My name is Alexa Cabrera-Martinez. I am an intern for Washington Recovery Alliance and I attend the University of Washington working towards getting a degree in Social Welfare. I had the privilege of interviewing RALI Washington where I learned more about the type of work that the coalition does for communities and organizations around Washington state. I interviewed Ana Naranjo, the Account Executive with RALI Washington, and Mark O’Brien, an Addiction and Recovery Expert for RALI.

A conversation with Mark and Ana

Alexa: What is RALI Washington and why was it established

Ana: RALI stands for The Rx Abuse Leadership Initiative (RALI) of Washington. RALI WA is a community with advocacy leaders whose goals are to address the opioid epidemic in the U.S. RALI was launched in Washington during 2019, and the main purpose and main practice of this organization is to provide a platform for organizations like Washington Recovery Alliance (WRA) to share resources and best practices for prevention and treatment for recovery. RALI WA recognizes how important it is to keep small organizations connected through networking and sharing what is currently established in each organization to gather more ideas and feedback from others.

Alexa: What areas in Washington does your organization focus on?

Ana: RALI WA engages with a number of organizations for anti-addiction; we also engage with caregivers, health providers, and EMTs. RALI supports groups like the WRA and especially supports groups that do a great job at supporting individuals who are struggling with substance use disorder. Aside from the WRA, other organizations we partner with include NAMI, Urban League of Seattle, and others. We even have connections to radio groups like KDNA radio to help reach Hispanic audiences in Yakima. One of our more recent needs was to reach out to groups who were disproportionately impacted by COVID-19. We created an outreach campaign to reach Hispanic communities in Washington and used resources provided by the WRA and NAMI and translated them to Spanish. RALI recognizes that we are at the forefront of helping these communities, so we send the translated list of toolkits–created by Ana Naranjo–to organizations that focus on helping Hispanic communities like El Centro de la Raza and Casa Latina here in Seattle. In the list of toolkits we provide warning signs of opioid use, teach appropriate disposal of opioids, and teach ways to keep opioids out of reach from young children. Apart from helping Hispanic communities in Washington, we also have an educational program called RALI CARES with a virtual tour of a trailer and essentially shows indicators of what it looks like if your child is engaging in substance use. This program can be seen in English or Spanish and has been noted to be helpful and valuable https://www.raliwa.org/rali-cares

Alexa: How common is it for people who have been prescribed opioids to develop a dependence/addiction?

Mark: About ¼ of patients who are prescribed opioids for chronic pain end up misusing them. But what exactly does misuse mean? Misuse sometimes means that opioids are not being used exactly how they are prescribed, which does not always include risky behaviors. In some cases, individuals may casually offer opioids to their friends and family without bad intentions and in other cases, they might double up on their prescription. About 8-12% of people who use opioids for chronic pain end up developing an opioid use disorder and can happen even when someone does not misuse the drug. Around 5% of people who misuse their prescription end up transitioning to heroin. In the 1960s the last wave of opioid use disorders occurred, and the initiation of opioid use started with heroin as well. The length of time that someone uses opioids (typically often for chronic pain) is a risk for developing a dependency on opioids. Now however, opioid overdose deaths have begun to decrease.

Alexa: What type of environments/circumstances have a higher likelihood of leading to opioid misuse?

Mark: Genetics is a large contributor that may lead individuals to develop an opioid use disorder. Substance use disorders run in families and other environmental factors may also contribute to this. It has been shown that for younger people, like teens, having a caring adult outside of their family makes a huge difference in their lives and leaves them feeling valued, feeling like they provide value, and feeling like they matter. In Black and Brown communities, heroin and fentanyl are more common, and when they are more common there is more probability of there being addiction and dependency. Another contributing factor to risk of opioid misuse is early exposure to alcohol–this can cause an increase in potentially trying other substances, like opioids.

Alexa: Do you have an idea as to why opioids are prescribed even while it’s well known that they are very addictive?

