Many thanks to Channel 2 WLBZ Portland for allowing me to explain some of the issues regarding the current Heroin/Opioid Epidemic - and don't think for a minute that it is only affecting Maine. In fact, it has become a worldwide issue, so maybe we should more appropriately be refer to it as a Heroin/Opioid Pandemic.
Over the past several weeks I have received several emails from readers and others inquiring about my background and why I decided to write Addiction on Trial. I want to use this week’s blog to explain why I wrote a novel, albeit based on medical and legal truths, and to share my background. So, bear with me as I babble along!
I am a physician who is the youngest son of a physician. My father came to the United States at a very young age, worked his way through college and medical school and chose to practice medicine in two offices attached to our home in Everett, Massachusetts. My mother was the bookkeeper, secretary, cook, laundry service and most importantly, my Mom. When the home phone rang (which was also the office phone) we all answered it the same, “Doctor Kassels office; may I help you.” Not infrequently, patients would come to the front door on holidays and weekends with “specimens”. These were the same patients that would make holiday gifts for my brother and me. I can still hear my Dad, “Put that bag with the bottle in it on the counter in my little office and then wash your hands – and wash them thoroughly – did you hear me Stevie?” I heard my Dad then and I still hear him now.
Why did I write Addiction on Trial: Tragedy in Downeast Maine? Simple answer: I wanted to.
Through my years of practice in Emergency Medicine and Addiction Medicine I have had the privilege to treat patients from all walks of life. From a medical perspective, it is very clear that we have differences but we are more similar than not – we all need hearts to pump in order to sustain our organs and to perfuse our brains. When we are sick, we all benefit from compassion and care. Society should not differentiate between diseases! But who wants to read another scientific book about addiction? Not me! That's why I wrote Addiction on Trial as a mystery thriller to both entertain and educate through the depiction of the realistic struggles of addiction. I hope you enjoy reading Addiction on Trial as much as I enjoyed writing it.
"The Scourge of Heroin Addiction"
Op-ed published by the Boston Globe April 1, 2014 http://b.globe.com/1kAzt54
Governor Deval Patrick has appropriately declared the opioid addiction epidemic as a public health emergency. The governor's directives will save lives and help to put some brakes on this run away scourge to society. But questions remain and more issues need to be addressed.
For example, why is medication management for the treatment of heroin/opioid addiction scorned by so many? In a recent Boston Globe article, "Heroin Epidemic Exposes Deficiencies In Care System" (http://b.globe.com/1iNFmzo), Ms. Jacobs, Director of Substance Abuse Services for the Commonwealth of Massachusetts, acknowledged, "medications are not used as much as they could be for opiate addictions because of stigmas attached to them, she said." We watch endless commercials about how to treat illnesses such as urinary incontinence or erectile dysfunction but public service announcements addressing the heroin/opioid epidemic and the proven benefits of outpatient cost effective medication management have been relatively sparse. The governor's directives, which include public health advisories to educate the public about opioid addiction treatment options, will hopefully demystify common misperceptions, such as crime increases when there is a treatment center in one's community. In fact, there is a 50% to 80% reduction in crime by heroin addicts when in treatment. (http://bit.ly/OVVRfh ; http://1.usa.gov/1dtb42B)
We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue – that we as Americans want instant results and we want total pain relief after an injury or procedure. Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of oxycontin pills, so they could not as easily be used to "shoot up" or "snort", resulting in more persons turning to heroin as a drug of choice; the increased availability of opiates through the internet; inadequate mental health treatment services resulting in some patients "self-medicating"; and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction. Despite the arrest of kingpins and drug pushers, big and small, we still have a supply and demand problem. The supply of heroin has increased and cost is down to as little as $4/bag. As fast as we take drug pushers off the streets, they are replaced by others - there is too much money involved. Governor Patrick is right to focus on the demand side of the issue.
If outpatient treatment is not more widely accepted and available, inappropriate hospitalizations and incarcerations of patients will continue. It is time for our locally elected officials to openly support establishing treatment centers in their communities? We all know heroin addicts, albeit we may not know who they are. They could be any one of a number of patients I have treated: your plumber; the mailman; your kid's college professor; the IRS agent who audited your tax return; the person selling flowers at the corner; the principal of an elementary school (http://bit.ly/1m6XMbL); someone who works in a mayor's office (http://bo.st/1hbtN20); or a neighbor; or a family member.
A recent study has shown that less than 20% of individuals needing addiction treatment actually received treatment (http://1.usa.gov/1hYRzvX).. Another study found that only 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment and that "most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge" (http://bit.ly/1o2l3Ax). Are we willing to accept as status quo the present system of unnecessarily hospitalizing or incarcerating patients? We are wasting tax dollars: it costs up to $50,000 or more per year to incarcerate (http://bit.ly/1iBKSlg ; http://nyti.ms/NW5dGQ) and approximately $5,000 per year for outpatient treatment (http://bit.ly/1rCh3G6). “There are things besides beds that are effective in this system,” Jacobs said. “More people should see this treatment as a viable option.” (http://b.globe.com/1iNFmzo)
There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let's focus on the solutions. The scourge of addiction is in all of our yards. The solution is to decrease the demand with bold public initiatives and a change in attitude. It is both the humanitarian and fiscally responsible thing to do.
Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine. He currently serves as Medical Director of Community Substance Abuse Centers and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.
‘Not in my backyard’ attitude doesn’t work with drug addiction
By Steven Kassels, Special to the BDN
NIMBY — “not in my backyard” — is the rallying cry when asked if there is a drug problem in one’s neighborhood.
“Sure, maybe we have a problem, but it’s really worse in the next town over.” Or maybe it’s “the next state over.”
That’s just malarkey — it’s in all of our yards, and it does not matter whether we live in the city, suburbia, the mountains or Down East Maine. It is everywhere.
The national annual cost of illegal drug use related to law enforcement, crime, judicial proceedings, incarceration, emergency room visits, hospitalizations, lost job productivity and workers compensation exceeds $180 billion.
The cost to treat one Maine heroin addict in an outpatient, medication-based treatment center with frequent random drug testing is approximately $3,000 per year, while incarceration costs more than $50,000 per year.
Even if one wants to ignore the scientific evidence that treating a heroin or “oxy” addict with a replacement medication is not simply trading one addiction for another, one cannot deny the documented fact that patients who enter into treatment have at least an eight–fold decrease in criminal activity.
Here are some statistics in Maine:
— The number of residents seeking treatment for prescription drug abuse tops the nation.
— Maine’s Medicaid cutbacks leave 400 patients with no access to state-funded treatment.
— More than 7 percent of babies born are addicted to opiates.
— Fatal heroin overdoses quadrupled from 2011 to 2012.
— More people die of drug use than from motor vehicle accidents.
— Maine drug-induced deaths exceed the national rate.
As a nation, we have tried to cut back on the drug supply for decades, yet we are again facing a heroin and opiate epidemic in New England. We can incarcerate all the current drug pushers, big and small, and we can continue to burn the fields in the countries that produce opium. But the profits of drug production and distribution are so great that others rapidly fill the void.
Expanded access and funding for treatment makes fiscal sense, regardless of whether we believe addiction is a disease or a weakness of moral character.
It is time for our politicians to lead by educating through scientific fact and not out of fear. I commend Gov. Peter Shumlin of Vermont for spending his entire State of the State address on this essential economic issue and his call to attack the epidemic on the demand side through treatment. He recognizes that putting more “addicts” in jail may make us feel good in the short term but does not solve the problem.
Gov. Paul LePage, in contrast, focused on expanded law enforcement and judicial response. Unlike many other governors from both parties, he apparently opposes placing the life-saving drug Naloxone in the hands of first responders and others to treat heroin and opiate overdoses.
Naloxone availability will not send the wrong message to heroin addicts that they can use the drug with impunity; heroin users, who are sons and daughters, are dying because the heroin on the street is stronger than they think or cut with other opiates. Without Naloxone readily available over the past couple years there has been a quadrupling of heroin overdoses; so when our politicians state that increasing Naloxone availability will lead to more drug use, well, it’s just baloney.
We allow for life-saving medications and oxygen to be readily available to treat diabetics and smokers with emphysema without speculating that, by doing so, we encourage more smoking or poor dietary compliance.
As the death of Philip Seymour Hoffman has again reinforced, drug addiction is an equal-opportunity disease and has no socioeconomic boundaries. This is not a problem of the welfare state or the poor or less fortunate. Making treatment available should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center. NIMBY no longer works.
Dr. Steven Kassels resides in Southwest Harbor and Boston. He has been board certified in addiction medicine and emergency medicine and currently serves as medical director of community substance abuse centers throughout New England, including in Portland and Lewiston. He recently authored the book, “Addiction on Trial: Tragedy in Downeast Maine.”
I felt proud to be a Massachusetts resident as I listened to Governor Patrick’s state of the state address a couple of weeks ago. However, unlike the Governors of Vermont and Maine in their state addresses, Governor Patrick never mentioned the words “drug epidemic”; “addiction”; “heroin” or “prescription drugs”. As a physician with years of experience in both Emergency Medicine and Addiction Medicine and as a resident of the South End in Boston, I was disappointed by Governor Patrick’s omission although I do not doubt that our governor cares deeply about this scourge to our society. But how can we talk about the fiscal health of the Commonwealth without drawing attention to the tremendous societal costs of the disease of addiction; and even if one does not want to acknowledge that this is an illness with biological/genetic; psychological and sociological components, one cannot deny its horrific cost in terms of tax payer dollars, and public health and safety.
