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Officials Credit Reversal Drug With Leveling of Overdose Deaths



Valley News Staff Writer
Saturday, March 31, 2018

West Lebanon — The Twin States appear to be curbing the rate of increase of drug overdose deaths, according to statewide data for 2017. But officials in both New Hampshire and Vermont say there’s still work to do to address the public health crisis related to opioid addiction.

In New Hampshire, where about 60 cases still are awaiting toxicology results, the number of fatal overdoses is projected to drop to 476, nine fewer than in 2016, according to a February report from the New Hampshire Office of the Chief Medical Examiner. The projected 1.9 percent decrease reflects the first annual drop in overdose deaths in the Granite State since 2012. It is, however, still higher than any other year since 2011.

A total of 101 Vermonters died of drug overdoses in 2017, which though five more than last year, marked a far slower growth rate than in recent years.

The number of drug-related deaths only tell part of the story, said David Mara, a former police chief in Manchester and former interim chief in Portsmouth, who now is New Hampshire Gov. Chris Sununu’s adviser on addiction and behavioral health.

“It’s not saying that the epidemic is leveling off,” Mara said. “What that’s saying is Narcan (the brand name of the overdose reversal drug naloxone) is more successful.”

New Hampshire still has a lot of work ahead, Mara said. Overall, the overdose death rate in New Hampshire last year is projected to be about 36 deaths per 100,000 people. New Hampshire’s count includes suicides and out-of-state residents who died in New Hampshire. It does not include New Hampshire residents who died out of state.

There were about 16 deaths of Vermonters per 100,000 people due to accidental drug overdoses, not including suicides or deaths of out-of-state residents that occurred in Vermont in 2017. There were six drug overdoses in Vermont that were determined to be suicides and six non-Vermont residents who died by drug overdoses in Vermont last year.

Nationally, 63,632 drug overdose deaths occurred in 2016, about 20 deaths per 100,000 people in 2016, according to the most recent data available from the Centers for Disease Control and Prevention. This number includes suicides.

Reducing the rate of overdose and addiction, Mara and health officials in Vermont say, requires a multifaceted approach, including efforts such as prevention, medication-assisted treatment, mental health counseling, peer support and housing.

Though the number of Vermonters dying of drug overdose deaths is still climbing, the rate of death due to opioid overdoses increased less between 2016 and 2017 than it did between 2015 and 2016, according to data released in March by the Vermont Department of Health.

The 101 accidental drug overdose deaths of Vermont residents in 2017 marked a 5 percent increase from 2016, substantially lower than the 30 percent increase between 2015 and 2016.

“People are still dying,” Vermont Health Commissioner Mark Levine said. But “it’s really nice to see that that rate of increase has really moderated to this degree.”

Vermont has a hub-and-spoke addiction treatment model in place that Levine said is making a difference, but it’s taken some time to fully build it out. The model relies on regional treatment centers, or hubs, and a network of clinicians throughout the state who treat addiction — the spokes.

Levine said he’s hopeful that 2018 numbers will show the effect of eliminating the state’s final waiting list for treatment, which was accomplished when the state opened the last “hub” in its hub-and-spoke model last fall in St. Albans, Vt.

“The next year may look far more optimistic because we’ve eliminated the waitlist,” he said.

Key to addressing the epidemic is ensuring that treatment is available to those who need it when they are ready for it, Levine said.

Vermont also has made efforts to expand the use of naloxone to treat overdoses. Levine said almost all first responders in Vermont carry the overdose reversal drug. There’s also a standing order across the state that allows anyone to obtain naloxone from a pharmacy without a prescription, he said.

In addition, Levine said Vermont has several active syringe-exchange programs. Such programs, including two in the Upper Valley operated by the HIV/HCV Resource Center in White River Junction and Springfield, Vt., provide those still using intravenous drugs with clean needles, as well as naloxone and information about treatment.

New Hampshire has three syringe exchange programs. Though the only one that was located in the Upper Valley — in Claremont — was forced to close last year after city officials notified its operators, Dartmouth College’s Geisel School of Medicine students, that the location was too close to a school.

Increasing Access

Mara, Sununu’s adviser on addiction and behavioral health, said he looks at the number of opioid-related emergency room visits in New Hampshire as an indicator of how the state is doing in addressing the crisis.

The number of opioid-related emergency room visits has increased from about 26 per 100,000 people in October 2015 to more than 41 people per 100,000 in January 2018, according to the most recent report by the New Hampshire Drug Monitoring Initiative.

That jump is “an indication that the problem is not leveling off,” Mara said.

To continue to address this crisis, Mara said, the state needs to “fill the gap in our treatment” by improving access to care and reducing wait times.

