The Needle and the Damage Done

Vital Signs » Fall 2014
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Boonshoft researchers find number of overdose deaths in 2013 'unprecedented'

The lowest point in Jack Lunderman III’s drug-use career came in March this year, when just two days out of his second stint at an inpatient drug rehabilitation program, the 26-year-old Oakwood man injected a half gram of heroin into his wrist, wandered downstairs to the living room, plopped into a recliner, and died.

When his parents noticed their son’s head drop and his cigarette fall into his lap, they rushed to his side, found no pulse, and started CPR, reviving their son just as paramedics arrived. The EMT squad raced Lunderman to Miami Valley Hospital in downtown Dayton, where he was treated and released some 36 hours later.

For sure the experience rattled Lunderman and his parents, but it couldn’t shake Lunderman’s addiction to heroin and the “warm blanket” of comfort and tranquility the drug offered with each hit.

“The scariest part about it was the next day I was using again—I was right back doing the same thing that had just killed me,” Lunderman reflected one September evening this year. “I thought about it for a while and said to myself, ‘Holy crap, this thing wants to kill me and I can’t stop doing it!’”

‘Tip of the iceberg’

Had Lunderman’s parents not saved his life, he would have become another statistic in a growing trend that downright frightens the health care and substance abuse treatment community, law enforcement, elected and other public officials, and any family touched by substance abuse: More people in Montgomery County and across the state are dying from accidental prescription drug and heroin overdoses than at any time in recent history.

In Montgomery County alone, 226 people died of an unintentional drug overdose last year, up 33 percent from 2012, according to the annual Poisoning Death Review report prepared by the Boonshoft School of Medicine Center for Interventions, Treatment and Addictions Research (CITAR). More than half of those cases (132) involved heroin.

The report, prepared in collaboration with Public Health—Dayton & Montgomery County (PHDMC) and the Montgomery County Coroner’s Office, states unintentional drug overdose deaths have increased continuously in the county since 2010, but the increase of 64 deaths from 2012 through 2013 is unprecedented. Moreover, the jump doubled the increase of 32 additional unintentional drug overdoses from 2011 to 2012.

“In my 25 years of doing substance abuse research here I’ve seen nothing like this in terms of the increases,” said CITAR Director Robert Carlson, Ph.D., who helped prepare the report as part of the Preventing Unintentional Drug Poisoning Project, funded this year by PHDMC and the Ohio Department of Health, with injury prevention block grant funds from the Centers for Disease Control and Prevention (CDC).

The numbers for 2014 look bleaker still, according to Ryan Peirson, M.D., assistant professor of psychiatry and chief clinical officer for the Alcohol, Drug Addiction, and Mental Health Services Board for Montgomery County.

“We were up to 125 deaths by the end of June this year, and we’re on pace in 2014 to meet or exceed the number of deaths in 2013,” Peirson said. “In addition to the deaths, we estimate that as many as 500 people in this area end up in the emergency room every year due to an unintentional overdose. That might not sound like a lot, but it means that more than one person a day has an overdose just in Montgomery County.”

Illicit opioid’s reach is far and wide, crossing several demographics, Peirson added. “We have patients in our richest neighborhoods standing in line for treatment with patients from our poorest neighborhoods.”

Statewide, Ohio Attorney General Mike DeWine’s office said at least 900 people, or about 17 a week, died from heroin-related overdoses in 2013, and those are just the cases that came to the state’s attention. The Dayton Daily News found nearly 300 heroin-related deaths between January 2013 and June 2014 in just three southwest Ohio counties—Montgomery, Butler, and Clark—according to an article published in July.

It’s the same story nationwide, as data from the CDC show 4,102 people died as an unintended consequence of heroin overdoses in 2011 (the most recent year for which data are available), compared to 2,789 deaths in 2010—a 47 percent increase in a single year.

Said Carlson: “Drug epidemics tend to go in cycles, and one would think this cycle would eventually decline, but I see no evidence of it in the near future, I just don’t. We have these precipitous increases in overdose deaths, and I think it’s just the tip of the iceberg.”

Twin epidemics

Carlson and experts around the country attribute the rising use of heroin to the declining availability and demand for prescription opioids. “It’s readily available and it’s much less expensive than pain pills,” Carlson said from his office in the Medical Sciences Building.

“We have been documenting the rise of these twin epidemics since at least 2002,” he said. “There was a huge public outcry a few years ago over the number of overdose deaths attributed to pharmaceutical opioids, so there was pressure to cut back on prescriptions. That made prescription painkillers more expensive and harder to find, so when the demand for those drugs leveled off, the demand for heroin took off. It’s all market driven.”

Lunderman said he used to spend $30 or more a pill for the painkiller Percocet, and he would consume about six pills a day. Heroin, on the other hand, would cost him anywhere from $5 to $10 a “cap,” about a tenth of a gram.