NIMBY – Not In My Back Yard – is the rallying cry heard from many politicians and citizens when asked if there is a drug problem in their neighborhood or if they would welcome a drug treatment facility. “Sure, maybe we have a problem, but it’s not that bad” or “it’s really worse in the next neighborhood over”, or “the next town over” or “the next state over.” Baloney – it’s in all of our yards and is as prevalent as the ragweed that grows in all of our lawns! It does not matter if we live in the city, suburbia, the Northeast Kingdom of Vermont or Downeast Maine – it is truly everywhere and New England has an especially high incidence of heroin and opiate drug addiction.
To truly understand the magnitude of this problem we need to examine the economic impact of addiction to society. There have been reports that when one considers the cost of drug use related to law enforcement, crime, judicial costs, incarceration, emergency room visits, hospitalizations, lost job productivity, and workers compensation; not to mention the deterioration of societal priorities or the overall risk to the public in terms of spread of disease (Hepatitis C & HIV) or secondary health and safety consequences such as domestic abuse or childhood asthma … the overall national annual cost exceeds $180 Billion. Moreover, as an example, to treat one heroin addict in an outpatient medication based treatment center with admission and yearly annual exams, laboratory screening for HIV and Hepatitis C, group and/or individual counseling on a regular basis, and frequent random drug testing, the cost for this patient in Massachusetts is approximately $5,000 per year. Halfway houses can cost $20,000 or more per year and incarceration of this patient costs upwards of $50,000 per year. And even if one wants to ignore the scientific evidence that treating a heroin or “Oxy” opiate addict with a replacement medication such as methadone or buprenorphine is not simply trading one addiction for another, one cannot deny the documented fact that patients who enter into this type of treatment have an approximate tenfold decrease in criminal activity.
I hope that our current state legislators and all our local politicians and citizens will look critically at the facts and not adopt a NIMBY approach to drug addiction that is ruining lives and stealing our tax dollars by inadequately treating and preventing this epidemic from expanding. Just look at some recent regional and national statistics:
- The Boston metropolitan area had the highest rate of ER visits for “illicit drugs” of any of the 11 major cities in the entire country;
- Greater Boston region ranked first in ER treatment for heroin overdoses, with a rate of 251 per 100,000 - nearly 4 times the national rate;
- MA Emergency Rooms see 4 times the number of cases featuring heroin compared to the rest of the country
- Opiate abuse-related MA hospital visits > 35,000/year;
- 950% increase in abuse of oxycontin and other opioids in MA in the last 10 years;
- MA had > 102,789 people admitted to hospitals for substance abuse in fiscal year 2011;
- Heroin use in past 3 years has doubled since reformulation of Oxycontin;
- An estimated 20 million people nationally need treatment for substance abuse but only 15% - 20% receive it;
- 2% of US citizens are opioid dependent;
- Heroin supply & purity is up and costs are down (as little as $4/bag);
- In Massachusetts, in one year, 916 persons died as a direct consequence of drug use. This far exceeds those who died from motor vehicle accidents (397) and firearms (207); and
- Massachusetts drug-induced deaths exceeded the national rate
But how should we attack this problem? There is no easy answer but we need to look at both the supply and demand. We have tried to cut back on the supply side for decades, yet we are again facing a heroin/opiate epidemic, most notably in New England. Yes, we can arrest and incarcerate all the current drug pushers, big and small, and we can continue to burn the fields of the countries that produce opium; but the profits of this organized occupation of drug production and distribution is so great that others rapidly fill the void. Just ask the Taliban how much money they make now that Afghani opium production has markedly increased since the beginning of the war. So, I ask that the citizens of the Commonwealth of Massachusetts and elsewhere take a fresh look at this issue and make some of the hard decisions; decisions that can only be made by fully understanding, whether or not we believe addiction is a disease or a weakness of moral character, that expanded access and funding for treatment makes fiscal sense. We must cut back on the demand to stand a chance of limiting the financial damage. And to our politicians, I know this is a politically hot issue, but lives and dollars are at stake and it is time to lead the charge to educate through scientific fact and not out of fear. I commend Governor Shumlin of Vermont for spending his entire state of the state address on this essential economic issue and his call to attack the epidemic on the demand side (treatment); recognizing that putting more people in jail may make us feel good on the short term, but does not solve the problem. Governor LePage of Maine addressed the issue of drug addiction as an economic issue as well, but he unfortunately spoke not of increased funding for treatment and access to care, but only of expanded law enforcement and judicial response.
As the death of Philip Seymour Hoffman’s has again reinforced, drug addiction, including heroin abuse, is an equal opportunity disease affecting all socioeconomic strata; and knows no boundaries. This is not a problem of the welfare state or the poor or less fortunate. It is NOT NIMBY!! The disease is present in our impoverished neighborhoods as well as our wealthy suburban communities and in our resort towns and backwoods of New England. Establishing treatment centers for addiction in one’s own locale should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center; both of which are illnesses that may be related to the disease of addiction. NIMBY no longer works!
Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine. He currently serves as Medical Director of Community Substance Abuse Centers (with treatment facilities throughout New England) and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.