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Public Health Officials Call on Providers to Treat Opioid Addiction as Medical Issue

  • Sharon Stancliff, medical director of the Harm Reduction Coalition in New York City, gives an overview of naloxone during her presentation at a daylong conference in Concord, N.H., on Jan. 18, 2018. “If you just want people to breathe again, we need more naloxone in the hands of more people in the community rather than more naloxone in the hands of the few,” she said. (Concord Monitor - Elizabeth Frantz)

  • John Drury, police chief in Farmington, N.H., said during a daylong conference in Concord, N.H., on Jan. 18, 2018, that his department uses naloxone heavily, generally administering it to someone in town at least twice a week. (Concord Monitor - Elizabeth Frantz)



Valley News Staff Writer
Saturday, January 20, 2018

Concord — Now that drug overdoses have become the leading cause of death for Americans under 50, public health advocates are urging providers to stop blaming people who use drugs for their addiction and instead treat them as they would any other patient who comes to them for medical care.

While some of the harms — such as overdose — caused by opioids are due to the chemistry of the drug itself, others are due to social policies and attitudes, Sarah Wakeman, the medical director of Massachusetts General Hospital Substance Use Disorders Initiative, said during an addiction medicine symposium focused on harm reduction last week.

“Those are choices that we’ve made as a society and there are ways we can make different choices as individuals and as care providers,” Wakeman said during the event, which was held on Thursday at the Arthur D. Kehas Criminal Justice Training Facility in Concord and sponsored, in part, by the Dartmouth-Hitchcock Substance Use and Mental Health Initiative and the C. Everett Koop Institute at Dartmouth.

Wakeman and other speakers outlined some of the challenges and successes they’ve encountered in preventing overdoses and the transmission of blood-borne diseases and getting people into long-term treatment.

They include the continued stigma against those who use drugs; obstacles to accessing medication-assisted treatment, the cost of naloxone, the overdose reversal drug; and the burdensome training requirements for law enforcement officers to administer naloxone.

All people should have the same right to care, but those who use drugs have often been blamed for their illness and treated differently than those with other health conditions, Wakeman said.

“What would it look like if we treated someone with another medical condition the way we treat people with addiction?” she said.

For example, she said, if a patient came to an emergency room after a heart attack, and was treated the way those who come in for a drug-use related emergency are — the hospital would be sued for malpractice, she said.

In this scenario instead of providing aspirin or another medication, the provider would tell the patient that he or she needs to meet with a nutritionist and make behavioral changes before they can get medication.

The patient would then be “sent home with a stern reminder not to have a heart attack again,” Wakeman said. “You would sue that doctor.”

But, somehow, she said people who use drugs often face these barriers to treatment. For example, though counseling is often a requirement of medication-assisted treatment for substance use disorders, Wakeman said there is no scientific evidence that requiring counseling helps people to be more successful in their recovery.

Several speakers advocated for expanding access to medication-assisted treatment by increasing the number of providers in various health care settings — including primary care, hospitals and emergency rooms — who are certified to prescribe methadone and buprenorphine to curb cravings in those with substance use disorders.

In his remarks, Gov. Chris Sununu described the state’s workforce needs to address substance use disorders, as well as other mental health and physical health issues as “the next big challenge.”

Sununu said employers in New Hampshire are struggling to fill positions in nursing, psychiatry and other clinical roles, echoing comments D-H CEO Joanne Conroy had made earlier in the week during a meeting with Valley News editors and reporters.

“How are we going to go and grab that workforce?” Sununu said, noting that he is committed to adding between $1.5 million and $2 million to the state’s student loan repayment program.

Needle Exchange

Two future doctors, second-year Geisel School of Medicine students Louisa Chen and Nasim Azizgolshani, spoke at the event in favor of expanding access to medication assisted treatment and said they intend to begin writing prescriptions to treat substance use disorders upon graduation.

“(We) will be certified before we’re licensed, so we can immediately start prescribing,” Chen said.

