November 12, 2019
Stigma still stymies some efforts in opioid battle
“I felt very bad for the addicts sitting in that room, having to listen to what people thought of them,” Moira Satre says of a Warrenton Town Council meeting last year. “It brought tears to my eyes.” A former nurse whose son died of an overdose, Ms. Satre founded Come as You Are (CAYA), a nonprofit coalition that has compiled a comprehensive list of resources, treatment options and support groups.
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“You suffer alone. You grieve alone,” says Culpeper librarian Dee Fleming, who lost her son to an overdose. Ms. Fleming has taken up the cause of getting local businesses to include the anti-overdose drug naloxone — widely known as Narcan — in their first-aid kits. She also advocates for clean-needle exchange programs.
The idea is so ingrained in our culture that a person makes a choice to become addicted,” said . “But, the research being done on brain development is showing how far that ‘choice’ someone makes when they’re 20 may have been predetermined by something that happened when they were 3 or 4 years old.”
— Rappahannock-Rapidan Community Services Executive Director Jim LaGraffe
By Randy Rieland
Piedmont Journalism Foundation
Her cry captured a crisis.
“I’m a heroin addict. Nobody cares. Nobody cares!”
Amanda Lambert watched the slight young woman screaming in anger and despair near the front steps of the Prince William-Manassas Regional Adult Detention Center. She couldn’t look away.
“She was maybe 90 pounds soaking wet,” recalled Maj. Lambert, director of support services at the jail. “My heart melted for her. I don’t know why. I’d never seen her before.”
The shouting continued after Ms. Lambert led the 23-year-old woman into a room at the jail.
“I’m a heroin addict,” she raged. “You don’t care about me. No one gives a s---.”
Her distress was so intense she was put in restraints to prevent her from hurting herself.
Maj. Lambert spent two hours talking with the woman, then showed up in court the next day and sat next to her during arraignment on a disorderly conduct charge. The judge released her, but Maj. Lambert managed to keep her at the jail until she could meet with Katrina King, one of the jail’s “peer navigators” who helps addicts get into treatment.
Within a day, the woman was on her way to a treatment center in Florida. Maj. Lambert said she has been clean about a year and recently has returned to the area.
“It’s one of our favorite success stories,” Mr. Lambert said. “There’s no doubt in my mind that if we hadn’t intervened, she would have gone back out and overdosed and died.”
It’s a feel-good story, but one that also lays bare a dark corner of the opioid crisis: the stigma of addiction. In this case, it’s reflected in the shame and hopelessness of a woman who sees herself as a social pariah with no expectation of help in regaining control of her life. But stigma also plays out in community resistance to recovery housing, doctors’ reluctance to take on patients needing substance abuse treatment and the persistence of the notion that helping addicts indulges them.
“There’s definitely still a stigma,” said Judge Melissa Cupp, who handles foster care and custody cases in Fauquier and Rappahannock counties. “People conjure up the image of a drug addict, but that’s often not who it is. If you met them at the library, you would have no idea of what had happened to them.”
The perception of substance abuse as a moral failing, rather than a medical issue, remains a stubborn stereotype. Research this year by The Pew Charitable Trusts found that 58 percent of those surveyed believed opioid addiction was something people brought on themselves.
But, the National Institute on Drug Abuse reports that 50 to 60 percent of addiction results from genetics. In fact, the children of addicts are eight times more likely to develop an addiction. Factors such as chaotic home environment or early childhood trauma also can play a role.
“The idea is so ingrained in our culture that a person makes a choice to become addicted,” said Jim LaGraffe, executive director of Rappahannock-Rapidan Community Services. “But, the research being done on brain development is showing how far that ‘choice’ someone makes when they’re 20 may have been predetermined by something that happened when they were 3 or 4 years old.”
Moreover, the seeds of the opioid epidemic were planted when doctors nationwide began increasing prescriptions of the painkillers in the 1990s, while the pharmaceutical companies underestimated their addictiveness. The companies aggressively marketed opioids even as overdoses and deaths rose dramatically after 1999.