At CITAR, Carlson and his associates are in the data analysis stage of a research project that began in 2009 involving young adults in Columbus who were misusing prescription painkillers. The thesis was to see who transitioned to heroin dependence over the following three years.

The group also conducted a pilot study in Columbus to study heroin and pharmaceutical opiate users who were self-medicating with buprenorphine (Suboxone® and Subutex®), a drug that can mitigate opioid withdrawal. The research found a growing trend of illicit use.

Instead of seeking professional treatment, which is expensive, users are buying the drug off the street from users who obtained the drug through legitimate prescriptions. One problem, notes CITAR Associate Director Raminta Daniulaityte, Ph.D., is that by sharing or selling part of a prescription, neither the seller nor the buyer is receiving an adequate dosage for effective treatment.

“There is a strong belief that they only need to take a small amount and it will work,” Daniulaityte said. “It’s a very hot commodity. People want to do something about their addiction on their own, and buprenorphine is a big thing right now.”

CITAR also is involved in a web-based project to understand attitudes and behaviors related to illicit buprenorphine use. Funded by the National Institute on Drug Abuse, the study is a collaborative effort between CITAR and the Ohio Center of Excellence in Knowledge-enabled Computing (Kno.e.sis) at Wright State.

Daniulaityte and Amit Sheth, Ph.D., professor of computer science and engineering, LexisNexis Ohio Eminent Scholar, and Kno.e.sis Center director, are principal investigators of the study. They’re gleaning information from web forums of drug users who share their experiences and post unsolicited, unfiltered, and anonymous questions, comments, and opinions about various drugs.

“We want to learn more about the population that is using it for nonmedical purposes and how they use it,” Daniulaityte said.

CITAR and Kno.e.sis developed an application, PREDOSE (Prescription Drug abuse Online-Surveillance and Epidemiology), that helps researchers access, retrieve, and analyze user-generated content about illicit drug use on various web forums. The application currently contains more than one million posts.

An unexpected finding has been the extra-medical use of loperamide (Imodium®), a nonprescription medication used to treat diarrhea. Illicit drug users have been posting on various web forums that they use loperamide to self-treat a wide range of opioid withdrawal symptoms. “That was surprising,” Daniulaityte said. “Nobody really knew that was happening, but since then we have found increasing reports of adverse health effects associated with such use, such as heart arrhythmias.”

The work at CITAR is fascinating, Carlson said, and never-ending.

“Drug abuse and drug addiction are not going to go away,” he said. “There’s no magic bullet for it.”

Getting hooked

Heroin is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. It usually appears as a white or brown powder or as a black sticky substance, known as “black tar heroin.” It is diluted with other drugs or with sugar, starch, powdered milk, or quinine before injecting, smoking, or snorting it.

Lunderman said the first time he tried heroin he felt an instantaneous rush of extreme euphoria, followed by a state of relaxing bliss.

“The first time I tried it, it was over—I was all in,” Lunderman recalled of that moment four years ago. “It’s the perfect feeling; it’s like this warm blanket all over your body. It calms your thoughts. You just feel so at peace and comfortable that nothing can bother you. The problems in your life just go away.” “With every other drug you have to give something back,” he continued.

“With alcohol, it’s hangovers; with crack, it’s paranoia. But with heroin, it’s all good—until you get addicted.”

Other physical symptoms of heroin include drowsiness, respiratory depression, constricted pupils, clammy skin, nausea, and dry mouth. That’s on a good day. If an addict is unsuccessful in his daily chase for the drug, the withdrawal symptoms can be brutal, involving vomiting, diarrhea, and muscle spasms. “It’s like your worst flu times 20,” Lunderman said.

Overdose occurs when the opioid floods too many opioid receptors in the brain, slowing the brain’s respiratory center, leading to a decreased breathing rate or respiratory arrest, which can quickly progress to cardiac arrest and death.

Dennis Mann, M.D., Ph.D., an emergency department physician at Miami Valley Hospital (MVH) and director of toxicology for Wright State’s Department of Emergency Medicine, said he usually sees at least one person a shift (but often several) who has overdosed on heroin or is going through withdrawal.

Mann said the usual treatment protocol involves naloxone (Narcan®), a medication known as an overdose reversal agent. Naloxone works by kicking opiates off the opioid receptors and taking their place. This awakens the brain’s respiratory center and restores breathing, provided the person overdosing has not slipped into cardiac arrest, in which case naloxone is ineffective and of no use.

“We started a Narcan distribution program at MVH in recent years,” Mann said. “The program allows for the free distribution of a Narcan resuscitation kit to persons presenting with symptoms consistent with an opiate overdose. These people are at very high risk of subsequent overdoses and death.”

The kit contains a two-milligram syringe of Narcan, a mucosal atomization device, and instructional materials. A training session is provided as well.

