CUNY Scholars Take on the Opioid Epidemic

Researchers at CUNY SPH say the struggle is less about developing evidence-based interventions to treat and prevent opioid use disorder (OUD) than about overcoming existing attitudinal and structural roadblocks to interventions, which have only been exacerbated by the coronavirus pandemic. To address this, they are studying the factors that are both driving the opioid epidemic and obstructing the adoption of proven interventions.

Trajectory of use

Alice first used opioid painkillers when she was 17. By age 18, she was crushing and snorting them.

“It was very simple,” the 25-year-old New York City woman recalled. “My stepfather had a massive back surgery but didn’t like the way the painkillers made him feel, so they were just sitting around the house. He would fill his prescription and never take them and never seemed to notice they were missing. I just kind of … I was taking them.”

Among the millions of Americans living with OUD are many young adults who came of age at the dawn of the opioid epidemic, when doctors, encouraged by the effectiveness and over-abundance of prescription opioids (POs), began prescribing them liberally, said Research Associate Professor Honoria Guarino, PhD.

“Doctors were prescribing opioids for any kind of pain. They thought they were doing a good thing,” Guarino said.

Ubiquitous in American households, opioids like OxyContin became easily accessible to teenagers, who used them recreationally, like marijuana, believing they were safe.

“The fact that the drugs were medically prescribed lent an aura of safety,” Guarino said. “Young people started taking them without realizing they could become opioid dependent.”

By studying OUD in New York City teens and young adults, Guarino and Associate Professor Pedro Mateu-Gelabert, PhD, also with the Institute for Implementation Science in Population Health (ISPH), have made important observations about the triggers and patterns of PO use. Many of these observations come from their recent study of 539 prescription opioid or heroin users ages 18 to 29. The study found that in this population, opioid use typically began at approximately age 17, largely with immediate-release oxycodone (OxyContin) or hydrocodone, which users obtained for free from friends, relatives or household sources, and took socially, mostly to get high, satisfy curiosity, and party. At around age 19, on average, participants transitioned from POs to sniffing heroin, which they began injecting at around age 20. Less than a year after starting heroin, participants experienced their first overdoses; more than half reported multiple overdoses.

An earlier study that Guarino and Mateu-Gelabert conducted of 46 New York City young adult PO users ages 18 to 32 produced similar findings: most notably, a pattern of escalating PO use and dependence over time, eventually leading to injecting them or heroin, or both.

Multiplying risks

Research shows that young, newly-initiated injection drug users have particularly high rates of injection-related risk behaviors, such as sharing syringes and other drug paraphernalia, which expose them, in turn, to even more risks—especially health risks—including hepatitis C virus (HCV).

HCV is an insidious, highly transmissible virus that spreads most commonly via shared needles or other drug injecting equipment and causes a liver infection that can become chronic and serious, leading to long-term health problems, or death. The Centers for Disease Control estimates that 2.4 million people in the United States are living with chronic HCV infection. A 2017 multi-state review of global HCV infection prevalence among injection drug users estimated that 38–68 percent are living with the virus. There is no HCV vaccine, although there are oral antiviral treatments that cure the virus within two to three months. Nevertheless, the best way to prevent HCV infection is to avoid injecting drugs and related behaviors.

Most participants in Mateu-Gelabert and Guarino’s study, 30 percent of whom had HCV, did not know this. They reported having very little knowledge of the HCV and HIV-infection risks associated with sharing syringes and other injection paraphernalia. What’s more, they reported having little access to information on the harm reduction practices—including education about the dangers of street drugs, the risk of HCV, and the likelihood of unprotected sex with casual strangers—that can both prevent users from progressing to injecting drugs, and arm those who are already injecting with information about avoiding HCV transmission and accessing treatment. Many of the users in Mateu-Gelabert and Guarino’s research had never accessed harm reduction or treatment; those who did had generally already begun injecting drugs.

The risk of being middle class

In both studies, most participants were white and had middle class backgrounds; nearly 40 percent of participants in the first study had had some college. Besides being unacquainted with the dangers of street drug culture, most perceived themselves differently than ‘junkies’ who injected drugs.

“There is a misperception that people with OUD are homeless or uneducated, but OUD is very much a white middle class phenomenon,” Mateu-Gelabert said. “These were young people who had greater access to recreational drugs, became dependent, and needed to take them every day. Being smart or in college or from a middle class family is not protection from the opioid epidemic. In fact, it’s more of a risk factor.”

