Report stokes fears as drug deaths soar

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Photo illustration by Hard Knox Wire

As expected, the release last week of the Knox County Medical Examiner’s annual report on drug-related deaths didn’t bring any good news.

In 2021, no fewer than 533 people died from fatal overdoses in Knox County, a 29 percent increase over the previous year, according to the report. An increasing number of deaths involved fentanyl and fentanyl analogues, usually sold on the street as heroin.

The opiate epidemic has been raging without letup since the early 2000s despite the strenuous efforts of police and prosecutors armed with ever harsher criminal penalties for drug offenders. Faced with a seemingly intractable crisis, local officials have tentatively begun to experiment with so-called “harm reduction” strategies as well as diverting addicts toward treatment rather than jail.

But the ever-growing death toll is leading to frustration over the apparent lack of progress. In last week’s report, Chief Medical Examiner Dr. Darinka Mileusnic-Polchan argued that maybe it’s time to “reevaluate” harm reduction strategies. 

To say that her suggestion has triggered concern or even fear among some of those on the front line of the local Drug War is an understatement.  

“These deaths are all preventable”

The 2021 report contains 30 pages of statistics and graphs detailing drug overdose deaths in Knox and Anderson counties, plus a two-page essay from Dr. Mileusnic-Polchan in which she discusses her findings as well as possible strategies for ending the epidemic. She couldn’t be reached for comment. (The report can be found here: https://www.knoxcounty.org/rfc/pdfs/KCRFC_DRD_Report_2021.pdf)

Of the 533 overdose victims last year in Knox County, 475 were white, 54 were Black, one was Asian, and three were described as “other,” according to the report. 

“The ratio of Black to white overdose deaths continued to be about 1: 9, which is reflective of the community’s demographic composition,” she noted.

Approximately 60 percent of the Knox victims were male and 40 percent were female, the reports said, with people between the ages of 34 and 40 suffering the most deaths of any age group. The largest percentage increase by age group, however, fell upon those between 55 and 64 years old. 

“Unfortunately, mixed drug intoxication continues to be the leading cause of death and fentanyl, fentanyl analogues, and some of the novel (new) synthetic opioids continue to be the most abused drugs. Methamphetamine remains the stimulant drug of choice, frequently used in conjunction with opioids. Alcohol continues to be in the top five most frequently abused substances leading to sudden unexpected death or death without medical attendance,” she wrote. 

Chief Medical Examiner Dr. Darinka Mileusnic-Polchan (Source: University of Tennessee Medical Center)

Also, 30 percent of the fatal overdose victims were taking anxiety, anti-depressant or anti-psychotic medications when they died.

To put those numbers into perspective, at least 1,740 men, women, and children died of overdoses in Knox County between 2017 and 2021. That means that more Knox County lives have been lost due to the opiate epidemic than to COVID, the Spanish Flu, or both world wars. 

For most of the 2000s and early 2010s, the majority of overdose deaths were caused by legal opiates like morphine and oxycodone. In recent years, however, most overdoses have been caused by the illicit opiate painkillers heroin and fentanyl, which replaced their legal cousins on the black market when the government cracked down on how narcotics could be prescribed. 

While the current opiate epidemic has raged for almost a full generation, local officials involved in treating addicts believe that significant progress was being made until the COVID-19 pandemic hit in early 2020, according to Karen Pershing, executive director for the Metro Drug Coalition.

Pershing said the number of overdose deaths had been dropping through the first three months of 2020, and there’s every reason to believe they would have continued to fall had the pandemic not happened.

The ongoing surge in deaths since then has been made all the more tragic by the fact they could have been avoided, she said.

“We are losing more than one person per day in Knox County and this is completely unacceptable. These deaths are all preventable,” said Pershing. “The data is showing that fentanyl and fentanyl analogues continue to be found in a large portion of these deaths.  We are also seeing alcohol-related deaths continue to climb. As a community, we cannot forget the toll excessive alcohol misuse has on individuals and families. Mixing alcohol and certain prescription medications and or illicit substances can be extremely dangerous.”

She explained that fentanyl is no longer found packaged only as heroin, which makes using almost any illicit drug a potentially lethal gamble.

“Due to the tainted drug supply, recreational use could be as life-threatening as those who have a substance use disorder,” she said. “As adults, we need to be having conversations with our kids and youth about the fake pills that are on our streets that are laced with deadly fentanyl. One pill could potentially take the life of someone who’s system is naive. Don’t ever think, NOT MY KID!”

Officials from the Knoxville Police Department, Knox County Sheriff’s Office and Knox County District Attorney General’s Office either declined to discuss the report or didn’t reply to requests seeking comment. 

