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From 2016 to 2017, more than 66,000 deaths across the US involved opioid overdoses. In Wisconsin, Kenosha ranked first among the state’s 72 counties for overdose deaths. Community leaders and health experts united rapidly in the fight against the opioid epidemic. Conversations then and now continue to focus on raising the community’s awareness about opioid overdoses.

“Opiates” are psychotropic substances derived purely from the opium poppy plant (heroin, morphine) or their synthetic analogues, which are generally referred to as “opioids” (fentanyl, dilaudid, Oxycontin, codeine, Vicodin, Norco). However, “opioids” is now used as the umbrella term for all opiates and opioids.

According to the United State’s Surgeon General’s advisory, two major factors have contributed to the epidemic of overdose deaths: 1) the rapid production of illicitly made fentanyl and other highly potent synthetic opioids; and 2) the increased number of prescribed opioids for long-term pain management.

Fentanyl is a synthetic version of heroin but much stronger and more potent. Fentanyl and other powerful, illicit synthetic opioids are being mixed with heroin; other drugs, such as cocaine; and even pressed into tablets to resemble the appearance of misused prescription pills. This unpredictability in illegal drugs has led to numerous overdose deaths.

In 2012, opioid prescriptions exceeded 250 million in the US alone. The proliferation of prescribed opioids increases both the risk of chemical addiction as well as accidental overdoses amongst individuals, even when taken as prescribed for pain. Anyone taking or using any form of an opioid is at risk of an opioid overdose; however, elevated risk factors for an overdose include: taking larger than usual dosage; using alone; injecting; long-term use; and using after a period of abstinence (recent incarceration or drug rehabilitation program).

Opioids affect various parts of the brain that control functions such as breathing, heartbeat, and emotions. Excessive and prolonged use increases a user’s tolerance. As the tolerance increases, so does the need and the amount of the drug in order to achieve continued effects (“the high”). Because the body is unable to manage this quantity over time, a threshold is breached, and an overdose occurs.

It is important to recognize the signs of an opioid overdose. Kenosha County educates its citizens by the B.L.U.E. acronym:

B: Breathing during an overdose is shallow, gurgling, erratic, or completely absent.

L: Lips and fingertips are blue. This is because of the decrease of oxygen throughout the body.

U: Unresponsive. The victim will not respond to verbal or physical stimulation because the high dose of opioids causes the brain to slow down.

E: Eyes (pupils) are pinpoint. The opioids constrict pupils to an unusually small size.

During an overdose, a pulse may still be present despite an ongoing depletion of oxygen. Therefore, immediate assessment, identification, and action can help save a life. If you encounter someone with a suspected overdose, assess the individual, administer Narcan, dial 9-1-1, and perform rescue breathing if able and needed.

For more information contact:

The Kenosha County Division of Health (262) 605-6741 or,

The AIDS Resource Center of Wisconsin (262) 657-6644

A recent survey indicates all of 53% of Americans believe that addiction is a disease. (https://www.usnews.com/news/news/articles/2018-04-05/ap-norc-poll-most-americans-see-drug-addiction-as-a-disease) Granted, this is an improvement, but the battle isn’t over, and it’s a wonder such a survey was done in the first place.

“Disease” is defined as “An abnormal condition of a part, organ, or system of an organism resulting from various causes, such as infection, inflammation, environmental factors, or genetic defect, and characterized by an identifiable group of signs, symptoms, or both”; therefore, regardless whether or not one “agrees,” addiction is, in fact, a disease. No survey is needed.

So why the question?

Likely because of the stigma associated with addiction. If we recognize that addiction is the chronic, progressive, lethal disease it is, we – incorrectly – assume that we can’t hold those who suffer from the disease accountable for their recover. Oh, but we can…and should. We would hold accountable a smoker with lung cancer, a person with diabetes who eats carbs with abandon, a person with heart disease who eats fried foods at every meal. So, of course we should hold accountable a person with a substance use disorder who continues to use substances in a way that they aren’t prescribed!

What we shouldn’t do is stigmatize people because of the disease they have.

First, we should always put the person first. Always. Language that labels people takes away their humanness. Therefore, there are no “junkies,” “druggies,” “alcoholics,” “addicts,” or the like. There are only people with substance use disorders or people with addictions, as in “My son who has a substance use disorder…,” or “My daughter who has alcoholism….” And even in reference to one’s self, “I’m a person in long-term recovery” or “I’m a person with a substance use disorder” beats “I’m an addict” any time. Language that labels is appropriate in some circles, but it is never appropriate in the general community because, sadly, when the general community sees “addicts,” we still see something very negative, at least today. That’s why we need your help to change it.