Chen and Azizgolshani, along with some of their classmates, began operating a needle exchange in Claremont last summer to provide sterile needles to people who use intravenous drugs such as heroin to prevent them sharing needles and spreading diseases such as HIV and hepatitis C. The students also collected used needles to get them off the street, provided naloxone and information about treatment programs.

The students stopped providing services in October after city officials said that their location in the Claremont Soup Kitchen was too close to a school to be legal under the state law allowing such exchanges that Sununu signed into law last June.

Despite the problem with the location, Chen said they are committed to finding a way forward for the needle exchange, named Project 439 for the number of New Hampshire residents who died of a drug overdose in 2015.

Though members of the Claremont community have asked the students whether providing sterile needles encourages people who use drugs to use more, Chen said no. Instead, by being available and showing concern about people’s health, the students helped people to stay safe while they used and also helped to connect people to treatment when they were ready, Chen said.

So far, the students have been unable to find another location for the needle exchange, in part because of the number of schools in Claremont. In time, however, the students hope to return to the soup kitchen to provide naloxone kits and testing for blood-borne illnesses such as HIV and hepatitis C, Azizgolshani said.

The only other needle exchange in operation in New Hampshire is Hand Up Health Services, based in Strafford and Rockingham counties. In contrast with Project 439, Hand Up does not have one location and instead operates by distributing needles and naloxone kits to people on the street, or wherever they might be.

“It was really, really simple,” said Dean LeMire, a Hand Up volunteer, who is in recovery himself.

LeMire said that Strafford County, in particular, was “starving” for access to sterile syringes, noting that sometimes people were reusing needles up to 80 times. Though by law pharmacies can sell up to 10 needles without a prescription, no pharmacy in Strafford County, which includes Durham and Dover, had opted to do so, he said.

“People were sharing syringes knowing that (they) had been contaminated,” LeMire said.

In addition to preventing the spread of disease with sterile needles and preventing overdose deaths with naloxone, LeMire said they are also spreading the word about available treatment options.

“When you tell them what’s available, they respond,” he said.

One misconception Wakeman said she aims to correct is the idea that people who use drugs don’t want to get well.

Instead of lacking the desire to be healthy, Wakeman said people who use drugs often, “don’t know how to access treatment ... or it’s not available.”

Community Buy-In

In his remarks, Andrew Shagoury, the president of the New Hampshire Association of Chiefs of Police and the chief of the Tuftonboro Police Department, acknowledged that there is a stigma within the law enforcement community and he was initially “concerned about what (allowing needle exchanges) is going to bring into our communities.”

But, through research and discussion with public health advocates, Shagoury came to understand that such programs aren’t going to increase crime and they should help reduce possible exposure to used needles found on the street.

Shagoury advised public health advocates to “get the community on board to buy in” to harm reduction efforts such as needle exchanges. “That, I think, is key,” he said.

Other harm-reduction strategies discussed on Thursday included changing the way providers discuss drug use with their patients; expanding access and training to naloxone; and establishing safe injection sites, places where people can use drugs they’ve obtained elsewhere. Though not legal in Vermont or New Hampshire, such facilities have shown promise in Canada, Europe and Australia in reducing deaths and illness caused by drug use, said Dr. Sharon Stancliff, medical director of the New York City-based Harm Reduction Coalition.

Stancliff described herself as an advocate for safe injection sites, but said such sites are “one small part of the solution” and require community support to be successful.

To support their communities, some police officers have become qualified to give naloxone to overdose victims, though they say the process for becoming certified to do so is burdensome and costly.

“We have to go through all these hurdles,” Shagoury said.

The need to overcome those hurdles, however, is clear to John Drury, chief of the Farmington Police Department, who said his community has been hard hit by the opioid epidemic. In 2015, 12 people in Farmington — a community of 7,000 — died of overdoses. That number has since dropped, and in 2017, Farmington lost one or two people to overdose, he said.

Aiming to reduce the death toll, Drury’s department has held “pancake breakfasts with Narcan,” the brand name of naloxone. And, he carries cards with information about treatment that he gives out to people with addiction, he said.

“(We’re) not there to criticize them, we just want them to get help,” he said.

Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.