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Updated Feb. 12
When Philadelphia announced it would “actively encourage” a comprehensive user engagement site to help combat opioid overdoses, DEA agents were not thrilled.
In general, the U.S. Drug Enforcement Agency views safe-injection sites as facilitation of criminal behavior, and it’s entirely possible the agency will take some kind of enforcement action against the Philly site (if and when it gets built).
The federal agency prefers to focus on its own overdose-reduction strategy — which relies less on personal touch, and more on big data.
What data? Death reports.
Every year since 2008, the DEA has collected overdose data and entered it into a database. In 2014 it began publishing that info as an official Overdose Death Report. The database is then used to inform its tactical response in the field, i.e. to help decide where to target investigations and where to mount busts.
For its 2016 annual report, the latest, the Philly Intelligence Unit added a new partner to help it sort through even more numbers, with the goal of becoming more nimble in tracking highly deadly strains of opioids. That partner was the University of Pittsburgh’s School of Pharmacy Technical Assistance Center (TAC), which runs the OverdoseFreePA website, and whose experts can interpret data with the medical knowledge.
Partnering with TAC has allowed the agency to expand its data collection reach, according to a 2017 presentation, and increase the speed in which it receives reports on things like 911 calls, emergency room admissions, and emergency service.
“It’s the most accurate and comprehensive real time database there is to track overdose data across the state,” Supervisory Special Agent Patrick Trainor of the DEA’s Philadelphia Office told Billy Penn. “However,” he hedged, “not every county participates in it,” because of limited access, scarce resources, and other factors, especially in more remote or rural counties.
Some scholars in the field are skeptical the DEA’s information — even the new and improved collection — will be relevant enough to actually make a difference.
“Counting the dead bodies is not only old-fashioned, it’s simplistic,” said Dr. Daniel Ciccarone, Professor of Family Community Medicine at the University California in San Francisco. Ciccarone leads a project called Heroin in Transition, which explores “the economic, anthropological, historical, clinical and public health dimensions of [the opioid] crisis.”
“We have a rapidly evolving epidemic, and you’re not gonna dig yourself out of it using data that’s 3 months, 6 months, 12 months old, 18 months old,” he said. “We need more modern techniques.”
As lethal as AIDS
Dr. Jeffrey Hom, a policy advisor at the Philadelphia Department of Health, told Billy Penn the scale of the threat posed by opioid overdoses in Philly could be compared to that of HIV/AIDS.
“In the height of the HIV/AIDS epidemic in Philadelphia,” Hom said, “there were between 900 and 1000 individuals who died.”
Last year, he said, preliminary statistics indicate there were 1200 overdose deaths in Philadelphia. “This is absolutely a public health crisis of epidemic proportions.”
The opioid-related stats have been steadily getting worse. Hom counted around 900 overdoses in the city in 2016, per a presentation given to the Mayor’s Task Force to Combat the Opioid Epidemic, a 20 percent jump from last year. That’s three times the number of homicides and more than 10 times the number of traffic fatalities in Philly during the same time period.
If Hom’s preliminary stats bear out, overdose deaths in Philly will have doubled between 2017 and 2014, when there were 629.
The increase in ODs may be due to the increased spread of fentanyl, a synthetic narcotic that’s similar to heroin, but much more deadly. Dr. Hom said that about 90% of heroin toxicology reports in Philly in 2016 indicated the presence of fentanyl.
Statewide, 2016 saw a tripling in fentanyl-related overdoses in Pennsylvania, and by the end of the year the monthly toll had increased by a factor of nearly five, from 50 in January to 238 in December.
This is exactly the kind of thing the DEA wants to use data to track — and potentially reduce.
Data mining to spot deadly trends
“We used to hear about fentanyl in fairly sporadic events,” Agent Trainor said, “but in the past two years in Philadelphia county we’ve really seen fentanyl outpace heroin as the drug that we’re seizing.”
Heroin traffickers package and distribute product to street dealers in denominations of “bundles,” usually made up of gram-weight bags, Trainor explained. All bags in the same bundle contain the same type and grade of drug, each sold to a different user. So if an especially deadly batch of super-potent heroin-mix came on the market, it was sometimes apparent by the rash of close-timed overdoses it caused.