Maps showing the locations of nonfatal overdoses (top) and fatal overdoses (bottom) in 2021. Source: Knox County Medical Examiner’s report.

“It may be time to reevaluate” 

Debates over how to combat illegal drug use in the United States have raged since the opening years of the 20th century when the first federal laws restricting drugs like alcohol, cocaine and opiates were passed. Alcohol was eventually legalized again, but virtually all other intoxicants remained illegal and eventually their users became subject to strict societal taboos as well as criminal prosecution.

Nowadays, the vast majority of the medical community that studies and treats opiate addiction maintains it’s a complex public health problem rather than a moral failing. Put simply, they say, addiction is primarily a brain disease and any policy that fails to recognize this fact is doomed to failure. 

Drug experts tend to recommend treatment, so-called “maintenance” programs, and the widespread availability of naloxone, a drug that can reverse an opiate overdose. They view addiction as a chronic disease and focus on managing complications and preventing deaths. 

Those on the other side of the debate, however, have dominated the issue politically for most of the last century. They tend to reject the disease model (at least in part) for the belief that addiction is a sin or moral weakness that’s best handled by punishing users until they sober up. 

They generally endorse continuing the Drug War, the mass incarceration of drug users and “zero tolerance” policies. They’ve usually gotten their way at both the state and federal levels, with the result that billions of dollars have been spent creating the largest prison system in the world. The fact that the number of both arrests and deaths have grown steadily isn’t necessarily seen as a major problem, since the goal isn’t saving lives but rather taking a moral stand against drug use. 

It’s not clear where Dr. Mileusnic-Polchan comes down on this issue — after all, plenty of people stand firmly in the middle of the two extremes — but her comments in last week’s report have left those in favor of the disease model more than a little concerned.

“It was incredibly disheartening to see many of the deceased individuals investigated by the RFC had records of completion (or multiple visits to) different drug rehabilitation programs and facilities prior to death,” the medical examiner wrote.

“With that in mind, it may be time to reevaluate many of the programs and  measures that have been instituted to combat this problem including medication-assisted treatments, availability of naloxone, and needle exchange programs, just to name a few,” she said.

She then turned her attention to the causes of the opiate epidemic, citing a long list of possible culprits that sound familiar to anyone who’s paid attention to the Culture Wars that have come to dominate American politics.

“The answer to why the opioid problem plagues us might be as diverse as the number of victims,” Mileusnic-Polchan wrote. “They could include the breakdown of nuclear familiar structure, peer pressure, negative influence of entertainment culture, loss of motivation and/or zest for creative and/or productive life, loss of moral values, loss of faith, sequelae of adverse childhood events or abuse; the list is unending.”

She added: “The call for preventative action should be universal and it starts in our homes and our schools.”

Chart showing where overdoses took place in 2021 from the Knox County Medical Examiner’s report.

“Drug use … will not be ended”

Dr. Lesly-Marie Buer has a somewhat different take on addiction. 

“Drug use has been a part of human history for thousands of years and will not be ended. What we can do is decrease the rates of overdose mortality and morbidity as well as morbidity and mortality from HIV, hepatitis C, soft-tissue wounds and other infections,” she said.

Buer, the research director for Choice Health Network, is a self-described “harm reductionist” whose efforts have helped put large quantities of both naxolone and clean syringes on Knoxville’s streets.

In fact, had it not been for the 60,000 doses of naxolone that Choice Health Network has handed out in Knoxville and other East Tennessee communities, last year’s death toll would have been far higher, according to Buer.

“Participants used over 7,500 of those doses to reverse 3,442 overdoses,” she said. 

Buer pointed out that overdose deaths have been sharply curtailed where authorities have been willing to direct their efforts away from treating sick people as criminals or pariahs.

“We have decades of research from the U.S., Canada and Europe to give us peer-reviewed evidence-based solutions. Some of these solutions include: widespread naloxone distribution; widespread availability of drug testing (including, but not limited to, fentanyl test strips); safer consumption spaces; safer supplies for injection drug use; access to supplies for routes of transmission that are safer than injection (like access to snorting and smoking kits); easy access to evidence-based substance use disorder treatment programs (buprenorphine and methadone are the gold standard); easy access to quality health care (mental health, primary care, pain management, dental care); and access to a safe drug supply,” she said in a written statement to Hard Knox Wire. “There are also structural factors, including access to jobs that pay a living wage; safe and affordable housing; and safe and quality education.”

She continued, “There are many factors, but that is the point. There is no silver bullet solution. Decreasing overdose mortality requires deep investment in communities over decades.”

