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WITHDRAWL
T R E AT M E N T W I T H D R AWA L
SYRINGE
T R E AT M E N T OPIOID
BASIC NEEDS OPIOID USE ACCESS
SUBSTANCE U S E
D I S O R D E R DENVER
METHADONE DISORDER P R O G R A M
NALOXONE
R E C O V E R Y
E D U CAT I O N
E D U CAT I O N
H E RO I N WELLNESS
HEROIN
M E D I C A T I O N
A S S I S T E D
T R E A T M E N T H E A LT H
BUPRENORPHINE E Q U I T Y
W I T H D R AW L
R EC OV E RY HARM REDUCTION
O V E R D O S E H E A LT H C A R E
S Y R I N G E SELF-CARE
H E A L T H TREATMENT
OPIOID
ACCESS B A S I C S U B S T A N C E
PROGRAM N E E D S E Q U I T Y U S E D I S O R D E R
R EC OV E RY OPIOID M E T H A D O N E H E A L I N G
ACRONYMS
DCAP - ACCESS POINT/DENVER COLORADO AIDS PROJECT
CDPHE - COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT
DDPHE - DENVER DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT
HRAC - HARM REDUCTION ACTION CENTER
HCV - HEPATITIS C VIRUS
HIV - HUMAN IMMUNODEFICIENCY VIRUS
OME - DENVER OFFICE OF THE MEDICAL EXAMINER
PWID - PEOPLE WHO INJECT DRUGS
PWUO - PEOPLE WHO USE OPIOIDS
10,552
United States, with opioid use driving this epidemic. Rates of drug-
induced death have consistently increased nationally over the past
15 years, and Colorado is no exception. According to the Colorado
Department of Public Health & Environment (CDPHE), 10,552
Coloradans died from drug overdoses between 2000 and 2015, with
opioid-related overdoses tripling during this period.1 COLORADANS
In 2015, Denver County rates of opioid- and heroin-related deaths D I E D F R O M
DRUG
were statistically higher compared to the rest of the state. Denver
experienced eight opioid-related deaths per 100,000 residents and
4.2 heroin-related deaths per 100,000 residents.
In 2015, Colorado experienced 5.8 opioid-related deaths per 100,000
residents and 2.9 heroin-related deaths per 100,000 residents.1 OVERDOSES
2015: OPIOID-RELATED DEATHS In 2016, 173 overdose B E T W E E N
PER 100,000 RESIDENTS fatalities were reported
by Denver’s Office of the
2000 & 2015
OPIOID HEROIN Medical Examiner (OME).
Of those deaths, 103
8 involved opioids — 50 of
which included heroin.
As of Nov. 13, 2017, the
5.8 OME reported 140 fatal
overdoses in Denver
HRAC CLIENTS REPORTED
REVERSING
187
during 2017 — 83 of
4.2 2.9
those overdoses were
attributed to opioids, with
35 specifically indicating
heroin as a substance
DENVER COLORADO involved in the overdose.2
234
of its clients died of an overdose in 2016. In a two-week period during
January 2017, six HRAC clients died of an overdose.
• In 2016, clients of HRAC reported reversing 187 overdoses.
• In the first 10 months of 2017, clients reported reversing 234
overdoses.3
Reports on opioid overdoses nationally and locally illuminate the
OVERDOSES
importance of being able to respond to and reverse an overdose and IN JAN.-OCT. 2017
the speed with which overdose deaths are increasing.
PURPOSE OF THE ASSESSMENT:
The purpose of this assessment was to better understand the opioid crisis
in Denver from the point of view of people who use opioids (PWUO),
1
Colorado Department of Public Health & Environment, “Examining Opioid and Heroin Related Drug Overdose
in Colorado,” https://www.cohealthdata.dphe.state.co.us/chd/Resources/pubs/Colorado-Opioid-and-Heroin-
Overdose.pdf
2
Denver Office of the Medical Examiner, www.denvergov.org/MedicalExaminer
Harm Reduction Action Center, www.harmreductionactioncenter.org
Needs Assessment on Opioid Use | 6
3
specifically heroin. The assessment aimed to understand people’s lived experiences using
heroin, and their experiences accessing and engaging in treatment. An additional goal was to
gain a better understanding of the post-nonfatal overdose experience as it relates to treatment
initiation. A key component of overdose prevention is providing supportive services, including
drug treatments that improve the lives of PWUO and reduce their risk of overdose. This report
examines the availability and accessibility of those services.