Indeed, being middle class was something of a barrier that discouraged users’ knowledge or use of harm reduction services, since the “junkie” behavior of injecting heroin was something they insisted they would never do. Yet, as government tried to stem the rising epidemic by tightening the flow of POs, and as the cost of usage climbed to $80–$100 per day, most did.

“Heroin was such a cheaper alternative,” said 25–year-old Alice, whose loss of a friend to a heroin overdose steered her away from the drug.

In 2015, the Centers for Disease Control cited PO misuse as the single greatest risk factor for heroin use.

“A heroin bag in New York City has been $10 forever, which is relatively cheap compared to OxyContin, which is $1/per milligram pill,” Mateu-Gelabert said. Thus, just one 60mg. or 80mg. pill, popular dosages among PO users, costs $60–$80. “If you have to take that pill everyday several times, it is hard to manage.”

Because participants in Mateu-Gelabert and Guarino’s research did not consider themselves “junkies” and generally could afford sterile syringes, they eschewed harm reduction services, like needle exchange programs.

“They bought syringes in pharmacies, which was a problem because they were less likely to learn about the risk of sharing injection paraphernalia other than syringes,” Mateu-Gelabert said. Many did not know where to find such services or that they even existed, he added.

Largely unaware of the risks of acquiring HIV or HCV, many participants also “selectively shared” syringes and other injection paraphernalia with friends and sexual partners who they saw as ‘trustworthy’ because they shared similar class backgrounds.

One such user, Linda, a White 31-year-old female, said, “People think, ‘I know this person from high school, his mom and dad are middle class, wealthy.’ They think that that person will not get Hep C or HIV, and say, ‘Do you have anything? No, then it’s okay for us to share needles.’ ”

But, as Mateu-Gelabert noted, “Unlike HIV, HCV does not require shared needles to pass from one user to another. Merely sharing paraphernalia like the mixing dish, cookers, filters, or drug-diluting water is enough to transmit the virus.” Diseases like HIV or HCV were not the only risks that participants faced. Substance use also increased their risk for unprotected sex and sexual violence. According to the 2017 National Youth Risk Behavior Survey, 29 percent of high school students are currently sexually active, and of these, 19 percent drank alcohol or used drugs before last sexual intercourse. Although alcohol is the most common substance associated with sexual violence, studies show that drugs also play a role. In one such study, college students reported that nearly half of rape cases involved drugs or alcohol. In a separate study, participants who had experienced sexual violence in the past year were five times more likely than those who had not to misuse POs during this same time frame.

Yet, the young people who Mateu-Gelabert and Guarino studied did not anticipate HCV infection or sexual violence, let alone opioid dependency. For them, opioid use was a rite of passage, part of their transition to adulthood, and sometimes, a coping mechanism.

“Early or emerging adulthood is a very stressful time in our culture,” Guarino explained. “Opioids are great in the short term for treating stress and alleviating social anxiety.”

In the past year, Mateu-Gelabert and Guarino have observed an overall increase in serious depression, anxiety, tension and other pandemic-related phenomenon in their study populations during the current health crisis. They have yet to gather such data as it pertains specifically to young people’s emotional health and drug injection behavior, although national data show that in the general population there has been a significant increase in the number of opioid overdoses and overdoses to which emergency personnel have responded, as well as significant increases in alcohol and drug use. Other pandemic-related changes that have been widely reported include difficulties in accessing drug treatment (especially forms such as individual or group counseling) due to social distancing mandates, and high rates of relapse.

Meanwhile, Mateu-Gelabert and Guarino have heard young adult injection drug users credit opioids for enhancing their sexual pleasure or performance. Others said that POs gave them “the most incredible feeling ever,” or made them feel “the best I’ve ever felt in my life,” or “how I was meant to feel,” Guarino recounted.

“You can see how irresistible this must be. Why wouldn’t everyone want it? They had no knowledge that the pharmacology of OxyContin is the same as heroin.”

By her junior year of college, Alice was using opioids regularly. She managed, on her own, to gradually reduce her opioid use and finish college but continued using them sporadically, while three of her roommates transitioned to heroin.

Stigma and shame as barriers to treatment

In addition to critical education gaps about OUD, the risk of addiction and HCV, and the value of harm reduction programs for minimizing such risks, Mateu-Gelabert and Guarino’s research identified stigma and shame as pernicious barriers to OUD treatment.

