Opioid Solution is Prevention

By Denise Kinder, Daily American Republic, October 27, 2017

“This was very eye opening,” Robin Sides with Pyramid Tri-County Hospice said while attending the Missouri Opioid Summit at Mount Calvary Powerhouse Church in Poplar Bluff. “I knew the issue with fentanyl patches, but I didn’t know some of the uses and how pure some of the forms could be.”

Sides was one of the many representatives from the community, including prevention and treatment workers, social services agencies, school and medical professionals, law enforcement officers and faith-based groups, who came together to address the opioid epidemic in the area and statewide.

The summit was hosted by the Missouri Department of Health and Senior Services in partnership with the Butler County Health Department.

According to Whitney Preslar of the Butler County Health Center Emergency response Center, about 250 people from all over the region attended the summit.

Fentanyl, an opioid medication used to help relieve severe ongoing pain, prescriber to many cancer patients, has become a growing problem in the area, especially when being mixed with heroin.

According to Butler County Sheriff Mark Dobbs, the issue hit close to home recently.

Dobbs recounted an incident where a young woman died from a drug overdose in her home and during the investigation drug paraphernalia was found.

Once processed, it was discovered the young woman died from an overdose of heroin mixed with fentanyl.

“It (fentanyl) is so dangerous to come in contact with and can remain airborn,” Dobbs said.

The officer, who packaged the substance from the scene to be tested, began to show symptoms of coming in contact with fentanyl and was taken to the hospital.

“He probably would not be with us if we had not gotten it addressed as soon as symptoms began to show,” Dobbs said.

Vice Chairman for Research from the Department of Psychiatry at Washington University Theodore Cicero told the crowd the situation is probably worse than they have heard.

Many patients that Cicero has come in contact with said their mindset for taking opioids was they were legal, “at least it was not heroin,” and they know the dosage amount they are taking.

“The drug they avoided before, heroin, they are now switching to because it is purer,” Cicero said. “They feel they have no choice because it has been made harder to get the pill they took before.”

Cicero said he has heard many other reasons as to why opioid users are turning to heroin, including a way of “escaping,” to chase a high feeling of self-esteem and other underlying issues.

Heroin, Cicero said, has an uncertain purity and things added to it make the approximate dose amount very hard to determine and in return, overdose deaths have increased.

Once tolerance levels build, Cicero said, many begin to snort or inject the drug to get it to the brain quicker.

“The bottom line is the opioid problem is not going away until it is addressed,” he said. “Treatment, or better yet, prevention is the first step,” Cicero said.

Assistant Special Agent in Charge with the Drug Enforcement Administration Larry J. Reavis said he wanted the crowd to take away a message of hope from the summit.

“There is power in prevention,” Reavis said. “We can’t arrest our way out of this problem.”

National Council on Alcoholism and Drug Abuse Executive Director Howard Weissman said when it comes to the disease of addiction, prevention methods have not been applied as with other diseases.

“When we are talking about prevention, we are not talking about wagging a finger at someone saying don’t do drugs,” Weissman said. “We are talking about ways to deal with self-esteem and depression issues.”

Funding issues came up during a discussion of school based prevention curriculum being incorporated into schools.

“I’m asked ‘how can we afford it?’ And that is not the right question,” Weissman said. “How can we afford not to?”

Missouri House Speaker Todd Richardson said during the summit he was glad to see so many people working together on a specific problem for the state of Missouri and the country.

A statewide drug monitoring program has been a focus of Richardson since the first day he took office, he said.

Gov. Eric Greitens recently signed an executive order establishing a prescription drug monitoring program statewide, no longer leaving Missouri as the only state in the country without such a program.

Richardson said he is hopeful Missouri will become a leader on how to combat the opioid epidemic.

The Opioid Summit concluded with a panel of local experts giving their take on the problem and needs they see in the community.

Poplar Bluff Chief of Police Danny Whitely was among one of the ten panel members.

“Somewhere around 2003 to 2005, we initiated a ‘prescription pill case’ locally,” Whitely said. “We identified a huge problem then with opioids, and we still have that problem today.”

It was during this investigation, Whitely said, Poplar Bluff was discovered to lead Troop E by a large margin in prescriptions written for hydrocodone, oxycodone, oxycontin, fentanyl, Xanax and soma.

“With the opioid prescription abuse, it has opened the door for heroin to become a major problem for all of Southeast Missouri,” he said.

