Covering statistics and misconceptions about opioid addiction in a recent forum, Clallam County Health Officer Dr. Allison Berry Unthank addressed the talk of the town: Medication-Assisted Treatment (MAT) facilities.
“What we know is the science is super, super clear that MAT works,” she said on Tuesday, Sept. 24 in the Sequim City Council chambers.
Unthank addressed an audience of about 40 people for the League of Women Voters’ opioid epidemic discussion.
“For most people, MAT is a period of years,” she said. “For some people they’re going to be on MAT for life. While on those medications, it blocks those receptors so they can function and it gives their brain time to repair.”
Unthank, a part-time physician at the Jamestown Family Health Clinic who also treats patients with opioid addiction, said she didn’t want to speak specifically about the Jamestown S’Klallam Tribe’s proposed medication-assisted treatment (MAT) facility, but noted she has no financial interest nor planning in the tribe’s Healing Campus.
Opiates’ reach
Unthank said the opioid epidemic has mostly been in rural counties across the country and that Clallam was hit harder than most rural counties in the state.
“As of 2016, we’ve had one of the highest overdose rates in the state,” she said. “We’ve been working hard to bring that down.”
Per 100,000 residents, Clallam County saw 62 opioid overdoses and 17 deaths in 2016, she said.
“Seventeen doesn’t sound like that many people, but the number of traffic fatalities we had was 11,” Unthank said.
In actual opioid overdose and death totals, the county’s numbers have gone down from 2016-2018:
• 2016: 62 opioid overdoses and 16 deaths
• 2017: 31 opioid overdoses and 10 deaths
• 2018: 30 opioid overdoses and 6 deaths
Unthank said preliminary numbers for 2018 stated there were only two deaths, but because of delays in toxicology reports through the coroner’s office, four more came in early this year.
“We did not do as well as we had hoped in improving overdoses,” she said. “That’s still better than where it should be, but this is something no one should be dying from. This is a very preventable thing. We like to get that number even lower.”
She said health practitioners and first responders believe the biggest reason for decreasing death totals was increasing access to Naloxone, or Narcan.
Three goals for the Tri-County Coordinated Opiate Response Project, a team of health officers and various elected and stakeholder officials from Clallam, Jefferson and Kitsap counties, includes: safer prescribing, increasing access to Naloxone, and increasing access to evidence-based treatment. Slide courtesy of Dr. Allison Unthank
Goals
A member of the Tri-County Coordinated Opiate Response Project, a team of health officers and various elected and stakeholder officials from Clallam, Jefferson and Kitsap counties, Unthank said the group set three goals: safer prescribing, increasing access to Naloxone, and increasing access to evidence-based treatment.
“We wanted to see if patients were taking pills and see if clinics have protocols,” she said. “We found out a lot of them weren’t.”
Unthank they’re “not pushing everyone to stop prescribing narcotics,” but instead, “trying to make sure everyone is safe about it.”
In recent years, she said, Clallam County physicians prescribed as high as three times as many opiates per person versus Washington state’s average. Now, however, local physicians prescribe at about 1.6 times that average.
She said from the most recent data available in 2012, Clallam County physicians were prescribing 76 pills per resident.
Unthank said it’s a misnomer that the number is high because of Clallam’s high elderly population.
“What we’ve seen nationwide, the number of opioid pills distributed doesn’t track with age,” she said.
Clallam County had an average of 50 and Jefferson County of 57, but that physicians there were prescribing less than half of Clallam’s rate, at about 28 pills per person.
“We’re very cautious how we prescribe to elderly people (because they) tend to be very sensitive to how they respond to medicine, so generally our elderly patients are on lower doses because we find they respond very strongly,” Unthank said.
The ample supply of pills being prescribed though were ending up on the street, she said.
“We’re working hard to change that,” she said.
Unthank said the No. 1 reason people start heroin is from pills, whether from a doctor’s office or someone’s medicine cabinet. She recommends patients lock prescriptions up.
Dr. Allison Unthank said Medication-Assisted Treatment does and does not do the following for opioid use disorder. Slide courtesy of Dr. Allison Unthank
About medication treatment
In 2018, Clallam County had more than 1,000 Medicaid patients living with opioid disorder, and Unthank said physicians know there are more in the county because it’s not counting those with private insurance and housing issues.
Of those diagnosed, Unthank said, about 45 percent have access to treatment right away.
“When we first started this treatment, the wait list was about three months, which is far too long,” she said. Since then, a few sites can begin treatment in two-three business days.
“It’s something we still need to work on,” Unthank said.
Currently, local physicians only subscribe Suboxone (Buprenorphine) and Vivitrol (Naltrexone) in Clallam County but no facility offers Methadone until a planned BayMark Health Services opens in Port Angeles.
She said all three medicines interact with opiate receptors and “if dosed appropriately they take the extra ones offline so you can feel normal.”
“Once we find the right dose for them, if you ask them how they feel, they feel fine. They don’t feel highs or withdrawals. They just feel normal,” Unthank said.
Suboxone and Methadone help withdrawals, she said, but Naltrexone does not because a patient must go through withdrawals first before being able to start it.
The treatment medications can prevent someone from feeling high if a patient were to take heroin making them less likely to relapse, she said.
Unthank said the biggest reason people relapse is because withdrawals feel terrible.
