Pam Santa Fe, substance misuse coordinator for the Greater Derry Public Health Network, studies the heroin epidemic on a daily basis. One of the needs she sees is for treatment for younger people. “What we have,” she said, “is mostly programs for 18 and older.”
By “younger” she means middle and elementary school, Santa Fe clarified.
Narcan, or Naloxone, is at the forefront of New Hampshire’s efforts to combat its heroin epidemic. State officials recently announced the use of $500,000 in Federal grant money to distribute 5,000 “overdose prevention” kits throughout the state. The kits will be accompanied by an “Anyone, Anytime” public awareness campaign.
Meanwhile, the Attorney General’s office has launched an investigation into pharmaceutical companies that may have minimized the risk of addiction from painkillers, one of the reasons people get hooked on harder drugs.
According to a Food and Drug Administration (FDA) Web site, Narcan “prevents or reverses the effects of opioids, including respiratory depression, sedation and hypotension.” Narcan is “an essentially pure opioid antagonist, i.e., it does not possess the morphine-like properties characteristic of other opioid antagonists. When administered in usual doses and in the absence of opioids or agonistic effects of other opioid antagonists, it exhibits essentially no pharmacologic activity.”
While Derry professionals involved in the fight against opioids recognize the effectiveness of and need for the drug, they prefer prevention and emphasize that education can’t begin too soon.
Emergency Management
Charles “Chuck” Hemeon, Derry Director of Emergency Management, said his department has been using Narcan since he was a paramedic responding to calls, for well over 30 years. “We’ve always had it,” he said.
What’s different now? The frequency of use.
“With the epidemic, it’s certainly used more as a response to opioid overdoses,” Hemeon said.
Is it effective? “Absolutely,” Hemeon said.
He explained that in an overdose of an opiate such as heroin, the user goes into a deep sleep and their body forgets to breathe. “Narcan competes with the opioid receptors, but it’s benign to the body,” Hemeon said.
In New Hampshire Narcan is available to all EMTs (emergency medical technicians), advanced EMTs and paramedics, Hemeon said. The state recently added first responders to the program, and now law enforcement personnel are also trained, he said.
How soon does it work? Hemeon said, “It’s not uncommon for my paramedics to arrive and find a patient unconscious, taking two or three breaths per minute.” Often the hypodermic needle is still in the person’s arm, Hemeon said.
Hemeon’s people administer the drug first by an internasal spray, he said. If that doesn’t work, they go to either an intravenous or intramuscular injection.,
“We are using it more,” Hemeon said.
In 2012, his crews used Narcan 38 times from January to December; in 2013, the number dropped to 36; in 2014 they saw a spike of 66 times, with the first unattended death; and in 2015, they have administered the drug 56 times from January to September, with two unattended deaths.
“We are on target,” Hemeon said, “for 80 to 100 uses in 2015.”
The drug is relatively inexpensive at about $40 a dose, but it’s also in short supply. “It is not a profitable drug for the pharmaceutical companies to produce,” Hemeon observed.
There is currently a national shortage of Narcan, and that makes Hemeon nervous. Some states are making the antidote available on an over-the-counter basis, and he’s a little leery about the Department of Health and Human Services initiative to train and equip substance abuse counselors. He’s all for saving lives, any way it can be done, but he’s worried that there won’t be enough Narcan for his people on the front lines.
Hemeon said he can train a person to administer Narcan in about an hour.
Public Health
Santa Fe said in a phone interview that the free kits will be going to smaller communities. The bigger, well-organized communities like Derry already have a protocol where the drug is administered by fire and ambulance personnel. But the smaller towns have a less precise division of labor, and it’s important to put Narcan in the hands of all first responders.
Santa Fe hesitated when asked what the biggest need was to combat the addiction crisis. “There are so many,” she said. “There are multiple issues, and it won’t happen overnight.”
One of the most crucial needs is for treatment, Santa Fe observed. Currently, drug addition is in a “triage mode,” with doctors responding to prescription drug abuse, usually of painkillers. But, Santa Fe warned, “If they don’t get into treatment for painkillers, they frequently go on to heroin.”
The state is working on getting more treatment options and that’s fine with Santa Fe. “But that’s the end of the line,” she said.
She’d rather see people make the right choices at the beginning.
“We need to put money into prevention,” Santa Fe said. “The need is so great.” But until recently, the health community hasn’t had the “prevention dollars” to make that happen.
“Sadly, what’s raised the awareness in this area is the deaths,” Santa Fe said.
Santa Fe sees the need for more school programming. While the DARE – Drug Abuse Resistance Education – curriculum is excellent and comprehensive, she said, she is concerned that it only targets fifth-graders. “It’s one grade, one year,” Santa Fe said. “What do they have when they get to middle school? Nothing.” High schools will hit the drug issues in their health classes, but “it doesn’t help if you don’t take health,” she said.