Think about the last test your doctor ran on you. Did the office call with results and say, “Hello, Mr. Smith…your test results are in, and you failed”? Of course not.

So why do we still – and many professionals in the field are guilty of this – insist on saying people “failed” drug tests? This type of test, as with all tests for health care, either has a positive or negative result. There is no “pass” or “fail.” They are also not “clean” or “dirty.” The results are simply the results…positive or negative.

I take medicine daily to stave off migraines, yet no one accuses me of being “addicted” to my medication. I have gone periods of time without taking the medications, and I end up with more migraines – a relapse, if you will. This would lead one to believe I’m dependent on my migraine meds, which I probably am. And no one cares. But we love to accuse those who use Medication-Assisted Recovery as prescribed by the doctor as trading one addiction for another. That’s not true! Treatment works. Medication-Assisted Recovery works. Recovery happens. But it happens differently for folks, and our “One time at band camp” stories, as in, “One time at band camp I knew a guy who was on methadone and he was using it to get high…” are not helpful to ANYONE.

Recovery can happen, and when it doesn’t, it’s not because “treatment didn’t work.” It’s likely because someone wasn’t working the treatment. There’s always next time…until there isn’t. Be supportive; be corrective; and be accurate. Our children are dying because of stigma, and they need your help to recover.

 

 

 

There is a lot of confusion in the lay press and among the general public (and even some healthcare professionals) about the various levels of care and treatment options. People mistakenly assume that all individuals with addiction need inpatient detoxification services. The American Society of Addiction Medicine (ASAM) has a well validated tool, known as the ASAM Criteria, to determine the appropriate level of care for individuals seeking treatment for addiction.

At what level of care should a person be receiving addiction treatment?

David Mee-Lee, MD, was instrumental in developing the ASAM Criteria tool and has an educational program at the ASAM website (asam.org) that provides great insight toward understanding the ASAM Criteria. ASAM Criteria were initially developed in the 1980s but are not static and have changed quite a bit. For example, ASAM Criteria now include a level of care for medications to treat opioid addiction, which was not initially recognized as a separate level. Medications include buprenorphine, methadone, and injectable naltrexone.

ASAM Criteria is both an assessment tool and a tool to determine what treatment is appropriate. It is important to realize that an individual’s treatment needs change throughout the course of the disease, and the treatment may require similar adjustment. Therefore, continually reassessment of patients is important.

What is the ASAM Criteria? Generic Overview

ASAM Criteria involves six dimensions for a multidimensional assessment.

DIMENSION 1 considers the severity of withdrawal from a substance or intoxication with a substance. It is important to note that withdrawal management can be accomplished at various levels of care, from outpatient to acute medical inpatient hospitalization, depending on the substance involved and the risk associated with the withdrawal syndrome.

The MOST INTENSIVE level of treatment for withdrawal management (Level 4) is Acute Inpatient Medically Managed Withdrawal that occurs in a full-fledged hospital that can provide multispecialty care and has access to emergency services (e.g., Ascension Wisconsin’s Inpatient Behavioral Health and Addiction Unit at All Saints in Racine). Level 4 withdrawal management is reserved for those with significant psychiatric or medical co-morbidities or for substance withdrawal syndromes that carry a high risk of death (alcohol withdrawal, sedative/hypnotic withdrawal, or any substance withdrawal with a severe complicating co-occurring medical [Dimension 2 of the ASAM Criteria] or psychiatric condition [Dimension 3 of the ASAM Criteria]).

The LEAST INTENSIVE level of treatment for withdrawal management would be outpatient, office-based, withdrawal management for uncomplicated opioid withdrawal, cocaine, amphetamines, hallucinogens, and cannabis.

Level 3 (Residential Withdrawal Services) includes residential facilities like Roger’s Memorial Hospital, the Dewey Center of Aurora Healthcare, NOVA, or the Gateway Foundation in Illinois, as well as therapeutic community facilities such as the Salvation Army, Teen Challenge, or Mount Zion House. Residential withdrawal management would be appropriate for those individuals who do not meet criteria for acute inpatient hospital withdrawal management but who require a controlled living environment, lack appropriate social support, or require removal from their usual living environment because it hampers their recovery. It is important to note that Wisconsin Medicaid DOES NOT currently pay for the room and board fees of residential treatment programs due to a federal restriction that requires a waiver from the federal government. Wisconsin is in the process of requesting that waiver.

Other Levels of Care for Outpatient Addiction Treatment (Level 2 Programs)

Partial hospitalization programs require intensive programming, generally about six hours per day, five to six days per week. Locally available programs include the Dual Partial Programs at Roger’s Memorial Hospital in Kenosha and Ascension Wisconsin All Saints in Racine.

