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John Engebreth: Overdose rise is ‘the third wave of the opioid epidemic’

“We saw an 18 percent increase nationwide in overdoses in March, a 29 percent increase in April and a 42 percent increase in May,” said Engebreth, who heads Minnesota Outpatient Services at Hazelden-Betty Ford. 

John Engebreth: "Some people are calling this the third wave of the opioid epidemic. We’re seeing that the overdose increase is largely due to the rise in fentanyl being laced into many drugs that are being dealt around the country."
Photo by Joshua Coleman on Unsplash

Media reports about the impact of COVID-19 usually focus on  the number of hospitalizations and deaths caused by the virus. But another, less frequently reported — and often deadly — side effect of the global pandemic is a startling increase in the number of drug overdoses in the United States. 

John Engebreth, Hazelden-Betty Ford executive director of Minnesota Outpatient Services, has firsthand knowledge of this increase: His organization works closely with many individuals and families directly impacted by drug addiction and overdose. 

The numbers are startling, he said: “Overall, drug overdoses, not necessarily deaths — but overdoses in general — have been on the rise during this pandemic. We saw an 18 percent increase nationwide in overdoses in March, a 29 percent increase in April and a 42 percent increase in May. These are numbers that we all should be paying attention to.”

While Engebreth finds statistics like these distressing, he also said that his work with people directly impacted by substance use disorder (SUD) gives him a reason for optimism. “Every day I see people and hear stories of individuals who are taking their lives back from addiction,” he said. “There’s a lot of sadness about what’s happening with this pandemic and the chaos it is creating in people’s lives, but I’m grateful we’re able to provide hope and healing. Recovery gives me an endless amount of hope.” 

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Recently, I spoke with Engebreth on the phone from his office in St. Paul. He shared his perspective on the COVID-fueled overdose increase and the role he believes Hazelden Betty Ford can play in helping people climb back up from the brink.  

MinnPost: The national overdose rates you’ve told me about are startling. Are the numbers similar in Minnesota? 

John Engebreth: In Minnesota, there was a 20 percent jump in overdoses in 2019 compared to 2018. So far in 2020, we are seeing a 23 percent increase. This is all Overdose Detection Mapping data. 

MP: Why do you think overdose rates have risen in the last six months? 

JE: There are a lot of explanations. Some people are calling this the third wave of the opioid epidemic. We’re seeing that the overdose increase is largely due to the rise in fentanyl being laced into many drugs that are being dealt around the country. The first wave of the epidemic was medically prescribed opiates. The second wave was heroin. The third wave is happening because of highly potent drugs that can be manufactured without the poppy plant. All three waves are still in play.

MP: Can you explain why fentanyl is being mixed with other drugs? 

JE: Because of the pandemic, there are a lot of shipping and travel restrictions. The foreign shipping channels that usually move the substances used in opiates into the United States are being disrupted. Fentanyl is a synthetic substance that can be manufactured in this country. Partly because of this relatively easy access, the use of it is spreading. 

We’re now seeing fentanyl laced into many drugs that usually don’t usually contain opiates, like cocaine and marijuana. Lately, we’ve even seen fentanyl being mixed in with benzodiazepines like Xanax

Dealers are getting their stuff from many different channels during this pandemic. Because of this, the drugs people are buying are often highly suspect. It’s more dangerous than ever. People who didn’t set out to use an opiate are dying from overdoses because fentanyl has been laced into a drug they didn’t expect to contain opiates. 

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MP: Why are dealers lacing fentanyl into other drugs? 

JE: There are probably a lot of reasons why this is happening. But the most likely answer is that fentanyl, like other opiate drugs, is highly addictive. The thinking is that the more people who develop an addiction to opiates the better it is for sales. 

MP: Sort of like cigarette manufacturers actively trying to increase rates of nicotine addiction.

JE: I think there’s an element of that at play.

MP: Is this increase in fentanyl use the main reason for the increase in overdoses? 

John Engebreth
Hazelden Betty Ford
John Engebreth
JE: Actually the majority of overdoses are likely still traditional users of opiates and opioids experiencing overdose in the ways they generally do — but the increase of fentanyl in so many substances has definitely added to this number. 

Layered on to all of that is the fact that we‘re in a pandemic. It is disrupting everything now, from health care to traditional recovery supports and everybody’s mental health on a larger scale. It complicates how people are attempting to get into recovery and achieve recovery during this time. This makes overdose way more likely.

MP: How does a disruption in mental health and recovery supports play into an increase in overdose?

JE: These days we’re all seeing a mandated increase in isolation. Because of the virus, we are asking people to not participate in typical, normal, healthy community engagement — and that’s difficult for everybody. It’s especially hard on people in early recovery, where essential activities usually include spending time in community with other people in recovery. We call that fellowship or mutual support

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Because of the pandemic, most recovery meetings are now virtual. Removing the in-person aspect of recovery has caused tremendous difficulty for many people. Layer that on top of the general stresses created by the pandemic and we’ve got so much to confront. It’s no surprise that for some people, substance use has gone up. And increased substance use raises the risk of overdose.

The pandemic is impacting everyone in our society right now, but the isolation that comes with this virus is extra difficult and impactful for people who are early in recovery. At Hazelden Betty Ford and in the Twin Cities’ broader recovery community, we’ve always put a lot of effort into creating social events, because boredom is a big trigger for substance use. But those events have had to be canceled or moved online. Unfortunately, boredom has been in abundance for six months now. This is something else that has been heaped on and is adding fuel to the fire. 

MP: Why do some people struggle with virtual meetings? 

JE: Virtual meetings create altered circumstances with a different level of accountability. When you are not seeing your peers in person, you may be slower to develop feelings of connection, especially if you are new to a group. It’s easier to slip through the cracks when you aren’t meeting with people face to face. That’s a time when a relapse can happen. 

