The Opioid Crisis Exposed by Maureen Bole

A year-long series, examining how the opioid epidemic is making an impact on the West Side communities of Cleveland, Ohio.

Published by The Opioid Crisis Exposed 1

Exposing the crisis in our communities

leveland’s Westshore suburbs are not immune to the nation’s opioid epidemic. States in the Midwest have been hit hard by the crisis, with overdose death tolls climbing at alarming rates. In Cuyahoga County, the opioid problem went from a public health crisis to a public health emergency in November of 2017. That status has remained well into 2020. After seeing 56 drug-related deaths in the first 23 days of 2018, our staff decided that this was something we had to cover. It was our responsibility as journalists to give a voice to this epidemic. In February 2018, we embarked on a year-long journey covering many aspects of the crisis in our own backyards. In a staff meeting we asked ourselves, “How would our coverage be different? How would we tell the stories of those affected by addiction in a new way?” We decided to look at it from the people perspective. Families are being torn apart. Children are suffering. Our neighbors are dying. Who are they? How did they get to that point? How are their families coping? How are community services attempting to fill needs, both with emotional support and medical assistance? Although people in our communities are dying at an ever-increasing rate from opioid overdoses, we recognized that, as a society, we may be growing numb to it. It’s kind of hard not to shut down after seeing harsh images of parents passed out in a car and a toddler crying in the back seat. Each month throughout 2018 and the beginning of 2019 our staff examined almost every aspect of the opioid epidemic. We talked to countless members of our communities: medical professionals, judges, parents of those addicted, volunteers and addicts themselves. We researched complex issues to present them in easy-to-follow informational graphics and sidebar stories. Each month, we met as a team to find new and innovative ways to bring multi-faceted coverage to our readers on this topic. This e-book is a compilation of those stories. The common thread was the people in our communities. The names and faces behind the deaths. They were more than just numbers. They were and are our neighbors. Our sisters. Our brothers. Our parents. Our cousins. Our friends. This is not an easy read. Our goal was to bring the communities of the West Side together in our pursuit to educate, understand, cope and gain empathy for those on the frontline of the opioid crisis. We aren’t going to cure it. But we can expose it, find the best ways to gain the upperhand, and maybe slow its ugly march forward. At the very least, we can point out — and continue to point out — the elephant in the room. We are bigger than this crisis. Together, we must not become immune to the numbers. We need to reach out to help our fellow community members who are struggling and help to halt this epidemic in its tracks.

Editor, Susan Condon Love Creative Director, Maureen Bole 2 The Opioid Crisis Exposed

Table of contents 7|

PART ONE: INTRODUCTION ......................... 4

PART SEVEN: MEDICATION ASSISTED TREATMENT .......... 92

Examining the epidemic ......................................... 5 Opioid timeline and glossary ................................ 10 Opioids in pain management ................................ 12 Illicit drugs 101 .......................................................... 15 Epidemic economic impact ................................... 18 Prosecutors target trafficking ............................... 21 Opinion: A different view of the epidemic ............ 24

Medication-Assisted Treatment ............................. 93 What is MAT? .......................................................... 95 Methadone ............................................................. 97 Suboxone ................................................................. 99 Vivitrol .................................................................... 102 Opinion: Addressing the pitfalls .......................... 104

PART TWO: NALOXONE ............................... 25

Narcan: Saving lives, buying time ........................... 26 Project DAWN ........................................................... 31 First responders experience ................................. 34 Opinion: Helping or hurting? ................................... 36

PART THREE: THE LEGAL SYSTEM ................ 38

Drug court programs ..............................................39 Local drug court judges ........................................... 43 Recovery court ........................................................ 46 Drug-related crime .................................................. 48 Project 180 .............................................................. 50 Opinion: What drug courts mean .......................... 51

PART EIGHT: RECOVERY ............................. 107

Recovery’s Got Talent ........................................... 109 Mental illnesses ................................................... 113 Mental Disorders ................................................ 116 Mental health & treatment ................................... 118 Opinion: Mental illnesses ..................................... 122

