‘Stigma kills’ — Efforts target ongoing opioid, drug use
- Published: August 15, 2019
As an emergency room doctor in Cincinnati in the mid-2000s, Dr. Shawn Ryan witnessed the early years of the opioid crisis.
In the ER, Ryan saw overdoses every day, while from his office, as a hospital administrator for patient safety, he watched worrisome data accumulate.
“I had a five-foot and 50,000-foot view,” of the opioid crisis, Ryan said.
But those struggling with addiction weren’t treated like other patients, Ryan noticed. Instead of being offered ongoing treatment from multiple medical professionals, patients with a substance use disorder were often left on their own.
“If you send someone here who had a heart attack, you make sure they can get their medication,” Ryan said. Everyone seemed to be waiting for people to “hit rock bottom,” Ryan noted.
“Rock bottom, for opioid use, is a coffin,” he said. “Rock bottom is end of life. What if American medicine said you don’t get insulin until we cut one of your legs off?”
It’s that stigma that contributed to more than 47,600 opioid-related drug overdoses in the U.S. in 2017, according to figures from the Centers for Disease Control, and that still keeps many who need help from seeking it, Ryan believes.
“Stigma continues to be the No. 1 problem in mental health and addiction today,” he said. “People think it’s the person’s fault and we should punish them.”
Ryan left the large metro hospital system to create his own string of out-patient addiction treatment centers in the region. His 10th clinic, BrightView, opened in June in Springfield, a city hard hit by opioid use.
Ryan’s model is a holistic approach, he said, and his patients get support from a team of medical, psychological and social services staff. And he’s seen it work.
“I’ve had patients go from the worst situations — being homeless with medical and psychological illnesses, unemployed without custody of their kids — fixing all of that.”
This week, the News looks at the progress made since the depths of the opioid crisis here a few years ago, including the interventions that helped and the ongoing challenges.
Resources for Substance Use Disorders For those in crisis — For those who need help — Appointments can also be made. The Greene CATS Yellow Line can take people to either office.
• SAMHSA (Substance Abuse and Mental Health Services Administration) National Helpline:
• Yellow Springs Police Dept.:
• Florence Randolph, Community Outreach Specialist, Yellow Springs Police
Department, 937-767-3716, email@example.com
• Mental Health Recovery Board of Clark, Greene and Madison Counties, 937-322-0648.
• TCN Behavioral Health Walk-In Clinics for Dual Assessments (substance use and mental health):
• Xenia, at 452 W. Market St. — Monday, Wednesday check-in 8:30 a.m., plan to stay until noon; Tuesday, Thursday check-in at 9 a.m. plan to stay until
• Fairborn at 600 E. Dayton-Yellow Springs Road — Check-in 8:30 a.m.
Resources for Substance Use Disorders
For those in crisis —
For those who need help —
Appointments can also be made. The Greene CATS Yellow Line can take people to either office.
It was two years ago that the Dayton area was ground zero for the opioid crisis, making national headlines as the Montgomery County morgue ran out of space for the dead.
Ohio ended up second in the nation for overdose deaths involving opioids in 2017, when 4,293 Ohioans died. Montgomery County had the highest death rate, while Clark County was third. Unintentional drug overdoses in Ohio, for comparison, were 1,000 percent higher in 2017 than in 2000. Nationally, drug overdoses — which soared to 70,000 — became the number one cause of death for Americans under 50.
But in the past two years, opioid overdose deaths have slowed. Montgomery County reported that its overdose deaths had fallen by 50 percent by the end of 2018, compared to the year previous. State and national data have yet to be finalized, but in Greene County, 45 people died from an unintentional drug overdose in 2018, down from the peak of 63 in 2017, according to figures from the county health department.
Although some progress has been made in treating opioid addiction, the public health officials, doctors and first responders interviewed this week see room for improvement.
“We have turned the corner a bit, but it is still too high,” Ryan said.
To Kirsten Bean, a Yellow Springs resident who works as the health education program manager at Greene County Public Health, the figures are an improvement from the “mass casualty incident” of 2017. That crisis was caused, in part, by the influx of synthetic opioids fentanyl and carfentanil, which can be much more potent than other opiates.
