Fentanyl, meth users present uniquely difficult challenges for Washington’s SUD-focused healthcare workers to treat


Shane Ersland


Inadequate living situations, unaddressed trauma, and lack of access to healthcare services are all factors that contribute to substance use disorders in Washington, according to experts who spoke at the 2023 Washington State of Reform Health Policy Conference


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Brad Finegood, strategic advisor at Seattle & King County Public Health Department, said 46% of the 1,007 people who died of drug overdoses in the county last year were either living unsheltered or in supportive housing.

“We know that one of the factors that leads to opioid use is trauma, and people living unsheltered,” Finegood said. “Seventy percent of those overdoses are fentanyl related. When you take out fentanyl, drug overdoses have actually trended a small bit down over the past number of years.”

Overdose data is incomplete, however, as many people—including individuals from communities of color and drug users—who experience overdoses don’t call 911 due to mistrust, Finegood said. 

“Even with that, the number of nonfatal drug overdoses increased to 5,206 last year,” Finegood said. “So for every fatal overdose, there’s about five nonfatal overdoses that are treated in our system.”

Jess Molberg, senior director of behavioral health at Coordinated Care, said the state needs more infrastructure to support co-occurring treatment for trauma.

“We just don’t have enough of it,” Molberg said. “And the [facilities] we do have are consistently at capacity. We can get them into a program, we can address the opioid, the alcohol use disorder. They’re there [for] 28-30 days. But then you’re discharged and where do you go? That trauma still exists.”

Washington needs to build a continuum that is supportive of individual traumas and treatment preferences, Molberg said. 

“We still have a lot of abstinence-based programs,” Molberg said. “There is still a lot of stigma for [medication for opioid use disorder] (MOUD) out there. I still see patients get rejected from facilities because they’re on MOUD and they say, ‘We’re not going to take them.’” 

Hon. Nathan Schlicher, MD, legislative affairs chairman for the Washington State Chapter of Emergency Physicians, said a prime example of a group of people who cannot access the services they need are those who have histories of violence.

“If you’re violent, no facility will take you,” Schlicher said. “The moment you assault somebody at the homeless shelters, you’re banned for three months, maybe a year. So 46% are unhoused. When they’re suffering an overdose, they’re now out of our health system. If they’ve assaulted staff at treatment facilities, the treatment facilities will say, ‘No, we’re here for voluntary treatment. We’re not in the violence game.’

So we’re left with folks that are struggling with addiction. Sometimes that addiction is driving their violence or at least exacerbating it, and there is no one willing to help them. They’re a high-utilizing, highly vulnerable population. They’re in the ERs 40-60 times a year. They’re getting involved with law enforcement, getting lots of services in our community. What are we going to do for those folks that have burned all their bridges and now can’t get access to care?”

Individuals addicted to methamphetamines can present especially complicated challenges that are often expensive, Schlicher said.

“It’s got huge cardiovascular impacts [like] heart disease, stroke, psychosis, mental health, [and] schizophrenia,” Schlicher said. “I’ve had shifts [where] 60% of my patients are there from meth-related pathology, but not meth treatment, not meth psychosis even, because of their cardiovascular [afflictions]. How are we going to tackle this because this is a very different issue?”

Meth is a stimulant, and Schlicher’s patients often use it as a makeshift treatment for homelessness or survival, he said.

“[They] work mainly night shifts or swing shifts because being on the streets is dangerous,” Schlicher said. “They use meth to stay awake so they can sleep during the day when it’s safer. That’s what they tell us. They’re using it as an adolescent housing solution, kind of a survivor mechanism.”

Molberg said California’s new Heart Plus Program could present an effective treatment model for Washingtonians.

“It’s starting this year as a response to the increase in meth use,” Molberg said. “Individuals that are picked up by law enforcement are referred to this program. It’s a 12-week program and they see a cardiovascular specialist, receive drug therapy support, [and] are connected to a case manager to address social determinants of health.”

The program utilizes contingency management methods, Molberg said. 

“The state is paying for, essentially, rewards operant conditioning,” she said. “Because we know that abstinence-based [treatment] doesn’t always work for everyone. So if you come in and have a negative drug screen, you’re going to get $10. And it’s $10 every time you come in twice a week. We see a larger change through any therapy with operant conditioning with contingency management with a positive reinforcement, rather than just withholding someone from a substance.”