Northern New York’s Opioid Crisis: What is the cost as the epidemic continues to grow?

WATERTOWN DAILY TIMES FILE PHOTO
Depending on insurance policies, a person requesting a naloxone or narcan kit at the pharmacy could be provided with one of several options.

BY: Nicole Caldwell
The opioid crisis has hit home with a vengeance.

    Opioids in 2016 were the cause of 42,249 deaths nationally—five times the amount in 1999. Between 2005 and 2014, opioid-related emergency room visits and inpatient stays skyrocketed by 200 percent across the United States. Around half of these incidents involve drugs prescribed by doctors.

     New York shows higher rates-per-capita than most, and those numbers are climbing. Drug overdose death rates in the state spiked by 32.4 percent between 2015 and 2016, according to the Centers for Disease Control and Prevention. Eighty-eight percent of New York Capital District professionals working to address the opioid crisis say it has gotten worse over the past few years, according to a Siena College Research Institute poll released in June.

     Meanwhile, Jefferson County is today considered to be a “high-risk” area for overdoses. The toll this takes on the community is measured in lives lost, families ripped apart, and a growing financial and time commitment by tri-county first responders, agencies and departments fighting this war. Who foots the bill for this work? And is there any end in sight?

AN EPIDEMIC OF EPIC PROPORTIONS

                From 2001 through 2017, the economic cost of this country’s opioid epidemic was estimated to be around $1 trillion, according to health research and consulting institute Altarum. In New York State, the relative per-capita total economic cost burden (a measure of economic burden-per-resident) was ranked at 1.04, slightly higher than the national average of 1. In that same year, the rate of opioid-connected overdose deaths per every 100,000 residents was 15.9.

                Altarum predicts this epidemic will cost the country another $500 billion by 2020 if something isn’t done—and fast.

                “The opioid problem is being described as an epidemic,” said Deputy Chief Russell J. Randall of the Watertown Fire Department. “During most epidemics, the goal is to eradicate the offending virus or disease. Historically, the resolution of most epidemics has taken what most believe to be too much time and too many lives before a solution was discovered and implemented. Even with extreme measures, it is unlikely that this goes away anytime soon.”

                What makes the opioid crisis particularly sinister is that today, being addicted to opioids doesn’t necessarily mean buying from dealers in alleys. The drugs in this crisis come packaged in a brightly lit pharmacy. That’s where the addiction starts—and why there’s a growing black market for all prescribed opiates, from oxycodone to morphine. It’s also why the epidemic can be difficult to quantify in terms of cost.

                “This problem has cost our company tens of thousands of dollars per year over the past few years,” said Bruce G. Wright, paramedic, president and CEO of Guilfoyle Ambulance Service, Inc. “We are mandated responders, meaning that for every call for help, we have to respond. We typically get paid by insurances and patients for treating and transporting patients to a hospital. A vast majority of patients that overdose on heroin, fentanyl, carfentanyl, or other opiates are woken up by first responders (police, fire, bystanders, EMS), take a few moments to collect themselves, then refuse to be treated any further and transported to the hospital—even if they were not breathing. Most insurances will not pay for treat-and-release scenarios (meaning us treating the patient and releasing them to their own or family care instead of a hospital), so we are not getting paid for the services rendered or equipment used on these calls.”

                Every quarter, the New York State Department of Health releases a report on the opioid crisis across the state. The most recent report came out in July. In it, data shows Jefferson County had 14 opioid-related overdose deaths in 2017. Of those, just one was from heroin; while the other 13 were from overdoses involving opioid pain relievers. In Lewis County, there were 11 fatal opioid overdoses in 2017. Just one was from heroin. In St. Lawrence County, all nine of its fatal opioid overdoses came from opioid pain relievers.

                To be sure, heroin is still a serious issue—the health department’s report also covers outpatient emergency room visits and hospitalizations, and heroin definitely factors into that data, which is steep. “On average Guilfoyle sees a few overdoses per week,” Wright said. “It fluctuates from time to time depending on the type of product that is on the streets. Some types of heroin or opiates are more potent than others. Sometimes, they are mixed with other opiates or drugs. If there is something more potent out there, then we are much busier with overdoses.”

                In the last two months alone, $100,000 in federal funding has been allocated to the tri-county region for opioid prevention. The Alliance for Better Communities in Jefferson County and the Massena Drug-Free Community Coalition in St. Lawrence County will each receive $50,000 from the Department of Justice’s Comprehensive Addiction and Recovery Act program.

                The two organizations will put the money toward drug-treatment programs and overdose prevention, with a focus on increasing the access law enforcement and emergency responders have to naloxone, a drug used to counteract an opioid overdose.

NALOXONE TO THE RESCUE?

                Naloxone is an emergency medication used to instantly reverse the effects of a narcotics overdose by blocking opioid receptors in the brain. The medicine is often referred to by its most popular brand’s name, a nasal spray called Narcan. When Narcan is administered into the nose of someone who has overdosed on fentanyl, heroin and prescription painkillers, the medicine can restore normal breathing for up to 90 minutes.

                Naloxone used to be highly regulated and limited. But as overdoses have increased nationally, all 50 states (as well as the District of Columbia) have made naloxone more accessible. Narcan is now available in more than 2,000 pharmacies in New York state.

                Researchers Jennifer Dleac and Anita Mukherjee conducted a study and found the prevalence of Narcan creates a “moral hazard” by which the access to naloxone led to a spike in opioid-related ER visits and theft without lowering opioid-related mortality rates. The reason, the researchers said, is that naloxone can provide a sort of “insurance” against an overdose, making opioid users more reckless in their drug use. Dleac’s and Mukherjee’s report, “The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime,” was published in March.

