Issue 1 is good for Ohio’s health
By Wendy Johnson
Hi Ohio, I miss you. I grew up in Toledo, went to OSU for undergrad and medical school, and took my first job as a young doctor at MetroHealth in Cleveland. I remain a die-hard Cavs fan (even now!) and a piece of my heart will always remain in Ohio. So, imagine my excitement when I heard about Issue 1. My home state could lead the way in addressing the opioid epidemic by implementing the most successful and well-proven intervention to reduce deaths from overdose: shifting the focus from criminalization of drug use to expanding treatment.
I know a lot about treating opioid dependence. Since 2013, I’ve led an effort to offer substance abuse treatment at our large family medicine practice in Santa Fe, New Mexico. The opioid epidemic in Northern New Mexico has been worse for longer than in many other parts of the country. In the 1990s, the two places in the U.S. with the highest rates of heroin use were Rio Arriba County, near Santa Fe, and Baltimore. Today, Rio Arriba’s overdose death rate is more than twice Ohio’s. But unlike Ohio, New Mexico’s rates are leveling off or dropping in many places. The key to our success? Making treatment more accessible to everyone, making the overdose antidote naloxone ubiquitous, and decreasing the criminalization of drugs.
My patients constantly inspire me with their courage, but I hear every day about the barriers they face putting their lives back together. The stigma is intense – sometimes quitting the opioids is the easiest part. Many struggle to find adequate housing for themselves and their children, or to keep a job. One patient finally got a convenience store job. After a few days, her boss told her she was one of the best employees he’s ever had. The next week she was fired because company policy forbade employing anyone with a felony. The boss apologized, but his hands were tied.
Even worse are my patients in recovery, doing well for months, things just starting to go right, when they are picked up on an old warrant and thrown in jail. Even if it’s just a few days or weeks, the treatment interruption puts them through excruciating withdrawal and greatly increases their risk of relapse and overdose upon release. Even short jail sentences or probation can ruin lives and make recovery so much more difficult.
I’ve heard the arguments from judges and prosecutors in Ohio opposed to Issue One. They say that people need the “stick” of incarceration to comply with treatment. They get mad because non-criminal-justice professionals are weighing in on this issue at all. Well, I’m a little peeved that people with no experience treating drug abuse are explaining how recovery works. Their view is contrary to all evidence. Studies show that legal pressure is no better than good access to treatment or prior positive experience with treatment in getting people to stop using and get help. Some studies find jail time is a major factor that impedes recovery.
The most effective treatment available today for opioid dependence is called medication assisted treatment, using medications like Methadone or Suboxone (buprenorphine in its generic form.) We have many decades of experience using these, and evidence shows they effectively treat opioid use disorders 50 to75 percent of the time. These medications lower risk of overdose death tenfold and lead to a tenfold decrease in criminal activity among participants. People in recovery, getting medications to treat their cravings, are able to get jobs and be good parents. They don’t participate in crime to feed their addiction.
Unfortunately, some treatment programs create unnecessary barriers to care and don’t consider the extreme poverty experienced by most people using drugs. Some programs require daily counseling or limit the time patients can be on medication without regard to individual circumstances. Some refuse treatment to those who relapse too much. Relapse is a normal part of recovery. If one of my diabetic patients slips up and has a coke, I don’t deny them their insulin, but the logic is exactly the same in cutting off those with opioid dependence from life-saving medicine. In Ohio, relapse carries the additional risk of incarceration. Many programs don’t offer medication at all, instead demanding that patients abstain from all drug use and participate in counseling only. Although few patients willingly choose this, it carries a higher risk of death and is less effective.
Access to medication assisted treatment with buprenorphine or methadone is severely limited in Ohio. The best way to make treatment more accessible is to offer it as part of primary care. This will take resources for training and case management in clinics across the state. Issue One will provide resources for expanding access to treatment through innovative programs like these.
I’ve seen that even some treatment professionals in Ohio cite the need for a “stick” approach. In a state that still incarcerates so many for drug offenses, I wonder if they see many people without that threat hanging over them, or if their programs are too difficult for people struggling with a mountain of other issues. In Santa Fe, we lower barriers as much as possible. We don’t have rigid counseling requirements (they aren’t proven to help), but 81 percent participate in our support groups. We provide help with transportation, child care or connection to housing. Over the past 5 years, we’ve treated 570 people with a success rate of 56 percent. The average time in treatment is 19 months, and we’ve delivered over 100 babies to moms in recovery.
We have a drug court, but we also have Law Enforcement Assisted Diversion (LEAD) where police can offer treatment instead of arrest. There is no record, not even a misdemeanor. The program has reduced arrests by almost 60 percent in the 20 cities using it. Even though we have LEAD, we don’t see our drug problems getting worse or dealers flooding our city. Our opioid overdose rates have gone down the past couple of years because we started doing what works, treating people who use drugs like human beings with an illness, and offering them treatment instead of jail.
The overwhelming majority of my patients do not come from LEAD or the drug court though. They come because they want to get better, work, take care of their families, and be good parents. Ultimately, people who use drugs are a lot like you and me. Dependence on drugs is a difficult and devastating disease. We are learning every day and treatments are getting more and more effective. We know what works and what doesn’t. Treatment works, incarceration doesn’t.
Almost 5,000 Ohioans died of overdoses last year. The system clearly isn’t working for them. The death rate will continue to rise if Ohio follows the same path.
I tell everyone I meet how great Ohio is! I brag about Cleveland’s West Side Market, Toledo’s Metroparks and Columbus’ Jeni’s Ice Cream (mmm). I’d love to be able to brag about Ohio leading the nation in addressing the opioid epidemic with a smart, evidence-based approach to drug treatment and criminal justice.
C’mon Ohio, do the right thing. Vote YES on ISSUE ONE.
Wendy Johnson, MD MPH is a former Medical Director of the Cleveland Department of Public Health and is currently Medical Director of La Familia Medical Center in Santa Fe, New Mexico.