Heroin: Part three of a three-part series
'This is a public health problem – addiction is a chronic illness.'
With the increase in heroin abuse throughout Delaware, many state, local and private agencies and organizations are working hard — and sometimes together — to find a
solution to the growing issue.
“The explosion in heroin is not new. It has been coming,” said Marc Richman, assistant director for Community Mental Health & Addiction Services, part of the State’s Division of Substance Abuse & Mental Health Services.
“Clearly, it has gotten worse, as law enforcement has done a better job with the addiction to prescription drugs. The heroin has been there, but now it’s much, much less expensive. Folks can’t as readily get their hands on prescription drugs, so they’re finding themselves going to heroin.
“It is by no means a Delaware issue,” he added. “It is certainly a national issue that’s overwhelming everybody.”
Law enforcement responds to growing epidemic
Richman said State agencies such as his are kept updated on the rise of heroin use through various outlets, including law enforcement.
“Law enforcement tells us that they’re pulling more and more off the streets at percentages that have never been seen before. It’s something that we clearly want to stay on top of,” he said. “Everyone is invested, from law enforcement to state policymakers to the governor to the treatment providers. We’re interested in working together and reducing the scourge.”
Sgt. Paul Shavack, director of public information for the Delaware State Police, said the DSP and its Governor’s Task Force — a unit that consists of state troopers — will continue to be vigilant concerning the growing use of heroin and associated crimes.
“We will continue to combat the scourge of heroin through continued active and aggressive statewide investigations, including joint investigations, and information and intelligence sharing with our partners from all local, regional and federal law enforcement agencies.
“These efforts are focused on targeting mid-level heroin suppliers in order to interrupt, disrupt and choke off the heroin supply from surrounding major cities,” said Shacack. “It will continue to be a battle.”
Frankford Police Chief William Dudley said that partnering with other agencies and keeping a strong informant base will help combat the growing problem.
“We do have a very good informant base around here. Most of the time, I’ll funnel what I get to the strike force unit.”
“We’re also gathering intelligence all the time on stuff that’s occurring outside of our jurisdiction. We’re making sure we feed that information to the proper authorities,” added Ocean View Police Chief Ken McLaughlin. “We’ve tried to hit this head on. We’ve had a number of ongoing investigations. Anytime we get information on illegal narcotics activity in Ocean View, we’re pouncing on it.”
The Rev. Kim Tephabock, pastor at Dagsboro Church of God, suggested that community members who are concerned about illicit drug activity that may be taking place within their neighborhoods keep an open dialogue with their local police department.
“If you have a question about what’s going on in your neighborhood, report it,” he said. “For some reason, people feel like, if they have a concern and see activity… If we don’t protect our neighborhoods, who will?”
The Worcester County (Md.) Sheriff’s Office, along with the Maryland State Attorney General’s Office recently launched Operation Circle of Trust, to help fight the cyclical abuse pattern.
“It’s a task force between us and Worcester County Sheriff’s Office to take down users and dealers,” explained Lindsay O’Neal, public affairs specialist for the Ocean City (Md.) Police Department. “The State’s Attorney’s Office has been partnering with the health department and area hospitals to really get these people help after they’re arrested, so they don’t fall back into it — to really try to stop that cycle.”
The Ocean View Police Department is currently seeking private grant opportunities to fund a narcotics-detecting K-9 unit.
“We’re looking for a dog that is dual-purpose — trained in narcotics and patrol work,” said McLaughlin. “The narcotics detection part of it will certainly enhance our abilities to detect the drugs. There are a lot of times where we come across folks that we suspect have drugs but we just don’t have the ability to detect that. The dog will help with detection.”
McLaughlin said he believes the K-9 unit will also discourage drug-related activity within the town.
“If the drug users and dealers know that Ocean View has a narcotics K-9, hopefully, they would be smart enough to go do business elsewhere.”
He added that having a K-9 unit will make it easier to apprehend suspects.
“On the patrol side, a lot of these heroin users are feeding their habits with the proceeds of thefts. Oftentimes, we’ll get a call that someone has fled on foot from a property crime, and the vast majority of the time, by the time the officer gets there, it’s almost pointless to try to initiate a pursuit on foot.