One goal, he said, is to improve access to sober housing both before and after a patient participates in a residential treatment program. In addition, New Hampshire is working to expand the number of doctors and other providers who are licensed to prescribe medications, such as suboxone, to ease the cravings of those addicted to opioids, Mara said.

“Within the medical field there’s really a big push to have that done,” he said.

Doctors and other prescribers also have made strides in reducing opioid prescriptions and providing patients with alternative pain management techniques, he said. The state also is looking to use telemedicine to expand addiction treatment to areas where providers may be in short supply, such as the North Country, he said.

To encourage employers to assist people in recovery by giving them the time they need to get treatment and being open to conversations about substance use, the state has created a recovery friendly workplace initiative.

The state also has an eye to prevention and hopes to encourage parents to speak with their children openly about drugs and substance use and to keep such conversations going over time, Mara said.

“It’s not like a one-and-done thing,” he said.

Harm Prevention

Deaths involving fentanyl are increasing in both states, while deaths involving heroin are decreasing. Fentanyl is a synthetic opioid as much as 50 times more powerful than heroin.

The rise of fentanyl is concerning, Levine said, because it takes more naloxone to revive someone who has overdosed on fentanyl than on heroin.

“We’re just going to have to see how that goes,” Levine said.

Levine’s counterparts in law enforcement are doing what they can to keep fentanyl off the streets, but it’s a challenge because they are “following a moving target,” he said.

To further expand services in Vermont, Levine said the state is exploring the idea of providing those who use intravenous drugs with a test strip that will tell them whether what they’re about to inject includes fentanyl. The state tried this with a small group of those who use drugs and found that rather than using the information about fentanyl to get a better high, the people in the test group used the information to do things such as adjust their dosage to use drugs more safely.

Safe injection sites also are under consideration in Vermont as a way to reduce the risk of harm to those using intravenous drugs. Though not currently in operation in the U.S., safe injection sites offer a place for people to inject with clean needles and access to overdose medication.

Levine, who attended a panel on the subject on Thursday in Burlington, said such facilities are expensive and have not been used in rural areas, where people must often drive themselves to get around.

“As health commissioner, I cannot overlook any potential pathway that may save someone’s life,” Levine said. But, there are “a number of reasons that I think that such a facility might not be in our best interest in Vermont.”

Geographic Differences

Upper Valley communities are not the hardest hit by overdose deaths in either state.

Ten residents of Windsor County died of drug overdoses last year, down from 14 the year before. Five people from Orange County died of overdoses last year, up from four the year before.

Levine was somewhat cautious in differentiating between counties because some have so few deaths each year.

He did, however, note that Chittenden County saw a 33 percent increase in drug overdose deaths, to 28 in 2017 from 21 in 2016.

“It makes you wonder if there’s something different going on that we need to pay attention to in Chittenden,” he said.

In Grafton County, at least 21 people died of overdoses last year, and in Sullivan County, at least four people did. New Hampshire’s numbers by county were as of Jan. 23 and did not include 90 cases for which toxicology reports were not yet complete, according to the New Hampshire Drug Monitoring Initiative, which disseminates data provided by the state Medical Examiner’s Office.

“We have been very fortunate here in the city as we are not seeing the same high incidents of opiate overdoses as other parts of the state,” Lebanon Fire Chief Chris Christopoulos said in an email this week.

Hillsborough County, which includes the cities of Manchester and Nashua, saw the highest number of deaths in the state by far, with 158 reported as of Jan. 23.

Deaths involving cocaine appear to be on the rise in Vermont, where such deaths went to 32 in 2017 from 17 in 2016.

“People rarely abuse one drug,” Levine said. “If they’re going to be in that social community of people who misuse drugs, often it’s misusing multiple drugs.”

There are some indications that cocaine, like heroin, is increasingly being laced with fentanyl, according to a Tuesday story by WBUR, Boston’s NPR station.

In New Hampshire, cocaine also has been involved in a growing number of deaths in recent years. Cocaine played a role in 19 deaths in 2012 and 63 in 2016. Data from 2017 is not yet complete, but so far 40 cocaine-related deaths have been tallied.

According to a note in the New Hampshire chief medical examiner’s February report, it can take two to three months to receive toxicology results and for pathologists to review them and determine a cause of death.

In New Hampshire, the work has been slowed by a vacancy in the Medical Examiner’s Office. Former Chief Medical Examiner Thomas Andrew retired in September. While the office has a new chief, Dr. Jennie Duval, it has a vacancy in the deputy chief position, Chief Forensic Investigator Kim Fallon said in an email.

“We are down to one full time pathologist (our new chief, Dr. Jennie Duval) and are using doctors from other states to fill in,” Fallon said. “We are trying to fill the deputy chief position.”

Vermont has two medical examiners, who have been able to keep up with the additional work related to the epidemic, Levine said.

“They work very hard,” he said.

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