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Addressing Heroin Crisis From Addiction Treatment, Legislative Perspectives
By Matthew Ferreira/Staff Writer/Posted Apr. 16, 2015 at 2:01 AM
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"It's becoming harder and harder to find someone who hasn't been affected by this." — Hillary Dubois, High Point Opioid Abuse Prevention Collaborative, Regional Director




MIDDLEBORO — Last week, The Gazette took a look at the current heroin epidemic in the state from a law enforcement perspective. This week, we spoke with two professionals working on the treatment side of the epidemic,

High Point Treatment Centers President and CEO Daniel Mumbauer, and Brockton-area director of High Point’s Opioid Abuse Prevention Collaborative Hillary Dubois, about their thoughts on the problem and what treatment options exist, and to State Rep. Keiko Orrall who spoke about what is being done at the state-level to address the crisis.

BIG PHARMA’S ROLE

Last week, Lakeville Police Chief Frank Alvilhiera and Middleboro Police Chief Joseph Perkins both agreed that the medical/pharmaceutical industries have played a major role in what the heroin problem in Massachusetts looks like today (See “Local police chiefs weigh in on statewide heroin problem”, Middleboro Gazette, April 9, 2015). Dubois agreed with their statements and went into the greater detail on the history behind the connection.

“To explore that issue you have to go back to Purdue Pharmaceuticals which is the maker of OxyContin,” she said. “Starting in the late 90s, this company started training their sales reps to go out and flood communities with prescriptions of OxyContin, telling people it was safe, non-addictive and appropriate for mild to moderate pain which they knew wasn’t true.

They knew that it was really only appropriate for people in severe, life-ending pain and they knew 99 percent of all people who used it would become addicted to it.

Around the same time, a lot of physicians’ groups on a national level started coming under pressure for not adequately medicating for pain so it was sort of a perfect storm. They were able to lie to all these doctors, prescribers, communities all that time until 2007 when they were found criminally guilty for fraud for mismarketing OxyContin. Purdue paid about $633 million in fines but no one did any jail time.”

Dubois notes that since 2007, the company has had to reformulate OxyContin several times to prevent tampering like crushing or melting down pills, which prompted many users to simply switch to other painkillers such as generic 30 milligram oxycodone tablets, or to switch to heroin which has become cheaper and more pure over the same time span.

Mumbauer says the correlation between rising pain killer prescriptions and the current level of heroin use is apparent.

“There’s a lot of documentation out there that suggests that there is a correlation between prescriptions for pain medicines and the number of overdoses, as well as the number of those addicted to opiates,” he said.

Some quick research turns up evidence that supports that claim. According to the Massachusetts Medical Society, fatal opioid overdoses in the state increased by 90 percent between the years 2000 and 2013, and according to data from IMS Health and National Institutes of Health, prescriptions for opiate-based pain medications increased nationally from 76 million in 1991 to 207 million in 2013.

According to the Massachusetts Department of Health, 11.1 percent of the state population received an opioid-based prescription in 2013. The average for Plymouth County was higher than the state’s at 13.2 percent.

OVERDOSES: WHY SO MANY?

Aside from increased usage, Mumbauer says there are other factors that play into heroin’s ever-growing death toll. While overdoses are possible with many controlled substances, heroin/opioids carry additional risks that are either absent or less pronounced with other drugs.

“One big difference, not so much in the nature of the addiction itself but in the risk-factor involved, is that with heroin, it’s very common for it to be mixed with other substances which can cause a bad or fatal reaction. If someone is, say, an alcoholic, they don’t have to worry about tampering like a heroin user does,” he said.

“Another unique characteristic that raises the risk factor with opioids is that when someone comes to a detox or a rehab, they get what we call ‘clean time’ while they’re there. But then when they go back into their communities, they now have a lower tolerance which means they’re at a higher risk of OD. People don’t always think about that if they do start using again.”

Dubois said that while sometimes impurities in heroin can cause a bad reaction, heroin being too pure can increase risk of overdose as well.

“Heroin is so pure now that users don’t have to inject it — they can snort it and smoke it too, and increased purity will lead to increased overdoses,” she said.

Dubois also explained what happens to the mind and body during an opioid overdose.

“There are opioid receptors in our brain and if you have too many opioids and not enough receptors it overwhelms the brain and it can no longer tell your body to breathe, and ultimately, you go into cardiac arrest because any part of your body that needs oxygen is shutting down,” she said.

TREATMENT METHODOLOGY

“When someone is seeking help with an addiction, the first level of care typically is to go to a detox,” Mumbauer said, noting a standard detox protocol of five days for opioid addiction. “From detox, we usually recommend that most folks go to a rehab where they’d stay for 10-14 days.

Then in some cases, especially in chronic cases of addiction, we’d recommend a halfway house or a recovery home where they’d stay for 3-6 months. A halfway house or recovery home wouldn’t be for everyone, but if someone is prone to relapse or they find it’s difficult to get any clean time in their community, they might benefit from more long term support in a structured environment.”

For those transitioning from a structured environment back into their communities, Mumbauer says outpatient services are recommended. Aside from typical outpatient services, High Point offers the SOAP Program at some locations, which stands for Structured Outpatient Addiction Program.

