Monday, September 14, 2015

Maine: The opiate issue (1/2)

Look Out Point; Maine

(Note - given the sensitivity of this issues discussed in this article, I am using people's first names only.  Also, some requested that their likeness not be used.  So I have decided to eliminate all last names for this article.)

     As I have traveled along the coast of Maine, there is one consistent thing I have heard in every town.  Business owners, ministers, public servants, people on the street - they all have made similar comments.  "You know we lost four kids last year."  "We had seven overdoses in one weekend last month." "We have an epidemic happening and nothing is being done about it."     

     What all these people are talking about is a plague of death coming from opiate use.  Small towns - places with populations of less than a thousand are seeing several deaths a year.  When I arrived in Portland the newspapers were talking about 14 overdoses that paramedics had responded to - in one day.  

     When a woman I had met on the Lighthouse Lover's Boat Cruise out of Bath offered to let me stay with her for a couple of days I was happy to accept.  It wasn't long until I found that she too had been touched in a tragic way by this epidemic. 

     Glenda worked at a local ship manufacturer for over thirty years, doing the best she could as a single parent to give her two children a good start in life.  She had a daughter, Stephanie, born in 1969 followed by a son, Rick, born in 1971.  

     In February of 2002, Rick died of an overdose at the young age of 30.  After talking with Glenda for some hours on the topic I decided I should try to do an article on the subject.  It turns out to be a much more complex topic that I anticipated.

      We start at the Portland Fire Department.  

     Kevin oversees the paramedic crews in Portland.

     Emergency calls for help with opiate overdoses will have paramedics in a corporate law firm bathroom helping someone to a park bench to help someone that is homeless - and everything in between.  Kevin makes it clear that opiates do not care about how much money you have, what sex or what race you are - they destroy lives with impunity. (The list of prescription opiates and opioids includes almost 100 medications.) 

     A decade or so ago opiates seemed to be confined to more of a subculture - street people who Kevin sees as trying to seek some relief from a tough life.  Kevin says people need meaning in life; being bitten by mosquitoes while sleeping on the concrete are bound to have anyone seeking some relief.

Sunrise in a downtown Portland park

     But that all has changed.  There is a huge new wave of addicts who have gotten addicted to prescription pain medications.  As their tolerance to these medications grow it becomes harder to acquire enough pharmaceuticals to satisfy the addiction.  Heroin is the cheapest opiate to acquire, so addicts turn to the streets.  Kevin doesn't see heroin showing up much in folks under 25 and phasing out in those over 45.  It seems that by the mid 40's the vast majority of folks are either dead from an overdose or from the lifestyle.   Precious few find a way to get clean and stay clean.

     One of the tools Kevin and his crews have to work with is a drug called Narcan.  When given intravenously, this drug goes straight to the brain and blocks the receptors the opiates use.  This temporarily prevents the brain from being overwhelmed and gives the body a chance to process some of the opiate out.  The average person has a misconception that the drug neutralizes the opiate - it does not.  The body actually breaks down this drug much more quickly than the opiates themselves.  So there are cases where they take a person to the hospital after bringing them back from death's door and the person, feeling better, checks themselves out of the emergency room.  The Narcan wears off and the opiates, still circulating in their system, go right back to work on the brain.  This is compounded because on release individuals "feels better now" and add more opiates to their system.  Narcan does save lives, but its usefulness is only to buy enough time to get the toxicity below the lethal threshold.

      Kevin says that beyond the Narcan and a ride to the emergency room, the only other thing the paramedics can give addicts is understanding and compassion.  He talks about how his crews try to interact with those that they have helped.  His frustration is that he knows people need a "workable plan for living," but besides the emergency room Paramedics don't have anything available to steer them toward.  Besides, he says, once addicted the vast majority don't want help even if it is available.  The only real solution is to somehow stop the flow of new addicts.

    So the Paramedics take them to the emergency room, then what?  I spoke at length with Jeff, who has worked as an emergency room doctor for over twelve years.

     Most opiate addicts Jeff sees don't come into the emergency room in an ambulance - they come in complaining of ailments.  They are practiced, and they know that in this country a doctor is obliged to treat pain.  So they complain of severe back aches, neck aches, joint pains and other ailments they describe as "excruciating."  After years of doing this, Jeff says he can spot most of the opiate addicts - there is a certain hardness about them.  But for the average person you can - and do - stand right next to them all the time and have no idea.

     Recent changes in medical record keeping at the national level now have computers talking to each other, so an addict cannot go from doctor to emergency room to doctor nearly and get drugs as easily as in the recent past. 

 Kennebunkport, Maine

      Jeff says more education is needed to teach medical people how to prescribe opiates safely.  Often a two day prescription is appropriate rather than a thirty day supply.  And often opiates are not needed in the first place.  There have been some attempts at educating medical personnel on this issue, but Jeff isn't sure how effective they have been.

     He says that legal intimidation does not work for the opiate addict.  It seems that only peer based approaches work.  Those who truly want to recover need interaction with others who are staying clean so that they have models to pattern their behavior after.

     As to the medical industry, Jeff's frustration is that administrators only care about numbers - move more patients through and maximize the dollars collected per patient.  Beyond avoiding potential liability, there is little concern for patient outcomes.  It is all about the dollars.  Doctors and nurses don't run anything - they are obliged to listen to administrators who are not in the business for the healing.      

Oceanfront residence in Kennebunkport Maine

     Opiate addicts find themselves in a death spiral with no way to get out.  Some start with a prescription for an injury, others start out by experimenting with drugs they find in their parents or grandparents bathroom medicine cabinet.  Nobody starts out putting a needle full of heroin in their arm.  Education is needed to inform people to get rid of their old meds immediately.  Jeff says there was some momentum to do an ad campaign a few years back, but somewhere along the line it died.  But just as importantly we have to educate everyone else that this is not a problem with "street people."  People caught in this spiral are everywhere and they are around you - all around you.