                Still, that moral hazard has been bet on as being better than nothing. And throughout the tri-county region (and, indeed, throughout the United States), Narcan is popularly encouraged as a way to prevent lethal overdoses by opioid users. And it has prevented many deaths.

                “We have also seen a price spike in Narcan, from two to three times more expensive rates due to the demand,” Wright said.

                “When I was first approached about providing Narcan on our apparatus,” Chief Randall said, “the cost per dose was $35. However, at the same time, there was legislation being passed that a non-EMS fire department could obtain the Narcan for free. But as we were an EMS fire department, we had to pay for the medication—a cost I did not think we could absorb. 

                “We were able to obtain the Narcan from the Fort Drum Regional Health Care Organization for free. The administration of said medication was also free, and was acquired and placed into service… There is no way to actually measure the occurrences within our community with the distribution to the public sector of naloxone kits which may be administered, but remain unreported.”

                ACR Health, a legacy of AIDS Community Resources, offers free Narcan trainings at 4 p.m. on the third Thursday of every month. These sessions cover overdose recognition tips, training in Narcan administration, and information on how to obtain Narcan at pharmacies. Kits are also given to those at risk for overdose and family members and friends who get trained through ACR Health.

                According to ACR Health’s website, the organization—which serves New York counties Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, and St. Lawrence—has since 2014 “trained thousands of people how to administer Narcan, the opioid overdose rescue drug, and distributed ‘kits’ free of charge to everyone trained. Very often the drug reached its expiration date without ever being used for overdose rescue. Now, in a policy shift, the state is trying to put Narcan (naloxone) into the hands of those most likely to encounter a drug overdose, while continuing to make Narcan widely and easily available.  The program is called N-CAP, Naloxone Co-payment Assistance Program.”

                Funding for all of ACR Health’s harm-reduction services comes from the New York state Department of Health, AIDS Institute, and Drug User Health.

                Julia LaVere, MSW, is the prevention director of syringe exchange programs at ACR Health. “I take pride in our programs and the harm-reduction approach used to engage individuals that are struggling with substance use disorder,” LaVere said. “We do not consider providing Narcan to individuals that are at risk of an overdose as a burden—the alternate cost is that lives are being lost.”

                In 2018, LaVere said, Narcan training and kits were issued to more than 800 individuals in ACR’s nine-county service area. Of those, 125 were reported as used to save a life.

                “The individuals trained range from those suffering from the disorder and their immediate contacts to staff at community-based organizations and law enforcement,” LaVere said. “From our perspective, EVERYONE should be trained in Narcan and how to respond to an overdose; because unfortunately, it is a more common occurrence than most would like to believe.”

Numbers are almost impossible to quantify while opioids become gateways to other dangers.

                “This crisis has affected our community mentally, spiritually, and financially,” Wright said. “It takes a mental toll on family, friends, caregivers because this illness is so tough to overcome. It is frustrating when a paramedic wakes up a patient and they refuse to go to the hospital for further care and the same paramedic is back within 24 hours pronouncing the same patient dead because the Narcan wore off but the opiate did not—or they kept using to try and get high again, and then the Narcan wore off and the patient overdoses and does not wake up.”

                Spiritually, Wright said, the opioid epidemic is particularly taxing. “It tests your faith limits because you are so overwhelmed with this problem both personally and in the community.” And lastly, there are the actual finances. “You keep spending money on programs or treatments, and patients relapse or stop the treatments. There are also long-term implications with this drug use. What is this going to cost down the road when other health problems arise in these patients?”

                And that’s just residual costs to non-drug users. There are more complications, of course—from opioids being connected in the North Country to sex trafficking; and the fact that when opiates get hard to come by, users often end up using methamphetamine.

WHAT ARE THE ANSWERS?

                “Every agency that we know of is trying their best to assist those affected by this problem,” Chief Randall said. “This issue is challenging as it includes people who unintentionally become addicted to prescribed opioid pain relievers, and others who have intentionally experimented with illicit drugs and are mixing or ‘cutting’ chemicals to make more potent compounds.”

                “Agencies in the North Country are doing the best they can with what they have,” Wright added. “You read about the law enforcement agencies making arrests and seizing drugs, weapons and money, but more just keeps coming in from outside the north country. You see treatment programs with full waiting rooms and people being seen and cared for.”

                Randall said solutions can come from increased education of potential hazards of addiction, and greater implementation of deterrents and penalties. “There is a lot of work that needs to be done, both now and in the future, to reduce the public’s exposure to drug usage,” he said.

                Unfortunately, things are not slowing down. “We are still having to respond to overdoses where people are barely—and sometimes not—breathing,” Wright said. “Most insurances do not pay us if we do not transport to a hospital. For us to be reimbursed or paid for our services, that would require changes to insurance law in Albany and Washington.”

                In data the chief provided, opioid overdoses in the last three years have accounted for less than 17 percent of overdose calls in the Watertown area in 2016; 14 percent in 2017; and less than 10 percent so far in 2018. But don’t be fooled by that slight down-tick.

                “While the numbers are trending down,” Randall said, “there is no way to actually measure the occurrences within our community with the distribution to the public sector of naloxone kits which may be administered, but remain unreported.”

                The key, these local experts say, is keeping your eye on the horizon in the midst of confusing data, unclear numbers and an epidemic that lives so much in shadows. Vigilance is the only way through.

                “We are not going to back down from this crisis,” Wright said. “We are going to do our best to fight back and get people healthy again and keep this crap off of the streets.”