by Chuck Hoven
(Plain Press, November 2017) Residents, community agency representatives and local experts joined together to listen to and interact with a panel addressing the opioid crisis. The panel discussion held at Cleveland Clinic Lutheran Hospital’s Castele Center Auditorium on October 11 was titled Heroin, Fentanyl and Carfentanil: The Triple Threat on our Doorstep.
Lutheran Hospital President Donald A. Malone, Jr served as the moderator of a four-person panel featuring Chief Executive Officer of the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County Valeria A. Harper; Cleveland Catholic Diocese Bishop Nelson J. Perez; Assistant United States Attorney Justin Seabury Gould; and Common Pleas Court Judge Joan Synenberg.
Moderator Doctor Malone stressed deaths from opioid overdoses nationwide, this year alone, are projected at over 60,000 fatalities, more than the 58,000 soldiers that died in the entire Vietnam War. He noted that opioid overdose deaths in Ohio are the highest in the nation, in both per capita deaths and in actual numbers of deaths. He said in Cuyahoga County, in 2016, there were 720 deaths attributed to opioids.
Malone said aggressive treatment of pain in the United States has resulted in the highest prescribed use of opioids in the world. He noted that 631 million opioids were dispensed by Ohio pharmacies in 2016 and that represented a 10% decrease from 2015.
Assistant U.S. Attorney Gould talked about the difference between heroin and the synthetic opioids: fentanyl and carfentanil. He said the increased potency of these synthetic opioids is the cause of the dramatic increase in overdose deaths. He said that heroin is twice as potent as morphine; fentanyl is 100 times more potent than morphine, and carfentanil is 10,000 times more potent than morphine. Gould says a dose of carfentanil, the size of a half a grain of salt, could kill you.
Assistant U.S. Attorney Gould said these lethal drugs are getting into the United States, being brought in by human trafficking mules, coming in via truck, and being mailed in from overseas. He said the United States Attorney’s office is working with governments, like China, to ban the manufacture of some types of opioids; working with truckers to have them help identify signs of traffickers; and working with Homeland Security and the United States Postal Service, Federal Express and other mailing companies,
to stem the flow of these drugs into the United States.
Controlling the overprescribing of opioids is another way to combat the epidemic. Most heroin users started with prescription opioids, said Gould.
Dr. Malone said efforts are underway to curb the overprescribing of opioids. He said that Cleveland Clinic has stopped using patient pain as a metric to measure how doctors are performing. Also, pain management clinics can now log into a system to check and see if a patient has already received pain medicine from someone else.
Bishop Perez said while the United States makes up 5% of the world’s population, it uses 80% of the world’s opioids. Perez said, “In the United States, we don’t like pain. We are pleasure seeking beings.” Bishop Perez related a story about being sent home from the hospital with pain pills he did not need. He said, “We want comfort. We don’t want a hard time. Pain is a hard time. Take a pill and make that go away.”
The Bishop advised, “We can’t anesthetize ourselves completely from pain. We need a cultural change. We need to work with the family, if the family is unstable.” Bishop Perez talked about family discord and the high divorce rate in our society. He said, “We can strengthen the human heart by strengthening the family.”
Bishop Perez talked about the stigma associated with treatment, saying we need to remove that stigma and let people know that treatment does work and that no treatment leads to death.
Dr. Malone mentioned the number of addicted babies now being born. He said the stigma of treatment may be preventing expecting mothers from seeking help. He said expecting mothers need to know “there won’t be legal consequences if you come forward.”
ADAMHS Board Executive Director Harper said area drug treatment programs saw a significant increase in addicts seeking treatment when they learned they could get treatment because of Medicaid expansion. She said the expansion allowed for families of four, making up to $24,600, to qualify for health care under Medicaid. She said through peer to peer conversations, the knowledge that treatment works spread like wildfire. She said the ADAMHS Board relies on Medicaid for people in treatment. Talk about ending the Medicaid expansion “makes us fearful,” she said. Harper said she is afraid what would happen if Medicaid Expansion ends in Ohio. She urged residents to call their elected state representatives and tell them “we need Medicaid expansion.”
Assistant Attorney Gould said because of the potency of carfentanil, there is no safe way to approach a person who has overdosed. He urged calling 911 when an overdose occurs. He said because of the Good Samaritan Law, you will not be arrested for a small amount of a drug when you call 911. He said first responders to overdoses, have hazmat protective suits. He noted even a small amount of carfentanil touching your skin can cause someone to overdose.
Dr. Malone called Narcan a “miracle drug” that brings overdose victims back to life. He said the problem is that some patients coming to, after being administered the drug, often say, “I’m fine” and leave the hospital while still having the dangerous synthetic opioid in their system. Dr. Malone said it may take 6 doses of Narcan to completely revive someone who has overdosed on fentanyl or carfentanil, while taking one or two doses to revive someone who has overdosed on heroin.
ADAMHS CEO Harper says her organization has spent over $100,000 to assist with the purchase of Narcan kits. She says the kits have saved 243 lives and, those are just the ones that have been reported and recorded.
Harper said that Project DAWN makes available Narcan kits to people who have family members who are opioid users. She said the kits are available in a number of locations including Thomas McCafferty Health Center on the Near West Side. She said Walgreens Pharmacies have a nationwide policy of helping to educate patients and family members on how to use Narcan kits.