PART NINE: PREVENTION ........................ 124

Teen drug use ....................................................... 125 Why do kids do drugs? ......................................... 129 Drug use warning signs ...................................... 130 Stopping before starting .................................... 132 Community Resource Officers ............................ 135 Opinion: Prevention can work ............................ 138

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PART FOUR: ADDICTION PSYCHIATRY ....... 53

Mental health perspective ..................................... 54 Addiction in the brain ............................................. 57 Debunking myths ................................................... 61 Opinion: Fixing what’s broken .............................. 64

PART FIVE: CHILDREN ................................ 66

Children of addicts ................................................... 67 Facts & figures ......................................................... 70 The foster care system ............................................. 71 Rosie’s Playhouse ..................................................... 74 The Providence House ............................................. 76 Opinion: Who hurts the most ................................ 78

PART SIX: FAMILIES ................................. 79

Families of addicts .................................................. 80 Families involved in treatment ............................. 83 Al-Anon & Nar-Anon ............................................... 85 Personal accounts ................................................. 88 Opinion: Affecting the family ................................ 91

PART TEN: HARM REDUCTION .......... 140

Harm reduction ................................................... 141 What is harm reduction? ..................................... 144 Community Outreach ......................................... 146 Law enforcement .................................................. 150 Opinion: ‘Get over it’ ............................................. 151

PART ELEVEN: TREATMENT ...................... 153

Treatment plans ................................................... 154 Road to recovery .................................................. 156 Coalition to end the epidemic .............................. 158 Getting clean, giving back ..................................... 161 Opinion: Surviving the horrors ........................... 164

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PART TWELVE: SYNOPSIS ......................... 166

Barriers to the epidemic ..................................... 167 A year of the epidemic ......................................... 170 The series in review ............................................. 174 Opinion: Fighting the stigma ............................ 178 Sources & resources ............................................. 180 The Opioid Crisis Exposed 3

part

In the first part of the series, we look at the epidemic as a whole: what it is and how we got here. ♦ Examining the epidemic on the Westshore ♦ Illicit drugs 101 ♦ Opioids in pain management ♦ Epidemic economic impact

introduction

♦ Prosecutors target trafficking ♦ Is it just opioids? ♦ Opinion: A different view of the epidemic

“I woke up from a severe overdose with an IV in my jugular vein because they couldn’t find (a good vein) anywhere else. I was just pumped with eight vials of Narcan. I had sticky paddles stuck all over my body because my heart had completely stopped. I was in so much pain, it felt like my veins had fire in them. They (the EMTs) dragged me out into the snow. I had a tank top on, barefoot and maybe weighed 100 pounds and (they) threw me on a gurney. This was like the third time they had come to my house. I was already withdrawing. It was instantaneous. I remember looking around the back of the ambulance and it was such deja vu, like, ‘Oh my god this is happening again.’ ” 4 The Opioid Crisis Exposed

Examining the epidemic on the Westshore

February 14, 2018 Written by Nicole Hennessey & Maureen Bole

auren Thompson, 30, vividly remembers one particular overdose she experienced in her dozen years as an addict. It happened when Lauren, who has been clean a year and now lives in North Olmsted, lived in Fairview Park. “I woke up from a severe overdose with an IV in my jugular vein because they couldn’t find (a good vein) anywhere else. I was just pumped with eight vials of Narcan. I had sticky paddles stuck all over my body because my heart had completely stopped. I was in so much pain, it felt like my veins had fire in them. They (the EMTs) dragged me out into the snow. I had a tank top on, barefoot and maybe weighed 100 pounds and (they) threw me on a gurney. This was like the third time they had come to my house. I was already withdrawing. It was instantaneous. I remember looking around the back of the ambulance and it was such deja vu, like, ‘Oh my god this is happening again.’ ” That wasn’t the last time she used. Like the rest of the nation, Cleveland’s West Side, middle-America communities in Lorain and Cuyahoga counties are in the throes of the opioid epidemic, facing daily reports of deaths or overdoses and countless police blotter reports of addiction-related crimes, as well as accidents. As is evident by endless reports, obituaries and whispers in every community, Lauren’s story is common. Ohio has emerged as the epicenter of the opioid crisis. Families and communities are being crushed by the loss of loved ones, as well as ongoing stresses on local and social services. This all began with the surge of prescription opioids about a decade ago. Pharmaceutical companies promoted opiate-based pain medications to doctors and patients as non-addictive options to treat acute pain. The federal government simultaneously began incentivizing and judging medical professionals on their ability to treat pain, which became the “fifth vital sign.” The potent pills were over-prescribed to patients for chronic pain, from a simple backache to pain from serious surgery - and everything in between. Once better regulations were put in place for prescribing, access to the drugs grew harder, but the number of people addicted to them remained the same or grew. That forced many of those who were still addicted to turn to the streets to get their fix The Opioid Crisis Exposed 5