But the larger crisis is ongoing, as drug overdose deaths in the county last year were still double what they were as recently as 2013.
“We have a substance use crisis,” Bean said. “Things are better compared to 2017, but there is more meth use and still a lot of heroin and fentanyl use.”
Opioids in Yellow Springs
In Yellow Springs, opioid overdoses did not reach epidemic levels, but the village still saw its share of overdoses in recent years.
Bean said Yellow Springs is “fairly average,” compared to other areas in the county. Greene County, meanwhile, is on par with state averages. In 2019, the unintentional drug-overdose rate in the county was 38.2 per 100,000 population, compared to 40.6 in the state.
“It’s not as high as Fairborn or some parts of Xenia, but there really is no community in Greene County that’s immune,” Bean said.
According to data from Greene County Public Health, four Yellow Springs residents presented at Greene Memorial Hospital or Soin Hospital with a drug overdose in 2017; two did in 2018. Looking at all Dayton-area hospitals, 13 villagers presented with an overdose in 2017.
Miami Township Fire-Rescue Chief Colin Altman said that in his perspective there is not an “opioid crisis” in Yellow Springs or Miami Township, but that MFTR has treated more overdoses here in the last four to five years.
“It’s certainly not to the extent that a lot of communities have seen it,” Altman said.
In the last 800 days, MTFR has gone on 16 calls for drug overdoses, eight of them involving an opioid overdose, Altman said. Of those, Narcan — the brand name for naloxone — which can reverse the toxic effects of an overdose, was used in all but one case.
Although MTFR has been carrying naloxone since the early 1990s, the squad has used it multiple times per year in recent years, up from about once per year previously, Altman said.
Altman admitted, however, that with the prevalence of naloxone, MTFR may not be aware of all overdoses here.
“Many more people have Narcan at home, so they might not call us. That’s probably a legit theory,” he said.
Yellow Springs Police Chief Brian Carlson also has seen a decline in opioid overdoses locally. In 2017, the department used 11 doses of Narcan, but six in 2018, according to Carlson. He added that multiple doses can be used for each overdose.
“We’ve seen a drop in the numbers,” he said.
According to Carlson, in recent years there has been one overdose death involving opioids, in 2017. The drug in that case was heroin.
Altman said that heroin is the most common culprit when it comes to opioid overdoses in the village. He went on to identify the cause of other drug overdoses.
“We do have some prescription medication overdoses, and every now and again, there will be cocaine overdoses, but they are few and far between,” he said.
To Altman, alcohol is a larger concern in the village. During that same close to two-year period, there were 39 incidents of alcohol poisoning.
“The vast majority of drug use we see is alcohol-related,” Altman said.
Carlson agreed that alcoholism is more of an issue in the village, in part because of the large number of liquor establishments here, he said. Alcohol abuse affects a growing homeless population here and is also causing more problems in Glen Helen Nature Preserve, Carlson noted.
Interventions that worked
Yellow Springs Police Department was one of several Greene County law enforcement agencies that received free doses of naloxone during the height of the crisis. Spreading that medication was a major effort of Greene County Public Health, and one they credit with saving many lives.
At the time there was pushback, according to Bean, as some police chiefs in the county declined the offer of naloxone.
“There are people who believe it is more of a personal choice and that there should be consequences [to overdosing],” she explained.
However, the controversy over naloxone is starting to wane, Bean added.
“I do think that attitudes are changing,” she said.
Now, the health department is looking to distribute the life-saving medication further. In partnership with TCN Behavioral Services, they have distributed 714 naloxone kits in two years, and have heard of 15 overdose reversals from their use.
The health department also started a needle exchange in Fairborn in 2017, and recently opened another in Xenia this summer. Bean says needle exchanges are essential to reaching vulnerable populations.
“It’s a judgment- and stigma-free place, Bean said. “We can reach them with information, referrals for housing and give them Narcan.”
The county has also given away 390 free fentanyl test strips since the beginning of the year, as the drug supply becomes “cross contaminated.”
“Meth users are finding that meth is testing positive for fentanyl,” Bean said.
Another message the health department has promoted is that “stigma kills,” Bean said. That’s because some who are addicted to drugs use alone because they are ashamed. That can be dangerous.