“There are 12 to 14 bags in a bundle, and it wasn’t uncommon, if you heard of 12 or 14 overdoses in a one day period, this indicated a hot batch.”
Agents used these patterns to perform a sort of plain-sight data-mining — it was a consistent pattern they could use to ascertain when a deadly-potent batch of drugs was in town, and respond with targeted enforcement.
With so many deadly batches occurring more frequently, the DEA wants to expand its sources of data and speed its ability to detect those fatal trends.
‘Death data’ gets old fast
So could Philly’s proposed CUES be a valuable source of additional data for the DEA’s effort, providing information that could prevent deaths by detecting trends in use? Not according to Trainor.
“Use trends are fairly widely known,” he insisted. “Unfortunately, the greatest indicator to all of us — whether that’s law enforcement, public health, treatment or medical community — is the fatals. Because if somebody takes a new drug out there and lives, we usually don’t hear about it.”
In Trainor’s view, it’s autopsies that provide the most valuable information. “We are able,” he said, “to obtain an awful lot of data, unfortunately, from people who died, because the toxicology indicates the presence of new or emerging substances.”
However, according to Ciccarone, the UCSF researcher, substances on the street change so quickly that once they’ve landed in a toxicology report, they’re often not being circulated anymore. Users on the street are onto the next thing.
“The reality of it,” he told Billy Penn, “is that time is always working against death data. Timely is weekly. Coroners can’t get weekly.”
The only practical way to test for deadly new mixtures before it’s too late to save the lives threatened by them, Ciccarone believes, is to have a means to test the actual drugs being sold on the street. Relying on autopsy reports means that “by the time [the DEA agents] get the data, that super batch is gone.”
Not that Ciccarone is opposed to efforts to improve the overdose reporting system. But he doesn’t necessarily think such a system should rely on coroners. “Coroners could be anyone,” he said, noting that they are not required to have formal training, as opposed to medical examiners, who must be licensed.
Dr. Hom, the Health Department consultant, recommended a holistic approach, noting that it’s important to seek information where it’s available — especially if timeliness is important.
“Fatal overdose data are important,” Hom said, “[but] I think also just recognizing that fatal overdoses are really only the tip of this very large iceberg that we’re facing here.”
What’s next?
The DEA seems committed to acting as tally-man, looking for patterns in the death toll to direct action on taking the most dangerous substances out of the supply chain.
And the agency won’t be looking to CUES as an addition source of data any time soon, Trainor made clear.
“We speak to a lot of people…and we all are working together to address the opioid epidemic,” Trainor said. However, he added, “I don’t think this is a surprise to anyone that no, the DEA as a federal law enforcement agency cannot come out and support or condone [safe injection sites] — and that’s kind of all we can say.”
On the other side, Ciccarone believes CUES may be, by definition, the perfect environment to detect the presence of a particularly deadly batch of heroin on Philly’s streets.
These are streets to which he is no stranger. In 2015, Ciccarone co-published a book for which he undertook an intensive ethnography that included lengthy interviews with users and dealers in Philly.
“I’ve spent a lot of time in Kensington, I know it well,” he said.
When an overdose occurs at a future CUES, said Ciccarone, not only would staff almost certainly be able to save a life with naloxone — there have been about 11,900 overdoses in total at supervised injection facilities in Canada and Australia, and no one has died, according to the AP — but the “hot batch” would be right there in the user’s syringe. Staff could test the dose and get much faster, more definitive results than a coroner can post-mortem, he said, after the body’s metabolism has altered the drug’s chemistry.
“People are going to bring in drugs from the street and those drugs can be tested on site,” he said, “and that gets you daily data that can be aggregated into weekly reports, which can tell you things like not just if fentanyl is around, but which stamps are being sold where.
This is critical, Ciccarone believes, because it is not so much the overall potency of fentanyl or other synthetics in the illicit market that has contributed to the current epidemic, but rather the wild fluctuations in potency from one “batch” to the next.
“It’s more than a drug problem. It’s a poisoning problem. It’s a contamination problem,” said Ciccarone.
“We have to get a little more clever about how we respond to it.”
