A Community Crisis
More than One Answer Needed in Responding to Heroin's Growth
Among the many chilling realities of the heroin crisis, this might be the most sobering: an increase in organ donations.
“If I were to describe that feeling in one word, it would be ‘bittersweet,’” says Jennifer S. Kramer, a nurse who manages Frederick Memorial Hospital’s Intensive Care Unit. “No matter the circumstances, it is always tragic losing a patient, but there is some small consolation in knowing that one person’s death can give the gift of life to others via organ donation. Many families recognize this, even in the midst of their tragedy and strongly advocate for their loved one to give that final gift of life.”
FMH recorded just three drug overdose organ donors in 2014, yet already reached that number by early May this year, according to Allison Byers, spokeswoman for the Living Legacy Foundation of Maryland. “The instances in which someone can become a potential organ donor are actually incredibly rare. To be a potential donor, a person has to be on a ventilator or experience brain death which is actually only 3 to 4 percent of deaths in hospitals.” FMH, typically, only has five donors all year, regardless of manner of death.
But there’s nothing typical about the heroin issue, a multi-layered public health crisis that requires many layers of response.
“Heroin addiction is not an inner-city problem, nor is it a disease attributable to those in poverty or those who are hardened addicts,” FMH’s Kramer says. “The face of heroin addiction has changed. It is middle schoolers and high schoolers and even promising young college students. It does not discriminate. It is here. It is in our community and it is not going to go away unless we all work together to address it.”
Nationally, the number of organ donors dying from drug overdoses has skyrocketed over the past decade, according to the Organ Procurement and Transplantation Network, with numbers jumping from 158 in 2005 to 848 in 2015. Data is kept in 15 categories regarding how death resulted for the donor; drug overdose is now number four, behind stroke, blunt injury and cardiovascular issue. Statewide, drug overdose donor numbers have also dramatically risen from three in 2005 to 25 in 2015.
More than 20 organs and tissues, including the heart, lungs, kidneys and liver, may be used to benefit the nearly 121,000 people waiting for life-saving transplants, according to the United Network for Organ Sharing (UNOS). “No matter the reason for the loss, so much good can come out of a tragic situation that the family has to deal with,” says Anne Paschke, the network’s media relations specialist. “Out of the death of a loved one, many lives can be saved. One donor can save up to eight lives through organ donation and another 50 through tissue and cornea donation.”
While heroin may be snorted through the nostril, a majority enters the body through hypodermic needles, which can lead to the spread of diseases such as hepatitis C and HIV. Some may wonder if the donor’s drug activity may put the organ recipient’s health at more risk.
“There is a somewhat increased risk of transmitting diseases based on [drug abuse] history,” says Dr. David Clausen, UNOS chief medical officer, “so those donors are screened very, very carefully. The Public Health Service has some guidelines that have been in effect for a couple of years for screening of donors. … The risk of transmitting those diseases, although not zero, is quite low. As a result, if a donor dies of an overdose like that, they are categorized as a potential higher-risk donor and so recipients have to give specific consent and be aware of that, so that is part of the policy.”
But Clausen adds another reality of the health crisis: “Because overdose cases tend to often be younger and otherwise healthy people. They are considered very appropriate donors.”
On a recent Tuesday evening, Frederick County Health Department clinical manager Sarah Drennan stood before seven people who came to receive training on how to properly administer Narcan, a drug that reverses opioid overdoses by restoring breathing. The free training course, which takes about an hour, started two years ago and has certified more than 800 people to administer the drug.
“An overdose happens when a toxic amount of the opioid overwhelms our body’s ability to handle it,” she says. “Very often this happens in combination with other substances. It could be too much of a single substance, but very often this is mixed so there could be different types of opioids.”
Heroin can be cut with the prescription pain medication Fentanyl, a more potent drug, which may be a deadly cocktail. “We are starting to see a lot more Fentanyl compared to what we used to see years ago,” says Frederick Police Department Capt. Dwight Sommers, who spoke briefly to the group. “…You are taking something more potent so you take the same dose believing it is heroin and then you overdose because of how potent it is.”
To the untrained, the obvious signs of overdose are a limp, unresponsive body, but they can also include lips and fingertips turning blue and skin feeling clammy or looking pale or gray. “Get in their face,” Drennan advises those in the class. “Shake their shoulders. Yell their name if you know it. Try to get them to come to. If they are not coming to, a sternal rub is a really effective way to bring somebody to if there is any chance that they are going to come to.” (A sternal rub requires making a fist with a slightly extended middle knuckle that pokes out, and then using that knuckle to roughly scrub the breast bone of another person. Drennan says it’s painful but should wake someone up who is not overdosing.)
