By Hannah Schoenbaum
BU News Service
Worcester has spent nearly $200,000 on overdose revival medications like naloxone since 2015, but even as the medication has become widely available, the city’s opioid-related death count has risen. That has led some in the community to question whether revival medications are a worthy investment.
Worcester is one of 10 municipalities in the state where the rate of fatal overdoses continues to climb, defying a broader statewide trend toward fewer deaths. According to data from the Massachusetts Department of Public Health, opioid-related overdose deaths in Worcester increased 55.8% from 2014 to 2018.
Naloxone, most commonly sold under the brand name Narcan, is an “opioid antagonist” medication that blocks the effect of opioids on the central nervous system and helps restore breathing to someone who has overdosed.
Worcester has spent an average of $33,000 on Narcan in each of the last five years, with the 2019 total reaching $39,382, according to spending records. Worcester’s Commissioner of Health and Human Services, Dr. Matilde Castiel, said the city will likely continue to increase its spending in the coming years.
“The goal is to get Narcan into the hands of every person in the community,” Castiel said. She said the rising death rate is all the more reason to invest.
Overall, Massachusetts has spent close to $1 million on Narcan every year since 2015 through its pilot program, according to the state spending ledger.
Though the program has been costly and statewide opioid overdose-related deaths have only declined slightly since 2016, DPH spokesman Fred Clifford said increased access to naloxone has been “integral” to the state’s strategy to combat the epidemic.
“Much of the money is used on overdose education and naloxone distribution,” Clifford said, “intended to educate opioid users, their families and others on how to recognize and respond to opioid overdoses.”
Naloxone has been available to cities and towns at a discounted rate through a bulk purchasing program since December 2015. More than 200 police and fire departments and several K-12 schools, universities and health boards have purchased discounted naloxone.
Police and fire departments are eligible for additional first responder naloxone grants from the DPH’s Bureau of Substance Addiction Services. The grants range from $5,000 to $50,000, based on the municipality’s population.
Clifford said naloxone is “user friendly” and is the best tool at the state’s disposal. He said nasal Narcan, the most commonly used form of naloxone, should be administered when it looks like a person has overdosed; common symptoms, he said, are “lethargy and suppressed breathing, as well as nonresponsiveness to verbal and physical prompts.”
Though Clifford said the state focuses its work on people at highest risk of overdose, Castiel said the goal in Worcester is to equip everyone in community with some form of naloxone.
In addition to the money from the state, the city has been applying for grant funding to expand naloxone access.
“It should be something that everybody carries with them so that the same way that we think about getting our entire community trained in CPR, we’re getting our community to learn how to administer Narcan,” Castiel said. “It’s really easy, but people need to feel comfortable doing that and carry Narcan wherever they go.”
Access and training
In August 2018, Gov. Charlie Baker issued a standing order in all Massachusetts pharmacies that permits them to dispense rescue kits to any person who may be in a position to assist someone at risk of overdosing. Every licensed retail pharmacy in the state is required to maintain a sufficient naloxone supply.
While there is no limit to the amount of naloxone pharmacies may dispense to an individual, Sen. Harriette Chandler, D-Worcester, said some drug users might be taking advantage of the easy access to the revival medication.
“There is a problem of people getting revived two or three times a week,” Chandler said. “But if you don’t invest in reviving them, you’re going to invest in burying them.”
People who identified themselves as drug users were responsible for 89% of the state’s 16,480 reported naloxone rescues from 2007 to 2018, according to a DPH data brief. Over that 11-year period, nonusers were responsible for just 1,844 overdose rescues.
Martha Akstin, director of prevention and screening at AIDS Project Worcester, said she thinks combating the opioid crisis needs to be more of a community effort.
Akstin said anywhere from two to 20 people attend the monthly trainings, but people can walk in anytime to learn. Drug users and their friends and family members are the most common attendees, but Akstin said she hopes more nonusers will take advantage of the trainings.
“Just our staff themselves have probably saved at least a dozen lives in the city of Worcester,” Akstin said, “so imagine all the good it could do if everyone in the city had Narcan.”
Each person who completes the training receives a nasal Narcan kit and can return to the center at any time for refills.
In September alone, AIDS Project Worcester completed 49 refill requests for people who had administered their provided dose. In each of those cases, the person survived.
“There’s 49 people that were reported in September who are alive today because of the Narcan that the state provided us,” Akstin said. “And that’s about an average number of refill requests that we get.”
Fentanyl kills progress
Naloxone has contributed to more than 2,000 rescues in Massachusetts every year since 2015, according to DPH data. But the increased presence of fentanyl on the drug market has caused more fatal overdoses than ever before.
Fentanyl is a powerful synthetic opioid that is 50 to 100 times more potent than morphine, according to the Centers for Disease Control and Prevention. Much of the heroin and cocaine on the current drug market is laced with illegally manufactured fentanyl – often without the buyer’s knowledge – and has become the leading cause of fatal overdoses over the last decade.