Mark: The rate of prescribing opioids has actually declined very rapidly since 2012. Physicians prescribe around morphine milligram equivalents and even though the rate has lowered, rates are still quite high. The reason that physicians prescribe opioids is because these medications work very well especially for acute pain, however overprescription still exists. One of the major factors of overprescription is due to the time constraints that physicians have. Physicians don’t have a ton of time with their patients so they tend to prescribe opioids to treat them. However, it is important to recognize that no amount of pain is unworthy of being treated. Opioids are powerful and effective, but also dangerous and the balance between this has yet to be found.

Alexa: Are there any alternatives? What is the difference between these alternatives and opioids?

Mark: The major difference between opioids and the alternatives is the parts of the body and brain that they operate on. Acetaminophen, NSAIDS, and ibuprofen all focus on inflammation, which are not as effective but are much less risky. It has been found however that acetaminophen alternated with NSAIDS has been very effective. Chronic pain is related to the psychosomatic phenomena and cognitive issues related to pain, so mental health treatment can be effective as well, but there is a lot of stigma surrounding this sort of treatment. There is also the new development of an alternative called AT121, which is a nontraditional opioid. This medication adheres to the Mu receptors in our brain, like regular opioids do, but this alternative prevents dependence and respiratory issues (caused by regular opioids). Because this medication is new, there is still a lot of research that needs to be done.

Alexa: Do you see opioid misuse more common in BIPOC or white communities? Can you explain why that is?

Mark: There are many different responses to this question based on the epidemic that occurred in the 1960s compared to the last decade. The earlier opioid epidemic is perceived of black communities and the current epidemic is occurring more in white communities. In the 1960s, the epidemic led to war on drugs and the current epidemic is being approached in a different manner. Public health is a larger focus now than it was before, whereas in the past it was more criminalized. Recent overdose increases have fallen a lot on the BIPOC population. It has been found that the reason for increased substance use disorders among the white community is driven by prescription of opioids from physicians due to being wealthier and having greater access to healthcare. Physicians are less likely to prescribe to BIPOC communities, which is why the current opioid epidemic is heavily falling on white people. However, death rates caused by overdose in Black communities have surpassed death rates among white communities in the last decade. Because of limited access to prescribed opioids, BIPOC communities are now using synthetic opioids which is causing an increase in overdoses. The difference in the opioid epidemic in the 1960s and in the current epidemic is that before it was a matter of public safety and now it’s more of a public health concern.

Alexa: What role does systemic racism or racial disparities play in the current opioid epidemic?

Mark: Disparities and prescription. This has never been just, but these unfair and unjust factors have in some ways benefited communities. The current epidemic has been affecting white people a lot more because they have better access to healthcare. This is not a good thing, but this seems to have been a protective factor. Because BIPOC communities have a limited access to healthcare, this has led to a decrease in being at risk for opioid use disorders. Problems of systemic racism have a long history to housing and generational wealth, which explains why BIPOC communities have resorted to synthetic opioids. 

Alexa: How do you think the opioid epidemic will change in the future?

Mark: Other synthetic opioids have been introduced that are more dangerous than fentanyl. Due to this, the system should continue to take a health focused approach to treatment, and other forms or treatment like harm reduction. This type of approach doesn’t always enable drug use like many people believe. Eventually, this will end but it won’t be the last one as it’s been found that there may be a following epidemic for meth.

Get to know Ana Naranjo: Ana graduated with her Bachelors in Communications and Spanish at Washington State University in Pullman, Washington. She serves as a bridge between RALI and other coalitions/organizations. She helps RALI with managing the coalition, sending letters to coalitions, and putting together tool kits and resources for communities. She is the go-to person to translate between the Spanish speaking community and non-Spanish speakers and she loves doing this!

Get to know Mark O’Brien: Mark has worked nationally with RALI for 4 years. He is a nonprofit executive working in behavioral health and criminal justice. He attended the University of Pennsylvania and describes himself as a creative problem solver and team builder. Just like the coalition based in Washington, Mark supports RALI coalitions all over the United States.