Overdose Awareness Day Requires Holistic Interventions
August 31st was recognized as International Overdose Awareness Day, with governments and entities around the world observing the annual campaign to “end overdose, remember without stigma those who have died, and acknowledge the grief of the family and friends left behind.” The campaign, starting in 2001 by sally Fin in St. Kilda, Melbourne, is used to highlight the health consequences of overdoses, provide an avenue for those who may be grieving a loved one to do so without external stigma, advocate for policy changes, and educate local communities about the issue. This year, the Biden Administration issued a proclamation, designating August 28 through September 3 as “Overdose Awareness Week” with special recognition of the day and a call to action for the country to “raise awareness of substance use disorder to combat stigmatization, to promote treatment and celebrate recovery, and to strengthen our collective efforts to prevent overdose deaths.”
The Biden Administration’s focus on the overdose crisis is largely centered on shifting the national stature of drug policy from punitive as an issue of moral character to treating substance use disorder as a health issue which mist addressed through social, structural, and medical intervention and not necessarily carceral intervention. This plan has recently been met with some push back, in large part due to the issue of stigma. Remarkably, that push back also comes amid a staggering report from the National Vital Statistics System (NVSS) that United States average life expectancy has dropped to its lowest in almost three decades – in large part due to the COVID-19 pandemic but also because of fatal drug overdoses. The report notes overdoses typically take three to six months to be appropriately assessed at the local level and those data may be delayed, underestimating the life expectancy implications of the crisis. Indeed, the cause of death which caused the second most substantial influence on average life expectancy was “unintentional injuries”, of which overdoes represent a largely significant segment.
The U.S. Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) announced awarding $79.1 million in grants to various programs aimed at addressing certain aspects of the overdose crisis, including projects targeting supporting first-responders and rural emergency medical services as a point of overdose treatment, capacity building and technical assistance to providers, residential programs, and an effort to strengthen support for medication assisted treatment. SAMHSA’s page recognizes the 30% rise in overdose deaths since 2019, racial disparities affecting Black communities and American Indian and Alaskan Native communities, and the fact of socioeconomic disparities dramatically impact overdose rates.
While not mentioned in the White House, HHS, and SAMSHA pages relative to recognizing International Overdose Awareness Day, the day is meant to also recognize the impacts of non-fatal overdoes. In particular to the issue of long-term physical health, non-fatal overdoes have deep implications as to viral Hepatitis and HIV transmission and our efforts to end those epidemics. In order to adequately address overdoses, we must recognize the syndemic nature of these issues and the systemic drivers of disparities affecting these communities. Mental health is often reflective of the socioeconomic experience of a person (and community); racism, for example, significantly but not singularly defines both the social experience and economic experience of racially marginalized people.
In recognition of International Overdose Day and the holistic needs of highly affected communities, we must consider society-wide, comprehensive interventions that treat these social ills as the causative factors they are.
Global & National Perspectives on HIV & HCV Co-Infection
On April 26, UNAIDS issued a report briefly detailing the state of HIV and Hepatitis deaths, globally, taking particular note of the issue of coinfection among people who inject drugs. Here in the United States, multiple jurisdictions have declared new HIV and ongoing Hepatitis C outbreaks, all combined with a surge in overdose deaths.
Domestically, federal public health initiatives have long sought to understand and address intersections of these issues, offer guidance, and shifted – albeit slowly – to understand HIV, HCV, and SUD exist as syndemics. And I want to talk about this language.
Syndemic, in general, means two or more linked health problems, interacting synergistically, and contributing to the disease burden of a given population; operating in a fashion that feed one another. To prevent or treat a syndemic, entities must not only treat each health problem but also the social ills that bridge these health problems.
This distinction is important – if we are to meet any of our public health goals on any of these, we need expertise, advocates, and structural support that both address the singular nature of each and the intersections, un-siloed from one another. Unique expertise in designing solutions is as valuable and necessary as expertise with the vision to see the whole system.
As we move through the COVID-19 pandemic, well-publicized discussion on the conflicts between national strategies and local actions mirrors fights patient and policy advocates have been fighting for four decades and continue to fight today. Even as we’ve made progress in ensuring direct acting agents (DAAs) are included in AIDS Drug Assistance Program (ADAP) formularies, at least one state has set an unchallenged precedent of denying this basic care to incarcerated people based on budgets and the Democratic mayor of the city with the “most concerning” HIV outbreak in the nation has back tracked on commitments to work with local public health experts.
This quarter’s HIV-HCV Coinfection Watch Report highlights some progress in syndemic-oriented policy changes and some more…unfortunate changes. While the American Rescue Plan, passed earlier this year, provides for more funding to address state budgets harmed by COVID-19 related revenue decreases, a few states have instituted – and currently maintain – restricted services. For example, while Georgia’s ADAP maintains DAAs on the formulary, payment for same is halted due to funding and Texas’s ADAP has removed all HCV medications, except one DAA from the formulary. Positive notes from earlier this year include Kentucky’s Medicaid program moving to a universal preferred drug list (PDL).
Of the space that has the greatest amount of room to progress and needing nuanced advocacy changes is harm reduction policies. Well-established federal policy and laws only reach so far if state and local laws act in direct opposition to those model positions or even merely lack the funding to establish comprehensive programs. One such space is the near universal adoption of “Good Samaritan Laws”, wherein, generally speaking, if a person, regardless of capacity, does their level best to help another, they cannot be held liable. However, several states have amended their “Good Samaritan Laws” or criminal codes to remove that liability protection from people who distribute illicit substances – disincentivizing reporting of overdose incidents and calling for medical help as they happen. Along the same lines, doctor shopping laws are aimed at preventing patients from seeking multiple prescriptions or seeking multiple providers if one is unsatisfied with their care. However, many states rely upon “lock-out” programs administered by insurance providers or managed care plans to implement under the guise of preventing “drug seeking behavior”. As Alison Gaye stated in a recent presentation to Louisiana’s Commission on HIV, AIDS, and Hepatitis C Education, Prevention, and Treatment, “drug seeking behavior often looks like care seeking behavior, subject to the personal biases of the examining provider”.
Harm reduction policies are in dire need to evolve and delve into the difficult nuanced spaces currently unaddressed if we’re to meaningfully work to end the syndemics of HIV and HCV. Far, far too often the solution found by policy makers in addressing public health needs has been to incarcerate those among us who need help. Driven by stigma, whether the issue is HIV criminalization or lack of access to standard HCV care or refusing adequate insurance coverage for recovery programs, shoving people into prisons has not served this country well on any front.
As we step into the next phase of our advocacy, evaluating existing programs, practices, and priorities cannot include a carceral mindset if we are to effectively reduce the harm caused by these syndemics and our past policies.