Denver’s Department of Public Health & Environment (DDPHE) recognizes that there are many
types of substance use disorders (SUDs). While the public health care system has been slow to
respond to behavioral health diseases, many public health agencies are now working to normalize
all aspects of discussion around these issues.
Furthermore, historically, both locally and nationally, there has been a disproportionate response
toward SUDs between public health officials and law enforcement officials. The criminalization
and stigmatization of mental health and people who use drugs has perpetuated societal and
institutional racism.
Due to the importance of equity and the history of criminalization of people who use substances,
the researchers prioritized interviewing populations most stigmatized and disenfranchised in the
community: people who inject drugs (PWID) and were experiencing homelessness at the time of
the interview.
METHODS
SEMI-STRUCTURED IN-DEPTH INTERVIEWS WITH PEOPLE WHO USE OPIOIDS:
Qualitative, semi-structured interviews were conducted with individuals who self-reported
current opioid use, specifically heroin. Interviews were conducted by two experienced qualitative
researchers — Marion Rorke, MPH, and Steve Koester, PhD., — between June 2017 and August 2017.
A purposive sampling strategy was employed to ensure the sample was composed of current
opioid users. Most participants were recruited through the city’s two community-based agencies
serving people who actively use substances: HRAC and Access Point, a program of the Colorado
AIDS Project. Both agencies operate SAPs. Additional participants were recruited through other
organizations and agencies serving community members who use drugs. Due to the increases
in EMS calls and overdoses in the area surrounding Civic Center Park and the adjacent Denver
Central Library, interviews with individuals in this area were prioritized. Therefore, it is important to
note that these individuals’ experiences may differ from those of people who do not congregate
in this geographical area.
The interview method provided participants the opportunity to give detailed responses and
allowed the interviewers to ask additional questions and gather further information.
All interviews were confidential and no names or other identifying information were collected.
Demographic information collected was limited to age, ethnicity, gender and current housing
status. Drug-use information collected was limited to current drugs used, previous treatment
experience(s) and whether or not the interviewee had ever experienced an overdose. The
purpose of the interviews was explained to all participants and each was asked to give verbal
consent to participate prior to the interview. Participants received $20 gift cards as compensation
for their participation. Interviews were audio-recorded, and the two interviewers also took field
notes. Interviews were transcribed and coded at the conclusion of data collection.
Needs Assessment on Opioid Use | 7
SURVEY OF SUD TREATMENT PROVIDERS:
Due to the barriers experienced by PWUO when attempting to access treatment, an additional
component of the assessment was a survey targeted to SUD treatment providers in the Denver
area. Survey questions were initially based on a similar assessment conducted in New Mexico.4
These questions were then modified to better reflect circumstances specific to Denver. Input on
survey design was provided by staff from a local harm reduction agency, a social worker from the
Denver Public Library, a methadone treatment provider and a staff member from the Colorado
Consortium for Prescription Drug Abuse Prevention.
At the time, comprehensive lists of Colorado treatment providers or of Denver treatment
providers were not available. Therefore, to identify as many agencies and providers as possible,
the researchers contacted multiple agencies and individuals that work to place clients in
treatment programs. Four separate listings of providers were combined, totaling 62 agencies
or individual SUD treatment providers. Those agencies and individuals were then contacted by
phone to obtain an email address to which to send the survey.
Survey responses were collected via SurveyMonkey between Sept. 18, 2017 and Oct. 2, 2017. At
the completion of data collection, survey responses were compiled into an Excel spreadsheet.
A N A LYS I S
SEMI-STRUCTURED IN-DEPTH INTERVIEWS WITH PWUO:
In qualitative research, the first stage of analysis occurs while the interviews are being conducted.
This enables interviewers to compare notes and to incorporate emerging findings into
subsequent interviews. Coding is the process of identifying and categorizing the collected data.
To ensure inter-rater reliability, meaning consistent agreement on the interpretation of the data,
the two interviewers — as well as two DDPHE staff members trained as qualitative researchers —
independently coded transcripts, compared codes and developed a common coding scheme.
