Com­mu­ni­ties in an­guish over re­viv­ing opi­oid ad­dicts

The Washington Post Sunday - - FRONT PAGE - BY TIM CRAIG AND NI­COLE LEWIS

middletown, ohio — The coro­ner here in the outer sub­urbs of Cincin­nati gets the call al­most ev­ery day.

Man “slumped over the din­ing room ta­ble.” Woman “found in the garage.” Man “found face down on the kitchen floor of his sis­ter’s res­i­dence.” Man “on his bed­room floor — there was a sy­ringe be­neath the body.” Coro­ner Lisa K. Man­nix chron­i­cles them all in au­topsy re­ports.

With 96 fa­tal over­doses in just the first four months of this year, Man­nix said the opi­oid epi­demic rav­aging western Ohio and scores of other com­mu­ni­ties along the Ap­palachian Moun­tains and the rivers that flow from it con­tin­ues to worsen. Hospi­tals are over­whelmed with over­doses, small­town morgues are run­ning out space for the bod­ies, and lo­cal of­fi­cials from Ken­tucky to Maine are strug­gling to pay for at­tempt­ing to re­vive, re­ha­bil­i­tate or bury the vic­tims.

As their bud­gets strain, com­mu­ni­ties have be­gun ques­tion­ing how much money and ef­fort they should be spend­ing to deal with over­doses, es­pe­cially in cases in­volv­ing peo­ple who have taken near-fa­tal over­doses mul­ti­ple

times. State and lo­cal of­fi­cials say it might be time for “tough love”: push­ing soar­ing med­i­cal costs onto drug abusers or even lim­it­ing how many times first re­spon­ders can save an in­di­vid­ual’s life.

“It’s not that I don’t want to treat over­dose vic­tims, it’s that the city can­not af­ford to treat over­dose vic­tims,” said Middletown Coun­cil Mem­ber Daniel Pi­card, not­ing this in­dus­trial town in north­ern But­ler County might have to raise taxes in re­sponse to the cri­sis.

The de­bate comes as de­mand for opi­oid antidote med­i­ca­tion surges, cre­at­ing new chal­lenges for po­lice and emer­gency crews al­ready emo­tion­ally drained as they watch their com­mu­ni­ties — and, in some cases, fam­i­lies — torn apart by opi­oid ad­dic­tion. Of­ten, the only thing sep­a­rat­ing whether an over­dose vic­tim goes to the hos­pi­tal in­stead of the morgue is a dose of nalox­one, also known by the brand name Nar­can, a med­i­ca­tion that can re­verse the ef­fects of opi­oid over­doses.

Two doses of an in­jectable form of nalox­one, Evzio, cost $4,500, up from $690 in 2014. The price of other forms of the drug, in­clud­ing the nasally ad­min­is­tered Nar­can, typ­i­cally range from $70 to $150 per dose, of­fi­cials say.

Com­pound­ing the costs, the po­tency of the new­est batches of opi­oids of­ten means first re­spon­ders must ad­min­is­ter mul­ti­ple doses of nalox­one to re­vive pa­tients. Health of­fi­cials say pow­er­ful ad­di­tives to the il­licit mar­ket — such as fen­tanyl and car­fen­tanil, an ele­phant tran­quil­izer — are to blame.

Even if saved, an opi­oid user of­ten is back on drugs within days, if not hours, of­fi­cials say. Here in Ohio, first re­spon­ders say it’s not un­com­mon for over­dose vic­tims to have pre­vi­ously been re­vived with nalox­one at least a half-dozen times.

Some of­fi­cials and res­i­dents are start­ing to ask how a com­mu­nity can bear to try to help those who do not ap­pear to want to help them­selves.

The de­bate has shades of the di­vi­sive pol­icy de­bates about drug treat­ment and tough jail sen­tences dur­ing ur­ban Ameri- ca’s crack epi­demic in the late 1980s and 1990s. But in the sub­ur­ban and ru­ral com­mu­ni­ties that largely es­caped that epi­demic, the de­bate this time is far more in­ti­mate, as res­i­dents’ tra­di­tional views about law and or­der — and how to spend lim­ited re­sources — are be­ing tested by a grow­ing num­ber of ad­dicts.

