects high levels of chronic pain among those who have deployed to the wars in Iraq and Afghanistan."

Social workers need improved screening tools and education to understand, identify and treat opioid use disorders appropriately, he said. "They also need more training to recognize the risks and signs associated with opioid use disorders and understand their options for referral to treatment. Training should include compounding social determinants like trauma and related health outcomes like depression and overdose risk."

Shame is both a key component in opioid use disorders and a common part of the veteran experience, he said.

"For military folks, there may be shame that comes from not having served in the way folks expect. Or, perhaps from actually having served in those ways," Albright said. "There's shame about surviving when your friends didn't. Shame about struggling with addiction or substance use after trauma. Shame about the circumstances surrounding trauma."

Many of our veterans carry multilayered invisible wounds, he said. Listening well — giving space, to both shame and pride — can help lift a heavy burden.

"It can allow social workers to connect affected veterans and civilians with the resources they need most-instead of the resources we assume they need," Albright said.

There is a shortage of social workers in addiction treatment and there are funding shortages as well, he said. Financing will be critical to the implementation and sustainability of effective programs.

First, examine community-based organizations as recipients of funding. They are often the entities actually serving veterans and other vulnerable populations. And, rural community-based engagement and partnership strategies are paramount to align expertise and resources. They're the bread and butter of social work, Albright said.

"Second, more support is needed for research and service provision on harm reduction, treatment, and recovery unique to rural communities," he said. "This support will help us develop best practices and disseminate our learnings. Finally,fund social work and social workers."


Prescription Limits


As of July 1, Florida residents with a doctor's pain prescription for opioids had a three-day limit, although in some situations a seven-day supply can be prescribed for acute pain.

There are exceptions-the limits do not apply to medications to treat cancer, terminal conditions, palliative care or serious traumatic injuries.

Florida is not alone. Unlimited access to opioids has been reduced in numerous states as they confront the opioid overdose epidemic. As of October, at least 33 states had enacted legislation related to opioid prescription limits, according to the National Conference of State Legislatures.

Massachusetts led the way early in 2016 when it passed the first law of that type in the nation.

According to NCSL's tracking, 33states had enacted legislation with some type of limit, guidance or requirement related to opioid prescribing by October. Most limit first-time opioid prescriptions to a certain number of days' supply. Seven is most common, but some limits are set at three-, five- or 14-day supplies. Most laws exempt treatment for cancer and palliative care from prescription limits.

A handful of states also set limits specifically for minors,the NCSL states.


Naloxone Saves Lives


Naloxone is a prescription medication that reverses the effects of an opioid overdose. All 50 states allow medical providers to prescribe it to patients at risk of an opioid overdose, according to the Substance Abuse and Mental Health Services Administration, an agency within the Department of Health and Human Services.

All 50 states and the District of Columbia allow providers to write prescriptions the patient can fill at a pharmacy. Third-party prescriptions are permitted in45 states and Washington, D.C., and 49 states and D.C. allow non-patient-specific prescriptions. In 26 states,lay distribution is permitted.

The Network for Public Health Law, on its website, states after "urging" from the U.S. Conference of Mayors, American Medical Association, American Public Health Association and the National Association of Boards of Pharmacy, all states made some changes "in two general varieties." First, some permit Naloxone to be prescribed to people other than the person at risk.

"The second encourages bystanders to become 'Good Samaritans' by summoning emergency responders without fear of arrest or other negative legal consequences."

As of 2014, more than 150,000 laypeople who had Naloxone kits and training to use it reported reversing more than 26,000 overdoses. And the National Bureau of Economic Research found the Naloxone access law is associated with a 9 percent to 11 percent decrease in opioid-related deaths in a state.

By July 2017, all states and D.C. had improved layperson access through legislation, it states.

The Daily Texan, the student newspaper for the University of Texas at Austin, published an article about its social work students holding "Operation Naloxone," their first overdose response training, on Nov. 10, 2017, shortly after President Trump had declared the opioid epidemic a public health emergency on Oct. 25. The university received a state grant for the project.

Funding for Naloxone can be a challenge. Some federal and state grants are available, and many nonprofit organizations provide it to individuals for free.


Roles for Schools


Schools have a role in the opioid problem, as high schools open for kids in recovery and university schools of social work are asked to add coursework covering addiction to their curricula.

There is an increased need for well-prepared social workers to support people struggling with addictions, said Valerie Arendt, NASW-North Carolina's executive director.

"Almost every frontline social worker will engage with a client struggling with substance use disorder over the course of their career," she said. "NASW-NC is working on ensuring that future social workers in North Carolina gain the knowledge to respond to their client needs."

The chapter is working with the North Carolina Schools of Social Work and the North Carolina Department of Health and Human Services to ensure future generations of social workers receive a strong foundation in preventing substance misuse, identifying substance use disorders and referring individuals to appropriate treatment and recovery support services, Arendt said.

Also in North Carolina, others are stepping up to help youth in recovery by opening high schools for them, McDonald said.

The Emerald School of Excellence is set to open in Charlotte in August, and Wake Monarch Academy will open in the Raleigh area in 2020, he said.

It started because of a movie. A group in Charlotte saw "Generation Found," a film about a recovery high school in Houston, Texas, McDonald said. "A recovery high school is where all of the students are on a pathway to substance-use disorder recovery. We're seeing a big move for recovery support services."

McDonald is hopeful the SUPPORT for Patients and Communities Act can help build up support for people in recovery with things like better access to transportation and eliminating barriers to their success, like expunging criminal histories.

"That could lead to the support people need to get better and well, to find housing and jobs," he said. "When you can build support in the community and remove obstacles to enhanced wellness, that's a prescription for success."


Right for the Task


"Our nation's social workers are on the front lines of this fight," Albright said. "They are being required to think more creatively than ever before about how to serve the vulnerable by providing care for the total person with limited resources."

They also work well in collaboration with broad-based coalitions.

"Our members are working with law enforcement, physicians and pharmacists, in office-based opioid treatment programs and in health care settings to educate and advocate for expanded treatment access and recovery support," Arendt said. "Our members can't fight this epidemic alone. NASW-NC is committed to being part of the solution."

As are the chapters in many other states across the country.

"We're going to bring more attention to this," Ellis-Murray said. "We're going to shine a light on it."


Resources


Substance use really tears at the most vulnerable among us-veterans, those in rural areas, children, those in isolation and people without connections to others.

Unlimited access to opioids has been reduced in numerous states as they confront the opioid overdose epidemic.

The Beginning

Pharmaceutical companies in the late 1990s told medical providers their prescription opioid pain relievers would not make patients addicted, and health care providers started prescribing them at greater rates, the National Institutes of Health's National Institute on Drug Abuse states in its Opioid Overdose Crisis report revised in March 2018. What followed was "widespread diversionand misuse of these medications before it became clear these medications could indeed be highly addictive."

Toll Rises

Opioid overdose rates started increasing, and in 2015, more than 22,000 Americans died from overdoses of drugs-including prescription opioids, heroin and fentanyl, a powerful synthetic opioid. An estimated 2 million Americans suffered from opioid use disorders, and 591,000 suffered from a heroin use disorder (not mutually exclusive).

Between 1999 and 2016, more than 630,000 people died from a drug overdose in the United States, according to the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control's 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes.

It breaks down fatalities into what it calls three waves during that time period. In the 1990s, "dramatic increases" in opioids prescribed for chronic pain drove the deaths.

"In 2010, rapid increases in overdose deaths involving heroin marked the second wave of opioid overdose deaths," the report states. "The third wave began in 2013, when overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl, began to increase significantly."