Addicts are drawn to the “instant overwhelming euphoria” of heroin laced with synthetic opioids and the enhanced drug is killing more heroin users in Dane County and Madison, public health supervisor Julia Olsen said.
When synthetic opioids are added to heroin, the result is a much stronger substance that binds more quickly to receptors in the brain — a draw for some users. Fentanyl is one example of a synthetic opioid and can be as much as 25 to 100 times more potent than heroin and other opioids such as oxycodone and OxyContin.
It also doesn’t take much of the synthetic substance to do major damage. Just a few extra micrograms of fentanyl can create a lethal dose, Olsen said.
“We’ve been making a lot of strides as far as people not dying. We’ve been preventing death. What we’re seeing is an uptick in synthetic opioid deaths,” Olsen said. “It’s harder to save somebody when fentanyl or some other synthetic opioid is on board.”
In her position with Public Health Madison & Dane County, Olsen works with policy analysts and program coordinators in areas like oral health and tobacco prevention, and works with data staff to dig into community issues, including the uptick in heroin use.
“Working at higher levels like state and national, you don’t really get to see that direct impact you’re having,” Olsen said. “Working with the community one-on-one and really getting input on what their concerns are, it really lets you dig down into these little things that can create a different impact on inequities in the community.”
Is heroin use a problem in Madison and Dane County?
We’re concerned in what we would say is an uptick. From the previous work I've done, it’s very similar here in that we started to see an uptick in heroin use as we were seeing this uptick in prescription drug abuse with opioids. We know some people certainly do transition to heroin when they can no longer get prescription opioids and that’s not the case for everyone, but that’s certainly the case for some people. With heroin, it’s so much more potent than prescription opioids. Obviously, there’s no quality control being done on how you manufacture your heroin.
It can be pretty deadly. People don’t always know what's in the substance they're getting, and it’s very addictive. Prescription opioids and heroin are pretty much the same thing. They do the same thing in your system and to your body with the opioid receptors in your brain. Sometimes people think they can take a pill and be fine … but you never know how your brain is going to respond to that particular substance. I’ve seen many people over my career who have had legitimate prescriptions either for an injury or something else. They just did not respond well to opioids and have become dependent.
What has contributed to the use of heroin in the community?
There’s a ton of research out there that will look at social determinants of health. There’s obviously been policy measures taken to curb access and overprescription. That’s one method. We have Narcan to save lives, but I think the piece where we’re struggling is how do we prevent, across the life course, how do we prevent people from getting involved with heroin, with other drugs?
With a substance use disorder, we see people really get there due to other mental health issues, traumas, other things that have occurred throughout the life course. A lot of times the resilience and coping mechanism are things we certainly want to build and work on as a preventative measure. You can’t prevent every single case, but we do know there are things that we can do … across the life course from kids to older adults to try to build these assets in the community and the individual to enhance our protective factors.
Do we know why heroin is such a problem? We certainly have ideas but I think part of the answer is it's hard to say because some of it is so individual and relies on a mixture of so many factors.
Can a synthetic heroin overdose be treated the same way?
When we’re seeing fentanyl with an overdose case, it often takes multiple administrations of Narcan to bring that person back because the fentanyl is so much stronger. A couple of best practices we tend to recommend would be you might need multiple doses.
The other problem is that we sometimes see people who have been given Narcan and they’re coming back from the overdose, slip back into that overdose state 15 or 20 minutes later just because the way the fentanyl works in the body. By overdose state, I’m talking about that respiratory arrest. With fentanyl present, it’s not uncommon that someone would go back into respiratory arrest after they’ve been brought back with Narcan. It might require additional monitoring. That’s why we’re so much more concerned with fentanyl.
Are there areas in Madison and Dane County where heroin use is concentrated?
It’s all over the map. It’s not just Madison. It’s Middleton, it’s Verona, DeForest, Sun Prairie, it’s Waunakee. We’re seeing it everywhere.
You might see certain populations. We might see marijuana use higher among an African-American population. We might see heroin and prescription drug use higher among a white population. We certainly see those differences and alcohol is a whole different story. I wouldn’t say it’s just an urban issue. It’s all over the map.
What do you think the approach should be for law enforcement on this issue?
Public health is working right now with Madison Police, Dane County Human Services and some partners from UW Family Medicine on the Madison Addiction Recovery Initiative grant. I think that’s a good step in the right direction, so we’re going to be exploring more the community policing model and make sure police have resources to get people into treatment. Through this program, it’s also going to link people to recovery coaches. It’s building on some of the other diversion programs that already exist in the community, but it’s not necessarily going to cut down on that wait time to get into treatment.
Law enforcement has come a long way in understanding that substance use and abuse is a mental health issue. It’s a medical issue. It’s a disease. It’s a chronically relapsing disease. I think there’s still a lot of work to do to overcome that stigma, but I really think our law enforcement is seeing that especially with the opioid epidemic.
Do you think there needs to be more support from the state?
Our state policymakers certainly have the power and the ability to help us move the needle. They can’t be responsible for everything, but we as a field, I think, can educate about the best practices and from our experience in the field, the barriers we’re seeing to people being able to utilize services or us as providers being able to implement what we know are best practices.
I think going forward you will still see the county be very concerned with access to care issues and further exploring solutions for access to care for mental health treatment, behavioral health and substance abuse treatment.
What is the public health department’s role in the heroin epidemic?
We work on that big picture systems change. We’re not providing direct clinical care for treatment from public health, but what we’re doing is working... on those issues of access. The issues related to reimbursement, trying to identify places within a system that we can make changes and certainly advocate for building prevention into already existing systems. I would say if anything, we try to act as more of a facilitator, conveners of conversation thinking about things in a different way.
One lens I think we really do add is trying to examine what inequities exist within the community or what inequities could possibly exist by implementing this new program, strategy, system, policy, whatever it is and doing a full health impact assessment on what that could look like.