For nearly two decades now, the nation has been embroiled in a battle with prescription opioid and heroin abuse. The rising human and financial costs of the crisis continue to hit Vermont hard despite dogged efforts to expand treatment and curb the influx of illicit drugs. But the challenges seem to be outpacing resources. D espite being named by the National Safety Council as one of only four states “making progress” in policy to address opioid misuse and addiction, overdoses have skyrocketed here since 2010. Vermont last year saw 106 opioid-related deaths, according to the Vermont Department of Health, a 41 percent increase from those reported in 2015, and more than double those in 2010. Vermont ranks ninth among the National Safety Council’s top 10 states with the highest heroin fatality rates per capita. An October 2016 Vermont Department of Health report states that for every fatal opioid overdose in Vermont, there are two infants born exposed to opioids. In 2015, approximately 1 of every 8 babies (12.75 percent) born at Rutland Regional Medical Center was exposed to opioids in utero; in 2014 it was closer to one in 12. Fear and fight The numbers paint a bleak picture. The state reports that naloxone, a drug which essentially acts as an antidote to an opioid overdose, was administered by friends, family or community members in 423 incidents in 2016. There were 835 total doses administered by Vermont EMS agencies in the same year to 587 patients (nearly a third of patients required two or more doses to be revived). Underlying all the data is an intense struggle with addiction, affecting Vermonters from all walks of life. “There’s a low rate of recovery and a high rate of death,” said Sarah White, co-clinical director of LifeMap Counseling in Barre. “And there’s a stigma attached to addiction that really gets in the way of that recovery. When someone is recovering from cancer, we bring them meals, we check on them, we drive them to an appointment. The community surrounds them. An addict doesn’t get that same sort of community, because there’s this idea that they did this to themselves so they deserve to suffer.” Former Gov. Peter Shumlin, in his 2014 State of the State address, spoke fervently of the need to approach the opioid crisis “as a public health crisis, providing treatment and support,” and to “stop quietly averting our eyes from the growing heroin addiction in our front yards, while we fear and fight treatment facilities in our back yards.” More treatment capacity Vermont has successfully expanded access to treatment in the intervening years, exemplified by the state’s integrated hub-and-spoke model of treatment, known as the Care Alliance for Opioid Addiction. The statewide partnership includes specialty opiate treatment centers (hubs) and office-based opiate treatment through primary care physicians and nurse practitioners (spokes). There are currently hub treatment centers in Berlin, Brattleboro, Burlington, Newport, Rutland, St. Johnsbury, West Lebanon, New Hampshire and, soon, in St. Albans. According to a recent study in the Journal of Addiction Medicine, Vermont had the highest capacity for treating opioid-use disorders in the United States. The Vermont Department of Health reports that in April of this year the total number of clients receiving treatment in hubs exceeded 2,500, with 105 on waiting lists. The number of clients waiting for treatment is down from 375 in April 2016 and a high of over 600 in January 2015. ‘Pills are heroin’ Research shows the speed with which a life-threatening opioid addiction can form is remarkably fast. According to a recent study published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, the likelihood a person will be a long-term user of prescription opioids increases with the length of an initial prescription: 1 in 10 people who received a fiveday prescription for an opioid will still be taking them a year later; that number doubles when the initial prescription is for a 10-day supply. Data from the Vermont Prescription Monitoring System and U.S. Census Bureau show 109,390 Vermont residents received at least one prescription for an opioid in 2014; that’s 17 percent, or approximately 1 in every 5 Vermonters. The National Institute on Drug Abuse warns that longterm use of opioids can lead to dependence, defined as “increased tolerance and difficulty or inability to discontinue use.” The CDC reports that people addicted to prescription opioids are 40 times more likely to become addicted to heroin. And 70 percent of those who reported using prescription opioids that were not prescribed to them obtained them from a friend or family member. The Center for Behavioral Health Statistics and Quality reported in 2013 that 3 out of 4 heroin users in the U.S. started abusing prescription opioids before they used heroin. “Those pills (prescription opioids) are (like) heroin,” said Kristen Williams, a drug and alcohol counselor practicing in Barre, who spent 2½ years as a counselor at the BAART Berlin methadone clinic. “So if you think ‘I’ll never be a heroin user, I’ll never do that,’ you need to know that it’s the same road, and you will end up there unless you can get off somewhere,” she said. “I know hundreds of addicts, and there’s no way out unless you get off and into treatment. You will end up being an IV heroin user, there’s no other end— or you’re going to die.” Rooted in trauma With overwhelming caseloads and low pay for counselors, Williams says there is high turnover in the treatment field and it can be difficult for Vermonters in treatment to build the relationships they need with counselors in order to move forward on the path of recovery. “People aren’t getting the quality help they need,” Williams said. “Because we are talking about a population, most of which have experienced trauma that we can’t even imagine. Generations of trauma.” As reported in The Times Argus/Rutland Herald in March, a recent study published by University of Vermont researchers established a link between emotional abuse in childhood and opioid misuse among adults, and numerous studies over the past several decades have demonstrated the connection between trauma and substance abuse and addiction. “There was a point in time before the current epidemic, I had never come into contact with someone who was addicted to heroin that didn’t come from an extremely abusive, traumatic childhood,” said Jim Pugliese, co-clinical director of LifeMap and a former screener for Washington County Mental Health Services. “Of course, there are exceptions to that, but for me as a clinician, there was always that linkage between a trauma background and the addiction piece.” Access and law enforcement