Lauren Thompson, 30, watches a video with her son Tyler, 5, in their home in North Olmsted.

through heroin, which is cheaper and more potent than prescription opioids. That’s how fentanyl, an opioid that is up to 100 times more potent than morphine, came into play. “Last year, before I went to jail, I overdosed three times in less than three weeks,” Lauren said. “I’m sure there was some heroin in it but most of it was just fentanyl. It’s everywhere, that’s all that’s really around. “Fentanyl is a lot cheaper than heroin. I know someone who dates a heroin dealer. You spend $200 on a gram but put 49 grams of cut in it. So then you sell those 50 grams for a $100 apiece. “But you’re killing people, daily. They (drug dealers) don’t care though. Junkies come a dime a dozen. There are junkies everywhere and there are new ones being formed as we speak.” Ohio leads the nation in opioid-related 6 The Opioid Crisis Exposed

deaths. The Ohio Department of Health reported a record 4,050 drug overdose deaths in 2016, which is a 33 percent increase from 2015. Because his staff covers one-fifth of Ohio, (more than 30 counties) Montgomery County Coroner Kent Harshbarger is quoted as saying the state would see 10,000 overdoses by the end of 2017 — more than were recorded in the entire United States in 1990. Montgomery County, which includes Dayton, holds the title of the overdose capital of America. Ohio has recorded 56 deaths in the first 23 days of this year. Lorain County saw 19 deaths in 2017 in our readership area - Avon, Avon Lake, Sheffield Lake and Sheffield Village. A preliminary report from the Cuyahoga County Medical Examiner’s office shows the six western Cuyahoga County suburbs tallied 21 deaths. In total, there were 524 opioid deaths in Cuyahoga County in 2017; In Lorain County, that number was 111 deaths. In August 2015, Barbara Folds of Olmsted Township learned on Facebook about the death of her beloved 23-yearold grandson, Taylor Folds, who died from an heroin overdose. His relationship with his family had grown strained over several years because of arrests in front of family, overdoses, stealing and trouble with the law. Folds’ pain was evident during a recent meeting when she pulled a handwritten letter out of a blue drawstring backpack overflowing with opioid-related pamphlets. It was written in anticipation of telling her story and included detailed notes on how to live clean and sober, drug awareness

programs and her roadmap to journey through a crisis of addiction in America. It started this way: “Twenty-nine months ago today was the last day I was truly happy. On Aug. 31 (2015) at 11:45 a.m., my son-in-law called me and told me that my beautiful 23-year-old grandson had died. My grandson suffered with the disease of addiction.” Folds’ sadness is palpable. “He was my only grandson for 10 years, so he and I were really close,” said Folds, holding up her phone, displaying a picture of Taylor with a huge smile, shining eyes and long dreadlocks. It’s hard for Folds, 68, to pinpoint the start of Taylor’s addiction. The North Olmsted High School honor roll graduate (a great accomplishment, Folds said, since she suspects he’d already started using at that point) loved playing drums and Bob Marley; he also played defense for the Eagles’ hockey team. Soon, the honor roll and hockey gave way to arrests and a struggle to survive, his family constantly worried he’d overdose; and praying that he’d stop using. Currently, the epidemic’s statewide economic toll is as much as $8.8 billion annually, a study by The Ohio State University found. The summary noted this is how much money the state spends on K-12 education annually. A study sponsored by the Nord Family Foundation and conducted by Altarum, a health research and consulting firm, found that prescription opioid misuse and abuse in Lorain County is 2.5 times the national average; and the total economic burden in the county for 2016 was nearly $200 million. State officials estimate nearly $1 billion

