Fatal synthetic opioid overdoses are rising in Multnomah County

From 2018 to 2021, fatal overdoses from synthetic opioids – mostly from fentanyl – jumped more than 500% in Multnomah County. County leaders say the increase in overdose deaths comes from a rapid change in the drug supply leaning towards fentanyl. Anthony Jordan is the addictions services manager for the county’s health department. Teresa Everson is the interim health officer. They join us to share more on what overdoses look like in the county and what is being done to address it.

This transcript was created by a computer and edited by a volunteer.

Dave Miller:  From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Overdose deaths from synthetic opioids like fentanyl increased more than fivefold in Multnomah County between 2018 and 2022. Local and national officials say that we are now in the fourth and deadliest wave of a decades-long overdose crisis. Meanwhile, it’s up to the County to promote the public’s physical, mental, and behavioral health. So how is Multnomah County responding to this crisis? Teresa Everson is the interim health officer. Anthony Jordan is the addictions services manager for the Health Department. They both join us now. Welcome to the show.

Teresa Everson:  Thanks for having me, Dave.

Anthony Jordan:  Thank you.

Miller:  Teresa Everson, can you just first give us a sense for the scale of the problem in Multnomah County right now?

Everson:  I will do my best. It’s hard to really capture this for folks who aren’t in the work, as much as we and some of the other community organizations we partner with are. But as you mentioned, we have seen in a short period of time since just before the pandemic, a fivefold increase in opiate related deaths. And for fentanyl specifically in 2022, we’re estimating 209 Multnomah County residents died from overdose deaths that involved fentanyl. And we’re seeing year over year increase.

So we hate, in these post pandemic times, to use words like unprecedented, but we’re really in an unprecedented time with fentanyl. We have decades of experience with other drugs. Most of us can remember our response to heroin, and there’s still folks who use heroin. But fentanyl really is a new beast. It’s much stronger. It’s cheaper, and it’s making this response much more complicated.

Miller:  There’s a lot to dig into there, which we will do in the next 20 minutes. But I’m just curious because the numbers that I mentioned, that fivefold increase in fatal overdoses, those go through 2022. But just last week we talked about overdose calls to 911 in the first six months of this year. They showed a huge spike just in the last few months. I’m wondering if the preliminary numbers that you are seeing are even worse this year than last year?

Everson:  Yeah, that’s an excellent question. So there’s a lot of different ways that we are monitoring this situation in public health. We, of course, look at our EMS (Emergency Medical Services) data really closely to see what calls are being made, what the responses are, what’s being done in those responses. And then, of course, we have to track our death data. We work really closely with the Medical Examiner’s Office to understand who are those suspected deaths, what are we suspecting that they’re dying from, and then to confirm, when we’ve got the lab results later.

We also listen to what’s happening on the ground from folks who are providing those direct services, to see what the experiences are of folks who use drugs in Portland? Are they noticing that when they’re using drugs, they’re nodding off deeper or longer? Are they having changes in their wounds? Just what’s the experience with the drugs that folks are encountering? So there’s a lot of surveillance that we do to try to understand what exactly the situation is. But we also have to recognize that there are a lot of folks who have non-fatal overdoses that we may never hear about. So even when we’re looking at our data, it’s not capturing everything.

Miller:  In terms of causes of death right now in Multnomah County, where does fentanyl stand?

Everson:  It’s hard to comment on fentanyl specifically. I’d have to pull up a chart of all the causes of death. But we know nationwide that overdose deaths have taken the lead even more than car accidents and motor vehicle deaths. So across the nation, opioid related overdose deaths are taking over as a leading cause of injury.

Miller: Anthony Jordan, I noted that this is being called the fourth wave of the overdose crisis. What does that mean?

Jordan:  It’s a good question. When we have looked at overdose in the past, this fourth wave, I think it’s why they’re bringing the fourth wave because it’s unlike anything we have seen before. What Teresa was alluding to, we have a new substance that’s unlike any of the substance before where only a small amount of fentanyl can kill you or you can overdose on. So I think we are calling it a “new” wave so we can highlight it, so that we can address this differently. This is gonna be unlike any other way that we have addressed overdose in the past, due to the nature of fentanyl.

Miller:  So let’s talk about treatments for a second. I mean, do medication assisted treatments that have been effective for drugs like OxyContin or Percocet addiction or heroin, do they work in the same way for people who are addicted to fentanyl?

Jordan:  They don’t. And Teresa can speak a lot to the medical piece of it. She’s an MD. But I’m listening to community partners. When people are going into treatment services, medication assisted treatment. Some people call it medication supported recovery. What it would take for people who came into a program from traditional heroin use, to get those on medication and what the sort of therapeutics were to sort of keep them safely out of withdrawals.

