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Last week, Human Trafficking Search spoke with Dr. Hanni Stoklosa, Director of HEAL Trafficking on the linkages between human trafficking and America’s opioid epidemic. The following is a transcript of our interview.

Hi, I’m Hanni Stoklosa, an emergency medicine physician at Brigham and Women’s Hospital, Harvard Medical School, and the Executive Director of HEAL Trafficking, a network of over 1,500 professionals that are fighting trafficking from a public health lens.

HTS: How do you come into contact with human trafficking in your profession as a doctor?

Emergency departments are on the front lines of human trafficking victim identification and referral. One study that my colleague Makini Chisolm-Straker led asked victims of trafficking in the United States – both labor and sex trafficking victims – what types of healthcare did you access while you were being exploited? Number one on the list was emergency departments. So we know that emergency departments are really the first doors that a trafficking victim may access while they’re being exploited and therefore it represents an opportunity for healthcare professionals to identify the victims that come through our doors and plug them into the care that they need.

HTS: To expand on that a little bit more, why is human trafficking a public health crisis, and why do you think more people don’t make this link?

We know that a majority of trafficking victims in the US access healthcare during their time of exploitation. That’s something that wasn’t known until the last couple of years. Trafficking victims, while they’re being trapped in their situations sometimes have opportunities to physically leave the environment of their exploitation – it might be because they’re so sick from an injury or infection that their trafficker lets them have that opportunity to get healthcare. Knowing that information, knowing that a majority of trafficking victims will at some point access healthcare means that healthcare professionals need to be aware of this problem. We know that – and this in many ways seems logical – there are a lot of health consequences to trafficking. On the mental health side trafficking victims have high rates of suicide attempts from the emotional and physical violence that they’re experiencing. We know that there are a lot of physical consequences of trafficking, trauma from falling off a scaffolding as a construction worker, being exposed to pesticides in the agriculture industry, having tuberculosis from living in close quarters with other individuals, as well as sexually transmitted infections and pregnancies – essentially there are a lot of health problems that can arise among trafficking victims that are specific to the exploitation that they’re experiencing. And we now know that those needs result in them coming to healthcare facilities on occasion. So we need be equipped and ready so we can identify trafficking victims, even if they only interface with healthcare once during their exploitation.

HTS: Given the ongoing opioid crisis in this country, what trends have you observed regarding human trafficking and opioid addiction?

We’re seeing that there’s this complex relationship between opioids and trafficking. An opioid addiction may lead someone to be vulnerable to being trafficked. In the Boston area, where I work, we have traffickers that will recruit and lure trafficking victims outside of methadone clinics. So right outside a place where they should be getting treatment for that addiction, that addiction is being exploited. In some cases, this leads them to being trafficked.

Traffickers also use opioids as one of the chemical tools to keep their victims in check while they’re being trafficked. They’ll even use things like the threat of acute withdrawal from Narcan as a way of getting them to comply. A trafficker here in the Boston area would shake Narcan over his victims’ heads after giving them a little bit of heroin. He’d say unless you go do X,Y, or Z I’m going to give you Narcan. And for any health professional that has seen someone get Narcan you can see how that’s a really awful threat to hold over somebody. Whenever somebody gets Narcan – yes, it’s lifesaving – but the person who gets it feels like they are dying, their entire body revolts, they may feel horrible pain, shakiness, sweatiness, and nausea. So, knowing all of that, just imagine that Narcan is one of the tools that the traffickers use. There’s also a famous case of a trafficker out of Florida, the Fields case, where he would go into hospitals where his victims were and would shake bottles of opioids and say unless you go do X,Y, or Z and come back to me, you’re not going to get your Oxycodone. Those are just a few examples of how we see opioids being used by traffickers.