“With a dog, however, with the tracking capabilities, it’ll make us more efficient catching these individuals and deterring them. We’re hoping it’ll help us out on a number of fronts.”
McLaughlin said that, although they are working hard at the local level, he would like to see a national campaign against heroin launched.
“Personally, what I would like to see at the federal level is a national campaign, similar to the campaign launched a number of years ago to reduce the number of tobacco users in the country,” he said.
“We see [drug abuse] all the time with Hollywood celebrities… there’s almost a glamour established with it. To me, that’s foreign… I think there needs to be a full-court press starting at the federal level, targeting all the heavy narcotic drugs that are out there. This is dangerous stuff, and it’s a life-altering decision to experiment with heroin for the first time.”
He added that his department’s doors are always open to those who are battling addiction.
“We’re here. Our door is open all the time. We’re not looking just to lock folks up. If somebody walks in here asking for help, we’re going to do everything we can to try to help them. That is certainly part of our mission,” he said. “There are a number of different resources available out there, and we will do what we can to help them out.”
State looking to offer better services
Richman said the State currently has four inpatient addiction facilities, one in Sussex County, one in Wilmington and two in the Delaware City area. Additionally, the State runs a detox facility in Kirkwood. Those facilities offer rehabilitation services not only to heroin addicts, but also to clients with various substance abuse and co-occurring psychiatric problems.
“We’re hoping to get additional ones statewide in the new fiscal year,” he said.
Along with the addiction facilities, the State offers crisis services to help those seeking immediate assistance.
“From our vantage point, we have to treat folks with the addiction. Those that want treatment — come to treatment, we can work with them and put them in treatment facilities, outpatient and rehab, when needed. Many, many end up doing rehab in the prison system because of arrests and things of that sort,” said Richman. “We have a pretty robust system in Delaware; it’s just not enough. And that’s the theme across the country.”
Richman said that, although there is a lot of negative press surrounding the rise in heroin use throughout the country, the attention is helping bring services to those in need.
“There is a significant amount of attention being paid on this now. I think that’s good. We have policymakers from the top of government in our state down to our division, and treatment providers. I’m very encouraged by the energy. I think when there is attention it gives us the opportunity to potentially get additional resources,” he said.
“In the national news and in the literature, there’s a lot of emphasis to study and treat. So, to me, I’m encouraged. People are not burying their heads in the sand any longer. This is public health problem — addiction is a chronic illness. We can’t ignore it. Ignoring it doesn’t make the problem go away.”
Richman said that, currently, the State treatment facilities try to give addicts the skills necessary to maintain sobriety once they’ve completed a program.
“We’re a product of our environments. If we go back to the same social and living setting and nothing has changed, we’re still associating with the same people who may be sharing the same lifestyle. There’s a greater likelihood of going back,” he said.
“Obviously, when you put people in treatment… you want to help people develop alternative ways of living — healthier ways of living, making sure they’re filling their time differently, in a more healthy fashion. You want to give people the skills through therapy to fight the urges and fight the pressure to go back to do the same things over and over again.”
In 2006, in an effort to help those who use intravenous drugs stay as healthy as possible, the Division of Public Health’s syringe exchange program was authorized by Senate Bill 60 as a five-year pilot program limited to Wilmington residents, run from a mobile van within the city limits.
“At the end of that five-year period, having proven itself effective, it was renewed as a standing program, and the residency requirement was removed from the code,” said Heidi Truschel-Light of the Delaware Division of Public Health, noting that there is no current effort to expand the program statewide. “At the present time, though service delivery sites remain limited to the Wilmington city limits, any Delaware resident that can get to Wilmington may participate in the program services.”
Truschel-Light said that more than 2,000 clients have enrolled in the program since 2007; the active census of clients at any given moment is roughly 600 clients. The program has incinerated more than 250,000 potentially contaminated needles.
“The overall goal of the program is to keep all of those suffering from addiction as healthy as possible until it is possible — through education, outreach and establishing trust over time — to enroll the clients into drug-abuse treatment programs.”
Additionally, it has provided more than 750 HIV screening tests to needle-exchange clients and more than 2,859 HIV screening tests to those in the communities serviced by the needle-exchange van, and 299 clients have enrolled in treatment programs through needle-exchange program referrals.