Another notable statistic of the epidemic is that 80 percent of heroin users started on painkillers, according to research at Washington University in St. Louis. Many used opioid medications recreationally, but for some the first exposure came through drugs prescribed for an injury.
“How do you change the stigma? It’s not easy,” Mr. LaGraffe said. “We had ‘Just say no’ and the ‘War on drugs.’ It’s been treated as a criminal, and not a medical, issue. And it’s seen as personal failure, not that there may have been a lot of other things that led you to this point.”
“You grieve alone”
So, addiction remains largely a private struggle, and one reason such a small percentage of addicts seek treatment — estimated as low as 10 percent. Getting treatment would require going public and risking the potential consequences of losing a job, being spurned and facing judgment from a doctor.
“Stigma is prevalent not only on a personal level from family and friends, but also on a professional level, and that hinders people from seeking treatment because they feel they will be shamed,” said Carol Levine, a researcher for the nonprofit United Hospital Fund, who with Suzanne Brundage, co-authored a report titled “The Ripple Effect: The Impact of the Opioid Epidemic on Children and Families.”
“What happens is that people internalize it, so it’s not just what others think about you. It’s what you start to think about yourself,” Ms. Levine said. “Everyone is telling you that this is your fault.
“Then there’s the impact on the kids. They often don’t want to tell other adults about what’s going on in their family. They’re afraid they’ll be taken away from their parents or separated from their siblings.”
The stigma casts a wide shadow, extending beyond users to their families. And it can persist even after the person fighting addiction has died.
After Culpeper librarian Dee Fleming’s son Joe overdosed on cocaine and fentanyl, a man whose daughter had died in a car accident stopped by the library to offer condolences. At one point, he said, “Doing drugs is a pretty stupid thing to do. I think this is nature’s way of weeding out the weak ones.”
Ms. Fleming was stunned.
“I read comments like that online all the time,” she said. “But, when I heard it to my face, I thought, ‘This is what parents like me hear.’ We don’t get the casseroles brought to your door or the cards. You suffer alone. You grieve alone.”
Since Joe’s death, Ms. Fleming has taken up the cause of getting local businesses to include the anti-overdose drug naloxone — widely known as Narcan — in their first-aid kits. She also has become a believer in clean-needle exchange programs, as many pill takers switch to using syringes.
“I never thought I’d say that,” she conceded. But then a friend of her son’s stopped by her house. He was dating an active addict, who had learned she was positive for hepatitis C. He said he wasn’t injecting drugs, but had contracted hepatitis C from her.
“Hearing that story about how it was affecting people who aren’t even using changed my mind,” Ms. Fleming said.
Both the use of Narcan and clean-needle exchange programs are components of “harm reduction.” That public health strategy acknowledges drug use but focuses on minimizing its harmful effects. Critics say it implicitly condones substance abuse, and they feel more comfortable with treatment based on abstinence.
Stigma, not surprisingly, is at the heart of that debate, too. Harm-reduction proponents point out that not long ago government and law enforcement officials generally opposed increasing the availability of Narcan because they objected to the costs — financial and social — of saving drug users who would likely use opioids again. But as the opioid death rate has risen, opposition has waned. In fact, Narcan has become a standard tool that many police officers and sheriff’s deputies in Virginia’s Piedmont carry. REVIVE!, a free training program on proper use of Narcan, is now offered to the public.
A similar shift in attitude is occurring with medication-assisted treatment (MAT), in which medications that reduce cravings — along with behavioral therapy — are used to treat opioid addiction. In a field where the treatment model has long been built around abstinence, MAT has been disparaged as essentially replacing one drug with another. But a 2016 report from the U.S. Surgeon General described it as a “highly effective treatment option.”
That aligns with the belief that addiction is more a medical than a moral condition.
“With opioid use, the brain is bathed in a high level of dopamine and things are not the same anymore,” said Alta DaRoo, a board-certified addiction physician in the SaVida Health office in Culpeper. “That’s very similar to when somebody makes horrible diet choices and they become obese, or they develop hypertension or diabetes.