Dr. David Stoven of Lutheran Hospital testified that medication assisted treatment works. He said he believed that patients on Vivitrol, a drug designed to limit cravings, do better than those on other drugs. He said studies need to be done, but the success of methadone maintenance may not be due to the pharmacology but to the treatment structure – a regiment that requires patients to show up for regular doses.
Common Pleas Judge Joan Synenberg, who administers the Recovery Court, agreed that Vivitrol allows patients to conquer the hurdle of craving and focus on recovery. She said in screening individuals in Recovery Court, they have often found dual diagnosis of trauma along with addiction disorder and treat the co-existing conditions together.
Dr. Malone said a dose of Vivitrol can last for 30 days so that individuals can focus on recovery and are “no longer dreaming of drugs.” He praised medication assisted treatment, saying there is “no question, people do better.”
ADAMHS Board CEO Harper said access to treatment is a problem. She said when people seek treatment “we need to take them in that day.” She said the ADAMHS Board is working to expand residential treatment availability by raising $1.5 million for expansion efforts. She said Cuyahoga County and the City of Cleveland each offered one time contributions of $250,000 toward the effort. Harper says the goal is to add 113 beds in six months’ time. Harper said some other efforts underway include ambulatory detox units and recovery coaches. The recovery coaches are recovered addicts that go to emergency rooms to speak with overdose victims and encourage them to seek treatment or learn how treatment works.
Harper said when treatment beds are not available, the St. Vincent Crisis Unit takes people while they are waiting for treatment beds.
Malone asked, “If individuals refuse treatment, what can we do?”
Bishop Perez said he is not an advocate of letting people “bottom out.” He said that can become a vicious circle. Instead, he called for helping the family to realize they can be supportive and urging patience. He said the community needs to reinforce the process by making information and education about addiction readily available. For example, he said “The potency of these drugs – who knows that? You are dealing with fire that can kill you. That is really not out there.” Bishop Perez said that when individuals decide they “have to get their life together, we have to be there with support.”
Valaria Harper agreed saying “We have to arm families with information. People don’t realize that addiction is a disease.” She said family members want more information about their loved one and the treatment regime. She said we need to support families and arm them with information.
Dr. Malone said the majority of people suffering from addiction, also are coping with a mental illness. He asked panelist, “How do we address both?”
Harper said agencies used to offer addiction support or mental health services, now agencies do both. She said it is common for people with an addiction to have experienced trauma. She said trauma treatment and the need to treat mental illness can also be layered with treating the addiction.
Dr. Malone said that in his 32 years of working in psychiatry, there has never been more light shined on the relationship between mental illness and drug abuse than there is now.
Bishop Perez, asked how the diocese is coping with the opioid crisis, spoke of educational forums planned for parishes, the work of Catholic Charities, and the rehab services available at programs like Matt Talbot House.
Bishop Perez also said the church has a role in being present for those entering recovery. He said, “The Church deals with things of the heart, soul and spirit that bring us all together.”
Judge Synenberg said the goal of the Recovery Court is sobriety. She said the court sees people whose lives are broken and helps them to restore their lives. She said clients of the court often have experienced trauma or death of a loved one. They often have lost the trust of their families and the population experiences rampant homelessness. She said 50% of the women coming to the court are pregnant.
Synenberg talked about Restorative Justice versus Retributive Justice. She said, “lock them up and throw away the key, does not work.” With restorative justice, the goal is for them to leave and not come back, she said. The court does have some leverage in getting people to choose treatment, Synenberg added, noting when the choice is “jail or treatment, sometimes treatment suddenly seems like a good idea.”
Synenberg talked about the Recovery Court’s graduation program for those clients that have successfully completed treatment. She said this year’s graduation was at the Rock and Roll Hall of Fame and graduates received Indians tickets. Synenberg said the very best part of her job is seeing the reunification of clients with their kids. She said most clients have kids. She said her clients experience emotional pain, isolation, guilt and shame.
Synenberg said it is wonderful to see clients whose lives have been restored through successful treatment. They are once again trusted with a key to their parents’ house, asked to babysit for a niece or nephew and can give back to the community by helping other people suffering from an addiction. “There are few advocates as powerful as one that has been through what you are going through,” she said.
Judge Synenberg called for providing more treatment beds in Cuyahoga County. She said, “the last thing we want to do is to put someone in jail while awaiting a bed.” She said the Cuyahoga County jail is currently the “largest de facto mental health agency in the state.”
During the question and answer period following the panel discussion, several topics arose.
An advocate for Sober houses spoke of their effectiveness in helping individuals kick a drug habit.
Several addicts spoke out about the stigma of addiction and the difficulty of getting on with their lives when people are afraid of addicts, and doors to employment are closed. Judge Synenberg read a poem to heroin from one of her clients that urged “keeping hope alive.”
ADAMHS CEO Harper offered some advice to parents on what to look for if they suspect their child is beginning to use drugs. She said some signs are changes in behavior, isolation, separation from friends, new friends, not a lot of interaction, taking money out of your purse, and staying out late. Harper advised parents to have a conversation with their children and arm them with information about the harmful impact of drug use.
A nurse in the audience offered another tip for parents discovering drug use. She said in talking with parents of addicts, she learned that a lot of tin foil in the garbage can is one sign of the snorting of drugs.
One audience member talked about barriers to treatment. He noted that when St. Vincent Charity’s Rosary hall began an Uber Transportation program to take people to treatment, attendance at the program jumped from 60% to 100%.