Beyond the Numbers

The terrible news arrives on her third day in jail. Joanna Churchill’s brother has died from an opioid overdose.

She has just begun a three-month sentence for a probation violation linked to a long string of drug-related convictions and her own opioid addiction. The 33-year-old’s incarceration will prevent her from attending her brother’s funeral. Alone with her thoughts in a southwestern Pennsylvania correctional facility, Churchill grieves.

Then, a month later, there’s more devastating news. Her fiancé, and the father of her two preteen children, has died from an overdose as well. Another funeral takes place far outside her jail cell walls as she tries to come to grips with the loss and the choices she will face upon release.

This wasn’t the life Churchill (not her real name) once envisioned for herself or her family. Yet, her journey has followed a path familiar to so many who become addicted to opioids, a class of drugs that includes heroin, certain pain relievers, and synthetic drugs like fentanyl. It began when she was a teenager.

“I started with pills,” she says. Soon, Churchill became hooked. When the prescriptions became increasingly difficult to obtain, she turned to heroin. She isn’t alone.

Opioid addiction is a national crisis in the United States. As agencies across the country work to address the causes, help its victims, and prevent further casualties, a team of researchers at the Pennsylvania Opioid Overdose Reduction Technical Assistance Center (TAC) within the University of Pittsburgh’s School of Pharmacy is on the forefront of an effort to find solutions and save lives­—through data.

Founded in 2016, the TAC has already partnered with nearly 50 counties across Pennsylvania to provide data-driven strategies for overdose prevention, intervention, and treatment. The center builds a collaboration among health professionals, first responders, public safety agencies, and community organizations, and then collects and standardizes their respective data. Once analyzed by the TAC, the data can provide a range of valuable insights including where, and to what groups, overdoses are likely to occur.

Washington County, about 30 miles south of Pittsburgh, is one of the center’s partners and home to Churchill and her family. Her experience with opioids is not unique locally or nationally. Beginning around 2010, heroin overdoses throughout the country increased significantly among users who first developed a habit through painkillers. Traffickers started importing or manufacturing synthetic opioids, like fentanyl, which are easier to acquire but deadlier than heroin. Drug deaths across the United States grew exponentially: 16,849 in 1999 to 37,004 in 2009 to 63,632 in 2016, according to the Centers for Disease Control and Prevention.

Pennsylvania has a particularly high rate of overdose deaths: 43 per 100,000 persons in 2017, compared to the national average of 22. In Washington County, which has a population of slightly more than 200,000, about 100 people die of drug overdoses annually—a far cry from an average of just six drug deaths per year from 1992 to 2001.      

“We used to just get calls about alcoholism,” says Erich Curnow, director of clinical and case management services at the Washington County Drug and Alcohol Commission. “While alcohol remains a problem, about six years ago calls about opioids began pouring in. Callers didn’t ask how to get their friend or family member sober in the next year. They asked how to keep them alive over the next few days.”

Like many other suburban and rural areas where opioid abuse has outpaced the rest of the country, Washington County’s networks of law enforcement agencies, courts, public health officials, and social services became strained. To complicate matters, Curnow says the responses felt “siloed,” or disconnected, a problem he and his colleagues were determined to address.

In 2016, Washington County approached the TAC to establish a partnership. Curnow says he was skeptical when the collaboration was first suggested. He had experienced many meetings that never resulted in any real change to the crisis. But the TAC group seemed different.

“They didn’t know us from a can of paint,” says Curnow. “But they listened.” The next time they met, “they had real ideas.”

Researcher and project director of the TAC Lynn Mirigian grew up in a small town in Indiana, a place not unlike the small Pennsylvania communities where the center has had the greatest impact. “I had heard about pills and painkillers growing up,” she says. “The problem was always hidden. I didn’t know the full extent until my involvement with the TAC.”

The work suits her well. As a youngster, science was a form of amusing discovery. “When I was growing up, I grew corn in different parts of the yard to see where it would grow quicker,” she recalls. “I tested different brands of markers to see how long they lasted.”

She trained as a biochemist and researched bone and teeth diseases at the National Institutes of Health in Maryland, studying cell stress and protein synthesis. Her days were spent in the laboratory. The thought nagged her: How could her work have a more direct impact?

Becoming the director of the newly formed TAC was “an opportunity to start a project from the ground up and learn from someone who knows how to change systems.”

That someone is Janice Pringle, a Pitt professor with the School of Pharmacy and the founder and director of the Program Evaluation and Research Unit (PERU), which houses the center and tackles research related to health services, patient safety, addiction treatment, and chronic disease prevention. The TAC grew out of methods she pioneered at Pitt.

Pringle collaborated with the Allegheny County medical examiner to improve overdose responses in the mid-2000s. That early partnership created a model she used to create the TAC’s approach: Extensive data collection from entities within the community—including first responders, law enforcement, courts, medical practitioners, and social service agencies—to build a comprehensive plan, free of silos, for tailoring more effective responses to specific situations.

For example, if coroner data demonstrated a significant number of overdoses occurring in people recently released from jail, a program might be initiated in which incarcerated individuals nearing release could receive extra assistance in their efforts to stay drug-free once they return to their daily lives.