Taylor Folds lost his battle against his addiction in August of 2015. More than two-and-a-half years later, Taylor’s Facebook page is still flooded with messages from friends and family members who are missing him every day.

is invested yearly to help communities address prevention, treatment, recovery and law enforcement. Even with additional federal, state and county funding, as well as money through nonprofits and private organizations, the OSU study found Ohio currently only has the capacity to treat 20 percent to 40 percent of the estimated 92,000 to 170,000 Ohioans who are abusing or dependant on opioids. Researchers and medical professionals recommend these gaps be filled by training more physicians to administer medicationassisted treatment, such as methadone, suboxone or vivitrol. This is controversial, though, since 12-step programs depend on abstinence. Fifty-one-year-old Dagi Temple of Elyria has been clean for almost two years. She The Opioid Crisis Exposed 7

was clean for six years when she fell back into addiction in 2009, using drugs for another seven years before getting clean a second time. She never used heroin. Her drugs of choice were cocaine and crack. But when she was back out using again the second time, she’d worry all the time that her drugs had been cut with fentanyl. “I had to use just to feel normal, and against my will,” Temple explained. “I think there’s way too much emphasis on the opioid epidemic rather than on the disease of addiction,” she added, remembering the end of her use and not wanting to live anymore. The focus on treatment and funding now, Temple said, is ”because all of a sudden the doctor’s daughter is shooting dope.” Having been clean before, however, Temple knew were to go: a 12-step program which she now hopes is her permanent home. She considers herself a “survivor of this disease.” The Cleveland Municipal Court or the Cuyahoga County Common Pleas Drug Court, as well as the Recovery Court through the Lorain County Court of Common Pleas also work to get people into recovery. In Cuyahoga, these programs are far from new, but Lorain County celebrated its first group of recovery court graduates last year. Jeff Capretto, special agent in charge of the Westshore Enforcement Bureau Drug Task Force (WEB), also sits on the board of Cuyahoga County’s drug court. He makes it a point to attend successful participants’ drug court graduations. People in drug court go through a period where they have to prove they’re in recovery instead of facing criminal charges, after which they graduate from drug court. Since 2009, 8 The Opioid Crisis Exposed

Dagi Temple of Elyria.

drug courts in Cuyahoga County have graduated more than 300 participants. Lorain County’s new court graduated its first four successful participants in 2017. To see people stand up and say, “I’m clean now; I’m doing well,” Capretto said, “It’s very rewarding.” WEB’s outreach includes Bay Village, Lakewood, North Olmsted, Rocky River, Westlake and Fairview Park. Later this month or in early March, WEB will launch a quick response team in partnership with MetroHealth Medical Center’s Office of Opioid Safety – a new program started in July. The city of Parma will also join forces. The plan is to send out a social worker and a WEB officer to the residence of anyone who overdoses. Peer-support specialists also work with patients in Metro’s emergency rooms. And the thread weaving through all of these programs is Project Dawn, which trains and equips safety services, as well as community members, with life-saving, overdose-reversing naloxone, known by the brand name Narcan. As many addicts and families as possible leave the hospital with this tool,

