“I wish I could sleep longer but if I don’t get there by 5, a bunch of people will line up ahead of me and I won’t get out of the place for more than an hour,” says Tom Skidmore as he wraps a hooded sweatshirt around his lean torso and dashes out the door. It’s 4:30 a.m. and Skidmore is heading to the River Shore Comprehensive Treatment Center.
Located in a small Riverwest industrial park, River Shore is one of three state-certified facilities within Milwaukee County that treats people addicted to heroin and other opioids. At the center, Skidmore (not his real name) will touch base with his counselor and receive a dose plus a two-week take-home supply of methadone.
Methadone is one of several medication-assisted treatment (MAT) drugs used to treat opioid addiction. It works by blocking the craving for and euphoric effects of opioids, including heroin, oxycodone, hydrocodone, morphine, codeine and fentanyl. Many addicts and their families as well as treatment providers welcome MAT, describing it as a much-needed tool in the fight against an ever-escalating disease. From coast to coast and nearly everywhere in between, opioid addiction is claiming lives, devastating families and weakening communities. It is often labeled an epidemic, a word choice backed up by Milwaukee and national statistics.
Milwaukee Health Officials Tackle the Epidemic
According to a March 2016 report prepared by then Milwaukee Common Council President Michael J. Murphy’s office, in Milwaukee County:
Deaths due to heroin increased 495% between 2005 and 2014.
Between 2012 and 2015, 888 residents died from opiate overdoses, twice the number that died from traffic accidents during the same period.
Milwaukee County Medical Examiner’s Office data show that:
343 Milwaukee County residents died from drug-related deaths in 2016, a 48% increase from 2015 when 231 people died from the same cause.
Heroin caused 148 of the 2016 deaths, an increase of 35% from 2015. Fentanyl caused 97 of the deaths, a 223% increase from 2015.
The Centers for Disease Control and Prevention reports that in 2015:
52,404 Americans died from drug overdoses, an 11% increase from 2014. Of these deaths, 33,091 were opiate-related. By contrast, fewer Americans (37,757) died from car crashes or gun deaths (36,252) the same year.
In Milwaukee, a newly formed City-County Heroin, Opioid, and Cocaine Task Force, led by city of Milwaukee Health Commissioner Bevan Baker, is tackling the epidemic head on. Task force member Ald. Michael J. Murphy sponsored the legislation creating the task force, which includes representatives from the Milwaukee Common Council; the Milwaukee County Department of Health and Human Services, Behavioral Health Division, Office of Emergency Management, and Medical Examiner’s Office; the Medical College of Wisconsin; and the city of St. Francis.
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The task force has set several goals and increasing MAT capacity is one of them. The reason? MAT works and capacity within Milwaukee County falls well below the current need.
According to the National Institute of Drug Addiction (NIDA), for people with opioid use disorder, medication-assisted treatment, when paired with counseling and other support services, is highly effective. Selahattin Kurter, a Milwaukee-area psychiatrist who treats opiate addicts with buprenorphine (another form of MAT) says “Medication-assisted treatment stops addiction in its tracks. It allows us [treatment providers] to engage the whole person, psychologically and physically.” Without such treatment, engagement is difficult. “Heroin,” he says, “hijacks the brain.”
Most researchers and treatment providers agree that opioid addiction is a brain disease, not a lapse of willpower or a moral failing. The brain-disease model is not necessarily well understood by the public, however, in part because it’s complex. According to the NIDA, over time repeated opioid use changes the brain’s reward and executive functioning centers, and these changes can prove difficult to reverse.
Mary-Anne Kowol, a physician and assistant professor at the Medical College of Wisconsin, also treats patients with addictions. She says prolonged use of heroin and other opioids changes the prefrontal cortex, the part of the brain that regulates stress levels. Opioids reduce stress and the brain retains a memory of what that stress reduction, or relief, feels like. When people experience high levels of stress, anxiety or emotional pain, those memories can trigger relapse; they remember that using allows them to escape the anxiety and pain, Kowol explained.
Heroin and other opiates also produce profound degrees of tolerance and physical dependence. Tolerance means more and more of a drug is needed to produce the same effect; physical dependence means the body has acclimated to the presence of the drug. When it’s withdrawn the user experiences extreme discomfort including such symptoms as restlessness, muscle and bone pain, insomnia, diarrhea and vomiting. While withdrawal symptoms usually subside in about a week, they can continue for months.