That scenario actually unfolded in Washington County. The TAC’s analysis of the area’s overdose data revealed a high number of people who left the county jail, immediately returned to using, and overdosed, in part because their tolerance of the drugs had diminished. Under the TAC’s recommendation, the Washington County Drug and Alcohol Commission implemented a program creating access to Vivitrol, a prescription drug that blocks opioid receptors in the brain for a month, making it difficult to get high. Injections are offered to individuals leaving jail and have become a resource that helps them remain less inclined to use drugs.

Such a data-driven approach could be used to save lives everywhere and could help provide a plan of action for communities throughout the country, says Pringle.

For now, it’s limited to Pennsylvania, where in 2016 PERU received a grant from the state Commission on Crime and Delinquency to begin the TAC and develop a strategic plan for any Pennsylvania county that was interested. The center, located a few miles from campus in Pittsburgh’s Shadyside neighborhood, incorporates 12 researchers, most with public health backgrounds.

The work has taken some adjustment for Mirigian. “In bench research, I control every aspect of my data,” she says. “Public health data doesn’t work in the same way.” There are unknown and uncontrollable factors and “you have to keep the target audience in mind.”

She calls the TAC’s assistance to counties a “concierge service,” explaining that “they need you to understand what is happening at a local level. This is not the kind of problem you can fix by handing everyone the same 90-page guide.”

Pitt’s TAC team has honed an effective system to partner with counties across Pennsylvania. After receiving an invitation from a local official, they schedule a meeting with as many county groups as they can bring together. At that first gathering, they use a technique to get all the representatives from various agencies and offices to focus on mutual goals and long-term planning.

“Everyone in the room gets five sticky notes and Sharpies, and we ask a very broad question: What needs to happen today to eliminate overdoses in your specific county?” says Allison Burrell, a TAC research specialist. “We give them 10 minutes. All of this is done in silence.”

The sticky notes are then put on a board. “Law enforcement may have very different ideas than public health,” says Burrell. Usually some goals are shared, like an increase in addiction treatment options or further access to naloxone, a drug that can revive a person from an opioid overdose. The groups then discuss what each could do to work toward those common objectives.

The TAC researchers then come up with a three-year plan. “Goals are pretty broad because we want to be flexible,” says Laken Ethun, lead research specialist. “We break it down into monthly tasks.”

Once a plan is in place, the TAC continues to receive data from local partners. Some county medical examiners or coroners send in overdose reports as soon as death certificates are written. Other local partners may send in nonfatal overdose reports, drug arrests, or jail data, with more than 22 potential data sets to use to continue understanding the scope of the crisis in each county and what action can be taken in response.

This process has made the center’s Web site, OverdoseFreePA.org, a rich source for micro-data about overdose deaths across the state. Through the site, anyone can track how fatalities climbed over the years and parse out fatalities by race, gender, age, and drugs present, bringing the scope or pattern of the problem into clearer focus. It’s one of the only such online resources available in the country.

Data-prompted responses vary county by county. After working with the TAC, leaders in Beaver County, about 40 miles northwest of Pittsburgh, changed the scheduling and staffing of its ambulance services to have more personnel available at times when overdoses were most common. In places with an uptick in female users (a common trend in the national explosion of opioid usage), the TAC has recommended expanded childcare, which can enable some women to have more convenient access to support groups or to meet with case managers or parole officers.

The TAC’s planning has produced impressive results. The group contracted with an international research group to commission a study comparing the overdose death rates of counties with a TAC-backed strategic plan versus counties without such a plan. The preliminary results indicate that counties with a TAC plan are seeing fewer overdose deaths every month.

Pennsylvania Physician General Rachel Levine, the state’s top medical official, says the commonwealth’s Opioid Operational Command Center has been encouraged by the Pitt center’s work. She encourages every county statewide “to have a coordinated plan for overdose prevention, and the TAC is one avenue to achieve that.”

With the TAC’s help, Washington County has zeroed in on at-risk populations and is implementing plans that have had results. Curnow and other local officials credit the TAC planning with a dip in the overdose death rate between 2016 and 2017. In several Pennsylvania counties, the center has helped chip away at exasperating trends that seemed irreversible.

The center is just one of many initiatives underway at the University of Pittsburgh to address the opioid epidemic. At the Graduate School of Public Health, a series of pilot research projects is helping to fill in the knowledge gap surrounding opioids and their effects. Last fall, a modeling system developed by the Pitt Public Health Dynamics Laboratory was awarded a $1.2 million grant from the Centers for Disease Control and Prevention to apply the model to studying opioid use. Additionally, a taskforce initiated by Chancellor Patrick Gallagher and chaired by Chancellor Emeritus and Chair of Pitt’s Institute of Politics Mark Nordenberg outlined a framework for the University and other higher education institutions to address the growing national crisis.

When it comes to the TAC, Pringle says it’s not just the structure offered by the group that has created change; it’s the will of these communities, heartbroken by addiction and compassionate toward their neediest residents.

“We hope we will be proving that if you are a community that has the will to touch every individual affected by overdoses, then you can have an impact,” says Pringle.

As for Joanna Churchill—alarmed and distraught by her loved ones’ deaths and the continuing costs of addiction—she was able to take Vivitrol after her recent release from jail. For her previous releases, she says she got high within an hour or so. Not the last time. Almost a year later, she continues to fight opioid addiction, working each day to rebuild a healthier life.

This article appeared in the Winter 2019 issue of Pitt Magazine. 

Opening image courtesy of Getty Images.