The program has identified nine new HIV patients and connected them to treatment services. An additional 11 clients previously known to be HIV-positive, but who had fallen out of care, were reconnected to treatment services.
“While there are reports of increased heroin use in Delaware and in areas of Delaware where heroin was not prevalent before, due to the nature of HIV infection (an asymptomatic infection lasting years), drug-using populations’ reluctance to access screening services and massive funding reductions in HIV prevention programs, it may take many years before any rise in HIV infection through increased use of injected drugs is evident,” noted Truschel-Light.
“It is important to remember that HIV is not spread by heroin use specifically, but by sharing needles while injecting any drug.”
State and advocacy groups working together to offer resources
Richman said the Division of Substance Abuse & Mental Health Services works with many advocates and community organizations.
“We all on the same page — we want people to get help,” he said. “The advocacy organizations can talk to the legislative body about resources, and that’s always a good thing.”
One such organization is “atTacK addiction,” formed by Don and Jeanne Keister of Hockessin.
“My son Tyler died of an overdose of heroin Dec. 23, 2012,” said Don Keister. “When this happened, we knew he had an issue, but it was always quiet. There’s a stigma attached to this that’s extremely damaging. Only 1 in 10 who need help seek it, because of the stigma. We decided we could get together and work on educating students.”
Keister said that he and his wife and daughter all have professional experience working for schools and wanted to focus on educating youth.
“As we started having our meetings, we became involved with a number of really great people and groups. The Red Clay school nurses group has been working on the curriculum, Smart Choices, that fits into what we were doing,” he said. “I would go to schools and tell Tyler’s story and talk about why I’m involved and why they shouldn’t get involved in drugs.”
Keister has spoken at a number of schools in the state and at various churches, while other organization members have spoken in prisons and run counseling groups.
In October 2013, Keister was able to have an hour-long meeting with Vice President Joe Biden regarding the organization’s goals and what they hope to provide for those struggling with addiction.
“I feel I obtained some good information. Joe was completely open to everything. He made a statement that, if there was one thing in this country that he could change, it would be dealing with the problem of addiction. He said it just ties up everything from the courts to the prisons — 60 percent of people in that are in the judicial system are there because of their issues of drugs and trying to get money to support their habit. They lie. They steal. They do whatever they can to get the money to take care of themselves.”
In March, “atTacK addiction” held its first 5K race and fundraiser; 900 people attended.
“We were absolutely blown away, realizing there are so many people involved in some type of drug-related issue that want to erase the stigma, that want to be involved,” he said. “There are 22 million people are in long-term recovery. When you start including family members and friends, that’s over 100 million people in our country. It’s something we really feel needs to be brought out in the open — the stigma of this disease.”
The organization also has members who were involved in lobbying for Senate Bill 116, the 911 Good Samaritan Law, which offers immunity to individuals who are illegally using drugs and who aid a victim during an emergency.
Currently, Keister said, the organization is working on a bill that would potentially allow citizens to administer a Narcan treatment to those who are overdosing.
“This is a substance that counteracts the nerve receptors from receiving the opiate drug. It can save lives. It has saved so many lives. There are a number of states that have also approved that,” explained Keister, adding that EMTs are already able to administer the life-saving medication.
“It’s a harmless thing, but it’s a lifesaving drug that we would like to see become more available for the community,” he said. “We would like to get it to individuals. In New Jersey you can have it. You go to a training class and can get it. It’s something that has saved a lot of lives, and it could save more. We would like to see that be available more to the community here in Delaware.”
Robbie Murray, operations division manager for the Sussex County EMS, said that the Seaford Volunteer Fire Department, Georgetown American Legion ambulance service, Rehoboth Beach Volunteer Fire Company and Lewes Fire Department ambulance crews are carrying the Narcan shot, as a pilot program that was started in January.
“The EMTs from those companies took the additional training to participate,” he said. “There was a noted increase in overdoses in parts of the state. In response to this, the idea of putting Narcan on the ambulances was established. Prior to this, Narcan was only carried by the paramedics.
“The pilot program is being constantly reviewed by state officials and medical directors,” he noted. “It is their hope that the program proves successful and is then rolled out statewide to all BLS ambulances.”