Community response

Similarly, medical, public health, and law enforcement communities in the Dayton region and across the state are actively participating in a Narcan kit distribution program called Project DAWN (Deaths Avoided with Naloxone), which allows police officers, opioid users, and friends and family of users to carry life saving naloxone kits with them.

East End Community Services in Dayton has hosted education programs on administering the drug through nasal mist. (East Dayton has the distinction of having two of the zip code areas with the greatest number of accidental drug overdose deaths in the county.)

County leaders have expanded naloxone distribution with the goal of arming every police officer in the county with a kit. They’ve put up billboards with heroin warnings, formed coalitions to study abuse and prevention and to educate addicts and the public on the epidemic. They’ve also initiated a program to assist opiate-addicted moms.

One new local effort with Boonshoft guidance is Brigid’s Path (brigidspath.org), a nonprofit whose goal is to provide inpatient medical care for drug-exposed newborns, nonjudgmental support for mothers, and education services to improve family outcomes. Its leaders say Brigid’s Path can relieve the financial burden on Ohio taxpayers by operating at a fraction of traditional hospitalization costs. Neonatalogist Marc Belcastro, D.O., a Boonshoft clinical associate professor, serves as its medical director.

Jim Gross, the county’s health commissioner and a Wright State graduate, said he’s encouraged that public officials across the county are working together to address the opioid overdose epidemic. “Clearly, this integration aims to provide our citizens with holistic services, rather than a fragmented and ineffective approach,” Gross said. “Action needs to flow swiftly and prudently, because we are losing a loved one every day.”

At the state level, Attorney General DeWine has created a Heroin Unit that includes investigators, lawyers, and drug abuse awareness specialists working together to combat issues associated with the epidemic, such as crime, addiction, and overdose deaths. DeWine’s office also has hosted several community forums, hired people to help with community outreach, and met with Boonshoft School of Medicine experts and researchers to gather information about the epidemic.

Grassroots efforts needed

In announcing his heroin task force last year, DeWine said, “We have to fight this epidemic at the grassroots level, community by community, neighborhood by neighborhood.”

One such effort is Families of Addicts (foadayton.com), founded last year by Lori Erion, a Dayton-area resident in long-term recovery from alcohol and drugs and the mother of a recovering heroin addict. The group meets Wednesday evenings at the Lutheran Church of Our Savior in Oakwood, where its members share personal stories of despair and hope and plan community outreach and support efforts, ways to help others touched by addiction find “a pathway to peace.”

“Our stories have power,” said Erion, echoing the group’s mantra. “What we’re trying to do is get our stories out there to help people and policy makers better understand addiction and the value of recovery, that this is a public health issue that deserves their attention and resources. We want to reduce the stigma of addiction and work to ensure this community has adequate treatment and recovery support services, because right now, it does not.”

Low points, lots of them

Jack Lunderman, an FOA member, said his drug-use career started in junior high when he was 13 and tried alcohol while hanging out with friends. Within a week, he tried marijuana and was hooked. Within a year, he discovered cocaine and that hooked him, too. The habits were costly, though, and Lunderman would lie, cheat, and steal from friends, students, stores, and his parents to support them.

In the early going, Lunderman and his friends got their drugs from older students, he said. But as soon as one of them could drive, they bypassed the middlemen, piled into a minivan, and drove through the streets of West Dayton to get the drugs themselves. It became a frequent, sometimes harrowing, journey.

At 21, he tried crack cocaine. “As soon as you take that first hit, you’re out in the stratosphere for 30 seconds, you feel super energized and powerful, and when you come down you come down real hard. After that, it becomes an obsession to get that high again. You’ll smoke it all day, and you cannot stop until your money’s all gone.”

After that, he tried Percocet. But Percocet was costly. Lunderman would spend up to $250 on the drug a day. At 23, a friend encouraged him to try heroin. In pursuit of the drug, the lying, cheating, and stealing continued. He was robbed multiple times, beaten, and pistol whipped by a drug dealer. And on one blazing July day in 2012, after scoring a hit that knocked him to sleep, Lunderman awoke six hours later and remembered he left his dog, Maya, in his car with the windows rolled up. By the time Lunderman got to his car, it was too late.

“It was horrible. It just made my drug addiction worse because I just wanted to numb it out,” he said, dropping his head.

Still, the drug use continued, even through two stints in a Columbus-area rehab center. It wasn’t until a few days after his temporary death earlier this year (he didn’t know the heroin he took that day was cut with illicit fentanyl, another rising issue in the drug-use world) that he sought treatment again. “I just realized there was nothing left,” he said. He stayed for 22 days.

“Counselors tell us the only options we have if you don’t get clean are jails, institutions, or death,” Lunderman said. “Well, I’ve been to jail, I’ve been to institutions, and I’ve died. I’ve been there, but I got back into treatment and I’ve been sober since March 24.”

—Anthony Gottschlich

Last edited on 02/20/2016.