Some districts have prevention programs in earlier elementary grades and some have them in middle school, but it’s inconsistent and depends on the district, Santa Fe said. She’d like to see a comprehensive, consistent curriculum for kindergarten through high school.
She’s especially concerned about middle-schoolers, noting that “their brains are still developing and their impulsivity is not in sync with their brain development.”
Also, the long arm of drugs is reaching younger and younger children. “What was once happening in high school is now happening in middle school,” Santa Fe said.
Santa Fe, who came of age in the ‘70s, observed that when she was a teen, marijuana was fairly common and some kids experimented with LSD. But heroin was for the inner city.
When do you have “the talk”? It should begin and never stop, according to Santa Fe. “We should be constantly checking our own behavior. If Mom has a bad day and pours a drink, is that okay? If Mom and Dad allow drinking at a party and say, ‘I’ll take your keys,’ is that okay? Is it okay to break the law?” she asked.
The conversation should begin with children as young as 2, Santa Fe said. A Web site, partnershipdrugfreenh. org, gives suggestions for age-appropriate discussions.
But parent education is important too, Santa Fe emphasized. “I’ve talked to kids in recovery and they say, ‘My mom had no idea.’ They’d tell the parent, ‘That’s a cold capsule. That’s a candy wrapper.’ And the parent believed them
Parkland
Parkland Medical Center Chief Executive Officer Chris Accashian is getting ready to have the conversation – he has two young children at home.
He’s aware of the issue professionally, and said Parkland is looking to expand its outpatient programs.
The new 14-bed inpatient facility, aimed at mental health clients, will be useful, he said, pointing out, “Substance abuse and mental health issues are not mutually exclusive.”
He meets regularly with Santa Fe and the staff of the Center For Life Management, and said they are developing an “organic data base” so substance abuse counselors will have a list of resources at their fingertips.
“We want to get that into providers’ hands,” Accashian said.
Police
Derry Police Capt. Vern Thomas said his department is not involved in the administration of Narcan, though officers are trained to use it if they have to. “The ambulances usually respond just as quickly,” he said.
In 2014 Derry police responded to 42 drug overdoses, 12 of them resulting in death. By the end of September 2015 the department had responded to 103 overdoses and 10 deaths, Thomas said, though he added that the number is a moving target.
“The number will change,” he said. “When a person passes away, the Medical Examiner does a blood test and we wait for the results.” Not all the drug deaths are attributed to heroin, Thomas said. Some are overdoses of another opiate.
The overdoses are up but the deaths are holding their own chiefly due to Narcan, Thomas said. With the aid of Narcan, “Fortunately, some of them are able to survive,” he said.
Thomas and the Derry Police have come up with some theories regarding the epidemic. For one, heroin is cheap right now, he said. “As a result, more people may use it because they have more access to it,” he said.
While the state is investigating the over-prescription and over-use of painkillers, Thomas said that hasn’t been Derry’s experience.
“There’s a theory that most of the users started with pain pills, but that’s not what we’re seeing,” he said. “Of the people we’ve interviewed, 26 percent say they started with pain meds, while 74 percent say they didn’t.”
But the abuse is universal, with arrests of people ranging from their teens to their 60s.
His department’s strategy includes linking up with other departments. “We have been involved in every round table, every discussion group,” he said. The Drug Take Back days, most recently Sept. 26, aren’t just about getting expired medication off residents’ shelves. It’s about getting it off the street.
“We don’t just take pills from the pharmacy,” Thomas said. “If you find marijuana in your house, you can bring that in too.”
Education is important, Thomas said, and his department participates when it can, giving talks to school children and staffing booths at events. The School Resource Officer, a Derry officer stationed at Pinkerton Academy, will make referrals if he sees a situation, Thomas said.
Thomas cited the lack of treatment options as a factor. “If we bring someone in here, we need a place to refer them,” he said. “But we need to have something that’s meaningful, useful, and works for that particular addict.”
Has crime gone up because of the heroin problem? “It’s more conspicuous,” Thomas said. “When we arrest someone and bring them in here, they often go into withdrawal.”
Shoplifting and other stealing is part of the collateral damage, Thomas said, and addicts are crafty. One popular strategy is to take something off a store shelf, conceal it, and try to return it for cash. But store owners are savvy too, he noted, and many have gone to giving gift cards instead. While it’s a not-so-happy return for the addict, they make the best of it, selling the gift card on the street or to pawn shops, which are all too eager to take the cards and dole out cash.
“Recovering addicts,” the veteran of many round tables and panels said, “will not accept help until they are ready.”