Codes included pre-set and emergent codes that were identified during the analysis of the
transcripts. The final stage of analysis consists of merging codes into themes. Finally, these
themes were presented to a focus group of HRAC clients for confirmation and feedback.
SURVEY OF SUD TREATMENT PROVIDERS:
For the purpose of this assessment, analysis consisted of examining the distribution of treatment
services and requirements among service providers. Aggregate information was tabulated to
show the number of agencies providing a given type of treatment. Wait times, restrictions, and
other barriers to treatment access reported by providers were compared with the interview
responses from PWUO regarding experiences with and perceptions of treatment access.
4
City of Albuquerque, “Opioid Needs Assessment.” http://www.cabq.gov/mayor/documents/
opioidneedsassessmentnms.pdf/view
AGE GENDER
9 9 23
8
4 1
6
18-24 25-34 35-44 44+ MALE F E M A L E TRANSGENDER
23 21 25 25
3 2 3 3
HEROIN M E T H / B E N ZO D I - MORE THAN 1 WHITE B L A C K H I S PA N I C NATIVE AMERICAN
S P E E D AZEPINES OR ALASKAN NATIVE
25
CURRENTLY EXPERIENCING
experiencing homelessness and those who had
HOMELESSNESS
previously been homeless were persuasive in
describing the multiple, interconnected challenges
that homelessness presented, including taking care of
personal hygiene, maintaining clothing and other personal
property, meeting treatment schedules and having hope
STAYING WITH FAMILY
2
that their lives were improving.
3
Several of the participants experiencing homelessness
STABLY HOUSED
who also inject heroin reported injecting
methamphetamine as well. Some of these participants
described their methamphetamine use as a response
to the need to stay awake at night to stay safe. They
explained that staying awake and vigilant reduced
their risk of being victims of violence and theft, as well
as reduced the risk of unwanted police encounters
for curfew, trespassing and unauthorized camping
violations. Participants also described the many
ways that homelessness significantly created and/or
exacerbated barriers to treatment.
. . . BY T H E T I M E YO U ’ R E
CLEAN AND PRESENTABLE
YOUR DAY IS PRETTY GONE.”
Needs Assessment on Opioid Use | 12
Obtaining Accurate Information
Participants said that it can be difficult to find out about services. There is no centralized resource
for learning about available services. Participants reported receiving inaccurate information
about services, and several said their best source of information was from other PWID or were
experiencing homelessness. One participant mentioned that this was how she learned about the
social workers at Denver Public Library and about a potential housing program.
Health Care and Insurance
Several participants mentioned Medicaid expansion as a significant and beneficial change, explaining
that having staff from social services available at HRAC to provide enrollment assistance was
particularly helpful. Importantly, one participant who was seeking treatment worried about starting a
Medicaid-funded methadone program for fear that Congress might eliminate the Affordable Care Act.
As a result, she was afraid to begin treatment, explaining that she didn’t want to become dependent
on methadone and then lose her coverage. While participants mentioned they were able to access
basic health care services, the lack of coverage for a wide variety of treatment options under Medicaid
impacted the effectiveness of Medicaid in providing treatment for participants.
TREATMENT:
An underlying assumption of this
assessment was that accessible drug
treatment is a critical component in
combating opioid overdose. A variety
of treatment options exist, including EXPERIENCE WITH TREATMENT
outpatient, intensive outpatient,
inpatient and residential services. The
most common treatment of opioid
use disorder (OUD), including heroin, is
medication assisted treatment (MAT).
All but two participants had some
experience with treatment for a SUD.
28
More than half reported experience
with MAT and more than 25 percent
were currently engaged in MAT.
Nearly all participants reported
previous experience with drug
17 8
treatment, including MAT. Of those HAVE ACCESSED HAVE ACCESSED CURRENTLY
with MAT experience, previous TREATMENT MAT ACCESSING MAT
treatment was with methadone or
buprenorphine. None had been
in treatment using naltrexone.
Experiences with other types of
treatment (non-MAT) also varied
by participant. While inpatient and
residential treatment was mentioned,
most reported it was inaccessible
due to cost.