which is controversial to some because it can allow addicts to get high without the fear of death. Still, it is saving lives. Lauren’s story is typical of many addicts. “I grew up in a drug-addicted household, no father. Was the oldest of four at that time. Had to grow up pretty quick, become the mother figure, by the time I was 8. I was mature for my age, real insightful. “It’s like something inside of you just cries for failure. I was always waiting for the other shoe to drop, so I made the other shoe drop. So I could control it. Like I had some sort of sense of control by messing it up on purpose instead of on accident.” Before launching Lakewood’s rapid response program, SOAR, or Supporting Opiate Addiction Recovery, officials stressed how necessary it would be for surrounding communities to work together, since the city will not be able to provide outreach to people in surrounding communities, even if they overdose in Lakewood. SOAR is seen by many as groundbreaking because it works through peer support, while many other programs work through law enforcement or medical professionals. Gina Bonaminio is working as a SOAR peer outreach specialist. If people accept, she heads to the ER to talk to them right away, which she’s done about five times now. If they don’t, she goes to their house days later. Bonaminio, 24, who’s an active and outspoken voice in the Ohio recovery scene, said she does this to encourage others to speak up; to fight against the stigma surrounding addiction and mental health. Shortly after graduating from Amherst High School, Bonamino started using heroin. She’d partied a lot and also got addicted to opioid painkillers after a jaw surgery. Around 2011, when law enforcement and government officials started cracking down on pills, Bonaminio, like many others, switched to heroin. “For me, it wasn’t a decision,” said Bonaminio. She was constantly sick and needed to go to work, so she felt she had no choice but to use. She’s been clean since 2015. And though she finds helping people to be incredibly rewarding, “We’re literally sprinting to catch up to this, and we’re not even close.” After her first stint in county jail, her fourth inpatient rehab program and several months living in a sober house, Lauren, who has a 12 year old and a 5 year old, gratefully has worked hard to maintain her recovery. She lives with the father of her youngest child and works a steady job. “Guess what? I’ve been clean for a year and haven’t got caught in a single raid, imagine that! No domestic violence charges, no DCFS (Department of Children and Family Services) at my door and what’s the one thing I haven’t done? Get high. It’s mind blowing. After Taylor’s death, Folds began organizing outreach initiatives in Olmsted Township and Berea, helping to set up a quick response teams through the police stations. Safe Passages, a national police-assisted addiction and recovery initiative, is now active in ten communities. Folds also runs a family support group that works in conjunction with Safe Passages, and she’s active in educating and engaging with democratic clubs throughout the Westshore. “We need to educate people about addiction,” she said. ♦ The Opioid Crisis Exposed 9

How did we get here? The history of opioids in America 1700s: Colonial America

1938: New safety standards for drugs

It was a common practice for doctors to prescribe opium to their patients suffering from pain, dysentery and cough.

The Food, Drug and Cosmetic Act replaces the Pure Food and Drug Act. It gave authority to the FDA to oversee the safety of consumer products; requiring drug manufacturers to prove that their product was safe before it could be sold.

1830s: The Industrial Revolution Morphine is developed from opium in Germany. The new drug makes its way overseas and is manufactured in the U.S.

1860s: The Civil War Morphine is used to treat battlefield wounds. The terms “Soldiers Disease” or “Narcomania” were used to describe morphine addiction. The safety of the drug comes into question when addiction becomes prevalent in war veterans.

1889: Legal heroin Heroin, a new drug considered less addictive than morphine, is introduced on the market to treat common aches and pains and as a cold remedy. Soon after it’s inception, heroin was given to morphine addicts for free to help them quit.

1906: The Pure Food and Drug Act & FDA The Pure Food and Drug Act required pharmaceutical companies to list all ingredients on their products, especially the most “dangerous” ones such as heroin and cocaine. The U.S. Food and Drug Administration was formed.

1924: Anti-Heroin Act The Anti-Heroin Act makes the manufacture and possession of heroin illegal. 10 The Opioid Crisis Exposed

1970: The Controlled Substances Act The Controlled Substances Act categorizes drugs into five categories based on their potential for abuse. See page 15 for more info.

1970-73: The Vietnam War After marijuana use is banned among G.I.s overseas, soldiers shifted their drug of choice to heroin. A study by the Pentagon found that 20% of soldiers were habitual heroin users during the war.

Late 1970s: Percocet & Vicodin New short-acting opioid painkillers Percocet and Vicodin hit the U.S. market.

1980s: False claims Opioid painkillers are deemed “safe” and addiction to them “rare” based on one small study and a letter in a medical journal. These studies became widely cited as proof that prescription opioids are safe, and should even be promoted, for the treatment of pain.

1996: Purdue Pharma introduces OxyContin A new long-acting opioid painkiller, OxyContin, hit the market. The drug was aggressively marketed to prescribers as less addictive than other short-acting opioids.

2000s: Widespread prescription abuse

Opioid Glossary

Reports of overdose and death from OxyContin began to skyrocket. The number of people who admitted to using OxyContin for non-medical purposes increased by dramatically from approximately 400,000 in 1999 to 1.9 million in 2002 and to 2.8 million in 2003.

