The Opioid Crisis: Causes and Consequences in NH, Part II

By Kim McNamara, NH Health Officer

This opioid crisis communities across New Hampshire are facing, is a whole community issue because the entirety of our communities is suffering.  This has rapidly reached unprecedented levels, and continues to accelerate.  From 2010 to 2014, deaths from all drugs in NH increased by 177.8%.  In that same period, heroin deaths increased by 653.8% and fentanyl deaths rose by 663.2%.  Throughout our state, individuals, families, and neighborhoods have been tormented by the personal loss of a relative, friend, or neighbor, affecting the physical and mental health and well-being of our entire communities. 

The heartbreaking loss of life, although the worst outcome possible, is just the tip of the iceberg.  There are innumerable additional poor outcomes piled up beneath.  Accidents and injury rates also increase while people are under the influence.  The effects on the brain and respiration can lead to short- and long-term psychological and neurological effects, including coma and permanent brain damage leading to life-long disability.   There are additional mental health and medical comorbidities that accompany opioid use, such as mood and anxiety disorders, cardiovascular and pulmonary disease, dermatological conditions and GI complications.  Public health strives for healthy people and healthy communities.  With the rising rates of opioid use and misuse, it is clear we are moving away from that most basic tenet on many levels.

Often the largest group of people with substance use disorders are of child-bearing age.  Children of addicted mothers may face neonatal abstinence syndrome (NAS), birth defects and developmental disabilities.   Opiates pass through the placenta to the baby during gestation.  When the mother is addicted, so is the child.  NAS is a painful withdrawal process leaving babies suffering from excessive crying, fever, vomiting, diarrhea, hyperactive reflexes, rapid breathing, seizures, trembling, poor feeding, slow weight gain, increased muscle tone, and other symptoms.  A most awful welcoming into the world.  Among the possible birth defects associated with opioid use, even when carefully prescribed, are spina bifida, hydrocephaly, glaucoma, abdominal wall and congenital heart defects.  

Parents who are incapacitated cannot care for or support their families, leading to children at risk at home, and children in placement outside of the home.  When children lose parents, due to death, incapacitation or incarceration, a heavy toll is paid emotionally and socioeconomically.

There is also significant risk of escalating infectious disease rates with this epidemic.  In January of 2015 a small rural town in Indiana experienced a spike of 11 cases of newly diagnosed HIV infections linked to shared needles used to inject the prescription opioid oxymorphone.  By April, 4 months later, 135 new cases of HIV were diagnosed in a community with a population of only 4,200 persons.  These patients ranged in age from 18-57, and 114 of them (84.4%) were co-infected with Hepatitis C.  373 people with contact with these patients were also identified as potentially at risk.  Of those, 247 were located, 230 tested, and 109, or 47.4% also tested HIV positive.   These people now have an even more difficult medical profile than substance use disorder alone to surmount.  

Devastating resource, economic and social consequences to their community occurred as well.  Businesses suffered because visitors would not come to town to eat in their restaurants, or receive services.  Neighboring school teams refused to play against their sports teams.  Local resources were not enough to adequately address this outbreak.  This small town in rural Indiana has a higher HIV infection rate than many developing nations.  It doesn’t take much imagination to see how those additional community effects could happen in many places in our own state. 

This outbreak requires we think differently about who is at risk of co-occurring morbidity.  It occurred in a rural population, historically at low-risk for HIV.  Infection spread rapidly because of a large network of people injecting prescription opioids within a community that lacked resources to adequately prevent and treat the substance misuse that was brewing within. 

The Indiana outbreak highlights the vulnerability of many rural, resource-poor populations to drug use, misuse, and addiction nationwide, and highlights the need for expanded mental health and substance use treatment programs in medically underserved rural areas.  Although much work is being done to build capacity here, most of New Hampshire has large gaps in prevention, treatment and recovery services, particularly in rural areas.

This calamity also illustrates why a public health response to this crisis is necessary. Intervention requires a coordinated and rapid response of different branches of public health; disease surveillance, drug monitoring, and behavioral health services.   However, other community resources separate and distinct from public health are also vital for a comprehensive and effective response.  Education and prevention efforts require involvement of our educators.  Law enforcement continues to be a vital partner with drug courts, diversion programs, drug take back, community outreach, and the all-important stemming the tide of illicit drugs within our communities.  Our EMS, community and regional medical and behavioral health partners carry a significant role in detox, treatment, and recovery services. Non-governmental organizations are also an important ally.