MP: Relapse after a period of sustained recovery can be particularly dangerous, right? That’s probably a big reason why it’s important for people to stay connected and accountable even in virtual groups. 

JE: Yes. There are traditional ways people overdose that aren’t pandemic-related but are always there. The biggest is tolerance. Prior to going into recovery, a person may have been using a certain amount of opiates. Their body builds up a tolerance for that level of drug. When they get sober for a few weeks or months and then relapse and return to using the same amount of drugs they were using before they got sober, that’s a recipe for overdose. You’ve lost your tolerance. 

MP: Thanks to the work of statewide advocacy groups like the Steve Rummler Hope Network, we’ve done a pretty good job of distributing naloxone overdose reversal kits in Minnesota. I’d think that would at least help keep some overdose deaths down.  

JE: We’ve done a pretty good job with access and education around naloxone in Minnesota. The problem is that the isolation we are living through now has led to more people using alone.  This creates a certain amount of overdose deaths. When more people were using together, they’d probably call 911 if they saw someone overdosing. Now, people are using alone with no one to call 911 or administer naloxone in case of an emergency. 

MP: I know you’re saying that some people have had a hard time connecting through virtual recovery groups. But almost all 12-step groups in the state are now online. Are some people making the adjustment? 

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JE: We’ve actually seen increased attendance in our virtual groups. In March, Hazelden Betty Ford moved all outpatient levels of care to virtual. That was not without its challenges. I’m guessing you’ve been in Zoom meetings over the last six months, so you understand how trying they can be. But after a few fits and starts, virtual is actually working for many people. 

Attendance at virtual meetings is up across the board. When you don’t have to leave your home and come into a place for a meeting, there are fewer reasons not to go. Technology has made it so we’ve been able to provide uninterrupted services during a time when people have a great deal of time on their hands. I think that’s a big reason why so many more people are participating. Pre-pandemic I would’ve said that addiction thrives in isolation and is best addressed in community, but we have to create community differently now. We’re learning how to do that and we’re seeing that it can work. 

MP: It seems like you’ve had good timing with technology. Just before the pandemic hit, Hazelden Betty Ford was actually getting ready to launch a new virtual platform for outpatient programs. 

 JE: That’s right. I’m grateful we had our RecoveryGo platform ready to launch. We’d already put in the effort and had all the technology in place. 

Many smaller recovery programs were not able to move online as quickly as we were. We want them to be able to use technology to reach their clients, too. These struggles have been hard on the overall effort toward treating addition. We’re all working toward the same goal. 

MP: Tell me about some of the benefits you’re seeing from your systemwide move toward virtual recovery. 

JE: I hear a lot of great stories of change and hope and recovery happening even now. Prior to the pandemic we were already focused on launching more virtual services. The fact that COVID hit and forced everybody to make their programming virtual was a coincidence. 

RecoveryGo was a big deal for us as a foundational strategic effort toward offering more treatment options for more people with SUD. We believe that virtual groups reduce barriers and increase access to care. If you live in St. Paul, you have lots of options for treatment programs. But if you live in northwestern Minnesota, for instance, you have very few options. Virtual programming can make treatment a viable option. 

MP: Sounds like you’ve got the bases covered with virtual options. How is the census at your residential treatment centers? Is COVID causing some potential clients to rethink their treatment plans?

JE: During the pandemic, our residential census has typically been stable at 80 to 90 percent. We’ve been very careful with instituting the many different safety protocols required in order for our programs to remain open. The people who work in our buildings every day are essential staff. Many people can no longer come into our buildings — including patients in outpatient treatment, visitors or guests. We’ve had to eliminate all on-site community 12-step meetings, though patients in residential treatment still meet in in-person groups.

MP: Have you talked to people about their experience in virtual groups? What kind of stories are you hearing?

JE: We’ve heard interesting things. There are groups that have created new traditions you never would’ve seen in in-person groups. Because they’re meeting at home on Zoom, for instance, they’ve gotten to know each other’s pets. They’re selecting “pets of the week.” 

Some groups have picked different weekly themes they mark with different outfits. And some have developed separate 12-step groups that get together independently at different times of the week for additional support. 

MP: People are adding extra meetings to their schedules? Is that because many of us now have extra time on their hands? 

JE: I think that’s the case. We’re seeing people choosing to stay in treatment longer — which is good from a chronic-disease management standpoint. We’ve seen length of engagement stretch out further because people now have an abundance of free time and they are discovering they need extra support in times like these.

MP: Even though you had your RecoveryGo platform up and ready to launch when the pandemic hit, did the switchover to an all-virtual format require extra time and commitment from staff members? 

JE: Our counselors are heroes. They learned how to manage groups virtually and manage a new technological system in a matter of days. This kind of change can be hard on therapists who are used to interpreting nonverbal cues in an in-person setting. Now they have to look at and study the reactions of individual group members through a Brady Bunch view. This is a real challenge and they stepped forward and took it on. 

MP: Someday, this pandemic will be behind us. What future-thinking steps are being taken at Hazelden Betty Ford to ensure the long-term health of the organization — and the people it serves? 

JE: We have an advocacy arm in our organization that supports legislation and initiatives to expand and increase funding overall to support substance use disorders and mental health. That team has been very much at work advocating for funding that needs to be added into some of the coronavirus spending bills. A month ago, Sen. Amy Klobuchar held a press conference from our site in St. Paul. She was advocating for a bill that would increase funding for mental health and substance use disorder treatment. Right now a lot of the advocacy efforts are around that — and expanding telehealth allowances in terms of state laws. These allowances will be important for the industry going forward.