When asked about her reaction to the report, Buer replied, “From speaking with harm reduction program participants, community members and harm reductionists across the country, Choice Health Network is seeing the continued fallout from the pandemic and resulting economic deterioration. When individuals, families and communities lose sources of income to pay for basic needs, and the licit economy doesn’t meet those basic needs, people will rationally turn to underground economies to survive. We also know that depression and anxiety accompany economic inequality and poverty. When mental health services are not available or accessible to help deal with that depression and anxiety, the most accessible self-care or coping strategy may be drug use.”

It’s no surprise that passing stricter criminal laws with longer sentences hasn’t helped, she said.

Dr. Lesly-Marie Buer

“As several law enforcement officers have told us across the Appalachian region, we cannot arrest our way out of this problem,” she continued. “From both long- and short-term studies, we know the legal system is ill-equipped to address a public health catastrophe. Policies targeted at decreasing drug supply do not work, and nearly 50 years of evidence demonstrates the ineffectiveness.

“In the short term, we know placing people who use drugs in jails and prisons does not decrease use, but instead places them at much higher risk of overdose when they reenter society. When our harm reduction participants enter the legal system, they accrue immense expenses they cannot afford. That creates debt that is nearly impossible to repay with low-wage work, which can encourage people to join or rejoin the underground economy to pay legal fees.”

As for the report’s suggestion that harm reduction programs are ineffective and should be reevaluated, Buer countered that very few addicts receive effective drug treatment or any other kind of help.

“Substance use disorder treatment remains incredibly underfunded, and there simply are not enough affordable spots at programs that are evidence-based,” she explained. “In states such as Kentucky that have Medicaid-expansion or have had periods of Medicaid-expansion, government insurance pays for more treatment. However, in a state like Tennessee, very few of our harm reduction participants qualify for government insurance, and the vast majority are uninsured. Even if spots in treatment programs are available, many of our participants cannot afford it, and buying drugs remains cheaper. Inpatient programs are especially expensive, and affordable spots are not locally available. Mental health services, too, are expensive and often inaccessible because of lack of availability.”

A general lack of funding, in fact, prevents many programs from being effective. 

“Harm reduction remains even more underfunded than substance use disorder treatment,” she said. “Programs in Tennessee cannot receive funds from the federal, state or local government for many supplies, such as syringes, that are imperative not only to operate a program, but also to prevent skin infections and transmission of HIV and hepatitis C. Harm reduction programs in Tennessee are left to piece together funding sources that do not meet the needs in communities.”

Terry Wright, a homeless woman pictured here rolling cigarettes for money, said she’d be dead if it wasn’t for the easy availability of naxolone. Photo by J.J. Stambaugh.

“I’d be dead right now”

Even the suggestion that the widespread distribution of naxolone or syringes should be reevaluated is enough to terrify those with firsthand experience of addiction. 

After reviewing the report on Saturday afternoon while sitting together on the front lawn of a church in the so-called “Mission District” downtown, a group of homeless men and women described their experiences with the naxolone (also called Narcan) provided by Choice Health Network and other groups. 

Terry Wright, an Anderson County woman who said she became homeless a couple of years ago due to family problems, talked while rolling cigarette after cigarette and selling them to passersby for a dime apiece. She used the plunger from an old syringe to pack tobacco into the paper tubes.

“We police ourselves down here for the most part, even with ODs and stuff,” she said. “Rarely does 911 get called. We resuscitate people when we need to.”

According to Wright and her companions, pretty much everyone carries Narcan with them, even people who don’t use “boy,” the favored slang term for heroin and fentanyl. 

“Most people have it,” she said. “If someone ODs and you don’t have any, then somebody’s got it and you just call them over … You breathe for them, you Narcan for them, and in most cases they come out of it. I’ve done it 20-something times now.”

As far as Wright is concerned, any disruption to the flow of naxolone would have dire repercussions. 

“I know without Narcan that a lot more homeless people would be dead right now,” she said. “I’d be dead right now. You never know what you’re getting when you buy something, and it’s easy to OD even when you’re careful.”

A few blocks away on Central Avenue another group of homeless people gathered in the shade behind a couple of businesses. No one was willing to give their name, but every one paid close attention as the report was read aloud by a young man who wore dark jeans and a hoodie despite the stultifying heat. 

“What in hell are they talking about?” the young man asked as he scrolled through the document on his cell phone. “I mean, the law acts like they want us dead anyway. Is that the plan here? Seriously?”

A slight woman who walked with a cane shook her head as she listened. “This is just scary,” she said. “They’re fixing to make things a thousand times worse out here than they already are, and they’re way bad enough right now.”

J.J. Stambaugh can be reached at jjstambaugh@hardknoxwire.com.

Published on June 20, 2022.

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