Miller:  Just to remind folks, drugs like methadone or suboxone, we’ve talked about in the past.

Jordan:  Yes. Correct. It’s not as effective. And then on top of it, one person may experience going to withdrawal differently. So there’s not even a protocol individually for specific people. There’s not a protocol. It’s been more individualistic. So what providers are looking to do is to come up with some kind of community or practice to keep people out of withdrawals. Teresa probably can speak more to the medical piece of it. But that’s what I’m hearing from providers on the ground.

Miller:  So where does that leave the support community, the medical community as well, if traditional methods are less effective for fentanyl?

Everson:  Yeah. And I’m glad you said it that way. Less effective. It’s not to say that medications like buprenorphine, which is the main ingredient in Suboxone. It’s not to say they’re not effective, but we’re finding that folks who need Suboxone or buprenorphine for their treatment, they may need higher doses. They may need to start the medication in a different way at higher doses or a faster initiation phase. So there’s this rapid change in practice right now in how we help people and get the same results that we may have had with the protocols we were using three years ago, now that fentanyl is so mainstream.

Part of it is this community of practice that’s not just here but nationwide, in making sure we’re keeping up with best practice. But then we also need to be considering is [whether] buprenorphine is gonna be the best choice for everybody. And do we need to consider other kinds of medications? I know we mentioned methadone. There’s still a lot of folks in Portland who rely on methadone daily to help prevent withdrawals and to manage their substance use disorder, but other, even other treatments that we need to be considering. So it’s just a rapidly evolving area in medicine.

Miller:  And we’re not just talking about fentanyl alone, right? We’re often talking about combinations of drugs, whether or not people who are taking them even realize they are taking combinations. How does that complicate efforts to prevent overdoses and prevent death?

Everson:  It complicates it in many real ways. So we know that folks who have polysubstance use, whether it’s intentional or unintentional [is] that there’s a greater risk of overdose and overdose death for those folks. So there’s just a complication and the experience people have when they use their drugs and what first responders or bystanders are encountering symptom-wise and management-wise when they’re trying to take care of an overdose. And then there’s the piece of how we manage people’s withdrawals if they’re withdrawing from several substances that may work in really different ways in the body, like a stimulant and an antidepressant, like an opioid. And then there are different ways that we manage substance use disorder with different kinds of chemicals.

So it’s complicated, in a lot of different ways, not the least of which is the dramatic increase in overdose risk when folks have polysubstance use.

Jordan:  Yeah, and I think one of the things that a lot of people are doing on the ground is letting people who use drugs make an assumption that any drugs that they use, whether it be methamphetamines or cocaine, for example, to assume that Narcan is in those drugs and even handing out Narcan.

Miller:  To just assume that fentanyl is in those drugs?

Jordan:  Yes, true. And to also hand out Narcan to people who use cocaine just in case fentanyl is in. So, you know, usually we would pass it out to only people who would use opiates, but because they are mixed with these other substances, we are passing out Narcan to all those individuals.

Miller:  Do you think… from the providers you’re talking to or the people who are actively dealing with substance use disorder right now, I’m curious how much you think that message has gotten out there for people who regularly say, use meth and don’t think or don’t intend to use fentanyl. How aware do you think they are that they could unintentionally be buying fentanyl?

Jordan:  Are you talking about the user themselves?

Miller:  Exactly. I mean, you’re saying you want users to know this. And I guess I feel like we’ve talked to experts for more than a year now who’ve made this point. And I’m just wondering how much of this information has filtered down to the street?

Jordan:  I think that would be hard to know. I know some places actually don’t call [it] fentanyl overdose. They call it fentanyl poisoning because people are going for one thing and then poisoned by another drug. So I’m not sure how much of that education is getting to the user themselves. I know that there is a lot of education that we are putting out to try to help users understand that fentanyl could be in the drugs that they use. There are places in Multnomah County, I think, carrying that message to the houseless population. But I really don’t know if I could put a percentage of the population of users who would know that.

Everson:  I would also add that we’ve been doing really consistently messaging on that, with clients that we serve through our Syringe Services Program are folks who are active in their use, maybe not ready for treatment. And I know other Syringe Service Program providers also do that messaging to not assume that what you’re taking is what you think it is or what you’re using is what you think it is. But some of that comes back to being able to engage folks and get them in the door. So the folks that we’re engaging, we’re making sure that that message is out there. We’re doing street outreach with that messaging. So as much as we can, we’re sharing that message.