In 2014, fentanyl was discovered in 41.6% of the state’s opioid-related overdose victims where a toxicology screen was available, according to a DPH data brief. By 2018, 89% of overdose victims tested positive for fentanyl.
Castiel said opioid addiction is not a new issue in Massachusetts, but the overwhelming presence of fentanyl on the current drug market has caused the overdose crisis most communities face today.
“There comes the need to use fentanyl more often to achieve the high that heroin would give you,” she said, “so people are shooting up more throughout the day and taking unsafe doses, which is why we’re seeing such an extreme rise in overdoses and have this dire need for Narcan.”
Addressing roots of addiction crisis
Because naloxone is only a temporary solution, Castiel said, the city is looking to address addiction at its roots with a new emphasis on harm reduction within the school system.
“If you look at a lot of our people who are suffering with addiction, a lot of what happened to them was trauma when they were young,” she said. “They start using drugs, drinking alcohol, typically around the age of 13, so the idea is, we need to reform our school systems to provide social and emotional learning in the schools with trauma-informed care.”
The commissioner said that Worcester has a “huge problem” with mental health and she believes the opioid crisis will perpetuate unless young people receive adequate support during their most vulnerable years.
“How do you build resilience in kids?” Castiel said. “That’s a process that has to be done in the school systems, and everybody has to be trained across the board, from the teacher to the cafeteria worker to the janitor, because that’s what’s going to prevent youth addiction and end the school-to-prison pipeline.”
Castiel said the city is brainstorming ways to expand mental health resources and substance abuse education, while ensuring schools have access to naloxone for more immediate drug abuse concerns.
As for residents with a history of drug use,the city is working to improve follow-ups with those released from jail or discharged from a medical facility.
Castiel treats some individuals who have been incarcerated for 20 or more years and said many people resort to selling and using drugs because they have difficulty affording the rising cost of housing and maintaining a job without proper support.
“People can easily relapse if any issues come up,” she said. “What I worry about is the ability to follow people to make sure that they have all of what we call the social determinants of health, like housing, access to food, access to transportation.”
Earlier this year, the city’s health and technical services departments teamed up with students from Worcester Polytechnic Institute to launch the Stigma Free Worcester smartphone application, which informs users about local resources related to substance abuse.
The app is available for download on both Apple and Android devices and can direct Worcester residents to clinics, hospitals, mental health professionals and rehabilitation centers. It also features a video tutorial demonstrating how to administer nasal Narcan.
In addition to services featured by the app, low-income residents have access to the Worcester Quality of Life Task Force, which travels to homeless encampments around the city providing aid.
Caseworkers from several agencies partner with the task force to identify people who struggle with addiction and provide them with mental health support, medical assistance and referrals to treatment centers.
Mortician puts opioid crisis on display
Worcester mortician Peter Stefan faces the gruesome reality of the opioid crisis in his job at Graham, Putnam & Mahoney Funeral Parlors. The local funeral director, known for never turning away those who could not afford his services, takes in the unclaimed bodies of about 50 overdose victims each year.
Most of those victims are between 20 and 40 years old, he said.
“Drug addicts aren’t bad people,” Stefan said, “just people our community failed.”
Stefan has a long-standing reputation for accepting bodies of the poor, diseased and socially outcast. He was one of the few funeral directors in Massachusetts who was willing to bury victims of the AIDS epidemic in the 1980s. But it was Stefan’s decision to handle the burial arrangements for Boston marathon bomber Tamerlan Tsarnaev that brought him nationwide notoriety.
“I don’t leave anybody, no matter who they were when they were alive,” Stefan said. “I now get most of the drug overdose people because they don’t have any money and nobody else will take them.”
A few years ago, Stefan decided to take his unique perspective on the opioid crisis straight to state and local lawmakers, with an elaborate traveling demonstration meant to scare communities into action. The mortician strapped a small mirror to the face of a mannequin and placed it inside an open casket, which he pulls behind his hearse.
Meant as a rolling illustration of the opioid crisis, the hearse features dangling syringes, a full-size tombstone with the words “Your Name Goes Here” and several posters explaining the immediacy of the epidemic.
“People think ‘it’s not going to happen to me,’ but when you see a casket and a sign up there that says, ‘This may be the last way your family will see you,’ and they look in and they see their own face in the mirror, let me tell you, we’ve shocked a few people,” Stefan said.
“My impression is that nobody really cares,” Stefan said of the opioid crisis. “I firmly believe that the government talks about it, but I don’t see them putting a real stop to it. It’s going to get worse and worse unless we can create some sort of fear and urgency in people.”
Though Stefan told the Telegram & Gazette on Tuesday that the state suspended his license for storing unclaimed bodies at unsuitable temperatures, he said he is committed to bringing his display to more cities in the coming year.
This article was originally published in the Worcester Telegram.