“We give them medication because we recognize those as medical conditions. I hope we can convince people in the general public that addiction is a disease process.”
Reducing cravings “keeps them alive and allows them to function,” said Ryan Banks, clinical services director of Rappahannock-Rapidan Community Services. “I’d like people to understand that we shouldn’t be judging people because they’re staying on Suboxone or methadone if that’s what is going to allow them to be successful in their lives.”
MAT had made inroads is in prisons and jails, which have become the front line in the opioid crisis. Research has found that users who have been incarcerated are at their highest risk of suffering a fatal overdose in the weeks after their release. More jails, including the Fauquier County Adult Detention Center, have set up programs where recovering users can be treated with medication, particularly Vivitrol, generally prescribed when an inmate is leaving jail because it prevents them from getting high if they use an opioid.
Since this summer, recently released inmates in Prince William County have been able to access MAT in a mobile unit that parks near the county health department in Manassas every Wednesday. They’re tested and provided with Suboxone, but also are given help to get into long-term treatment and therapy programs. Yet, some who have taken advantage of the service admit that they’re wary about doing so.
“They feel there’s a stigma with them going into that van,” said Maj. Lambert. “They’re afraid police officers and parole officers are going to see them. The staff in the unit has had to work very hard to convince them that the stigma is going away and everyone is on board with this.”
Needle exchange support lags
But another harm-reduction element — clean-needle exchange programs — hasn’t made much progress in the Piedmont, or in most of the state, for that matter. In 2017, the Virginia General Assembly passed a law permitting cities and counties to set up programs where people could trade in used syringes for clean ones. The impetus was a dramatic spike in new hepatitis C cases, especially among 18- to 30-year-olds. The number was 2-1/2 times higher in 2017 than in 2011, a direct result of drug users sharing needles.
The shift to needle use is reflected in overdose deaths. Prescription opioids were the leading cause of overdose deaths in Virginia until 2015, when deaths from both heroin and synthetic opioids, such as fentanyl, went ahead, according to state health officials.
The state Department of Health authorized needle exchanges in 55 communities where the rise in hepatitis C cases has been particularly alarming, including three in this region — Fauquier, Culpeper and Orange counties. Overall, the rate of hepatitis C in the Rappahannock-Rapidan Health District (Culpeper, Fauquier, Madison, Orange and Rappahannock) jumped 330 percent for that age group between 2013 and 2017.
So far, however, only three communities in the state have functioning needle exchange programs — the City of Richmond and Wise and Smyth counties in Southwest Virginia — while Roanoke is about to launch one. The reason for the slow response is that the legislation requires local governments and law enforcement agencies to sign off on opening a needle exchange, and they’ve largely resisted.
April Achter, population health coordinator for the Rappahannock-Rapidan Health District, has spent months making the case for needle exchanges to local officials. Ms. Achter cited research showing that providing clean needles doesn’t increase drug use and studies concluding that people who use exchanges are more likely to eventually seek treatment. She shared the estimated cost of treating hepatitis C — about $200,000 per patient — and noted that outbreaks are often followed by an upsurge in HIV cases. Ms. Achter also pointed out that exchanges reduce the risk of the public’s exposure to discarded dirty needles.
She acknowledged that it can be a hard sell. “When it comes to programs like needle exchange, the stigma puts a higher burden on us to provide more education,” she said. “We’re looking at it from a medical perspective. My role is not one of judgment, my role is one of protecting the public health.”
But Ms. Achter’s lobbying was unsuccessful. In August, the Blue Ridge Narcotics and Gang Task Force, composed of Piedmont law enforcement officers, rejected a needle exchange. But several members say the reason is legal not moral. Under state law, possessing a syringe containing narcotics residue is illegal.