Intensive Outpatient Programs (IOPs) represent the most widely available level 2 outpatient treatment programs. Many IOPs have success rates as high as partial hospitalization or residential programs. Racine Behavioral Health, Ascension Wisconsin All Saints, Aurora Healthcare, and Roger’s Memorial Hospital in Kenosha all have IOPs. IOPs involve a combination of group therapy, psychoeducation, and individual therapy; some individuals do well while others require a higher level of care.

Lowest Level of Care for Outpatient Addiction Treatment (Level 1 Programs)

Outpatient Treatment may be individual or group therapy, but it’s generally only one or two times per week. ASAM Criteria calls for the least restrictive effective setting for treatment, so, unless there’s physical medical evidence to the contrary, if a person hasn’t had previous failed attempts in treatment, the lowest level of care – outpatient treatment – will be indicated.

Regardless of where the traditional treatment is provided, we need to overcome our stigma towards medications for addiction. While it is true that methadone and Suboxone are opioids, their use is linked with recovery from opioid use disorders (OUD). One model for us to consider is that of France, which experienced its opioid epidemic in the ’90s. The French government deregulated use of Suboxone to treat opioid use disorders, reducing mortality from opioid overdose 85% in five years. Medications are not a miracle, but they can be life-saving and life-changing for many individuals.

Further, there is no evidence that medication should be stopped at some predetermined time. In the past, providers would treat with medications for six months or one year, then begin tapering, especially with Suboxone, because data was not available to support long-term use. However, more recent studies suggest that discontinuation of medication assisted treatment (MAT) leads to relapse in 80% of individuals within two years of discontinuation. As is the goal of any treatment, care should be taken to use the lowest effective dose. In other words, MAT should be tapered to the lowest dose that controls the disease of addiction.

The above said, some patients have a better profile to consider a taper. For some individuals early in the course of addiction who have not developed significant permanent changes to the brain and who are able and willing to make the lifestyle changes that are needed to control the disease (similar to patients with diabetes who must change their lifestyles), taper after a shorter time may be feasible and appropriate. Such tapers must be individualized and discussed with the patients. Additionally, there are times when MAT must be discontinued; those decisions, too, must be discussed with the affected individuals.

DIMENSION 2 takes into account the individual’s medical problems such as hypertension, diabetes, pancreatitis, liver function problems, heart problems, or any other condition that could cause complications during the withdrawal process or otherwise hamper recovery. Pregnancy is one criterion that qualifies for acute INPATIENT withdrawal management. Typically, however, uncomplicated opiate withdrawal is either accomplished as outpatient or residential withdrawal.

It is important to remember that “detox” is not treatment and without additional treatment can actually increase the risk of overdose for an individual with an opioid use disorder. Evidence-based treatment strongly encourages medication assisted treatment (MAT) such that insurance companies are starting to deny funding if MAT is not being offered.

DIMENSION 3 takes into account co-occurring psychiatric conditions such as psychosis, suicidal ideation, bipolar disorder, and schizophrenia.

DIMENSIONS 4, 5, AND 6 all involve assessment of the patient’s social and environmental support structures and the patient’s own motivation for change.

Treatment should be seen as a continuum of care, meaning that individuals can move up and down the continuum. Transitions of care should be seamless but can be hampered by fragmentation of the health care system, which is why partnerships between different organizations is critical – to allow for seamless transition across the continuum. In order for the treatment system to work, different healthcare entities need to stop seeing each other as competition and start working together to provide seamless care for the patient. It is important to realize that different health systems may provide complimentary, but not identical, healthcare services.

Such cooperation between healthcare systems is crucial given that there is a significant workforce issue in Wisconsin; we currently lack ample psychiatry, addiction medicine, primary care, and psychotherapy services. A model similar to the wheel-and-spoke one from Vermont could work well here, provided we start working together to build stronger systems of care for those affected by the disease of addiction.

“And I would have stayed up with you all night; had I known how to save a life.” (The Fray)

Since the 2017 declaration of the opioid epidemic as a public health emergency, the Kenosha County community diligently combined forces in the battle against the worst drug crisis in the nation’s history. The opioid epidemic has claimed the lives of too many community members, and the staggering count continues to rise. The swiftest way to combat the number of overdose deaths is through the administration of the emergency medication, naloxone – better known as Narcan.

An opioid overdose occurs because opioid medications/drugs (such as heroin, fentanyl, Vicodin, Oxycodone, morphine) depress the respiratory system, resulting in a slow onset death by depleting the oxygen in the body. No oxygen, no life. Narcan, the opioid overdose antidote, reverses an overdose by blocking the effect of an opioid and restoring a patient’s breathing. It is safe, effective, inexpensive, and relatively easy to administer. Because of these characteristics, family and friends become first responders who can intervene promptly and save a life.

