According to the Oregon Health Authority, an average of five people in Oregon die each week from opioid overdoses. And in just a one-year period, from October 2020 to October 2021, drug overdoses in Oregon increased by more than 40 percent. Driving this surge is fentanyl, a synthetic opioid up to 50 times more powerful than heroin. Criminal drug networks are mass producing counterfeit pills made to resemble oxycodone and other prescription painkillers that contain potentially lethal amounts of fentanyl, according to law enforcement. Joining us is Todd Korthuis, a professor of medicine and public health and the chief of addiction medicine at Oregon Health & Science University, who says fentanyl is fueling a public health crisis in the state.
Note: The following transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Oregonians are dying every day from unintentional opioid overdoses. And the number is rising. Overdoses increased by more than 40% between 2020 and 2021. This surge is being driven by fentanyl, a synthetic opioid up to 50 times more powerful than heroin. Criminal drug networks are mass producing counterfeit pills with fentanyl. It’s also being put in heroin and in meth. All of this adds up to a public health crisis that could get worse. That’s according to Todd Korthuis, a professor of medicine and public health and the chief of addiction medicine at OHSU. He joins us now with more. Welcome to Think Out Loud.
Todd Korthuis: Thanks so much, Dave. Happy to be here.
Miller: I checked back through our files and we first talked about fentanyl overdoses in Oregon on Think Out Loud back in June of 2017. So almost five years ago. So it’s not like fentanyl is completely new in Oregon. So what is new? What has changed more recently?
Korthuis: That’s a great question, Dave. The thing that’s changed is the extent of fentanyl in the drug supply and the change in how it’s ended up in Oregon. Back in 2017 and through 2019, fentanyl, and I’m talking here specifically about illicitly, illegally manufactured fentanyl, which was mixed into things like heroin and cocaine and methamphetamine and ecstasy. And now what’s happening is it’s been illegally manufactured as counterfeit pain pills and Xanax pills and other things that people think they’re taking, but in reality they’re exposing themselves to fentanyl.
Miller: How significant is that? I mean, what does that mean in practice?
Korthuis: Well, fentanyl is 50 to 100 times more powerful than morphine or heroin and consequently it’s much more addictive, it carries a much greater risk of overdose, especially for young people and people who don’t have experience using opioids previously.
Miller: Yesterday, some members of our team spent much of a day in various parts of Portland talking to people who are experiencing homelessness. This is for our show that’s going to be on in a couple of weeks. We saw multiple people shooting up in broad daylight on the sidewalk. When you see that now, is it your assumption that it’s heroin cut with fentanyl?
Korthuis: If someone’s using drugs in Oregon right now, they should assume that what they’re using has a good chance of being contaminated with fentanyl. Gradually, what’s happening is fentanyl press tabs have the potential to replace heroin altogether. And the drug supply is the opioid of choice.
Miller: Who are the populations in Oregon right now who are most at risk for harm from fentanyl?
Korthuis: There are two populations that are high risk for fentanyl. The first are people with limited exposure to any sorts of opioids before and those are our kids and young people and young adults who really haven’t had much experience with things like heroin or oxycodone and they perhaps think, they’re taking something from a friend or at a party and it turns out to be fentanyl which is much more unforgiving than previous pills have been in the past. And it can result in an unintentional overdose and death on the first exposure. The second group of people at risk are people who regularly use drugs and fentanyl can easily be mixed in with whatever they think they’re using so that even for stimulants like methamphetamine, or MDMA, fentanyl can contaminate these and cause an overdose.
Miller: If folks listening now are struggling with substance abuse, they can call the Oregon alcohol and drug helpline. The number is 1 (800) 923-4357. We’re talking right now with Todd Korthuis, he is the chief of addiction medicine at OHSU. So let’s start first here in terms of treatment with the status quo, which is that Oregon has consistently been among the worst states in the country in terms of access to treatment. Why is that?
Korthuis: That’s a great question. I think the place to start is that treatment works and that’s the exciting, good news. We have medications including methadone and buprenorphine that are quite effective at really turning things around for people who are regularly using things like fentanyl and other opioids. The challenge has been a couple of things. First of all, reaching the people who are at highest risk, not all of whom live around treatment programs. And the second is making sure that we have treatment beds available for people with complex drug issues. A lot of opioid treatment can be treated by primary care doctors and nurse practitioners and physician assistants in the healthcare system. But a lot of people who use drugs are using multiple drugs in Oregon, including methamphetamine and have quite complex social issues and challenges that I believe sometimes would benefit from a residential treatment facility or intensive outpatient therapy. And those resources are much more limited, particularly in our rural counties.
Miller: In 2020 Oregon voters passed measure 110 decriminalizing the possession of hard drugs like methamphetamine and heroin for personal consumption, also allocating money for drug treatment and recovery services. What do you think so far, one year on, about the implementation of measure 110?