“The biggest indicator was whether someone overdosed in the line of sight of another person,” Bean said of overdose deaths. “You can’t administer your own Narcan.”
Another message the health department is promoting: recovery is possible.
“It’s not hopeless,” Bean said. “There are treatment options out there, you can recover and you can live a life not dependent on drugs.”
The YSPD’s hiring of a community outreach specialist has been an important development in how village first responders attend to overdoses. Both police officers and MTFR medics now refer those who have overdosed to that specialist, Florence Randolph, who will later follow up with them.
Fighting stigma, offering help
In Ryan’s experience, because of the ongoing stigma associated with substance use disorders, many people wait too long before seeking help. That’s something he is hoping to change.
“Addiction is disproportionally addressed at a later stage,” compared to other illnesses, Ryan said. “We don’t normally address addiction until [the person] is long gone.”
Ryan believes that early screenings are vital for substance use disorders, just as pap smears and colonoscopies help identify possible medical conditions.
“We do screenings for other diseases, but with addiction, we wait,” Ryan said.
As a result of waiting, the medical system is dealing with patients who are suffering from a severe addiction, like “grams of heroin or pints of vodka a day,” Ryan added. That can make treatment less likely to succeed, and it can take far longer. Instead, catching an addiction problem early should be the goal.
“When using a substance starts to affect your life negatively, people should come in, or their families should refer them,” Ryan said.
To address the stigma, the BrightView website explains that addiction is a “chronic, progressive and potentially fatal disease” and not due to “a lack of willpower.”
Ryan laid out the three factors in disease — genetics, environment and exposure — and how none of them is the fault of the person who became addicted during the opioid crisis.
“No one is controlling their genes, very few people controlled their environment growing up and exposure is what the pharmaceutical push was all about,” Ryan said.
Roots of the crisis
Ryan was still working in a Cincinnati hospital when he saw the rapid increase in doctors prescribing opioids, such as OxyContin and Vicodin, for pain. At the time, pharmaceutical companies were aggressively marketing opioids while promoting the view that they weren’t addictive. But that’s contrary to solid scientific evidence going back 60 to 70 years, Ryan said.
“The industry did such a terrifyingly strong job of convincing the public and medical community of the lack of addiction related to opioids, and of the need to treat pain no matter what,” he said.
“You can’t freely prescribe mind-altering substances for 20 years, and not expect anything to happen,” Ryan said of what followed.
In 2010, Ohio providers wrote more opioid prescriptions than there were Ohio residents, according to the Centers for Disease Control. Nationally, there were 289 million prescriptions written in 2016 — enough for every American adult to have their own bottle, Ryan relayed.
A 2011 Ohio law helped shut down the “pill mills” responsible for the availability of large volumes of opioids, but pushed some people who were already addicted to heroin. As a result, overdoses from prescription opioids dropped, but those from heroin and synthetic opioids rose over the last decade.
So far, 49 states, including Ohio, and numerous counties and local governments have sued pharmaceutical companies for their role in the opioid crisis. Recently, 1,600 of those cases were consolidated and transferred to a judge in the U.S. District Court’s Northern District of Ohio.
BrightView offers a holistic approach that includes psychological counseling, peer support, connection to social services and medication-assisted therapy, according to its website.
While some critics of using medication deride the approach as “a drug for a drug,” Ryan said the science shows that, for opioids, it is more effective than an abstinence-based treatment.
But it’s important to address other addiction factors at the same time, Ryan said.
“The medication is a key component, but it will not address the social issues,” he said, drawing parallels to other diseases.
“You can’t treat someone’s COPD if their house has mold,” he said.
Meanwhile, the psychological component is also critical. As Bean explained, much substance abuse has its roots in childhood trauma, and especially sexual abuse.
“Substance use is often a way to cope with traumatic upbringings,” she said.
In addition to BrightView, there are other local service providers specializing in substance abuse disorders (see sidebar).
And while Yellow Springs has not seen as many opioid overdoses as several of its neighboring communities, the opioid crisis has, no doubt, impacted many here, Bean said.
“I think everyone knows somebody who has been touched by the opioid epidemic.”