By Mark E. Wilson, MD
We have an epidemic in the Birmingham area that is killing an alarming number of people, mostly young adults, and even a few teenagers. Although it is not initially fatal in every case, it is very hard to eradicate and it tends to relapse. It also increases the risk of several other diseases. The risk of precipitous death is always there. It affects people from all socioeconomic groups. It causes extraordinary suffering and disruption in families. It negatively impacts our schools and our neighborhoods, and its economic toll on society is enormous.
What is it? A resurgence of heroin: cheaper, more potent and more widely available than ever before. Deaths from heroin overdose in Jefferson County increased from 13 in 2008 to 30 in 2011, and then jumped to 58 in 2012 and 58 again in 2013. The confirmed death count so far in 2014 is 36. Shelby County reported no heroin overdose deaths in 2008, but in 2011 there were 10, climbing to 16 in 2012. Seven heroin-related deaths have been confirmed for 2013; four more deaths are believed to be heroin related, pending confirmation by toxicology reports. Tuscaloosa County has seen several deaths as well.
Many users start with prescription painkillers (opiates) and then move on to heroin. Teenagers often get their start with medicines taken from home medicine cabinets. But some are trying heroin without first using prescription pain medicines. Because the heroin supply is of variable potency but sometimes very pure, it's like playing Russian roulette. Any outbreak of disease with a death rate this high would call for swift public health intervention, but the heroin epidemic is much more complex than most disease outbreaks. We need a multimodal approach with involvement of multiple sectors of the community to successfully reverse the current trend.
Federal, state and local law enforcement launched an coordinated effort to dismantle and disrupt the heroin supply chain beginning in September 2012. They have had some notable successes which appear to have checked the dramatic increase in deaths. A major drug bust in September 2013 resulted in the arrests of about 50 heroin dealers. But more drug dealers are surely filling the void. The effort to limit the supply must be paired with a robust effort to curb the demand. We must all wake up to the problem of addiction in our own families and throughout our community and take action.
First, we need to increase awareness and overcome the naive assumption that "this couldn't happen to my child" or "this isn't a problem in our school." We need to listen to the stories of families who struggle with heroin addiction or have lost a loved one to heroin overdose. These stories can help us all approach the problem with humility and with compassion for the addicts and their families. Addicts have made bad decisions, for sure. But most people, once they become addicted actually want to quit, but feel trapped. Heroin addiction alters the brain so that the drug seems as essential as food and water. For those who try to quit without medical assistance, the withdrawal symptoms are horrible: nausea and vomiting, diarrhea, abdominal pain, severe body aches - they often say it feels like they are going to die.
We need to take specific, pragmatic steps to prevent deaths from overdose. We should adopt "911 Good Samaritan" policies that provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help to the scene of an overdose.
The vast majority of heroin use is in the company of other people, but the majority of people who have died from overdose are found alone, abandoned out of fear of arrest. These policies protect only the caller and the overdose victim from arrest and/or prosecution for simple drug possession, possession of drug paraphernalia, and/or being under the influence, but not those who traffic drugs or commit other crimes. Naloxone (Brand names Narcan and Evzio; generic available) is a drug that can be given by injection or via nasal spray to temporarily reverse an overdose of heroin or other opiate, buying time for emergency responders to arrive.
Many lives have been saved in Alabama by emergency medical personnel who carry naloxone in their ambulances. Several states have passed laws that allow naloxone to be used by police officers, or prescribed to family members or friends of addicts as a rescue medicine. While this is not without controversy, we need to at least have a meaningful policy discussion about what is most appropriate. We need to strengthen and expand effective prevention efforts and increase access to addiction treatment. Prevention is obviously preferable to treatment after heroin use has begun, but it's not simple or easy. Treatment of heroin addiction is challenging and failure is common. There is not a one-size-fits-all approach; we need to pursue a variety of evidence-based approaches. Some addicts have been successful with non-pharmacological treatment programs. Others are able to lead safe, law-abiding and productive lives with the help of drug replacement therapies such as methadone or Suboxone.
We need to engage parents, educators, medical professionals, policy-makers, addiction treatment specialists and others in a community-wide discussion to develop these and other strategies. The United States Attorney's Office for the Northern District of Alabama, the UAB School of Public Health, and the Jefferson County Department of Health are hosting an all-day community awareness summit on June 10, 2014 at the UAB Alumni House, titled "Pills To Needles: The Pathway to Rising Heroin Deaths – A Community Alert and Call to Action." U.S. Deputy Attorney General James M. Cole will be the keynote speaker, and there will be multiple other speakers and panelists. The summit will end with a draft community action plan, and there will be smaller follow-up meetings to further develop specific strategies. For more information about the summit, or to get involved in the action plan, contact Lyndon Laster at email@example.com.
Mark E. Wilson, MD is the Jefferson County Health Officer. He can be contacted at firstname.lastname@example.org
By Special to AL.com AL.com
on June 02, 2014 at 7:00 AM, updated June 02, 2014 at 7:11 AM