And then, because of the mental health trauma that trafficking victims experience, some survivors of human trafficking turn to drugs after their exploitation as a way of numbing the emotional pain. The relationship between opioids and trafficking can interplay at any of those stages. Before somebody is being trafficking and using addiction as a vulnerability, to getting them hooked on it while their being trafficked, to something survivors may turn to as a coping mechanism afterwards. I had one patient who had been hooked on heroin and her trafficker met her at a detox center.  While she had traded sex for drugs multiple times before she had never had another person controlling her in that situation. This time she connected with the wrong person who basically locked her in a hotel room and forced her to have sex with multiple people over the course of a week. Thankfully she escaped to my emergency department from that situation of trafficking. I can’t help but think, was there an opportunity that was missed for us to prevent her from being trafficked? Before she was trafficked, she had probably been in and out of emergency departments with overdoses or skin infections and had been in and out of detox centers. If we had seen this vulnerability as what it was, a vulnerability to trafficking, if we could have intervened in some way, maybe we could have prevented her from ultimately being trafficked.

HTS: You recently attended the Freedom Network USA Human Trafficking Conference, was there acknowledgement of the role of the opioid crisis in human trafficking there, were there discussions around this issue?

Yes. One session in particular comes to mind. Susie Baldwin, who is the President of HEAL’s board and a co-founder, presented on a panel that explored harm reduction in relation to trafficking. The panel addressed the importance of using public health responses, not criminal justice responses to addressing drug use in relation to trafficking and as well as commercial sex work. For example, taking approaches of harm reduction strategies that understand principles of “Stages of Change” rather than punitive models.  Not to get too medical, but in terms of what we’re hearing from the community of providers that are treating trafficking victims that also have opioid addictions, the same tools that we know work for opioid addiction writ large should really be employed for trafficking victims. Buprenorphine is a wonderful medication; what’s different about it from methadone is methadone ties someone to a specific location. As I mentioned traffickers can recruit outside a methadone clinic because you’re going there so regularly. Also, as somebody’s trying to get out of their trafficking situation, having to go every single day to one particular place can prevent them from having a regular job and can really prevent them from rebuilding their lives. The beauty of buprenorphine is it’s something that an individual can take on their own schedule and it doesn’t link them to a physical location and it can be started right away, preventing withdrawal and relapse. We have also learned from opioid experts that long-acting naltrexone (Vivitrol) is problematic. So on the medical side of things, buprenorphine is a promising strategy that would be applicable for trafficking survivors. The other piece that really has been under addressed, in my opinion with opioid addiction in general, and is really relevant to trafficking survivors is the treatment of the mental trauma they’ve experienced. Trafficking survivors have experienced horrific physical and sexual violence and require lifelong therapy and mental health treatment. If you’re not treating the trauma they’re going to turn back to drugs. Treatment of addiction needs to be coupled with treatment of the mental health side of trafficking and we need the resources to do so.

HTS: To conclude, can you tell us a little bit about HEAL and what HEAL is doing on this issue and to reach survivors.

As I mentioned HEAL is a network of over 1,500 professionals fighting trafficking from a public health lens. We work on research, education and training, protocol development, media and technology, as well as advocacy.  We are a survivor-informed group and have three survivors on our board. In addition to working with the Office on Trafficking in Persons on this issue, we’re convening a working group that is coming up with policy recommendations for the United States and particularly the health care community around substance use disorders and trafficking. Our internal working group seeks to identify recommendations based on what we’ve learned from intersecting fields such as domestic violence and opioid addiction so that we can build on those foundations to make recommendations for what policy makers should be suggesting for trafficking victims that have opioid addiction.

HTS: Thank you for joining us Hanni.

This interview uses the terms “victim” and “survivor” to refer to individuals who were trafficked. The term “victim” has legal implications within the criminal justice process and generally means an individual who suffered harm as a result of criminal conduct. “Victims” also have particular rights within the criminal justice process. “Survivor” is a term used by many in the services  field to recognize the strength it takes to continue on a journey toward healing in the aftermath of a traumatic experience. In the context of this interview, both terms are intended to honor those who have suffered, or are suffering, the effects of being trafficked.

For more information on the relationship between human trafficking and the opioid epidemic, review the following resources:

Human Trafficking is a Public Health Problem: Here’s Why

Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

Anti-Trafficking Policy Developments Impacting Health Care Providers

W.Va. Officials Warn Of Increased Cases Of Human Trafficking

Human Trafficking and the Opioid Crisis Webinar

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