“You got half the pop­u­la­tion, prob­a­bly more, who have been af­fected by this, and they un­der­stand and get it, that this is a dis­ease,” said Scott Gehring, head of But­ler County’s Com­mu­nity Health Al­liance. “And then you have the other side, and it’s very easy for them to say these peo­ple are just a bur­den.”

In Maine, Gov. Paul LePage (R) has pushed to make over­dose sur­vivors pay for their Nar­can. LePage also ve­toed a bill to ex­pand ac­cess to the medicine, but the legislature voted to over­ride him.

In towns across Ohio, sim­i­lar de­bates are emerg­ing as leg­is­la­tors pon­der both the fis­cal and emo­tional costs of an opi­oid epi­demic that killed nearly 4,000 peo­ple in the state in the last year, ac­cord­ing to the Ohio’s Health Depart­ment. Though fig­ures for 2017 are pre­lim­i­nary, many Ohio of­fi­cials an­tic­i­pate this year’s toll will be even higher.

Larry Mul­li­gan Jr., mayor of Middletown, said the city has spent $100,000 on Nar­can in the first six months of the year, a ten­fold in­crease from what the town spent dur­ing all of last year. Paramedics in Middletown have re­sponded to nearly 600 over­dose calls in 2017, al­ready eclips­ing the 2016 to­tal, ac­cord­ing to city of­fi­cials.

Pi­card, the coun­cil mem­ber, has pro­posed a con­tro­ver­sial three-strikes pol­icy in which first re­spon­ders wouldn’t ad­min­is­ter Nar­can to re­peated over­dose vic­tims. In 2016, Ohio EMS units ad­min­is­tered at least 19,570 doses of Nalox­one, ac­cord­ing to state records cov­er­ing the first nine months of the year.

“First re­spon­ders are reach­ing a new level of frus­tra­tion re­spond­ing to mul­ti­ple calls, for re­peated vic­tims, and they just don’t feel like they are mak­ing progress,” Mul­li­gan said. “We can’t just keep re­viv­ing peo­ple. We have to ad­dress so­lu­tions.”

In Mary­land, con­cerns about fund­ing also have forced the Bal­ti­more Depart­ment of Health to ra­tion its dwin­dling nalox­one sup­plies, pro­vid­ing kits to ar­eas where the need is great­est.

With the help of an al­go­rithm, Leana Wen, Bal­ti­more’s health com­mis­sioner, makes de­ci­sions about where to sup­ply nalox­one kits, pri­or­i­tiz­ing nee­dle ex­changes be­cause ad­dicts who in­ject drugs are at a high risk of over­dos­ing.

More fund­ing is start­ing to trickle in from Mary­land and char­i­ta­ble groups, but Wen cau­tions that current fund­ing mod­els are not sus­tain­able be­cause of the scope of the epi­demic.

“If this was any other ill­ness, we would never ac­cept ra­tioning of an antidote,” she said.

Congress last year ap­proved a bill to pro­vide $1.1 bil­lion to help ad­dress the opi­oid cri­sis, and lo­cal of­fi­cials hope that even more fed­eral fund­ing is com­ing. Sev­eral phar­ma­ceu­ti­cal com­pa­nies who man­u­fac­ture nalox­one are pro­vid­ing the drugs free or at a dis­count to first re­spon­ders and state health de­part­ments.

In Ken­tucky, of­fi­cials pay for nalox­one with a mix of fed­eral fund­ing and set­tle­ment money from a tobacco law­suit. Of­fi­cials say they have enough nalox­one to go around, for now.

“I wouldn’t say we are do­ing great, but we are tread­ing wa­ter — we are hold­ing our own,” said Van In­gram, ex­ec­u­tive di­rec­tor for Ken­tucky’s Of­fice of Drug Con­trol Pol­icy, a state that saw 1,404 over­dose deaths last year.