There are numerous other community consequences.  Crime increases to support addiction or due to the effects of substance misuse.  Our EMS, emergency departments, health care providers and legal systems are under considerable stress with the pace and breadth of this issue.  The far reaching affects are too numerous to list and many are unquantifiable, but the fabric of communities is in jeopardy.

A key social measure that requires community buy-in is eliminating the stigma which is a significant barrier to care and recovery of individuals and their families.  Even if services exist, because of public attitudes, there is reluctance to seek treatment.  Communities must embrace, care for and protect those among us who are struggling and suffering.  This acceptance and support often brings non-traditional partners such as the arts and humanities groups into the fold. They quite frankly often bring heart to the issue and are better at telling stories, raising awareness and raising capital than the more clinical and statistical approach of traditional public health and law enforcement groups.

Significant barriers to treatment and recovery remain.  The importance of evidence-based therapies cannot be overstated.  Medication Assisted Treatment (MAT) has been proven to be an effective intervention for opioid addiction.  MAT was originally developed in response to the proven ineffective treatment regime of detox followed by abstinence, which did little to slow relapse.  MAT began with the use of Methadone in 1964, and in 2000 buprenorphine under the brand names Subutex and Suboxone was FDA approved.  Naltrexone followed in 2014.  MAT has been show to allow patients to remain abstinent, or greatly reduce the use of illicit opiates, reduce the use of other illicit drugs, decrease criminal and risky behaviors, and with careful monitoring, improve neonatal outcomes.

Although MAT has been proven to be clinically and cost effective, and significantly reduce the need for detox and inpatient services, it is still underutilized.  Reimbursement, regulatory and workforce barriers have been cited for these lost opportunities.  The requirement for prior authorization, limitations on time during treatment medications can be used, and a lack of reimbursement are some of the financial barriers.  These issues are being worked on, but legislation always lags behind need.

A more perplexing barrier is the specific restriction on MAT practices.  In 2000 the DATA 2000 law was passed, allowing physicians to prescribe these newer (buprenorphine and naloxone) opioid-based medications for the treatment of addiction.  However, for unclear reasons, this law restricts the number of patients a physician can treat in the first year of their new certification to 30.  After one year of providing MAT, providers can expand their treatment to 100 patients.  This arbitrary limitation is specific to medications used in MAT only.  No other prescription practices are similarly restricted, including those that govern the prescription opioids that are at the heart of this crisis.  

Numerous other barriers exist and the State of New Hampshire’s Department of Health and Human Services, through regional public health networks are embarking on an updated assessment of NH gaps and assets, due out this summer.  The goal of public health is to assist in building a state-wide Continuum of Care for all persons struggling with substance use disorders. The continuum spans health promotion and prevention, early identification and intervention, detox and treatment, and recovery supports.  Some pieces of the puzzle are falling into place in NH, but there is a long way to go and it takes our collective effort to help ourselves.

Acute emergency treatment for overdose/detox is short-term. Inpatient rehabilitation centers, intensive outpatient programs, and recovery support services are very much needed beyond the acute phase of the Continuum of Care to help individuals remain safe and rebuild their lives.  A few inpatient treatment facilities and recovery centers currently exist in NH, and a few more are on the horizon.

Recovery centers bring together a system of prevention and recovery, and meet the need of ongoing care after formal short-term treatment.  Recovery centers follow a national model, and provide vital education, training, referral, and support services to persons in recovery, their families and loved ones. Peer Recovery and Support Services efforts are most effective when leadership in the peer recovery organization are people who are in long term treatment themselves, and success can be measured.   Indicators of effectiveness include numbers of people participating in long-term recovery, fewer incidents of recidivism in judicial system, reduced Emergency Department visits and, number of trained individuals in recovery and peer support services. 

Peer recovery and support centers meet people where they are in their illness or recovery.  Not everyone’s needs are the same, therefore, not every step on the Continuum of Care is needed for every person.  A person can step in and out in the areas that fit their particular situation.  A multi-purpose recovery center responds to the specific needs of the community and as such services will evolve as indicated.  Therefore, because of the wide variety of services they provide these have the potential to serve a large portion of our population.

It is easy to get overwhelmed in the face of the opioid crisis.  The challenges seem insurmountable.  The seriousness of this epidemic is haunting.  However, part of the message to our communities has to be that SUDs are treatable.  Many people do recover and lead happy, healthy and productive lives.  There are countless members of our own communities that are living proof of that and we, as a community must help those who are caught in this struggle to believe that they too will have a successful recovery.  There are a lot of good souls working hard towards that.  Hang in there.

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