“They’re asking law enforcement to turn their heads because of what they feel is a greater cause,” Culpeper Police Chief Chris Jenkins said. “Absolutely, we’re in favor of reducing hepatitis C and HIV. But, dirty needles are against the law in Virginia. Law enforcement is saying it’s not our role to turn our heads.”
Fauquier Sheriff Bob Mosier agreed. “I understand that this is part of the mission of the Department of Health. But if we observe a violation of the law, we need to take appropriate action. The state legislature needs to be involved. If they can change the law, it wouldn’t put law enforcement in an awkward position.”
“It’s hard to hate up close”
Recovery is a slow and tortuous process, whether it’s for a person climbing the biggest hill of their lives or a shaken community trying to find a way forward. There is no magic remedy, no straight-line cure. And stigma, a tenacious toxin, lingers.
But it matters that many of the victims of addiction are familiar, rather than faceless stereotypes from a distant, different place. As Jan Brown, founder and co-director of SpiritWorks in Williamsburg, put it, “It’s hard to hate up close.”
Moira Satre offered a more poignant perspective. “The minute it touches you, it changes everything,”
Ms. Satre is a former registered nurse whose son, Bobby, died of a heroin overdose in 2015 at 31. She subsequently launched Come as You Are (CAYA), a nonprofit coalition that has compiled a comprehensive list of resources, treatment options and support groups.
When you ask her about stigma, Ms. Satre brings up a Warrenton Town Council meeting last year when a proposal by the McShin Foundation to open a residential sobriety facility in the central business district was discussed. Several recovering addicts and parents of adult children who died of drug overdoses spoke in support of the plan. But opponents argued that having recovering addicts in the neighborhood would drive down property values. The plan was rejected.
“The things people said were really hurtful,” Ms. Satre said. “I felt very bad for the addicts sitting in that room, having to listen to what people thought of them. It brought tears to my eyes.”
At that same meeting, former Warrenton Mayor Powell Duggan spoke publicly for the first time about the death of his son, Dan, who overdosed at 38 in 2015. Mr. Duggan remembers it as something of a watershed moment because it motivated people to become more engaged in responding to the epidemic.
“Dan, he didn’t want others to know about his addiction,” he said. “He kept it private. I wanted to respect that. That’s why it took until that meeting for me to say something. But I thought the time had come to see if other people could be helped.”
It’s that kind of gesture that makes those tackling the opioid epidemic more hopeful, despite the challenges most rural communities face in providing critical services, from mental health care to treatment facilities and sober housing to public transportation.
“What makes me optimistic is that I know recovery is possible,” said SpiritWorks’ Ms. Brown. “People are getting better and staying well and being productive citizens. If we can bring the same resources to everyone in a community, everyone can have the same results.
Others point to the promise of a new, more open-minded generation of doctors, nurses, psychologists and social workers.
“These kids are ready to tackle this, they’re prepared to integrate it into primary care, and they’re not shy about talking about stigma and fear in the way that older generations are,” said Jodi Manz, the state’s assistant secretary of health and human services.
Small but meaningful breakthroughs are occurring. At Fauquier County’s jail, staff members now join in celebrating inmates’ sobriety milestones. At the Prince William Adult Detention Center, peer navigators — some who themselves were once incarcerated there — now play a pivotal role in getting inmates into treatment.
“We didn’t know how the staff was going to respond to working alongside former inmates,” Maj. Lambert conceded. “I mean, they’ve been told they can’t have relationships with these people. They’re bad people, right? It was a difficult culture change.
“But I’ve found that using peer navigators is the key. That’s the missing link in connecting with people brought in here.”
But Maj. Lambert doesn’t delude herself about how much work needs to be done, how hard it is to change a mindset about addiction that’s so deeply embedded.
“We’ve made great strides. But we don’t want to be setting people up for failure,” she said. “We want to be able to say, ‘Here’s your services. Here’s your treatment. Here’s your driver’s license back to help you get a job and support your family.’ Unless we wrap that all up, nothing will change.
“We’ve taken on a 1,000-piece puzzle. Slowly, we’re putting it together.”
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