How did you first get involved in working on drug policy?
Growing up, I was passionate about health and social justice issues, and I understood the two as inextricably linked. When I came to New York City in the early 1990s, I was focused on women’s health, but drug policy was everywhere. I first worked in a program in the Bronx for parenting women who had had their children removed, or were under investigation, for drug use. I learned that needle exchange programs, which prevent HIV and Hepatitis C transmission, were controversial and mostly nonexistent in the U.S., radically different from where I grew up in Toronto, where the city government had implemented these programs in the 1980s. So I was fortunate to become the director of a harm reduction program in 1997, to begin modeling some of what I believed in, and my trajectory was set.
Why did you decide to come to Vital Strategies to do this work?
The organization is committed to building capacity and scaling implementation to address urgent public health issues in countries around the world. I couldn’t refuse the opportunity to bring that energy and focus to the issue of overdose and drug use in the U.S., where this kind of public health attention and investment has been sorely lacking for so long. It is a great privilege to do this work at Vital Strategies.
What has caused such a steep increase in the number of overdose deaths in the U.S.?
We talk about the current overdose epidemic in this country as a triple wave of deaths. The first wave was produced by opioid over-prescribing, and the second wave was led by heroin and generated by user transitions from prescription opioids, with crackdowns on prescribing and the expansion of heroin markets. This third spike we are now experiencing is caused by the widespread presence of fentanyl in the illicit drug market, which is a very potent synthetic opioid.
Why is Vital Strategies focusing on Pennsylvania and Michigan first?
Both Pennsylvania and Michigan have experienced high and rising overdose mortality in the current epidemic. They have concentrated problems related to drug use in both urban and rural regions of the states, diverse social and economic landscapes, and a lengthy history with drug policy and drug use. We hope to support efforts there that can be replicated in other similar areas around the country.
How do you tackle such a complex problem?
We need to take a comprehensive approach to reducing overdose deaths if we’re going to have a lasting impact. We need to stop responding to drug use with punishment, and make it easy for everyone to get help, support and care. We need to challenge and overcome the stigma associated with drug use, which is the consequence of a legacy of criminalization and moralism. Fundamentally, we need a humanistic, harm reduction approach.
What resources and partners are needed to respond at the level of scale and urgency this crisis calls for?
We need all sectors involved—health care, criminal justice, social services, public health—and we need a collaborative approach, with coordinated efforts. We need local governments to mobilize and lead, and state governments to facilitate and promote structural change, so that systems can operate and even integrate their processes with one another. Federal dollars should be incentivizing changes in health care and providing social investments in communities. Federal laws related to drugs and drug use should be grounded in evidence. And communities, who bear the weight and suffering of this crisis, should demand this level of effort and change from their elected officials.
Too many people who want treatment can’t get it. Why is that, and how do we change that?
Historically, the substance-use disorder treatment system developed separately from mainstream health care, prioritizing abstinence above all and pushing “behavior change” with practices that were often not evidence-based, and sometimes even abusive. Traditionalists in this perspective even advocate against opioid-agonist medications such as methadone and buprenorphine, labeling them as drugs. As a consequence, we don’t have enough treatment available, and what we do have is not always regulated. We need to integrate treatment into primary care, and to give it the same attention as other chronic health conditions. We need to make sure everyone has insurance coverage, and that coverage is generous for substance-use disorder treatment, including for medications, counseling, and care. We need to make it as easy to prescribe buprenorphine as it is to prescribe any other opioid medication, and to make methadone available as a treatment through health care, rather than limiting it to separate programs. We need to make it easy to find care, at any time and in any place, and to get and stay engaged with it. Treatment needn’t be finite—it should be person-centered, responsive to individual need, just like primary care.
What gives you hope when it comes to reducing the number of people dying from overdose?
Other countries have faced this problem and reversed the trend. France made medications for opioid-use disorder, buprenorphine and methadone, easily available through their health care system, albeit with a national health insurance scheme already in place. Portugal decriminalized drug use and invested massively in health and social services to prevent and treat drug problems. Switzerland mounted a large-scale, coordinated harm reduction response, including safe consumption sites. It is entirely within the scope and capacity of the U.S. to dramatically reduce the harmful consequences of drug use and promote safe and healthy communities.