You don’t have to be a medical professional to understand the opioid epidemic. Here is a list of compounds and medication names to help decipher the difference between drugs.

2006: Striving for safety

Where does the term “opioid” come from? Opium poppy: A species of flowering plant from which opium and poppy seeds are derived. Opium: A highly addictive narcotic drug acquired in the dried latex form the opium poppy seed pod. Opioid (or narcotic): A variety of substances that dull the senses and relieve pain Natural opioids: An organic chemical compound that occurs naturally from the opium poppy Semi-synthetic opioids: Chemical compounds created or enhanced in labs from natural opioids Synthetic opioids: Completely man-made chemical compounds that mimic naturally occurring opioids Fentanyl analog: A highly potent synthetic opioid structurally related to fentanyl

The Food and Drug Administration Amendments Act (FDAAA) became law. This gave the organization new authority to ensure the safety of prescription drugs. Manufacturers would now be required to ensure the benefits of the drugs continue to outweigh their risks, called Risk Evaluation and Mitigation Strategies (REMS) During this time, Fentora (fentanyl) and Vicodin also came under fire with the FDA about their compounds, use and warning labels.

2011: The prescription drug epidemic The White House Office of National Drug Control Policy releases a report outlining an action plan to address the national prescription drug abuse epidemic.

2012: Turning to a cheaper alternative In previous years, the CDC cited oxycodone as the leading cause of overdose deaths nationally. As government organizations began to crack down on the pharmaceutical industries to better regulate prescription opioids, the drugs became harder to obtain. This left thousands of Americans addicted with limited resources to get their pills. Many prescription opioid users began turning to cheaper alternatives to get their fix: street drugs. This year was the first year heroin overdose deaths surpassed those from prescription opioids.

2014: Deadly street drugs Overdose deaths linked to heroin tripled in four years. Fentanyl became more prevalent and deadly as well, with overdose death tolls doubling in one year.

2015: Operation Pilluted The DEA announces the completion of the largest prescription drug bust in history. In this sting, more than 200 people were arrested in connection with careless prescribing opioids or operating pill mills.

2016: Official regulation of opioids In order to curb the prevalence of opioids, the CDC steps in and releases guidelines for prescribing opioids for chronic pain.

2017: A public health emergency President Trump declares the opioid epidemic a national public health emergency. Cuyahoga and Summit counties become two of the first municipalities to file lawsuits against pharmaceutical companies and pharmacies.

Top ten most potent opiates Carfentanil: The most potent fentanyl analog detected in the U.S. One hundred times more potent than fentanyl, it’s used by veterinarians to sedate large animals. The drug is not intended for human consumption. Fentanyl: A synthetic opioid that is medically used to help patients manage severe pain after major surgery. It can be up to 50 times more potent than heroin. Heroin: A semi-synthetic opioid derived from morphine, a natural compound that comes from the opium poppy. The drug is completely illegal and has no accepted medical uses. Hydromorphone: A semi-synthetic opioid derived from morphine, structurally modified to be more potent. Used medically under the brand names Dilaudid and Exalgo to treat severe pain. Oxymorphone: A semi-synthetic opioid once marketed under the brand name Opana, until it was withdrawn from the manufacturer in 2017 because of its widespread abuse. Generic options are still on the market today. Methadone: A synthetic, long-acting opioid used under strict medical supervision to treat opioid addiction. Oxycodone: A semi-synthetic opioid prescribed to treat moderate to severe pain. Found in brand-name drugs Oxycontin and Percocet, it has a high potential for abuse. Morphine: A natural opioid derived directly from the opium poppy. Typically used in hospitals or hospice care. Hydrocodone: A semi-synthetic opioid synthesized from codeine. Found in brand-name drugs Vicodin and Lortab, it is the most commonly prescribed opioid in the U.S. Codeine: A natural opioid derived from morphine that is often paired with acetaminophen to treat moderate pain, diarrhea and cough. The Opioid Crisis Exposed 11