The area also was one of the leading in meth manufacturing, but the requirement of a prescription for Sudafed has reduced the number of meth labs dramatically, Whitely said.

“Legislation in the areas absolutely works,” Whitely said. “It is tried and proven.”

With the assistance of the Sudafed prescription requirement and drug monitoring program, Whitely said, law enforcement can concentrate on other criminal activity.

Butler County EMS Manager David Ross said they are seeing a slight decrease in opioid calls.

When a call comes in of an unresponsive person, Ross said, the first order of business is to assist with breathing.

Ross described a person believed to have overdosed on opioids as sweaty, have shallow breathing and are blue in color due to lack of oxygen.

Once arriving at an overdose situation, Ross said, Narcan is administered and is very effective, but has to be given immediately.

Narcan is used to counteract the life-threatening effects of opioid overdose.

Many times, Ross said, there is a hesitance to call for help in an overdose situation. “They might have waited too long, and there is nothing we can do,” he said.

In an effort to combat the growing number of fatal drug overdoses in the state, Missouri lawmakers passed the “Good Samaritan Law,” which allows someone present during an overdose to call for help without fearing they would go to jail, even if they have drugs on them or in their system.

Emergency doctor at Black River Medical Center Christopher Pinderski said 140 overdose patients came through emergency services last year.

So far in 2017, 125 overdose cases have been treated, and Pinderski said, if the trend continues, the year will top out with 160 cases.

“This is a 10 to 15 percent increase,” he said.

Between Black River Medical Center and Poplar Bluff Regional Hospital, Pinderski reported about 47,000 emergency room visits each year.

Emergency service doctors are trying the number of opioid prescriptions written, Pinderski said.

To help reduce the number of unused, unwanted or expired prescription medications in the community, police departments across the U.S. are participating in Prescription Takeback Day Saturday, October 28.

The police departments in Poplar Bluff, Dexter and Puxico are all drop off locations for prescriptions.

Last year, more than 1,000 pounds of medication were collected during Prescription Takeback Day and kept off the streets.

If citizens are not able to make it to Prescription Takeback Day, the Poplar Bluff Police Department has a box located in the lobby to drop off prescriptions at any time.

Preslar said everyone at the Butler County Health Department believed the summit went great and was very successful.

“We were able to get out information that people didn’t know,” Preslar said. “Many knew opioids were a growing concern, but realizing it was an epidemic was eye opening.”

Opioid Summit

By Donna Farley, Daily American Republic, October 20, 2017

Butler County saw nearly 1,000 drug-related hospital visits over a three year period of time. Nearly 700 people were sent to prison, probation or parole because of drugs, and almost 80 students were disciplined at Butler County schools. Over 900 people were arrested on drug charges. More than 30 people were injured in drug-related car crashes. And 40 people died from causes that involved drug use.

These numbers capture the real life problem of all drug-related incidences reported to state officials in 2014, 2013 and 2012, the most recent data available.

Community partners will hold the fourth Missouri Opioid Summit on Tuesday in Poplar Bluff, to address the specific problem of heroin use and prescription pain reliever misuse.

The free event will be held from 8:30 am to noon at Mt. Calvary Powerhouse Church, 1875 Speedway Drive.

Opioid abuse has been identified by state officials as one of the most pressing drug problems facing the state today, reaching what they have described as epidemic proportions.

These summits are designed to be a collaborative effort across the state to bring awareness, spur action and address problems specific to individual communities, according to the Missouri Department of Health and Senior Services.

Butler County Health Department has partnered locally with the agency to hold this event.

“A lot of us are awfully naïve about what is going on in our community, and this is a real opportunity to start working on it, addressing it,” said Robert Hudson, administrator of the BCHD. “We’ve got to work on getting the word out and making these things stop happening.

All community partners are invited to attend this event, Hudson said, including health care and school professionals, prevention and treatment workers, law enforcement, social services agencies and faith-based groups.

The first half of the morning will include state and regional speakers, discussing the history of the opioid problem and current trends.

The conference will also include personal stories from local residents affected by opioid use, including those battling addiction, family members and others.

Missouri Speaker of the House Todd Richardson (R-Poplar Bluff) has been invited to provide a legislative update, Hudson said.

A panel of local experts will help conclude the summit with a discussion on problems and needs they see in the community. It will include Poplar Bluff Police Chief Danny Whitely, Butler County Sheriff Mark Dobbs, David Ross of Butler County EMS, and representatives of treatment, hospice and medical professions.