Referencing a 2003 study in The Lancet, she said 90-plus percent of people fail on abstinence from drugs.
“While it sounds good on its face, it just doesn’t work for a vast majority of people,” she said.
Researchers no longer compare abstinence versus treatment programs because they feel it’s unethical because patients might die.
Objection
During a Question and Answer session, Jodi Wilke, president of the group Save Our Sequim, attempted to contest some of Unthank’s data points but was stopped as she didn’t present a question immediately.
After the meeting, Wilke said some of her points of contention included how much availability there is in Clallam County, treatment turnaround times, abstinence rates and more.
Citing research from the group’s webpage, Wilke said once Baymark opens in Port Angeles, one in 81 county residents could receive treatment in the county but once the proposed Jamestown MAT opens it would be about one in 66 residents.
Wilke compared Pierce County, one in 435 residents having access to treatment, and that with the Jamestown clinic opening, it would significantly increase capacity here.
“The question it begs is whether the lack of treatment in the metropolitan areas will drive this (opioid use disorder) population in our direction,” she said.
Wilke also questions the treatment availability in Clallam County because Olympic Peninsula Health Services, who offers MAT services, in Port Angeles is only open three days a week.
She also said that Methadone can get people high in higher doses going against prescribed doses.
“Drug addicts divert drugs often and are also prone to manipulate providers into increasing doses,” Wilke said.
“Most will do what it takes to get high, including combining Xanax and meth amphetamines with methadone to get a similar effect as heroin.”
Wilke also said everyday people are only a part of the people who face addiction.
“This is not the face of the people living on the streets of PA or in the camp in Aberdeen,” she said.
“To focus on the population that is not troublesome as if it was representative of the whole gives an unreasonable, perhaps even negligent perception that we have nothing to worry about at all.”
Clallam County Health Officer Dr. Allison Berry Unthank answers questions about MAT clinics and treatment
• Do MATs get you high?
“A MAT dosed appropriately does not,” Unthank said.
“But if you give a pile of Methadone to someone whose never had Methadone before, yes you can make them high. So don’t.”
MAT patients function just as well or better than those going cold turkey at driving, their jobs, school and more, she said.
MATs aren’t exchanging one hard drug for another, Unthank added.
“Methadone is a long acting opiate. It’s kind of slow on, slow off. Suboxone is a partial activist and can’t get high if you try. Naltrexone is just a blocker,” she said.
“These are not the equivalent of heroin.”
For MAT, Unthank said, patients don’t show up, get pills and leave. They can be treated for a number of things along with addiction and receive standard care such as pap smears, mammograms and more.
She said physicians try to screen for mental health disorders and provide the counseling and care they might need.
who is addicted
• Who is addicted?
Unthank said you cannot tell who is addicted and not to opioids.
“There’s no particular group that gets addicted to opioids,” she said.
One of the largest groups of addicts, Unthank said, is doctors because they have access to money.
“It’s not going to show,”she said. “We don’t have to steal. until you really fall off the wagon, you can’t tell.”
• Are addicts dangerous?
Unthank said there’s no data for that.
“There are drugs that can make you more dangerous. Opiates are not one of them,” she said. “Opiates make you go to sleep. They don’t make you rage at the people in your life.”
She said her MAT patients “are some of the most rewarding to work with.”
“They are interested in improving their lives,” Unthank said.
While there isn’t a 100 percent success rate, Unthank said no treatment she does is for everyone but she finds her MAT patients do a better job of controlling than most of her other patients with chronic conditions.
• Where will patients come from?
With current MAT capacity for local clinics, Unthank said Methadone is the best treatment for people and the only people they can gain access to it is off the Olympic Peninsula.
She said the only busing she knows of is from Clallam County to Aberdeen, Everett and/or Tacoma daily.
“To me that’s dedication to sobriety,” she said. “We want to get people access to the treatment they need.”
Unthank said she doubts people will come from big cities for treatment.
“You can go down the street (in Seattle) and get treatment,” she said.
“The only people busing people is us. Cities are taking our patients, which luckily they’re willing to do,” she said.
If people receiving treatment do move here it’ll be likely to move with family, she said, but not in large influxes.
• The Jamestown S’Klallam Tribe receives a higher reimbursement rate from Medicaid patients. What will they do with the money?
Unthank said any profits are, by law, to be reinvested back in health care.
At a League of Women Voters opioid, Dr. Allison Unthank, Clallam County health officer, said you cannot typically tell who is addicted to opioids. “There’s no particular group that gets addicted to opioids,” she said. One of the largest groups of addicts, Unthank said, is doctors because they have access to money. “It’s not going to show,”she said. “We don’t have to steal. until you really fall off the wagon, you can’t tell.” Sequim Gazette photo by Matthew Nash
On whether people will come to Clallam County for Medication-Assisted Treatment, Dr. Allison Unthank said she doubts people will come from big cities for treatment. “You can go down the street (in Seattle) and get treatment,” she said. “The only people busing people is us. Cities are taking our patients, which luckily they’re willing to do.” Sequim Gazette photo by Matthew Nash
At a Sept. 24 League of Women Voters forum, Clallam County Health Officer Dr. Allison Unthank presented the following misconceptions to a crowd of about 40 people. Slide courtesy of Dr. Allison Unthank