Korthuis: I think the effectiveness of measure 110 remains to be seen. I think it’s encouraging and exciting that Oregonians as usual are thinking outside of the box and there’s room for tremendous innovation there that has a lot of potential. Many of the innovations are just getting off the ground. The initial burn applications were submitted just a few months ago and it’ll be a while before they’re fully implemented. So I think it’s too early to say what the effect of Measure 110 is.
Miller: Well, I mean, it seems like you’re being careful, which I understand, there’s a lot at stake here, but what is the best case scenario for where we could go from here as a state in terms of implementing this, legalizing these drugs or decriminalizing them? What’s the best case scenario and what’s the worst case scenario?
Korthuis: I think the best case scenario is, first of all, we’re sending fewer people to jail and prison whose only offense is substance use. And that’s a good thing. It’s good for the people who have been caught up in drug use. It’s good for society as well in terms of redirecting resources to treatment where it’s needed most. That being said, I think there’s an opportunity here to build better bridges to treatment and harm reduction services and decriminalizing drug use is not in itself an incentive for people to engage in treatment. So I, as Measure 110 continues to be rolled out, my hope is that we build in strong pathways for people to engage in treatment.
Miller: What’s the definition of success in opioid addiction treatment? I mean, I guess what I’m wondering is, is success that simply somebody did not die from an overdose or is it that they can hold down a job and actually be a present and effective parent to their kids? How do you think about success?
Korthuis: That’s an excellent question and I think it’s one that’s been a bit overlooked. Success, as in the past, has been really defined as abstinence. And while that is clearly a worthy goal that we promote, it’s not the whole story. In my mind, real success is reengaging in the life activities that bring me, and family, and relationships, addressing those legal issues and financial issues that had been on the back burner during active use. And ultimately being in a place of recovery overall in life. Abstinence may be one piece of that, but it’s not the whole story.
Miller: Given that fentanyl is, as you noted, 50 times stronger or 100 times stronger than morphine or heroin. Clearly, that’s led to a big increase in overdose deaths. Has it also made treatment itself more difficult?
Korthuis: It has in some ways. But here again, I want to emphasize that treatment works and we have three FDA approved medications that can be used for treatment of opioid use disorder. They’re widely available in Oregon and if people are struggling with any sort of opioid use problem, including fentanyl, I would just encourage them to really reach out and seek out treatment.
Miller: One of your recommendations is for the state to develop a rapid response reporting system for both fatal and for non-fatal overdoses. What is this and why would it be helpful?
Korthuis: We’re continuously playing catch up when it comes to public health approaches with drug use and overdose. And one of the reasons for that is a lack of timely data that can be acted on. Right now, both fatal overdoses and non-fatal overdoses take at least nine months for the data to percolate back to public health and there’ll be an option to do something about that. I would like to see something along the lines of what’s being done, for example, in King County or in San Francisco Public Health Department where overdoses are reported real time, or nearly real time from medical examiner offices, in the case of fatal overdose or from emergency departments and 911 calls, in the case of non fatal overdoses and that information is quickly synthesized at a public health level, and then rather than just having the data in a data set somewhere, rapidly transmitted in an actionable way to our community based organizations, especially our peer organizations who are so skilled at outreach and being sensitive to families, and people who have been affected by drug use, specifically with real time interventions.
Miller: I’m still trying to understand how interventions, what would those real time interventions be because I mean, as you’ve been describing it, these pills are everywhere. We can assume, you can assume that, you’re saying that drug users of meth or heroin should be assuming already that fentanyl is in their drugs. So what other actionable information could a public health authority actually glean and tell residents that we don’t already basically know?
Korthuis: Well, first of all, I think a lot of people at risk don’t know and that’s particularly important for our young people and in schools. So for example, if there’s two or three non-fatal overdoses among people under the age of 20 in a community, rather than wait for this situation to worsen, I could envision some sort of response where outreach workers would go and do local community based education, where local community based organizations could approach schools or in the case of a fatal overdose, provide support for families who are are struggling.
Miller: In other words, a couple of weeks ago, for example, we talked about the terrible situation at McDaniel High School where two young students died within about 24 hours of each other. You’re saying what we should be doing is when there are non-fatal overdoses, we should have the same kind of public health outreach to young people or to the community to say, watch out for this, we almost lost people. But you want to see that messaging happening much more?
Korthuis: That’s exactly right. And I think it’s important to remember the biggest risk factor for dying of an overdose is first having a non-fatal overdose and there’s an opportunity for a real intervention.
Miller: Todd Korthuis, thanks very much for joining us.
Korthuis: Thanks so much, Dave.
Miller: Todd Korthuis is a professor of medicine and public health, the chief of addiction medicine at Oregon Health and Science University.
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