Murray said that there has been an increase of 38 percent in Narcan administration in 2014, compared to 2013. He also noted that Narcan is not administered solely for the purposes of heroin overdoses.
“The paramedic is trained to handle overdoses of prescription medications and illicit drugs. Based on the patient’s condition, the treatment may range from supportive care to the management of the patient’s airway. The paramedic has many diagnostic tools and treatment options at their disposal. One treatment option is Narcan, which is used to reverse the effects of narcotics,” he said.
Murray said the decision to use Narcan is based upon the EMS assessment at the time of treatment.
“It is not given to everyone that is suspected of using a narcotic. The primary insult that warrants the administration of Narcan is compromise to their airway and breathing,” he explained. “Specifically, patients who are conscious and breathing without difficulty would not be administered Narcan.”
Murray said that Narcan can be administered via several routes. Paramedics typically used intravenous and intramuscular administration in the past; however, more recently, paramedics have started giving the medication intranasally.
“An adapter is put on the syringe, and when the Narcan is administered, it becomes a fine mist, which allows it to be absorbed via the nasal mucosa. This is a very effective delivery route and is the route used in the pilot program with the basic life-support ambulances.”
Keister added that he has seen State agencies actively trying to respond to the rise in heroin use but isn’t sure the action has been swift enough.
“The groups within the State, up to the governor, are working hard to developing more places for treatment, more places for detox,” he said. “Right now, I’m willing to continue to fight the battle to remove the stigma, to make families and students aware of the issues and the problems. It’s still increasing. I am optimistic about our state and some of the things they are doing. We haven’t seen the results that I’d like to see yet, but I’m optimistic.”
Keister said that, when it came to his son’s addiction treatment, the family couldn’t find the facilities or resources needed within the state.
“The State does have some things available. It’s just so hard to find that information,” he said. “In my son’s case in particular, he was taking methadone. I do know that his amount of methadone was so much that there was no place in the three surrounding states that would detox him. He needed a medical detox because of the amount of methadone he was taking. We sent him to Florida to do that. In fact, anytime we had issues, we sent Tyler out of state. His first time was to Colorado.”
Richman said that, although some people struggling with addiction go to inpatient treatment facilities, most individuals seek outpatient treatment within their communities.
“We certainly feel it in Delaware, but it is certainly in every single state,” he said. “We’re in the process of working with the Governor’s Office on our substance-abuse redesign, so we can get more treatment spots out there for all levels of service — not just inpatient. We’re looking at medication-assisted treatment to counseling — all forms of treatment that can be helpful. We’re not going to be able to arrest our way out of the problem, that’s for sure.”
Education in schools and at home
To begin educating children at a young age about the dangers of drug abuse, the Indian River School District offers students drug-abuse prevention education through health classes.
“The classes include information about drug prevention, the damaging effects of illegal drugs, where to turn for counseling — these are the types of topics covered in those courses,” said Dave Maull, spokesperson for the Indian River School District.
“Also, in the high schools, a couple of times a year they have a discipline assembly where they bring the student body together and go over a variety of discipline issues. During that assembly, the consequences of drug and alcohol abuse are discussed with the students.”
In the high schools, students also have access to wellness centers, where they can be confidentially referred to state agencies if they are struggling with a problem or know someone who is.
While elementary schools in the district no longer participate in the Drug Awareness Resistance Education (DARE) program, many classrooms actively take part in the national Red Ribbon Campaign. Sponsored by the National Family Partnership, the campaign aims to play a leadership role in drug prevention, education and advocacy.
Cathy Showell, school counselor at Long Neck Elementary School, said the students all enjoy participating in the weeklong campaign.
“Every year, we do different activities promoting preventing substance abuse,” she explained. “We have a whole week where we have different themed days and the kids dress up like, ‘Don’t be crazy enough to do drugs’ — that’s crazy hair day.”
Showell said the school also makes announcements, hangs posters and has an assembly at the end of that week.
“Then, as a school counselor, I do lessons with all the classes about substance-abuse prevention,” she explained. “Right now, in second grade, I’m doing, ‘What’s Wrong with Tobacco.’ In third grade, I do, ‘What’s Wrong with Alcohol.”
Showell said she also has a tobacco-prevention fair funded by a grant from the American Lung Association.