“(The summit) is clearly to bring awareness to the opioid issue, but it’s not intended to be one meeting and then we quit,” Hudson said. “Our role as the health department is to convene those partners together and start the dialogue of what are you doing, what are we doing, where can we augment things and start working toward solutions.”

Southeast Missouri Behavioral Health, which provides medication assisted treatment, will also participate in the panel discussion.

“Our participation and role in this crisis is that there is immediate, effective medication treatments coupled with psycho-social services that can save lives by reducing overdoses and overdose deaths regardless of any insurance or ability to pay,” said Clif Johnson, Director of Clinical Compliance and Physician Services for the agency.

SEMO Behavioral Health: Treating addiction without painful withdrawals

  • JACOB SCOTT
  • Daily Journal
  • Updated
Telehealth
Southeast Missouri Behavioral Health Center staff demonstrate the use of telehealth equipment, which allows doctors to connect with patients in remote or rural areas.

With southeast Missouri being particularly affected by the opioid crisis, service providers as well as state and federal departments are stepping up to the challenges posed by the situation.

The federal Substance Abuse and Mental Health Services Administration has awarded grants to states on the basis of need, with a total estimated funding of $485 million per year. Missouri was awarded about $10 million a year for two years.

The awards are known as State Targeted Response to the Opioid Crisis Grants, or Opioid STR for short. According to Southeast Missouri Behavioral Health Center’s Director of Clinical Compliance and Physician Services Clif Johnson, southeast Missouri has been designated a high-need area for those grant dollars to go to work.

“For this area, meaning St. Francois County, Washington County, over through Crawford and Dent County, it’s a target for extra funding,” Johnson said. “We’ve received our second grant to help target the uninsured population that’s becoming dependent on opioids because of the number of overdoses in general, not just deaths.”

SEMO Behavioral Health Director of Administrative and Support Services Dan Adams said the focus of the second grant is slightly shifted from that of the first, though both were awarded to combat opioid abuse in the community.

“The focus of the first grant for this area was more targeting the illegal use of prescription opioids because it was really high,” Adams said. “But it’s changed so that heroin is as much a problem as prescription drugs.”

The grant dollars came at the perfect time for SEMO Behavioral Health, as they had begun employing a new system of support for clients including medication-assisted treatment and telehealth services.

“The big term being used now is ‘medication first,’” Johnson said. “So the focus is that if you come here, call in or walk in and you’re an opioid user, you’re going to get in front of a physician and get medication first. We’re not going to mess with paperwork, assessments, or the regimens you go through when you go to see your physician. You’re going to see a nurse for your vitals check and then you’re going to get in front of a doctor.”

Adams said the idea of providing opioid-dependent clients with medication as quickly as possible is because of past experience with those who were facing withdrawal symptoms. “It’s frustrating when you get somebody in and they start withdrawing,” Adams said. “They know how to feel better so they’ll walk out and use. With the old way you’d suffer through social-setting detox and then if you can make it four or five days and get through the diarrhea and vomiting, then we’d get you some help. But you realize we don’t do anybody any good if they walk out. So we’ve got to keep them here, and the way to keep them here is to make them feel better.”

Johnson said clients who were not undergoing residential detox would often not return after the first visit because the withdrawal symptoms became too great to bear. The point of medication first is to quickly get a client onto medication that eases those symptoms so they are more likely to continue treatment and counseling.

“If they started feeling bad they might go and use,” Johnson said. “And the problem is if they go use they may overdose and die. I mean, people are dying so we had to do something different as a treatment provider because this is something we haven’t ever seen with people dying like this and the community afraid. Families are afraid, clients are afraid, law enforcement is afraid — they don’t know what to do with all of these overdoses. That’s why you see families and clients starting to get Narcan.”

Once a client receives medication, often Suboxone, and are feeling better, Johnson said it is then easier to convince the client to take the steps to further resources. “They have all the problems a normal substance abuse disorder client has,” Johnson said. “They have family issues, children issues, job issues, legal issues and housing issues. But if they’re not feeling good and they’re craving, then you’re not going to be able to deal with it. And if they’re not alive, we’re not going to get anywhere.”

“It’s Maslow’s Hierarchy of Needs,” Adams explained. “If somebody’s hungry or thirsty, you’re not going to talk to them about self-actualization. And if they’re sick and vomiting, you can’t say, ‘Hey, you really need to change your lifestyle.’ You take care of the vomiting first and get them on medication.”

