West L.A. isn’t the epicenter of the opioid crisis, but it’s here too

By Danny Karel

As little as two milligrams of fentanyl could constitute a lethal dose
Photo courtesy of the Drug Enforcement Administration

It is almost impossible to read, watch, or listen to the news without hearing about the unprecedented opioid epidemic that has gripped our nation by the throat. In 2017 alone — the latest year where victim totals have been fully counted — the CDC reported 70,237 overdose deaths in the United States, with 2,199 of them occurring in California. However, reports of the crisis’ impact within Los Angeles, and particularly the Westside, have been scant. But that doesn’t mean it’s not happening here, too.

John Shain is a substance abuse counselor who has worked on the Westside for almost five years. He’s the owner of Keep Left Recovery in Mar Vista, a private counseling business, which he founded after working for Muse Treatment in Culver City. Counselors like Shain have watched the opioid epidemic unfold from front-row seats, and he says he’s noticed some patterns among local clients.

“It usually starts with an injury of some sort, or they find the medications in their house — like either their parents had [an opioid] prescription, or their grandparents had a prescription,” says Shain. “And usually it just evolves into finding fentanyl and heroin.”

Fentanyl, a particularly powerful synthetic opioid, was implicated in the death of Los Angeles Angels pitcher Tyler Skaggs, an alumnus of Santa Monica High School.
Photo by Keith Allison

Fentanyl is a synthetic opioid that’s become the most terrifying player in the opioid epidemic. Fifty times more potent than heroin, it can be deadly when only “a few grains — as little as a quarter of a milligram” are ingested, according to a recent Los Angeles Times article. It has medical applications as a surgery anesthetic, and as a way to manage pain in terminal cancer patients, but illicit drug manufacturers have also recognized an upside. Compared to heroin, which is developed from poppy seeds and requires months to cultivate, fentanyl is much less expensive and less time consuming to produce. As a result, the drug claimed no fewer than 31,000 lives in the United States in 2018. It was also implicated in the recent death of Los Angeles Angels pitcher Tyler Skaggs, a Santa Monica High School alum.

“I would say 80% to 90% of my clients that I have dealt with in the past two years, either in treatment or privately, are all [using] fentanyl,” Shain says. “They tell me that heroin doesn’t really exist on the streets anymore; it’s mainly all fentanyl.”

Through his clients, Shain has also learned that where addicts go to find drugs is shifting towards the Westside.

“A lot of my clients over the past year haven’t been going to Skid Row, they’ve been going under the 405 freeway,” he says, mentioning the homeless encampment on the north side of the Venice Boulevard underpass. “You find paraphernalia all up and down Venice Boulevard, from needles to aluminum foil to you-name-it. Everyone knows it’s there. All of my clients know it’s there, and they know where to get it.”

Homeless Deaths Go Underreported

Despite the presence of drugs like fentanyl in the streets of a metropolitan area as large as Los Angeles, a comparatively few opioid-related overdoses — exactly 493 — were recorded in the city in 2018. However, that number is expected to climb as “pending” cases are closed. And although this figure represents an alarming 40% increase from the number of deaths recorded in 2016, it also means Los Angeles will continue to have one of the lowest overdose rates per capita anywhere the state. There are a number of ways to explain this, including factors related to L.A.’s ethnic diversity, the serious possibility that many deaths simply go unreported, and local preferences for other controlled substances.

Police officers in Santa Monica carry Narcan, a potentially lifesaving antidote to opioid overdoses, but rarely find occasion to use it, said Sgt. Erika Aklufi of SMPD’s Homeless Liaison Program.

“Compared to parts of the Midwest or East Coast, where they’re giving two or three cans of Narcan a night, we’re not seeing anything like that. When it actually pops up, it’s kind of odd,” Aklufi said in an interview late last year. “That being said, meth[amphetamine] is something we do commonly see. …

“When I started 15 years ago, we dealt with a bunch of drunks out on the street. If you had drugs, you were hard core. Now our drunks have become meth addicts — at least the great majority of them — mostly because it’s cheaper and the supply pipeline is broad.”

As of mid-October, Santa Monica police had logged 734 cases in which drug use was the only or primary offense, 189 of which (25%) indicated the suspect was homeless. That’s out of about 120,000 calls for service per year.

Decriminalization of minor drug offenses by the 2014 state ballot initiative Proposition 47 means police officers who confiscate drugs and paraphernalia are often forced to issue citations to suspects rather than take them to jail. Options to place drug users into addiction rehabilitation programs also remain scarce, however.