The cost of nalox­one of­ten isn’t the only is­sue in deal­ing with over­doses. In re­cent weeks, But­ler County Sher­iff Richard K. Jones has drawn na­tional at­ten­tion for vow­ing that his deputies will never carry Nar­can be­cause he doesn’t want them play­ing the role of para­medic.

But Jones — a con­ser­va­tive fire­brand who re­cently ad­vo­cated that the U.S. military bomb drug car­tels in Mex­ico — says his views also sym­bol­ize the com­mu­nity’s tran­si­tion from frus­tra­tion to des­per­a­tion.

Peo­ple in the na­tion’s heart­land, Jones said, are fed up with “en­abling these peo­ple” amid a surge in drug-re­lated foster care cases, prop­erty crimes and emer­gency room vis­its.

“I’ve had three ba­bies born in my jail in 18 months, and the last one was born in the toi­let,” said Jones, not­ing that the fe­male pop­u­la­tion in the But­ler County jail more than dou­bled in re­cent years be­cause of drug-re­lated of­fenses. “The judges, to save the ba­bies, sen­tence the mothers to jail. But when the women get here, they in­duce la­bor so they can get back out and do more heroin.”

But­ler County’s chief pros­e­cu­tor, Michael T. Gmoser, gets an­gry when he hears about com­mu­nity op­po­si­tion to nalox­one.

He wor­ries that such views are un­der­cut­ting south­west­ern Ohio’s rep­u­ta­tion for de­cency and ci­vil­ity.

“What the hell busi­ness do we have say­ing, ‘You don’t get Nar­can to treat your sick­ness; we are go­ing to let you die’?” Gmoser said, pound­ing his fist on his desk. “I don’t care how many times that sick per­son comes back ask­ing for another shot of Nar­can.”

The sher­iff’s stance also puts him at odds with the broader law-en­force­ment com­mu­nity. Ac­cord­ing to the Bureau of Jus­tice As­sis­tance, 38 states have im­ple­mented nalox­one pro­grams for po­lice of­fi­cers.

“It’s not just the opi­oid users them­selves that we are pro­tect­ing,” said Keith Cain, the sher­iff in Daviess County, Ky., and the chair­man of bureau’s Drug En­force­ment Com­mit­tee. “What about the child who gets into mommy’s or daddy’s stash?”

In­stead of re­belling against Nar­can, drug pol­icy ad­vo­cates say lo­cal of­fi­cials should fo­cus on get­ting more users into treat­ment. Not far from But­ler County, in Miami County near Day­ton, of­fi­cials are do­ing just that.

County paramedics and po­lice now re­spond to be­tween 50 and 100 over­dose calls per month. But in the city of Troy, the county seat and home to 25,000 res­i­dents, a para­medic, a po­lice of­fi­cer and a so­cial worker hit the streets ev­ery Wed­nes­day to fol­low-up with those who they’ve pre­vi­ously saved.

Af­ter ap­proach­ing a woman slumped over a pic­nic ta­ble in a city park last week, the so­cial worker spoke with Kelly Bruner, 30, about her op­tions. Bruner agreed to be trans­ported to a re­ha­bil­i­ta­tion cen­ter.

Bruner said in an in­ter­view she has over­dosed on heroin 13 times in the past year, and she has been re­vived with Nar­can 10 times. Bruner said she and her friends have now started do­ing “CPR on each other,” af­ter hear­ing of Pi­card’s three-strikes pro­posal in nearby Middletown.

“As long we know you have a pulse and a heart­beat, we aren’t go­ing to call the cops, be­cause no one wants to use that Nar­can,” Bruner said. “Be­cause if we can only get Nar­can three times, that means there are only two more left be­fore we die.”

“We can’t just keep re­viv­ing peo­ple. We have to ad­dress so­lu­tions.” Larry Mul­li­gan Jr., mayor of Middletown, Ohio


But­ler County Sher­iff Richard K. Jones de­cided not to let his deputies carry nalox­one, a life­sav­ing medicine for those suf­fer­ing opi­oid over­doses, be­cause his of­fi­cers are not paramedics.

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