Adams said a “perfect set of circumstances” occurred to produce the opioid epidemic existing today, especially for those who first became addicted to prescription opioids before moving on to heroin. “We’ve had the perfect storm,” he said. “Physicians that went through medical school in the late ’80s and into the ’90s were told to treat the pain, so there were a lot of prescriptions for opioids. There was research, mostly done by pharmaceutical companies that said if you’re really in pain you don’t become addicted.

“So you get that group, then after all the opioid abuse stuff came out, medical schools started teaching the opposite. So you have new doctors coming in the last five or six years who won’t prescribe an opioid for a chronic condition. So they may come into a practice where there’s been another doctor and they’ll have patients that are really addicted to opioids for their chronic pain and they’ll cut them off.”

Adams said at the same time, a high grade of heroin has been coming into the country that can be effective without injection, allowing those with substance abuse disorder to avoid the use of needles.

Staff pointed out SEMO Behavioral Health Center was a particularly good candidate to receive grant funds because the service provider had already put in place much of the infrastructure for the programs being employed today. “We were in a good position to get these grants, and we could implement them quickly,” Johnson said. “We could start treating clients immediately. We were the first to get the STR grant and we were literally the first in the nation to start seeing clients.”

A key component of the center’s effectiveness is the inclusion of telehealth, which allows doctors to connect with clients who are miles away via specialized communication equipment. This is particularly effective in rural communities where there is a shortage of physicians and a large number of potential clients. “We’ve been so fortunate,” Adams said. “We got our first telehealth equipment through a grant with the University of Missouri. We thought, ‘Oh, this will be great for psychiatry.’”

The equipment was first used to connect autism specialists in Columbia with clients here in southeast Missouri, saving families hours of travel time and expense. When the idea arose to use the telehealth program to get opioid abuse clients quick treatment, the center received support from the Missouri Department of Mental Health, which Adams says is a national leader. “So when we decided to do more telehealth, the Department of Mental Health was like, ‘Yeah, we think outside the box. Let’s go for it.’ So we didn’t run into the bureaucratic nightmares that a lot of states have. The Missouri Department of Mental Health has been great.”

The Farmington SEMO Behavioral Health Center’s Director of Services Rob Gould said the expanded resources allow the center to find a way to help someone affected by substance abuse disorder, one way or another. “No matter what — if a client comes in, calls in, gets dragged in or the police bring them in, they’re not going to get turned away,” he said. “We will find a way to get you in no matter what program it is. We’ll find a way to help.”

Johnson said while the community has been very open and accepting of the work being done by SEMO Behavioral Health Center, there are sometimes still problematic attitudes encountered. “Sometimes there’s an attitude of, ‘Why should we spend money on those people?’” he said. “There’s that stigma, which I think keeps people from wanting to get help because they’re thrown in that basket. It’s a hard stigma to break through,” he said. “And it’s a shame that it takes a crisis like the opioid crisis to get people to kind of pay attention. But I think people are still thinking, ‘Well, they just need to quit. Why should we spend all this money?’ And that’s a hard nut to crack.”

Jacob Scott is a reporter with the Daily Journal. He can be reached at 573-518-3616 or at jscott@dailyjournalonline.com.

Heroin epidemic creates new challenges for local healthcare providers

  • Oct 27, 2017
  • Daily Journal

Heroin and healthcare

Patient Care Tech Courtney Barnhouse rushes a bed down the ER hall at Parkland Health Center – Bonne Terre.

Kathy Ferguson and Heather Moran have seen firsthand how the number of heroin overdoses have increased in this area, and the effect the cases take on local healthcare providers.

Both Ferguson and Moran work at Parkland Health Center. Ferguson is the Emergency Department nurse manager and Moran is an RN/CEN (Certified Emergency Nurse).

Ferguson says the last few years the number of heroin overdoses has probably doubled. She said the problem has become greater than the meth problem, and the amount of cases each day varies. Ferguson recalls one time where the hospital had seven overdose cases come in on the same day from the same party.

According to Moran, when several come in at one time it can be because of a bad batch of heroin from a different provider than usual.

“You learn just from working here and seeing it,” she said.

The amount of overdoses varies from week to week. The ER may see several in one day and may not see any the next day.

It’s all hands-on-deck when something like that happens. Many times the patients arrive alone and without any identification or insurance information.