Needs Assessment on Opioid Use | 13
WHAT IS MEDICATION-ASSISTED TREATMENT?
• The requirement of MAT programs that clients do not use any drugs.
WANT HELP NOW
YOU SHOULD BE ABLE
Participants were wary of MAT because treatment programs
routinely test for all drug use and may impose consequences for
signs of use. For participants this was particularly troublesome in
TO GET IT...
WISH I COULD GO TO
the case of marijuana, a legal substance in Colorado and one that
many reported using regularly.
A PLACE AND GET
ON SUBOXONE
• The lack of supportive services.
MAT programs rarely offer assistance regarding other facets
RIGHT AWAY,
P E R S O N A L L Y .
of people’s lives that have direct impact on their drug use,
including everyday needs like housing, coping mechanisms and WITHOUT QUESTIONS.
employment. I CAN’T GO HOME,
• The limited amount of counseling and therapy that MAT clients NOT DO ANYTHING FOR
receive. THREE DAYS AND COME
BACK... IT WON’T WORK.”
Some participants described their drug use in terms of self-
administered medication for underlying emotional and
psychological problems, suggesting the need for more intensive
counseling than some MAT programs typically offer.
BEEN
— ASSESSMENT PARTICIPANT
Ideal Treatment Components
While individual perspectives varied, there was some consistency
among participants regarding the important components of treatment THROUGH IT.”
for OUDs. These include:
• Humane withdrawal and treatment on demand.
• Marijuana use not being a reason for being unable to “move up phases.”
• Long-term inpatient and residential services.
• Individualized treatment plans that address the underlying causes of a
client’s SUD.
• Peers/people with lived experiences as a part of the treatment staff.
DISCUSSION
The purpose of the assessment was to gain an understanding of the availability and accessibility
of treatment services and the potential of a nonfatal overdose to serve as an intervention point to
initiating treatment. However, the researchers found that while there are people actively seeking
treatment, the number of other daily concerns and difficulties related to securing shelter, food,
transportation, and medical and social services resulted in a lack of urgency and/or interest in SUD
treatment. While overdoses were not considered a deterrent to drug use, or a gateway to treatment,
many described the importance of recognizing and responding to overdoses. Overdose education
and training including the distribution of naloxone is perhaps the most successful strategy to date
for reducing overdose.
AS OF SEPTEMBER 2017, HRAC HAS TRAINED 1,800 CLIENTS ON NALOXONE USE, AND
CLIENTS HAVE REVERSED 730 OVERDOSES SINCE THE PROGRAM STARTED IN 2012.5
When addressing homelessness and SUDs, it is important to emphasize that not all people
experiencing homelessness use drugs (including opioids). The opposite is also true; not all
PWUO are experiencing homelessness. However, to impact OUDs and overdoses among PWID,
homelessness must also be addressed.
The challenges presented by homelessness create enormous barriers to meeting basic human
needs, accessing services, and initiating and remaining in treatment. For the people interviewed
for this assessment, homelessness as well as policies aimed at the homeless influence every
aspect of their lives including their comfort, health and dignity. To encourage more PWUO to
access treatment, additional services must also be available and accessible, including toilets,
shower facilities and transportation.
While treatment was not one of the most important daily considerations for most participants,
some were already on MAT. Others had previously tried to access MAT or were interested in
starting treatment, but described a multitude of barriers, including cost, requirements and stigma.
As mentioned earlier, MMT has often provoked a bit of controversy among PWUO and the public
at-large. Research has largely dismissed the former critique, and a 1999 study conducted in
Denver demonstrated that MMT is an effective form of harm reduction for the minority of clients
who continue to use heroin.6 This finding has been confirmed by several subsequent studies.
6
Substance Use and Misuse, “Active Heroin Injectors’ Perceptions and Use of methadone Maintenance Treatment: Cynical Performance or Self-Prescribed Risk
Reduction?” http://www.tandfonline.com/doi/abs/10.3109/10826089909039442
7
Harm Reduction Action Center, www.harmreductionactioncenter.org
8
Substance Use and Misuse, “Heroin and Methamphetamine Injection: An Emerging Drug Use Pattern.” http://www.tandfonline.com/doi/full/10.1080/10826084.2016.1
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