At PublicSource’s March 24 event on heroin, there were too many questions for us to answer them all in one evening. So we asked some of our panelists to answer the remaining questions from the audience. Here are their questions and answers.
Dr. Neil Capretto, Medical Director at Gateway Rehabilitation
Q: Why is there so much heroin in the market right now? Why is it so inexpensive?
A: The main reason there is so much heroin in the community is because heroin is an opioid. We have a major opioid problem, which was driven by the explosion of prescription opioid medications throughout all communities. This resulted in thousands of new people addicted to prescription drugs. Once the thousands of people addicted to prescription opioids progressed to larger daily amounts and could not afford the cost of prescription opioids or the supply of prescription opioids ran out, they turned to heroin, which was much cheaper and more readily available.
My theory on why it is so inexpensive is that whenever cartels or organized crime groups are involved with drug trafficking, they are mainly in the making money business. The drugs are just a resource that allows them to make money. My understanding is that growing poppy plants and producing opioids, such as heroin, can be done rather inexpensively and that, combined with the large volume of demand, has contributed to the proliferation of inexpensive heroin. We can be certain that they would not be making heroin available if they were losing money. I read recently that the production of poppy plants has more than tripled in parts of Mexico in the last few years, resulting in large amounts of heroin entering the United States from Mexico.
Q: Are the needs of addicted moms and pregnant women being met?
A: There are increasing efforts to try to meet the needs of addicted mothers. Both Allegheny Health Network and UPMC have maternal addiction programs that involve putting pregnant females on methadone, and also some on view buprenorphine. This also includes a fair amount of social services. Although the number of people they are reaching is definitely increasing, there are still many women who go through their pregnancies without getting additional help, especially in more rural communities. We have seen a significant increase in addiction and pregnancy because we have seen an increase in opioid addiction in women of childbearing age.
Q: What are physicians doing to monitor their patients' therapeutic dose and compliance?
A: I assume you're referring to physicians involved with prescribing opioid pain medications. Although as a whole, I believe the medical profession is doing a better job with monitoring their patients on opioids than we were 10 years ago, there is still much room for improvement. [The monitoring] probably looks like a bell-shaped curve, with a small group doing very good work, the majority doing average and another smaller group doing very poorly. For good monitoring, you need good upfront screening for addiction, good medical assessment of what you're actually treating and looking at all resources that may help the patient's symptoms of pain, not just opioid medications. Other monitoring would include regular drug screens and random pill counts. Physicians who are involved with prescribing methadone and Suboxone also should be involved with close monitoring.
Rebecca Perkovich, Blairsville Support Group Against Drugs
Q: What can an average citizen do in their community to help heroin addicts?
A: Education in the community! Attending and even organizing public events. The more we spread awareness and knowledge the more our communities will understand the disease of substance abuse. So many people don't realize this affects us all.
Q: Is there any specific legislation we should be looking at?
A: The Prescription Drug Monitoring Program (PDMP) will hold everyone accountable.
[The drug monitoring program, passed by the legislature and signed by Gov. Tom Corbett in October, would allow doctors to check to see whether patients seeking opioids had already received prescriptions from other doctors. The electronic system is scheduled to be operational in June. (checking this with Department of Health).
Q: How do we get in touch with the Reality Tours and Sage’s Army? (These are groups that do outreach in the community regarding drug abuse.)
Mike Krafick, CRS Supervisor, Armstrong-Indiana Drug & Alcohol Commission
Q: How do you envision the role of harm reduction services in addressing the recent heroin/opioid surge? Are there any moves to expand harm reduction oriented services to rural areas?
A: Our No. 1 goal at this time is to reduce/prevent heroin and opioid fatal overdoses. Armstrong, Indiana, and Clarion Counties have all hosted Overdose Prevention Trainings with Alice Bell of Prevention Point Pittsburgh, where people who could be in the presence of someone overdosing are given naloxone vials and syringes, after completing the training. Rural treatment providers have been encouraged to include overdose prevention information as part of their treatment curriculums. Pamphlets and pocket guides on recognizing and treatment of an overdose have been developed by the Drug–Free Coalitions in each of the three counties. Town hall meetings have taken place in all three counties to alert the public to the issue. Press releases were sent to all media sources in the three counties after the passage of Act 139, which allows first responders and third parties to be prescribed naloxone. The Armstrong/Indiana/Clarion Drug and Alcohol Commission was also the recipient of a $50,000 grant from Staunton Farm Foundation to fund the distribution of naloxone to treatment providers and clients in the 10 county area in Southwestern PA.
Q: How are rehab facilities credentialed and regulated? What oversight body governs these institutions? How do you gauge your success rate?
A: Treatment Rehabilitation facilities in Pennsylvania are required to be licensed by the PA Department of Drug and Alcohol Programs (DDAP). Annual reviews are conducted by DDAP to remain fully licensed or, if there are a number of findings, possibly reduced to a partial license with six month reviews. In order to accept Medical Assistance through the HealthChoices program, treatment facilities also are credentialed by the managed care company that authorizes services in their area. Once credentialed with the managed care company, the treatment provider must also apply for a PA PROMISE Identification number in order to bill Medical Assistance.
Treatment facilities measure their success rates in many different ways. Some measurements include successful completions, reduction of re-admissions to inpatient levels of care, abstinence from substances, reduced usage of substances, abstinence at 30, 60 and 180 days after discharge, absence of arrests or legal issues and other standards.
U.S. Attorney David Hickton
Q: Is any action being taken to allow recovering addicts convicted of possession to get their license to drive back?
A: I am not aware of any action currently taking place to change the law that impacts driving privilege for those convicted of non-driving drug possession and/or paraphernalia charges.
Q: Since opioids are the gateway to heroin, what is being done to regulate doctors and overprescribing?
A: The Commonwealth of Pennsylvania and the Pennsylvania Medical Society have issued guidelines addressing the use of opioids for the treatment of chronic noncancer pain. These guidelines are intended to help healthcare providers improve patient outcomes, and do not replace the individual prescriber’s clinical judgment. In addition, we are working to implement a recommendation in the Opioid Overdose Reduction Action Plan to encourage leadership at hospitals and managed care entities to develop ongoing physician education about the risks and benefits of using opioids to treat chronic pain.
Q: Why is it that they make rehabs for the users but not the dealers? Selling drugs is an addiction itself. Helping someone who sells drugs is one less person selling drugs to our family.
A: Addiction is a chronic disease of the brain, not a lifestyle choice. Trafficking drugs is an illegal activity in which the dealer chooses to prey upon the vulnerable. I always draw a clear distinction between the two, stressing that we need to help the people suffering from addiction get into treatment, while aggressively prosecuting criminal dealers who profit from the illness of others.
Q: How can you get local law enforcement to educate themselves on the stigma of addiction?
A: We all need to move away from pejorative, harmful words like “addict,” “junkie,” “alcoholic” and “drunk” when referring to individuals with substance use disorders. Only by gaining a greater understanding of the disease of addiction can we ensure that those who are suffering have a greater likelihood of receiving the appropriate treatment.