When the Drug is More Important than Life
Over prolonged opiate use, tolerance plus physical dependence often adds up to addiction, a chronic relapsing disorder of varying degrees characterized, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), “by a strong desire for opioids, inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, and spending a great deal of time to obtain and use opioids.” As Kurter puts it, “Users begin to believe that the drug is more important than anything, than job, family and even themselves.”
“At my worst,” Skidmore recalls, “I did care that my addiction had led to losses—I had given up my job, lost some friends and damaged the trust of my family—but I still didn’t want to stop. And to think that it all started with prescription painkillers.”
Skidmore’s story, which isn’t a lot different than that of many other heroin addicts, attests to the insidious power of prescription painkillers. In fact, according to SAMHSA, in 2014 an estimated 1.9 million people had an opioid use disorder related to their use.
In his early 20s, following major surgery associated with a chronic illness, Skidmore took physician-prescribed oxycontin—a powerful opioid—to relieve pain. The pain subsided, his prescription ran out and he recovered. But the surgery didn’t work as intended. Throughout the next 10 years he underwent more surgeries—about 20 in total—and, again, doctors prescribed opioids to relieve post-surgical pain. When the pain pills ran out, Skidmore wanted more. “I wasn’t experiencing ongoing physical pain,” he says, “but the pills eased my stress, all my worries about trying to cope with a chronic illness.” When he couldn’t get the pills from doctors, Skidmore bought them on the street. After a while, the usual dose stopped working. “I was building up a tolerance,” Skidmore says, “so I started buying more…and more. Before long, I couldn’t afford them. Using heroin—a less expensive substitute—was almost preordained.” Within two years of starting heroin use Skidmore had developed a serious, life-threatening addiction for which he eventually sought—and stuck with—MAT.
Opponents of MAT argue that it simply replaces one addiction with another and, therefore, isn’t effective. The evidence indicates otherwise, and the real problem, according to John Schneider, Chief Medical Officer for the Milwaukee County Behavioral Health Division, is a lack of MAT.
The Treatment Gap
Using epidemiological data, Schneider estimates there are roughly 45,000 Milwaukee County residents addicted to opioids. The SAMHSA website lists 117 physicians in Milwaukee County authorized to treat opioid dependency with buprenorphine on an outpatient basis. “Not all of the 45,000 have serious disorders or even want treatment,” says Schneider, “but if you estimate that half, or 22,500 people, need and want treatment, and divide that number among the 117 physicians, each physician should be treating 192 patients.” Physicians are allowed by law to treat only 30 patients annually unless they apply for and receive a special waiver to treat up to 100. According to Schneider, many physicians don’t apply for the waivers. On average if each physician were treating 45 patients annually, the gap would be huge: 22,500 people with opioid use disorders minus a treatment capacity of 5,265 means 17,235 people are left with no access to physician-provided treatment. In light of the acute need, Schneider hopes more physicians will seek the waivers.
The state-certified treatment centers close some of that gap and state Sen. Lena C. Taylor (D-Milwaukee) appreciates that the Wisconsin Assembly recently passed a bill creating two to three additional centers in underserved areas of Wisconsin. Gov. Scott Walker has signaled he will sign the bill as well as several others addressing Wisconsin’s opioid epidemic. One potential problem noted by Taylor is that there’s no guarantee any of the new centers will be placed in Milwaukee. “The [addiction] issue has been in our community for a very long time and you can’t say you’re legitimately addressing it if you leave out a place that has been pushing for help and assistance for some time,” she said.
Taylor also criticized Walker for refusing to accept a federally funded expansion of the state’s Medicaid program. “Other states—including red states—have found that expansion has played a key part in helping them fight this [opioid] epidemic,” she said.
Wisconsin recently received $7.6 million in federal dollars to help fight the epidemic, and in response to the state’s request for proposals, the city of Milwaukee is submitting one. The dollars can be used for a variety of purposes including treatment expansion. Task force chair Baker said he hopes the state will consider “demographics on the ground” as funding decisions are made.
By February 2018, task force members will have formulated evidence-based recommendations for addressing the epidemic and will forward them to the Milwaukee Common Council for consideration and possible action. As task force members continue their deliberations, they will welcome and consider community input. A meeting for that sole purpose will likely be scheduled this summer. The next regular task force meeting will take place Friday, June 16, 2017 at 9 a.m., room 301B Milwaukee City Hall, where members of the public can make brief comments following the conclusion of task force business.