However, reluctance, lack of knowledge, and deep-rooted stigmas and societal divides over mental health and addiction are limiting the use of Narcan. Many people who are not in the medical field are afraid to administer a medication without knowledge or license. Narcan is very user-friendly and needs no special knowledge or licensure for administration. In fact, United States Surgeon General Jerome Adams stressed the importance of Narcan with his following statement:

“For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone (Narcan) and keeping it within reach can save a life.”

Rarely in this day and age can any of us say that we are NEVER in contact with people at risk for opioid overdose, so, what he’s suggesting is that pretty much every single American should know how to use naloxone (Narcan) and keep it within reach so that we can all save a life.

Research shows a decrease in opioid overdose deaths in communities where Narcan and opioid overdose education is readily and abundantly available. Laws have therefore been designed that permit and protect those who administer Narcan and call for help during an opioid overdose emergency. The Kenosha County Division of Health and the AIDS Resource Center provides complimentary Narcan training programs. In just 30 minutes, individuals are exposed to Narcan and educated on the fast, easy steps to administering Narcan via nasal spray or shot.

Strategies around awareness and promotion of Narcan continue to develop, and members of our community cannot sit idly by any longer, wishing this epidemic to end. It is imperative we raise awareness and empower our community to help in this fight. Anyone can carry Narcan; anyone can administer Narcan; anyone can help save a life with Narcan…together we all can.

For free Narcan training through the Kenosha County Division of Health, contact the Narcan line at (262) 605-6741 or email [email protected]

The AIDS Resource Center of Wisconsin also provides training and can be contacted at 262-657-6644 for more information.

 

The Kenosha County Substance Abuse Coalition (KCSAC) invites you to start three medication habits: DISCUSS, SECURE, DISPOSE. Of course, if you’re already doing these, please do continue!

DISCUSSING treatment options with your health care provider and being an informed consumer is the first step. You are in charge of your healthcare and, potentially, that of others. It’s OK to ask your doctor for more information about their recommendations before deciding which is the right choice for you or your loved one.

DISCUSS why your doctor feels the recommendation is best for you.
DISCUSS why you think it may not be.
DISCUSS the benefits, side effects, and risk factors of a medication before deciding to take it.
DISCUSS other options available to you, including those that are non-medical.

SECURING your medications is an important and easy way for you to help keep your family and friends safe. Most people think only those with little ones or teens need to secure their meds. However, while children are more susceptible to accidental ingestion, anyone experimenting with drugs or struggling with a substance use disorder may sneak your medications.

Furthermore, according to the Partnership for Drug-Free Kids, two-thirds of teens who misused pain relievers in the past year say they got them from family and friends, including their own homes’ medicine cabinets, making safeguarding medicine in the home vitally important. Safe storage and disposal of medications diminish opportunities for easy access.

SECURE means using a lockbox rather than a medicine cabinet for your medications.
SECURE means keeping that lockbox in a safe place, such as a locked closet, inaccessible to those who may abuse the medications.
SECURE means knowing exactly how many medications are being dispensed and how many are left.
SECURE also means securing the medications only for use by the person they were prescribed to. Sharing medications is illegal and unsafe.

DISPOSING of your medications properly is the last step in safe medication habits and can benefit your whole community.

DISPOSE of your medications at one of the many medication drop box locations that you can find here. Research indicates that Lake Michigan is being contaminated by improperly disposed pharmaceuticals; don’t be a person making that contamination worse by flushing your pharma!

DISPOSE of unused medications using DisposeRx, a simple home waste disposal solution that uses non-toxic polymers to permanently sequester prescription drugs. DisposeRx works for powders, pills, tablets, capsules, liquids, and patches, making them inert and unavailable for illicit use or contamination. Contact us for more information or a DisposeRx packet.

DISPOSE of unused medications so they aren’t tempting or available for misuse by family or friends.
DISPOSE of your unused medications when the reason you were prescribed them is no longer relevant. It’s important to get rid of all those partially-used prescriptions that so many of us have laying around. Holding on to that prescription “just in case” you need it again one day is not a good idea: any accident or impaired driving charge that occurs while under the influence of drugs taken not as prescribed or taken outside the prescribed period can lead to enhanced charges, including charges of possession of controlled substances because, technically speaking, those medications are illegal.

Please start these three easy medication practices: DISCUSS, SECURE, DISPOSE. By doing so, you really might SAVE A LIFE.