Fentanyl, the potent synthetic opioid that surpassed the deadliness of prescription opioids, contributing to nearly 20,000 deaths in 2016, is particularly prevalent in New England. And Massachusetts has one of the highest synthetic opioid-related death rates in the nation, third only to New Hampshire and West Virginia.
While Lawrence reportedly had its own production hub, cheap white powder fentanyl is typically imported from China or Mexico and used to cut more expensive drugs, like heroin or cocaine, to improve profit margins and to trigger a more intense, fast-onset high. For now, fentanyl-laced heroin is more prevalent east of the Mississippi because it closely resembles the white powder heroin that’s widely used in the region. It’s harder to mix fentanyl into the black tar heroin commonly found west of the Mississippi.
Fentanyl’s short half-life means that the drug kicks in quickly and fades faster than a heroin high. To stave off withdrawal, people who use fentanyl might have to inject up to eight times a day, while people who inject heroin would typically inject two to four times daily to avoid withdrawal. Injecting more frequently means there’s a greater temptation to share needles if clean ones aren’t readily available through programs like needle exchanges.
Lawrence’s reported illegal manufacturing operation made the drug so cheap to buy there that many people in the area have turned to injecting pure fentanyl. To give a sense of scale, local production makes buying illicit fentanyl three times cheaper in Lawrence than it is in Lowell, and five times cheaper than buying fentanyl 30 miles to the north in Manchester, New Hampshire.
Complicating matters is the high homeless population in Lawrence and Lowell. Homelessness in Lowell nearly doubled between 2005 and 2017, according to the Department of Housing and Urban Development. HUD did not report city-specific data for Lawrence, but roughly 700 of Massachusetts’ 17,565 homeless individuals reside there.
And CDC investigator interviews confirmed what’s visually evident by walking along the cities’ Merrimack River, which is dotted with deserted sleeping bags, old clothes, liquor bottles and the occasional used needle: Everyone the investigators interviewed who reported injecting drugs had been homeless at some point during the previous year.
Everyone the investigators interviewed who reported injecting drugs had been homeless at some point during the previous year.
Homelessness “breaks up consistency and it makes sustaining care and continuity of care harder,” Alpren said, noting that incarceration, also highlighted in the report, similarly has the potential to disrupt HIV care and treatment.
For Judy Lethbridge’s clients at Lowell Community Health Center, many of whom are unstably housed, finding an affordable place to live is a pressing daily concern. Even with a housing voucher, rents in Lowell and in Massachusetts at large aren’t affordable, explained Lethbridge, the center’s quality coordinator. Often the vouchers that are available fall short of rent prices. Many times, the only neighborhoods that people with vouchers can afford are in the core of where local drug use happens. That structural instability makes keeping up with health services like addiction or HIV treatment nearly impossible.
“It’s particularly difficult to keep housing if you’re using, and it’s difficult to take your medication if you’re homeless,” Lethbridge said. “It’s all intertwined with the drug use.”
A City Without A Needle Exchange Is ‘Setting Up For Disaster’
Massachusetts is one of the few states that provides state funding to syringe service programs, but neither Lawrence nor Lowell had a state-authorized exchange before the outbreak. The ad hoc exchanges that did exist were not robust enough to counter the effects of fentanyl use.
“They may have had underground syringe service programs, but they did not have supported, funded, fully staffed syringe service programs,” Stopka said. “That’s true about many small cities throughout the country. That’s setting up a situation for disaster.”
Needle exchanges are a positive step toward reducing the spread of infectious disease from a public health point of view. But Mark stressed that people who use drugs often feel a sense of urgency to get high immediately ― especially if they’re going through withdrawal ― and increasing clean needle exchange hours would only make so much of a difference. When you’re addicted, Mark explained, you’re willing to suspend disbelief momentarily about a partner or friend’s health status.
“People just don’t care,” he said. “When it comes down to it, if you’ve got a bag in your hand and somebody next to you’s got a dirty needle, you’re not going to run and find a clean one.”