If the person doesn’t come to or is showing other signs of an overdose, 911 should be called. “The big, big key to getting through an overdose is keeping oxygen in the body. You don’t want their brain to be without oxygen for too, too long,” Drennan says.
Administering the Narcan nasal spray is the next step. “You can’t abuse it,” Drennan says. “You can’t get high from it. You can’t hurt somebody with it. … You are not going to overdose somebody on this. You are not going to hurt them, so if you are not sure that it went up there, do more [sprays]. You are only going to have to give it about a minute to see if they start to respond. If they don’t start to come to [after one to three minutes], you can give the next dose.” The drug does wear off in about 30 to 90 minutes, so it’s important to call for emergency personnel because there may be additional drug effects that need to be tended to medically.
The Frederick County Sheriff’s Office has 177 deputies proficient at Narcan, says Cpl. Amanda Ensor. She recently administered a Narcan shot but the patient fled the hospital before treatment could be provided. Some wake up from the shot and “they often don’t even realize they were in cardiac arrest,” she says.
Every city Police Department officer is trained to administer Narcan, says Lt. Clark Pennington, commander of the Special Operations Division. “We have seen an increase in heroin overdoses over the last year. We are 36 over what we were at this time last year [during the first week of May}. … We are seeing an increase in the number of Narcan [kits] we are using to help save some of these individuals that are overdosing on opiates. It’s a significant increase over last year.”
City police changed its heroin/opiate response plan this year. “Anytime an overdose is reported within the city, we are contacting an investigator to respond and begin the investigation from the onset,” Pennington says. “Now we do have a Good Samaritan law in Maryland. Anybody who calls for assistance with an individual who has overdosed, that Good Samaritan law protects them from any level of arrest for possession or use of a controlled, dangerous substance at that point, including alcohol. What we are doing is we are responding, we are immediately trying to debrief anybody who is there, the victim … trying to identify exactly what it is that caused the overdose.” If there is a fatality, police will conduct a death investigation to try to link the drug back to sellers, in an effort to make an arrest.
Part of the response plan also includes having officers provide information to addicts on treatment options. “Look, this isn’t an epidemic or an issue that is just medical,” Pennington says. “It is also not an epidemic or issue that is just law enforcement. We can’t combat this issue by ourselves. We know that. We work with the health department. We are working with treatment programs. We are working with education prevention and enforcement. We know we can’t do this alone. There is no way one entity can combat this situation alone so we are working together.”
Two of the biggest issues addicts face when contemplating getting clean is to get help and where to turn for the help. “Reaching out and asking for help is important with so many parts of our lives, especially something that is causing hurt or causing pain in our lives and with our loved ones,” Drennan says. “We don’t always know how to treat this ourselves. Draw a comparison with other medical conditions. Nobody expects me to know how to handle my diabetes on my own without getting guidance and help from another professional. This is really like any other medical condition where you would seek the advice and the help of an expert in the field. Because it does call for lifestyle changes and maintaining lifestyle changes, the best help comes from peers and people with lived experiences. Finding help from others who have been through it before and can offer suggestions and ways to make it work, is really where we see great success.”
Frederick Memorial Hospital is able to offer patients assistance with connecting to a variety of community resources. “I think it is important for people to know that addiction is a chronic disease that affects the brain and their behavior,” Kramer says. “Most patients need long-term or repeated care to stop using completely. … Medical detox is only the first step of a long recovery process. Between 40 to 60 percent of all drug addicts and up to 90 percent of heroin or opiate addicts may actually experience relapse. This is comparable with the relapse rates of other chronic diseases like asthma, diabetes and high blood pressure, so it should be treated accordingly.”
The county Health Department offers a range of services for addicts. People can call, go to their website or go to one of their facilities to discuss options. “Somebody doesn’t have to know what particularly they are looking for,” Drennan says. “We would provide education and information about what is available and what is out there. There are some people who absolutely know they want to try medication. They might even know of a certain medication they want to try. Then there are others who know that they want to try counseling without medication. Then there are those folks who just want to know what is out there and what is recommended and it really comes down to getting them connected for an assessment. It’s kind of like going to your doctor for a check up. I don’t go to my doctor and already know the procedure that I need, but I go to the doctor to talk about what is going on, what’s bothering me in my life and then together we decide the best course of action.”