“Drug use is not only illegal but also heavily moralized in this country,” Guarino said. “People who become dependent on opioids are seen as morally weak. They may feel the need to hide it from almost everyone they know except a small number of peers.”

Stigma and shame colored every aspect of users’ lives, often driving them to hide their behavior or worse, away from harm reduction services or treatment, Mateu-Gelabert said.

The ‘NIMBY’—not in my backyard—effect

The stigma of OUD sometimes blinded parents as well as communities to children’s opioid problems, presenting another barrier to treatment.

“The insistence that ‘this is not happening in my community’ gets in the way of individual treatment, treatment in communities, and treatment funding,” Mateu-Gelabert said. Methadone programs or ‘substitution therapies’ that wean individuals away from opioids are a case in point.

“Often times people think of substitution therapy as switching from one bad drug to the other,” Mateu-Gelabert said. Moreover, a community may fear that a methadone clinic will undermine its safety.

“Everywhere you have a methadone clinic you have a community board that wants to get rid of that methadone clinic,” Guarino said.

What people don’t realize, Mateu-Gelabert said, is that methadone and other evidence-based medication-assisted therapies have proven positive outcomes. “It is important for parents to know that medication-assisted treatments with bupenorphrine, methadone and naloxone (for reversing overdoses) are science-based and the best treatments we have.”

Barriers to medication-assisted treatment also exist in the health care system, which traditionally has required candidates to have long histories of drug dependence, and doctors to have a specific Federal waiver—which requires them to take an 8-hour certification course—to prescribe buprenorphine for opioid dependence. Only specially licensed Opioid Treatment Programs (OTPs) or clinics, whose operations are heavily regulated at the Federal and state levels, can prescribe methadone for opioid dependence.

Yet, certification does not ensure that patients will seek a doctor’s help.

“Many young people see their pediatrician until age 18,” Mateu-Gelabert said. “It may be hard to talk about their struggle with OxyContin with the doctor they’ve seen since they were eight years old.”

Jails, where people with OUD often land, have their own treatment barriers. “We need to tell district attorneys that we don’t want our young people incarcerated, and that it’s not okay to incarcerate someone without treatment. We need to divert them to drug treatment instead,” Mateu-Gelabert said. More importantly, he stressed, “We need to find young people before they develop full-blown drug dependency or transition to injection drug use.”

The pandemic—and resulting social distancing protocols—have presented additional barriers, such as needle exchange programs’ reduced operating hours and limited open door policy.

“We have seen a significant increase in the number of people who are re-using their own syringes, due to fewer numbers who can go to needle exchange programs,” Mateu-Gelabert said.

Individuals have also experienced trouble accessing methadone clinics, which have been trying to address the problem by distributing greater supplies of methadone for at-home use—with mixed results—he noted.

Need for education & prevention

Guarino and Mateu-Gelabert’s research underscores the need to target communities, and especially vulnerable pre-adolescents, with culturally tailored, non-judgmental, and discreetly accessible education about OUD and stigmatization, addiction, and related health risks such as overdose and HCV, as well as harm-reduction and treatment options.

One such intervention, Staying Safe, is designed to reach young adult injection drug users who are neither HIV- nor HCV-positive. In its first phase, Staying Safe features four small, consecutive in-person groups in which users can learn basic harm reduction skills for protecting themselves against HIV, HCV, and overdose.

“We focus on avoiding crisis points that make young people more likely to share drug paraphernalia, and how to avoid these situations or at least be armed with sterile equipment,” Guarino said.

The second phase of Staying Safe involves a mobile phone app designed to remind users about safety strategies, and to help them track their injection frequency, episodes of sharing syringes and secondary equipment, and of withdrawal, which increases risk of overdose.

A separate mobile intervention called OnTrack, which Guarino is developing with Michele Acosta, PhD, Principal Investigator at the National Development and Research Institutes, Inc., in New York City, provides facts about opioids, overdosing, tracking and usage, as well as cognitive and dialectical behavior therapy skills for avoiding or controlling opioid use.

“The goal is to help young people not become injectors,” Guarino said. “They can use relaxation, breathing, or visualization to help them find other ways to manage intense emotions that don’t involve opioid use.”