Abandoned clothing and sleeping bags near the Merrimack River are signs of Lawrence and Lowell's homeless population. In Lowell, the homeless population nearly doubled between 2005 and 2017. (Erin Schumaker/HuffPost)
Abandoned clothing and sleeping bags near the Merrimack River are signs of Lawrence and Lowell's homeless population. In Lowell, the homeless population nearly doubled between 2005 and 2017. (Erin Schumaker/HuffPost)
Still, there are advantages beyond the equipment itself. Stopka stressed that syringe exchanges provide a valuable link between doctors and people who use drugs.
“For many people in the throes of addiction, this is their only contact with public health services and health care services,” he said. “It’s essential for these programs to be in place.”
The state health department authorized Lawrence’s formal needle exchange after the 2016 uptick in HIV cases, and Lowell voted to authorize its own exchange in June. But neither exchange was fully established at the onset of the outbreak.
Even now, there’s a huge unmet need for clean needles, according to the report. The hours of the current exchanges are limited, and more syringes need to be distributed to discourage people from reusing and sharing needles. That’s like the rest of the country, where geographic, financial and social barriers to opening and running exchanges mean that far fewer people have access to clean needles than need them.
The Rest Of The Country Needs To Prepare
The case of Lawrence and Lowell isn’t the first large-scale drug-related HIV outbreak in recent years ― that distinction goes to Scott County, Indiana, where an HIV outbreak ballooned to more than 200 newly diagnosed cases in 2015. The culprit there was Opana, a prescription opioid that, like fentanyl, has a shorter half-life than heroin. In response, the CDC released a list of 220 counties most vulnerable to an HIV outbreak due to drug use in 2016. The bulk of the hot spots were clustered in Kentucky, Tennessee, West Virginia and Ohio.
No counties in Massachusetts made the CDC’s list, suggesting a myopic focus on rural risk factors at the time.
“Scott County shook everybody pretty hard,” said Jon Zibbell, a senior public health analyst at the nonprofit research group RTI International who worked on the CDC’s vulnerable counties assessment.
When it comes down to it, if you’ve got a bag in your hand and somebody next to you’s got a dirty needle, you’re not going to run and find a clean one.
Mark, a Lowell resident who stopped injecting heroin after contracting HIV from a partner
Zibbell said that some of the indicators the group used to determine which counties were vulnerable, such as race, may have skewed the results toward capturing rural areas with the same vulnerabilities as Scott County, and overlooking more urban localities.
“Doing that eclipsed all these other urban areas that were also at risk for an HIV outbreak,” he said.
Even at the time, Dr. Alfred DeMaria, a former Massachusetts state epidemiologist, thought focusing on rural counties would miss a swath of at-risk suburban and urban areas. “They were all places that looked like Appalachia,” said DeMaria, who helped lead the investigation this spring. “There are big issues in Lawrence and Lowell, and huge disparities, but they’re not exactly rural.”
Zibbell thinks it’s time for a follow-up assessment that looks specifically at vulnerable urban counties.
“We tend think it’s just rural areas that have limited access to syringe exchange programs,” said Regina LaBelle, who worked in the White House Office of National Drug Control Policy during the Obama administration. LaBelle noted that Lawrence and Lowell’s nascent syringe programs were reactions to an uptick in HIV cases.
“Unfortunately, we tend to solve yesterday’s problems rather than looking at how to prevent outbreaks such as this,” she said. “Now there’s an urgency to open it but unfortunately, too late for those who have been infected.”
“Lack of access to sterile syringes is paramount,” Stopka said. If people are injecting drugs in communities that don’t have reliable needle exchanges or pharmacies selling clean needles, they’ll likely be reusing and sharing syringes. The groundwork is then laid for an outbreak.
At present, 15 states ― primarily in the south and western U.S. ― have bans in place against needle exchanges.
“If it can happen in Massachusetts, which has all the support in the world and all the services in the world, it can happen anywhere,” Lethbridge said.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