Miller: Teresa Everson, you mentioned the syringe program. Some of our listeners may be familiar with the very public backtracking at the county level in the last couple months, where people in the Health Department told members of the Board of Commissioners that they were going to be doing, as part of harm reduction, handing out straws and foil so people would not be injecting fentanyl. And then it was made more public in Willamette Week. And the Board of Commissioners, all of them very loudly said, “No, this is a bad idea. This was rolled out poorly. We’re not gonna do this.” It was a very public lashing at the Health Department. And that policy is not gonna happen.

Broadly though, it does make me wonder what harm reduction looks like in the age of fentanyl?

Everson:  Well, harm reduction, as a principle, is doing everything that we can to try to keep people as safe as possible while they’re in their substance use, whatever that substance is. And when I say safe as possible, it’s [including] preventing infection. A lot of this started around trying to prevent HIV, which we know is shareable through injection drug use primarily. Also preventing things like Hepatitis C, other kinds of infections that can be transmitted through injection use. There are also other injuries and wounds that can happen. And then there’s the risk of overdose. So really, harm reduction encompasses a lot of different activities to just try to keep as safe as possible while they’re still using. When we provide our harm reduction services, that’s also an opportunity to be engaging with folks and finding out what else they need, whether that’s housing or food or insurance or connection to treatment, if they’re ready for that connection, to primary care.

So there’s a lot that goes into harm reduction services. But one of the things that we’ve always focused on in our Syringe Services Program and in our Harm Reduction Services, is making sure that we’re staying current with what folks are doing, how they’re using their drugs, the kinds of injuries they’re having, and trying to be responsive to what we’re hearing from clients. So we just published our 2022 Client Services Survey from our Harm Reduction Program to talk about what their experiences are and how they’re using their drugs. And this is not unique to Portland. This is something that’s across the Northwest and the West Coast. There’s a lot more smoking of drugs on the West Coast than there are in other parts of the country. So that was something that we heard really clearly from folks.

And I don’t wanna get into it too much, because it is something that we’re not moving forward with right now. But we know that injecting in general, from a couple of decades of experience with heroin and harm reduction, injecting in general is not safer from an overdose standpoint. It’s not safer. It’s more harmful from an overdose standpoint and tends to transmit infectious diseases more. So it was a natural conclusion. It was an evidence-based conclusion. It’s also clearly something that folks are not ready for in our area. So I wish I could give you a comment about the future of that. But I don’t have a comment right now. I don’t have a crystal ball but, from a public health standpoint, it was a sound recommendation that clearly, we’re just not ready for right now.

Miller:  Anthony Jordan, what pieces do you think are missing right now in the ecosystem of treatment services? What don’t we have, at the county level or the state level, that you think we need?

Jordan:  One of the things I’m gonna say at the beginning is enough investment in prevention services. I oversee prevention as well, and I think we don’t make a good amount of investment in prevention. It’s usually one of those things that takes a long time to come to have some great outcomes. We focus a lot on crises. But I wish that we would put more funding into prevention services. That’s the first thing.

The second thing in the crisis that we are in, we don’t have withdrawal management services. We have some, but we don’t have an adequate amount of withdrawal management services. They’re all limited. Beds for those individuals. I was talking to some providers today and one of the other places that we don’t have is stabilization. Because people with fentanyl often, as Teresa was alluding to… while people are adjusting to the medication, once they leave a formal withdrawal management, they’re usually not stable enough to go into services.

And so I want to say Chair Vega Peterson and other commissioners have convened a group to look at what those gaps of services are. And they’re committed to finding that gap and how to fund this sort of stabilization. This sort of crisis or group of people can’t move into either residential treatment or outpatient treatment because there’s this lack of stability for them to get into. We also, at least in Multnomah County, sometimes lack this coordination of services, where if someone leaves one level of service, how do we move them? Let’s say someone is houseless and they go into services. How do we quickly move people into a service, when they’re needing it? Usually, if someone was houseless, we wanted to provide them some type of service, we either don’t have the housing piece for it or we don’t have the service itself freely available. It’s a long wait list or some wait list or some kind of process that they have to go through in order to get into that service.

So I think that those are probably the three highlights. Once people get into services in Multnomah County, they do really well. The outcomes are pretty good. Getting ‘em into those services has been the challenge.

Miller:  Anthony Jordan and Teresa Everson, thanks very much.

Everson:  Thank you.

Miller:  Anthony Jordan is the addictions services manager at Multnomah County Health Department, where Teresa Everson is the interim health officer.

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