Additionally, Mateu-Gelabert and Kristen Marks, MD, an associate professor of medicine in the Division of Infectious Diseases at Weill Cornell Medicine, are conducting an Accessible Care Study, which will compare the effectiveness of accessible care with usual care in linking and engaging opioid users in drug treatment, and retaining them in care for hepatitis C, addiction, and HIV prevention. Unlike usual care, accessible care occurs in community-based locations where people can access services without fear of shame or stigma. It does not require users to control their drug intake and provides counseling only if requested.

Unexpectedly, Mateu-Gelabert and Kristen Marks have noticed a significant reduction in drug use among participants in the Accessible Care intervention, which they attribute to its positive impact.

“I’m happy to see that participants have been able to face Covid-19 without resorting to more drug use or drug injection,” Mateu-Gelabert said, adding that drug use in the control group remained the same. To adapt to social distancing guidelines, the researchers make all follow-up interviews virtual, he added.

HEALing Communities

Evidence-based interventions for opioid prevention and treatment exist, yet governments, communities, and health care are failing to work together to implement them on a population-wide basis, said Professor Terry TK Huang, PhD, MPH, MBA, chair of the Department of Health Policy and Management and director of the Center for Systems and Community Design. Huang is leading CUNY’s participation as technical advisor to the National Institutes of Health’s HEALing Communities Study, a multi-site trial designed to help communities overcome roadblocks to evidence-based OUD interventions across multiple settings including health care, behavioral health, and justice. The Columbia University School of Social Work is the study’s principal investigator for HEALing Communities in New York State, while CUNY, New York University, Cornell University, and Montefiore Medical Center/Albert Einstein College of Medicine, and the University of Miami are co-investigators.

The study will target 67 communities in four states—New York, Kentucky, Ohio, and Massachusetts—with high rates of opioid overdose deaths, including 16 counties in New York State. Under Huang’s direction, CUNY will use systems science to help communities create a coordinated, data-driven approach to planning and implementing a continuum of evidence-based interventions, including school and community based primary prevention, prescription drug monitoring programs, medication-assisted treatment, behavioral therapies, and recovery support services, while identifying roadblocks to implementing these interventions.

“The opioid problem is a complex issue, but the real problem is not clinical in nature,” said Huang, the CUNY site principle investigator. “The real problem is the human-organizational implementation challenges regarding adoption, reach, and coordination that are so difficult because they’re dependent on humans thinking outside the box, communicating with each other, and doing things that traditionally have not been part of their job description.”

Jails have not been charged with dispensing opioid medication, for example, even though OUD affects many incarcerated people.

“To get such a sector to adopt new practices and see themselves as being part of a broader public health system is a real implementation challenge,” Huang said. HEALing Communities will convene jails, community advisory boards, hospitals, health care providers, emergency medicine departments, and other stakeholders to forge the united front that an effective response requires, he explained. “If a whole society of stakeholders coordinates and collaborates, then they can more effectively drive down the rates of opioid overdose and death.”

Supporting stakeholders in this joint effort calls for data. As part of its contribution to HEALing Communities, CUNY, under the guidance of Distinguished Professor Denis Nash, PhD, MPH, executive director of the ISPH, is developing an opioid overdose ‘dashboard’ that will compile existing data from numerous sources to display a real-time picture of each community’s opioid crisis.

“The study is about communities,” Nash said. “It takes a wide, inclusive view, recognizing that OUD, opioid overdose and related deaths are not something hospitals or governments will solve on their own. They are multi-sectorial and need the engagement of many different people and entities that are in positions to support the effort.”

Conclusion

So far, the opioid epidemic has presented an uphill challenge, overshadowing the strides of progressive cities like New York in promoting and providing access to harm reduction and treatment through methadone programs, free needle exchanges, and the distribution of naloxone, Mateu-Gelabert said. Still, he and his CUNY colleagues agree, much work remains to be done.

“We need to do better to reach young people and provide them with knowledge about HIV and HCV injection risk, and access to medication-assisted therapy,” he said.

The stigma and shame of OUD, and the misperception that drug dependency happens everywhere but home must also end, Guarino added.

“Most drug users are not publicly visible, they’re actively hiding because they have to,” she said. “People don’t realize that drug users are right next to them all the time. They’re not the other. They’re us.”

Accepting this truth might be the first step toward overcoming barriers to proven interventions.

“Increasing the availability of drug treatment is within our power,” Mateu-Gelabert said. “The cost is relatively low. The cost of not acting is way too high because it’s killing our young people.”