“Occasionally a bed will open up and we can get someone into treatment, but we need more of that,” Aklufi said. “We’re waiting for the county to build up capacity for treatment.”

Lello Temesa, an associate medical director with the Los Angeles County Department of Public Health, explained in an email why many opioid overdose deaths likely miss the final tally: “… when an opioid overdose occurs in the street or in the community, law enforcement or the fire department may or may not be called. If they are, this data is registered in their respective databases. … However, overdoses that occur in [a] community where law enforcement, the fire department or health systems are not involved are not consistently captured in our aggregate data. For that reason, overdose related data is likely underreported.”

Homeless communities, in particular, appear to be the locus of many unreported opioid overdoses, Temesa and others suggest. This is more than just tragic: Accurate victim totals are useful for organizations looking to allocate resources to combat the epidemic. They are also needed if responsible parties are to be held fully accountable. Unsurprisingly, the question of blame is both complex and contentious — the only thing generally agreed upon is that there’s a lot of it to go around.

Local Doctors Are Changing Protocol

While pharmaceutical companies like Purdue Pharma, maker of the deadly opioid OxyContin, are perhaps the easiest culprits to identify — in 2003, the company flatly ignored a warning from the FDA stating that its OxyContin advertisements “grossly overstated the safety profile” of their marquee drug, leading consumers to underestimate its powerful addictive quality — medical doctors, the ones actually writing the prescriptions, have also fallen in the crosshairs.

In response to the epidemic, two Marina del Rey doctors have decided to stop prescribing opioids to manage their patients’ pain. Dr. Hooman Melamed, an orthopedic spine surgeon, and Dr. Akash Bajaj, a specialist in interventional pain management, have independently developed and implemented alternatives that leave no chance for patients to become addicted.

“I put patients on what I call a non-narcotic protocol,” says Melamed. “I give them a cocktail of a few medications right before surgery, put them on an anti-inflammatory diet, then afterwards we continue on the anti-inflammatory diet.”

He believes that many doctors are aware of alternatives, but they tend to fall back on their medical training, which recommends combating pain with opioids. Too often, this leads to overprescribing.

“You follow this protocol. All the doctors go into [medical school] without asking why we are we doing this,” he says. “You just follow it, and when you come to practice you just follow protocol.”

Bajaj made a similar observation.

“A large part of it is the way we’re trained,” he says. “We’re trained very classically. I think it’s a matter of taking what we already know as doctors, adding common sense, and realizing there are superior alternatives.”

Bajaj has made use of ketamine in his own practice, a promising but controversial anesthetic most commonly known as a party drug, and Alpha Mac, a naturally occurring enzyme that inhibits inflammation.

Not All Users Get Hooked

Opioid alternatives seem to be working for Melamed, Bajaj and their patients, but their practices are still far from mainstream. Many, if not most, doctors still see opioids as the best remedy we have to combat pain.

Dr. David M. Cutler is director of Saint John’s Global Health Program and Chairman of the Santa Monica Family Physicians medical group. He’s noticed that, in response to the epidemic, many doctors are becoming more reluctant to prescribe opioids. This may seem like a step in the right direction, but for many patients, it means difficulty securing treatment.

“Most patients are not impacted by [addiction],” he says. “Quite frankly, they are inconvenienced by it, because they may require a small amount of opioids.”

Studies reported by the National Institute on Drug Abuse back Cutler’s assertion that the majority of patients who are prescribed opioids do not develop an addiction. However, the number that do develop a dependency still seems unreasonably high. For patients who are prescribed opioids to manage chronic pain, between 21% and 29% misuse their prescription. Between 8% and 12% develop an opioid addiction. Of those who misuse their prescription opioids, between 4% and 6% make the transition to heroin.

These statistics demonstrate why the epidemic requires novel solutions. Pain patients are caught between choosing to forgo narcotics and accept their pain — a route often taken, Cutler notes, in foreign countries — or to roll the dice and accept opioids, and the possibility of developing an addiction. Often, pain patients don’t know enough about the drugs to make an informed decision.

In the coming months and years, numerous lawsuits, organizations, governments, clinics, and individuals will attempt to battle the opioid epidemic on various fronts. At the same time, 130 people in the United States will continue to die every day. There are no indications that this number is going to decrease, at least any time soon. Statistics like these are not abstractions. The deaths they account for, along with the instances of addiction that precede them, are happening here, on the Westside.

“These problems evolve slowly and resolve slowly, so I don’t think there’s going to be any major change in the years ahead,” says Cutler. “Until we find better alternatives than opioids for pain, it’s going to remain a problem.”