“We really try to emphasize to these students, even at a young age, about the importance of making good choices,” she said. “Once they start making unhealthy choices, you never know where that’s going to go. If they say no to cigarettes, hopefully, they’ll continue to say no. We just want to provide students the information to make healthy choices. I don’t think you’re ever too young to start.”
Keister noted that education in the schools is important but that parents should also take the time at home to speak with their kids.
“Parents have the idea that it can’t happen to them. They need to have continual conversations with their kids regarding this. Statistically, they’re much less likely to become involved in substance abuse when parents do have conversations with them.
“They have to realize it’s not the old stereotype. In fact, most of the people are not those stereotypical people who live under the bridge and are homeless. It’s a middle-class person. It hits anyone, of any socioeconomic group.
“Parents need to have conversations with their kids, learn about prescription pill issues,” he said. “They need to realize it can happen to anyone. They need to find out what their kids are doing and be on top of them.”
Information for those seeking treatment
Richman said that the Keisters’ concern regarding the stigma of drug abuse is not unwarranted, but he believes it is slowly getting better, allowing more addicts to feel OK about seeking treatment.
“With all addiction, folks are still concerned about stigma,” said Richman. “I think it’s getting better. There’s something about addiction, that many — not all, but many — people get ashamed. Addiction is a disease and largely a chronic disease, and we have to treat it as such. Hopefully, we don’t have too much stigma for people with diabetes or asthma or kidney disease. Addiction is a disease.”
“Whenever anything is illegal, there’s an additional level of social stigma right there. Even with pot, which is illegal, there’s a vigilance, which users feel that wouldn’t be present if the substance were legal,” agreed Michael J. Hurd, a Bethany Beach-based psychotherapist, and licensed clinical social worker in Delaware and Maryland.
Hurd, whose most recent book is “Bad Therapy, Good Therapy (And How to Tell the Difference),” said that, sometimes, the act of having to be secretive about an abuse such as heroin can make it more desirable.
“However, neither the social stigma nor illegality make a major difference in whether a person continues using or not. If you’re hooked, you’re hooked, and the illegality and/or social stigma associated with the substance just makes a difficult situation even more difficult.”
To those who know someone whom they believe is struggling with an addiction, Hurd suggests asking them a simple question.
“‘Can I be honest with you about something I’ve noticed?’ Don’t rush in unsolicited. This will foster defensiveness and evasiveness. Be direct, kind, diplomatic, yet truthful,” he said. “If you don’t know them well enough to do this, then stay quiet about it, but stop short of pretending. Comment on the consequences of the problem, if not the problem itself.
“For example, ‘I noticed you looked kind of tired yesterday,’ or, ‘Notice you didn’t come to class/work.’ Then leave it at that. This way, you’re not participating in the denial, but you’re not making yourself a hapless crusader, either.”
Tephabock suggested that those who know someone who is struggling with addiction and want help go the extra mile to help them.
“Don’t just suggest they go — help find them a ride,” he said. “I’ve done that myself just in the last month.”
Assisted medicated treatment is available in Delaware, at such facilities as AMS Delaware in Rehoboth Beach, which prescribes methadone, as well as Suboxone and Subutex.
“It’s a popular thing that we hear, ‘Why would you want to replace one with another?’ We know the negative health effects for not treating it in [ways] we know work is pretty significant,” explained Richman. “For some people who are in need and want, if you’re replacing something illegal, dangerous, with something that is monitored — for example, something like methadone or Suboxone — then you can monitor it and manage it.”
Richman added that not everyone who receives medication-assisted treatment remains on the medication permanently.
“Many, many people choose to eventually get off of medication. They are the means of helping people deal with the very serious withdrawal effects. There are people who remain on medication because that’s the only way they can stay essentially clean and healthy. You don’t want people using needles and developing Hep-C, HIV and those types of things.”
April Lathbury, the program director of Aquila, a treatment center in Sussex County that focuses on treating adolescents, said that the increase in patients who are struggling with heroin addiction was “rapid and struggling.”
“Aquila is a dual-diagnosis, or co-occurring illness, treatment facility. In order to come here, normally we get referrals from courts, probation, sometimes from families for kids who have been abusing substances,” she explained. “We provide outpatient treatment services that are trauma-informed. We provide them with group, individual and family counseling, all on an outpatient basis.”