     And so the best emergency room folks can do is try to show some compassion and refer people for counseling or longer treatment programs.  Very few are interested, and there are very few affordable resources available for those that do.  The emergency room folks have to move on - they have to heed the demands that as few doctors and nurses as possible see as many patients as they possibly can.

     Recently, Portland's primary detox center lost its state funding and closed down.  I was able to spend several hours with a fellow named Mark who worked there for twelve years as a counselor.   

Land's End, Maine

     "There are no casual opiate abusers" says Mark.  "With alcohol, you have those who are casual drinkers, problem drinkers, heavy drinkers and then you have your alcoholics.  With opiates, once they have their hooks in you you are in - for life.  There are no 'weekend' opiate warriors."

     As a pharmaceutical user's need escalates they only have a few options to meet their addiction's demands.  They can "doctor shop," which means going to multiple doctors and getting numerous prescriptions.  Some find ways to buy opiates in quantity from other countries, others find others who have prescriptions they don't use and still others will get a job caring for the elderly to try to continue supplying their habit.  But sooner or later most turn to heroin.

     Heroin is so much cheaper than the street price of pharmaceuticals that an addict can continue the facade of work and family for a few more years.  But in that they expose themselves to an uncertain supply.  They never know its level of purity and it is often mixed with other drugs with serious and sometimes fatal side effects of their own.  Sooner or later the inevitable comes - the addiction requires so high of a dosage of the opiate that they have to walk right up to the line of death to get the relief they seek.   This isn't the only way opiates kill - many die of other side effects.  Deep depression leads many to suicide, many die of complications from HIV and Hepatitis from shared needles and others die committing crimes to try to get their drugs.  And we aren't even discussing the hundreds of thousands who end up in prisons.

Business card on the public counter at the Brunswick Police Department 

     The symptoms of withdrawal from opiates are not life threatening as they are with alcohol and a few other drugs, but they are very uncomfortable.  An addict faces at least two weeks of symptoms far worse than any flu.  Every cell in their body - even their bones ache and fluids come out of every body orifice.  The physical symptoms usually subside after four to five weeks, and then the mental obsession sets in.  Addicts talk about doing fine for a while and then finding themselves loaded again with little or no conscious memory of setting out to get drugs or putting them in their body.  Clean addicts talk about a hole inside that they try to fill with other things - work, relationships, money or any of countless other things, but nothing will fill that hole inside.

Kennebunkport, Maine

     Mark talks about how people use up every resource in their life in their efforts to feed this demon, and by the time they start arriving in detoxes they have lost their ability to work, they are without insurance, family and friends have given up on them and they have burned every last material resource they can think of.

     But a detox doesn't really do these people any good - a detox is only designed to help someone get through the first few days of withdrawal.  Longer term resources are needed, and there aren't many available.  And so Mark, like the paramedics, finds himself in the position that all he can really offer the opiate addict is some love, some respect and some hope.  

Land's End, Bailey Island Maine

     I also spoke with several paramedics, policemen and medical people that I promised to not quote or use their images in exchange for candor.  

     They are all see a carnage that far exceeds what is published.  They express frustration with a government that is so driven by outside money that they will not force solutions at the source.  They see a pharmaceutical industry that takes no responsibility for a huge problem they are fueling while they keep coming out with more and more potent opiates that they push for profits.  They see incredibly potent drugs being prescribed and then being left lying around for young people to experiment with - only to quickly become hooked for life.   They see a steady parade of new prisoners who resort to crime to try to pay the high street prices of prescription drugs.  They see a media that works hard to avoid talking about the underlying source of the addicts and only talks about the "heroin problem."   And they see the same people in all manner of trouble - again and again and again until they finally read about them dying of one thing or another at way too young of an age.

River scene close to Topsham Maine

    I heard several thought provoking and a few stunning perspectives.  One officer bitterly stated that "The Partnership for a Drug Free America" is primarily funded by the pharmaceutical companies.  They don't want a drug free America he said - they just want an America that is free of any competition to their drugs.  

     Another stated that pharmaceutical companies are much more interested in long term customers than they are in cures.

     A retired military office had another view.  He said we lost more men and women in Iraq and Afghanistan than we did on 9/11, but the number of our youth that died as a result of the heroin our servicemen smuggled into the states from Afghanistan dwarfs both numbers.

     An addict with 26 years clean who now works in the medical field told me that when he recently he overheard a discussion among the nurses at the clinic he works at.  The were talking about the local detox being shut down and the fact that addicts no longer have a place to go.  "I sure hope we don't have to deal with any of 'those people'" one of the nurses said.  "It's too late," he replied.  "I am already here."  She gave him a blank look - clueless as to what he was saying.

     And there was the officer I spoke with who said that given our approach to this problem, cheap heroin is probably a blessing.  It saves countless people from committing robberies and other crimes to get their drugs.

     Tomorrow we will talk to some folks from a long term rehab to talk about what approaches to treatment are available and we will meet some addicts who have managed to put together some time clean.  

     That brings us to today's "Faces in the Crowd," one of my favorite photos ever taken.

     This fellow was standing on a street corner in Portland while I sat in traffic.  When he spotted me with the camera on him he instantly assessed me as a prospect.  Just after the shutter clicked he yelled "Brother, have you been saved?"  Right then I did get saved - traffic started moving.  I smiled and waved as I moved along and couldn't help but wonder - was that God doing for me what I couldn't do for myself? 

     Today's parting shot was taken on a back road somewhere around Land's End, Maine.

     I guess the guy can say that he keeps his other woman right out back behind the barn.

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Make it a great day !!

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