The Vermont Intelligence Center run by Vermont State Police reported in 2015 that, on average, Vermont law enforcement is seizing illicit opioids daily, and that represents only a fraction of the state’s illicit opioid marketplace. The Drug Enforcement Agency’s 2015 National Heroin Threat Assessment determined that the increased availability of heroin and fentanyl in Vermont is due to the volume being trafficked to the state in response to demand; increased demand is due in part to prescription opioid users shifting — after the addiction has taken hold — to the cheaper and more easily obtained heroin. — Nearly 90,000 dosage units of heroin were seized by Vermont law enforcement in 2016. A dosage unit is one 31.5 mg bag of heroin. — In 2016, state prosecutors filed 311 heroin possession, delivery or trafficking charges and 186 charges for the sale of heroin (excluding charges filed in Vermont’s federal court system). — Currently there are only three counties with treatment or “drug” courts — Rutland, Chittenden and Washington. According to the state, these counties serve at least half of those coming through Vermont’s court system. — Rutland’s Drug Treatment Court was cited as a key part of the successful Drug Market Intervention strategy to address the addiction epidemic in the September 2016 United States Attorneys’ Bulletin. Drug treatment court graduates — in Vermont and other parts of the country — have shown significantly lower recidivism (repeat offense) rates. Advocates for expanding such courts say they save taxpayers money and allow offenders to access a comprehensive support system, from addiction treatment to employment opportunities. — Introduced in February by Rep. Maxine Grad, D-Moretown, House bill 213 proposes statewide access to drug and DUI treatment courts programs by 2022. Federal help A recent federal grant awarded to the state will provide money for a number of initiatives to pad out support for Vermonters. “A lot of people are wanting to know if (the grant) is going to cover more treatment,” said Barbara Cimaglio, Vermont’s deputy health commissioner. “The answer is, not really. Vermont is a bit different than other states in that we’ve developed a treatment network, with good coverage, so we looked at areas where we had gaps.” Those areas include workforce development for physician’s assistants and nurse practitioners, who will be able to prescribe medicationassisted treatment under a new change in a federal regulation that will hopefully strengthen the spoke piece in Vermont’s treatment model. Community and peer-based support systems also are on the list to receive grant money, including development of an app and an 800 number to link up with the Vermont Recovery Network. “We know a lot of people now are very connected to their phones,” said Cimaglio. “This will provide peer recovery support via technology, for those who may want to get sober reminders, and be able to connect with someone via telephone. It will be kind of a new thing, but nationally it’s gaining a lot of traction.” Controversy and stigma Syringe exchanges— which protect injection drug users against blood-borne illnesses, abscesses and infection and bring them into a place that provides education and information about treatment — remain controversial and are still illegal in New Hampshire. “If it were up to me, I’d have safe injection sites, because the problem is ... prohibition,” said Williams, the drug and alcohol counselor. “All the stigma around heroin, that it’s somehow categorically different than overeating, now we’ve arbitrarily determined what we can judge, when really addiction is all the same process for every human being: We just want to feel better. The attitudes of people, even in the medical community, are shocking. “By and large, addicts are not having a good time; very quickly the getting high part is over, and then it becomes an increasing amount just to reach ‘normal’ and prevent withdrawal. They’re suffering, no matter how exasperated they might make you feel at times, because of their behaviors and not cooperating. They are suffering,” Williams said. The recent move by Chittenden County State’s Attorney Sarah George to form a task force of community leaders to consider the possibility of opening a “safe injection” site in Chittenden County sparked even more controversy. A bill, H.108, introduced in the Vermont House by Rep. Selene Colburn, P/D-Burlington, would, for all intents and purposes, legalize such a site. The bill waits in committee, having been referred in March to the House Committee on Human Services. Monitoring Other efforts are being made to keep tabs on the crisis: — Federal money will provide peer recovery support workers to three hospitals in the state (University of Vermont Medical Center in Burlington and Central Vermont Medical Center in Berlin, and a third — yet to be announced) to help anyone admitted with substancerelated emergencies. — A partnership with the Vermont Parent Child Centers will provide education and skills for families to identify and cope with addiction and provide support for family members. — The Vermont Prescription Monitoring System will be updated to allow physicians to view and compare their prescribing practices with others in their specialties. — The drug disposal network will be expanded through a partnership with the Vermont Sheriffs’ Association. Among a few other programs, the grant will provide money for supporting communities that want to enhance their local efforts, like Rutland’s Project VISION, which pulled together a broad segment of the community in the battle against addiction. Organized in 2013, the group has focused on three areas to address the challenges of opioid abuse in the Rutland community: “treating addiction and substance abuse, reducing crime and building great neighborhoods,” according to its website. Gov. Phil Scott has touted Project VISION as a major achievement in community-based problem solving, resulting in lower crime rates in the city and building community awareness and support, because police and counselors are not the only Vermonters on the front lines. “ We are social,” said Pugliese. “We are wired to be social and we are part of our community. We are all interconnected. It’s not just your neighbor’s problem, it’s your problem. Stigma needs to be decreased, and that’s not to say that we shouldn’t hold people accountable for their behavior, but we should make it easier for people to come forward and say, ‘I have this, please help.’” What are your thoughts on this issue? Let us know by submitting a letter to the editor at timesargus.com or rutlandherald.com

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