“It’s a great transitional program — some call it ‘day treatment,’” Mumbauer said. “When you’re in detox and rehab, you’re in a 24/7 support environment. For some people, maybe they don’t need to go to a halfway house but they need something more than an hour a day which is what a typical outpatient program would do. So SOAP is a four-hour a day program, five days a week where folks come in, participate in therapeutic groups, educational groups, counseling services.”

There are also prescription medications meant to assist in addiction recovery, such as methadone and Suboxone and Vivitrol, which is administered monthly by injection. Dubois explained that all the drugs come with their own advantages and disadvantages.

“Methadone is an opioid, but it’s a long-acting opioid, so the idea is that you go to a methadone clinic, receive your dose from that structured environment, and you don’t get cravings to use because your opioid receptors stay satisfied from the methadone for 24 to 36 hours till you get your next dose,” she said.

“Suboxone is a combination of naloxone, which is what Narcan is, and buprenorphine. If you try to abuse — snort it, take too much — you get full dose of naloxone. If taken properly you get semi-synthetic opioid effect and the receptors in the brain stay filled. The thing with Suboxone is it’s a tab or a strip where many people get take-home prescriptions so it gets hard to make sure everyone’s taking it properly.

There’s a huge market for Suboxone on the street so some people don’t take their doses, sell most of their scripts and then they take it right before they go into their Suboxone clinic or doctor so it’s in their system. Vivitrol doesn’t help as much with the cravings, but at the same time people can’t get high while they’re on it and just knowing that, most people won’t waste their money on drugs.”

Dubois notes that while the use of such prescribed drugs in promoting one’s sobriety is criticized by some, her theory is, “whatever works.”

“I’m not one of those people who thinks that these are ‘cheating’,” she said. “Different people take different steps to recovery and if one of those works for you then I say do what you have to do to get your life in order. But at the same time, people shouldn’t think that they’re going to get better just from using these drugs alone. It should always be coupled with therapy, maybe group meetings — something that will support the psychiatric side of recovery.”

ADDRESSING OPIOIDS AT THE STATE-LEVEL

Both Mumbauer and Dubois note that despite often being referred to in Massachusetts as a “state-wide epidemic”, opioids are more of a nation-wide problem. However, according to Dubois, Massachusetts has become a national leader in addressing the issue at the state-level.

“The federal government gives certain funding to states and Massachusetts had always used that money to combat youth smoking and drinking. Well in 2007, the state said, we’ve already done so much with youth tobacco and alcohol issues, but what’s killing and affecting our young people the most right now is heroin overdoses, so the state asked for funding to address that, which was a novel idea at the time.

There was no existing framework for that type of programming, so Massachusetts was a frontrunner both in recognizing this problem and in some successful outcome measures,” she said. “Some of the things that have come out of that is the Narcan programs, re-looking at health curriculum in schools to include prescription medication and heroin, promoting proper disposal and storage of medication, just as some examples.”

State Representative Keiko Orrall noted that in addition to Governor Charlie Baker’s opiate taskforce, Mass. legislation has put forth many bills relative to the opiate problem, including bill H2104, “An Act increasing awareness of suspected opiate overdose deaths”, and SD1442, “An Act strengthening punishment for heroin dealers.” Other bills address drug education in schools, regulating electronic prescriptions for opiates, and treatment of OD victims.

“The state is not just looking at this from one side. There’s been legislation to address improving awareness and educating kids in school about the effects of these drugs, there’s legislation to make harsher penalties for heroin dealers, legislation to limit access to opiates, to provide communities with more resources, and then of course there’s the opiate task force assembled by Governor (Fred) Baker. So, legislators, the governor, the Attorney General — they’re working together to form an all-around view of the issue and put together a comprehensive approach,” she said.

“There is also a prescription drug monitoring program in place and right now we’re trying to figure out how to get more doctors and medical practices signed up for it.”
In the end, Rep. Orrall says it’s important for people to be aware of the severity of the issue and for it to stay in the public’s collective consciousness.

“It’s important for stories like these to get out there because it’s important that people are talking about this. Unless it’s on people’s minds I don’t think we’re going to reach that level of understanding on how serious this is,” Orrall said.

Dubois, in closing, said she believes “humanizing” the issue may be the key to addressing it properly.

“We need to look past the stigma around this. Too many times when it comes to these issues we get finger-pointing, saying it’s someone else’s problem, but I think at the end of the day, what’s going to help people get better are community-based initiatives that are looking at humanizing this issue,” she said. “We’re now losing people from overdoses at the same rate as we were at the height of the AIDS epidemic. It’s becoming harder and harder to find someone who hasn’t been affected by this.”

High Point Treatment Centers’ Middleboro site is expected to open its first unit on June 15, and the final of four units by September. It should be noted that the site will be classified as a psychiatric hospital that specializes in treating “dually-diagnosed” patients, meaning patients who have been diagnosed with psychological issues as well as addiction.

For more information on High Point Treatment Centers locations and services offered, visit www.hptc.org. Existing facilities include those in Plymouth, Taunton, Brockton, and New Bedford.





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