Pubdate: Sat, 15 Jul 2017
Source: Washington Post (DC)
Copyright: 2017 The Washington Post Company



MIDDLETOWN, Ohio -- The coroner here in the outer suburbs of
Cincinnati gets the call almost every day.

Man "slumped over the dining room table." Woman "found in the garage."
Man "found face down on the kitchen floor of his sister's residence."
Man "on his bedroom floor -- there was a syringe beneath the body."
Coroner Lisa K. Mannix chronicles them all in autopsy reports.

With 96 fatal overdoses in just the first four months of this year,
Mannix said the opioid epidemic ravaging western Ohio and scores of
other communities along the Appalachian Mountains and the rivers that
flow from it continues to worsen. Hospitals are overwhelmed with
overdoses, small-town morgues are running out space for the bodies,
and local officials from Kentucky to Maine are struggling to pay for
attempting to revive, rehabilitate or bury the victims.

As their budgets strain, communities have begun questioning how much
money and effort they should be spending to deal with overdoses,
especially in cases involving people who have taken near-fatal
overdoses multiple times. State and local officials say it might be
time for "tough love": pushing soaring medical costs onto drug abusers
or even limiting how many times first responders can save an
individual's life.

"It's not that I don't want to treat overdose victims, it's that the
city cannot afford to treat overdose victims," said Middletown Council
Member Daniel Picard, noting this industrial town in northern Butler
County might have to raise taxes in response to the crisis.

The debate comes as demand for opioid antidote medication surges,
creating new challenges for police and emergency crews already
emotionally drained as they watch their communities -- and, in some
cases, families -- torn apart by opioid addiction. Often, the only
thing separating whether an overdose victim goes to the hospital
instead of the morgue is a dose of naloxone, also known by the brand
name Narcan, a medication that can reverse the effects of opioid overdoses.

Two doses of an injectable form of naloxone, Evzio, cost $4,500, up
from $690 in 2014. The price of other forms of the drug, including the
nasally administered Narcan, typically range from $70 to $150 per
dose, officials say.

Compounding the costs, the potency of the newest batches of opioids
often means first responders must administer multiple doses of
naloxone to revive patients. Health officials say powerful additives
to the illicit market -- such as fentanyl and carfentanil, an elephant
tranquilizer -- are to blame.

Even if saved, an opioid user often is back on drugs within days, if
not hours, officials say. Here in Ohio, first responders say it's not
uncommon for overdose victims to have previously been revived with
naloxone at least a half-dozen times.

Some officials and residents are starting to ask how a community can
bear to try to help those who do not appear to want to help themselves.

The debate has shades of the divisive policy debates about drug
treatment and tough jail sentences during urban America's crack
epidemic in the late 1980s and 1990s. But in the suburban and rural
communities that largely escaped that epidemic, the debate this time
is far more intimate, as residents' traditional views about law and
order -- and how to spend limited resources -- are being tested by a
growing number of addicts.

"You got half the population, probably more, who have been affected by
this, and they understand and get it, that this is a disease," said
Scott Gehring, head of Butler County's Community Health Alliance. "And
then you have the other side, and it's very easy for them to say these
people are just a burden."

In Maine, Gov. Paul LePage (R) has pushed to make overdose survivors
pay for their Narcan. LePage also vetoed a bill to expand access to
the medicine, but the legislature voted to override him.

In towns across Ohio, similar debates are emerging as legislators
ponder both the fiscal and emotional costs of an opioid epidemic that
killed nearly 4,000 people in the state in the past year, according to
the Ohio's Health Department. Though figures for 2017 are preliminary,
many Ohio officials anticipate this year's toll will be even higher.

Larry Mulligan Jr., mayor of Middletown, said the city has spent
$100,000 on Narcan in the first six months of the year, a tenfold
increase from what the town spent during all of last year. Paramedics
in Middletown have responded to nearly 600 overdose calls in 2017,
already eclipsing the 2016 total, according to city officials.

Picard, the council member, has proposed a controversial three-strikes
policy in which first responders wouldn't administer Narcan to
repeated overdose victims. In 2016, Ohio EMS units administered at
least 19,570 doses of Naloxone, according to state records covering
the first nine months of the year.

"First responders are reaching a new level of frustration responding
to multiple calls, for repeated victims, and they just don't feel like
they are making progress," Mulligan said. "We can't just keep reviving
people. We have to address solutions."

In Maryland, concerns about funding also have forced the Baltimore
Department of Health to ration its dwindling naloxone supplies,
providing kits to areas where the need is greatest.