Lathbury said Aquila accepts private insurance but also works with Medicaid to offer services to those who are uninsured. She said treatment depends on the patient’s assessment of both their mental health and level of abuse.
“Then we would make recommendations to kids and families around what we feel would be the best course of treatment for them,” she said. “If the person happens to be heroin-dependent — meaning they are going to have a physical withdrawal if they stop, based on what they report — we would make a referral to someplace to help them begin detox first, before we begin treatment here.”
Maintaining sobriety can be a difficult struggle for heroin users, as users become physically dependent on it.
“That itself poses a real challenge to people trying to get clean on their own,” she said. “With heroin, just like with any substance abuse, it really depends on that person’s level of commitment to being clean. People need to change their peer associations and where they go — things like that — if they’re serious about staying clean. But I would say it is fairly successful if they are serious about it.”
Millville counselor Allison Scrivani said that one thing many users don’t consider is the long-term effects on cognitive function.
“Once you seek treatment, you’re in rehab and actually stop doing it, you have to go through a period of time — what I would call your brain resetting itself back to normal. Depending on how long they’ve used heroin, it could be a very long time. It’s not a quick fix. “
Scrivani said she offers patients help when they are seeking resources to combat their addiction.
“It does not always work the first time around, I can promise you,” she said. “When they come back, I see them on a regular basis in an NA/AA group, and get them support out there. It has to be the most important factor in their life once they’ve gone through rehab. That’s what they have to put all their effort into.”
She added that confidentiality is crucial when it comes to treating her patients.
“Anytime anyone sees me for any reason, it is super-confidential, and no one ever knows they’re here. That’s so important.”
For those who are struggling with addiction, Hurd suggested finding alternatives to emotional repression.
“Cognitive psychotherapy helps people become aware of their emotions, while also applying reason/logic/common sense to those emotions. When people learn to be less afraid or ashamed of their emotions, and more confident in their reasoning minds, they will find it less of a struggle not to drink or abuse drugs.”
Hurd said that recovering addicts have more choices than AA and NA programs when it comes to recovery.
“Rational Recovery and SMART Recovery are movements designed to accomplish similar things by somewhat different methods,” he said. “Find what objectively works for you. Don’t listen to anyone’s dogma — most particularly any attempts to intimidate you into a particular point-of-view. Simply listen to what other people have to say, think about it and try to determine what makes most sense to you.”
He also suggested that the addict seeking treatment be “introspective” and honest with themselves.
“Don’t lie to yourself or rationalize. That’s where a lot of alcoholics and others ‘in denial’ go wrong,” he said. “And once they go too far down an addictive road, they start to fear that it’s too late to go back.
“This fear is always mistaken. It’s never too late to reverse course and go down a different road — not so long as you’re alive and conscious. No matter what your views, we can probably all agree on this much. Ask anyone who has reversed course in this regard for inspiration.
“In the end, the most basic issues are self-respect and self-esteem. Create values — important relationships, career options, meaningful work — in your life. In so doing, you’ll have more that you do not wish to lose or undercut via your drinking. Build something in your life to lose, and then you’ll have more motivation not to abuse drugs or alcohol.”
Hurd said that, no matter how hard law enforcement might work to keep illegal drugs out of a user’s hands, users will continue to find means to use until they make the conscious effort to stop.
“People who don’t abuse drugs tend to be naive in their thinking that, ‘If we keep these drugs illegal, then fewer people will use them than would otherwise be the case.’ This is what happened with alcohol during Prohibition, and it’s working out about as well with drugs as it did with alcohol.
“What only substance abusers, some counselors and ex-abusers seem to understand is that, when you’re really hooked on something, then you crave it more, and nothing external is going to stop it. It becomes the most important thing in your life, which is the defining nature of addiction.”
In the end, Hurd said, it’s up to the abuser to make a change that will result in permanent recovery.
“You cannot be helped to make such a fundamental lifestyle change (including one with social and legal stigmas, such as heroin) unless you first resolve that you wish to make the change. Once the abuser makes that fundamental decision — whether it’s the first step of AA/NA, or any other context — then all kinds of external help does become meaningful or possible. But not a moment before.”