“People just roll up to the door and push them out (of the vehicle),” Ferguson said. “They don’t want to get in trouble or be involved.”

She said when these patients arrive unconscious that emergency room personnel know nothing about them.

“Not knowing who they are makes it harder to treat them,” Ferguson said.

“We won’t know their name or any medical history,” Moran said. “We just have to do what is best for them with what we know.”

Ferguson said the treatment includes the “ABCs” – airway, breathing, circulation. But with overdoses they administer the drug Narcan into the usual procedure. Each patient is treated the same way.

“It could be anyone,” Ferguson said. “It’s not poor. It’s not rich. It could be anyone. It is very, very sad though. People do risky things that they wouldn’t normally do.”

Ferguson said what the heroin has been cut with can affect the treatment methods. If it is cut with fentanyl, it is very strong and takes more Narcan to try to revive the patient.

“Sometimes we have to give them multiple doses of Narcan,” she explains.

There is now a new opiate called Carfentanil which is 100 times stronger than heroin and fentanyl. Carfentanil can be transferred through the skin putting healthcare providers at risk of death. Due to this new threat healthcare providers have to take extra precautions.

“You have to gown, glove, and mask for every overdose because we don’t know what is coming in the door,” Ferguson said.

There’s been an alert put out about it. It’s a new process/procedure in order to keep everyone safe.

“You can also inhale any residual powder,” Moran said, adding that when patients wake up from the Narcan they are being thrown into instant withdrawal and pain.

“They get mad when you wake them up,” she added. “I had one spit blood on me.”

If the patients are alert and oriented they can leave the hospital.

“They just wake up and check themselves out,” Moran said.

Missouri state law mandates that healthcare providers report child abuse and neglect to the Missouri Division of Family Services. This includes if a baby tests positive for an illegal substance.

“Almost every drug passes from the mother’s blood stream through the placenta to the fetus. Illicit substances that cause drug dependence and addiction in the mother also cause the fetus to become addicted. At birth, the baby’s dependence on the substance continues,” said Dr. Karin Clauss, pediatrician with BJC Medical Group. “However, since the drug is no longer available, the baby’s central nervous system becomes overstimulated causing the symptoms of withdrawal.”

Dr. Clauss adds that some drugs are more likely to cause withdrawal than others, but nearly all have some effect on the baby. Opiates, such as heroin and methadone, cause withdrawal in over half of babies exposed prenatally.

“Symptoms of withdrawal may vary depending on the type of substance used, the last time it was used, and whether the baby is full-term or premature. Symptoms of withdrawal may begin as early as 24 to 48 hours after birth, or as late as five to 10 days.  Symptoms can range from tremors and excessive crying to diarrhea and vomiting,” Dr. Clauss said. “Longer term effects may include, but are not limited to, birth defects and seizures.”

Southeast Missouri Behavioral Health Leads Fight in National Opioid Crisis

Heroin and other opioid use disorders have become a national crisis with overdose becoming the leading cause of death among young adults. Medical advances have made treatment for opioid use disorders much more effective than in the past and a combined state and national effort is underway to incorporate these medication assisted therapies (MAT) with more traditional evidence based treatment practices.

Southeast Missouri Behavioral Health (SEMO-BH) is a state and national leader in the provision of MAT. For the past 3 years, SEMO-BH along with one other behavioral health organization have participated in federal grants through the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) and Center for Substance Abuse Prevention (CSAP). Most recently, beginning in July 2017, State Targeted Response to the Opioid Crisis Grants (STR) allows states to develop programs addressing the opioid crisis by increasing access to treatment and reducing unmet treatment needs. The overall goal of STR is to reduce opioid overdose related deaths through the provision of prevention, treatment and recovery activities.

Southeast Missouri, along with the St. Louis area, was earmarked as high need by the Missouri Department of Mental Health due to the number of opioid related deaths. SEMO-BH was able to begin using the Opioid STR grant funding to provide treatment services before any other agency in the United States due to experience in MAT and existing resources. SEMO-BH has developed a working relationship with over a dozen physicians, psychiatrists, and advance nurse practitioners and linked them to high need underserved areas with telemedicine. This structure makes Medication Assisted Services available upon intake so that immediate relief is provided to opioid users increasing the likelihood they remain in treatment and are successful in recovery. Southeast Missouri Behavioral Health has 17 sites where clients can access Medication Assisted Treatment and supporting services at little or no cost.