With the help of an algorithm, Leana Wen, Baltimore's health
commissioner, makes decisions about where to supply naloxone kits,
prioritizing needle exchanges because addicts who inject drugs are at
a high risk of overdosing.

More funding is starting to trickle in from Maryland and charitable
groups, but Wen cautions that current funding models are not
sustainable because of the scope of the epidemic.

"If this was any other illness, we would never accept rationing of an
antidote," she said.

Congress last year approved a bill to provide $1.1 billion to help
address the opioid crisis, and local officials hope that even more
federal funding is coming. Several pharmaceutical companies who
manufacture naloxone are providing the drugs free or at a discount to
first responders and state health departments.

In Kentucky, officials pay for naloxone with a mix of federal funding
and settlement money from a tobacco lawsuit. Officials say they have
enough naloxone to go around, for now.

"I wouldn't say we are doing great, but we are treading water -- we
are holding our own," said Van Ingram, executive director for
Kentucky's Office of Drug Control Policy, a state that saw 1,404
overdose deaths last year.

The cost of naloxone often isn't the only issue in dealing with
overdoses. In recent weeks, Butler County Sheriff Richard K. Jones has
drawn national attention for vowing that his deputies will never carry
Narcan because he doesn't want them playing the role of paramedic.

But Jones -- a conservative firebrand who recently advocated that the
U.S. military bomb drug cartels in Mexico -- says his views also
symbolize the community's transition from frustration to

People in the nation's heartland, Jones said, are fed up with
"enabling these people" amid a surge in drug-related foster care
cases, property crimes and emergency room visits.

[The opioid crisis is straining the nation's foster care

"I've had three babies born in my jail in 18 months, and the last one
was born in the toilet," said Jones, noting that the female population
in the Butler County jail more than doubled in recent years because of
drug-related offenses. "The judges, to save the babies, sentence the
mothers to jail. But when the women get here, they induce labor so
they can get back out and do more heroin."

Butler County Sheriff Richard K. Jones stands next to a horse saddle
and framed pictures of John Wayne inside his office on July 12 in
Hamilton, Ohio. Jones has decided not to let his deputies carry
Narcan, a potentially lifesaving medicine for those suffering opioid
overdoses. (Ty Wright/The Washington Post)

Butler County's chief prosecutor, Michael T. Gmoser, gets angry when
he hears about community opposition to naloxone.

He worries that such views are undercutting southwestern Ohio's
reputation for decency and civility.

"What the hell business do we have saying, 'You don't get Narcan to
treat your sickness; we are going to let you die'?" Gmoser said,
pounding his fist on his desk. "I don't care how many times that sick
person comes back asking for another shot of Narcan."

The sheriff's stance also puts him at odds with the broader
law-enforcement community. According to the Bureau of Justice
Assistance, 38 states have implemented naloxone programs for police

"It's not just the opioid users themselves that we are protecting,"
said Keith Cain, the sheriff in Daviess County, Ky., and the chairman
of bureau's Drug Enforcement Committee. "What about the child who gets
into mommy's or daddy's stash?"

Instead of rebelling against Narcan, drug policy advocates say local
officials should focus on getting more users into treatment. Not far
from Butler County, in Miami County near Dayton, officials are doing
just that.

Twila Fair, a recovering heroin addict, talks to Mike Bessler, left,
of the Miami County Recovery Center, Patrolman Brian Ross of the Troy
Police Department and Greg Dilts of the Troy Fire Department, all
members of the Quick Response Team, which meets those struggling with
addiction. (Ty Wright/The Washington Post)

County paramedics and police now respond to between 50 and 100
overdose calls per month. But in the city of Troy, the county seat and
home to 25,000 residents, a paramedic, a police officer and a social
worker hit the streets every Wednesday to follow-up with those who
they've previously saved.

After approaching a woman slumped over a picnic table in a city park
last week, the social worker spoke with Kelly Bruner, 30, about her
options. Bruner agreed to be transported to a rehabilitation center.

Bruner said in an interview she has overdosed on heroin 13 times in
the past year, and she has been revived with Narcan 10 times. Bruner
said she and her friends have now started doing "CPR on each other,"
after hearing of Picard's three-strikes proposal in nearby Middletown.

"As long we know you have a pulse and a heartbeat, we aren't going to
call the cops, because no one wants to use that Narcan," Bruner said.
"Because if we can only get Narcan three times, that means there are
only two more left before we die."
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