Opioids in pain management

February 14, 2018 Written by Kevin Kelley

ustin Braley’s first experience with painkillers was not problematic. A doctor prescribed Braley, a substance-abuse counselor in Lorain County, some Vicodin after he tore ligaments in a basketball game. When the prescription ran out, he stopped taking them. But about six months later, while working long days in a kitchen, he complained aloud about a sore back. A coworker offered him Vicodin. “I know they worked, so I started taking them,” he said. He realized the drug also relieved the stress from a busy night at the restaurant and life’s other problems. Using painkillers as a stress reducer lead to a psychological dependency, he said. He sought more medications from numerous doctors, the South Amherst resident said. “You’d just work your way up” to stronger medications, Braley said. Braley, 39, said he tried heroin on a few occasions, but his 15-year addiction centered mostly on prescription medications. After being sentenced in 2008 for drug possession when he was caught with a large quantity of Percocet, he entered an outpatient rehabilitation program and participated in a 12-step program. Today, he’s a substance abuse counselor at the LCADA Way in Lorain, a private organization offering addiction and mental health treatment to residents of Lorain and Medina counties. The “doctor shopping” Braley did is largely not possible now, as the medical community has tightened control over prescription painkillers. Today, physicians in Ohio must report prescriptions of controlled substances to a computer database to prevent an individual from obtaining painkillers from more than one doctor. Braley said many in their 30s and 40s that his agency helps trace their addictions to prescription drugs. In the past decade, many persons who had become addicted to the painkillers Oxycontin and Opana moved on to heroin, he said. Nearly 80 percent of Americans using heroin, including those in treatment, reported misusing prescription opioids first, according to the National Institute on Drug Abuse. Between 21 percent and 29 percent of patients prescribed opioids for chronic pain misuse them, and an estimated 4 percent to 6 percent who misuse prescription opioids ultimately use heroin, the agency reported.

12 The Opioid Crisis Exposed

In the late 1990s, pharmaceutical companies marketed opioid pain relievers to healthcare providers with the assurances they were not addictive, and physicians prescribed them more frequently. The amount of opioids prescribed nationwide peaked in 2010, then decreased, according to the Centers for Disease Control and Prevention. But the amount of opioids prescribed remains about three times as high as in 1999. In October, Cuyahoga County filed a lawsuit against several drug companies, saying they downplayed the risks of the drugs in pursuit of profits. The lawsuit seeks compensation for the high toll the opioid epidemic has taken on communities. Randy Jernejcic, chief medical officer at University Hospitals Ahuja Medical Center, said he recalls drug representatives saying less than 1 percent of those prescribed Oxycontin would become addictive. “They were really pushing it a lot,” said Jernejcic, who is leading UH’s response to the opioid problem and serves on the Ohio Hospital Association’s Opioid Response Initiative committee. Opioid drugs work by blocking opioid receptors on brain cells, thereby keeping pain signals from reaching the brain, Jernejcic said. The drugs can also cause feelings of euphoria, he said. In an overdose, the brain stops sending signals to the lungs, and breathing can slow or even stop. For relieving severe, acute pain, such as experienced with a broken arm, few alternatives exist to opioids, Jernejcic said. “It’s not ‘how do we stop prescribing them?’” Jernejcic said. “It’s ‘how do we make sure that only the people that need them get only the amount they need

Many of those who are addicted to opioids today started with prescription pills for an injury or chronic pain.

safely and not any more?’” Jernejcic said a real risk exists that, given the increased scrutiny, some doctors may be reluctant to write opioid prescriptions and some patients may experience pain needlessly. “I don’t think we’re there,” Jernejcic said. The focus needs to be on safely prescribing only the amount of painkillers needed for a limited time, he said. University Hospitals’ physicians, nurses, pharmacists are taking a multidisciplinary approach to follow prescribing guidelines, Jernejcic said. Patients often need other resources – such as mental health services, physical therapy, acupuncture, meditation and yoga– to combat chronic pain and the addiction threat, he said. “If there’s a lack of resources in the area, opioids become more attractive,” he said. Scott D. Petersen, a physician’s assistant and pain management specialist at the Cleveland Clinic’s Avon Hospital, said the health care community has been taking a closer look at the use of opioid medications. “We’re prescribing opioids a lot more judiciously than we did before,” he said. The Opioid Crisis Exposed 13

Randy Jernejcic, chief medical officer at University Hospitals Ahuja Medical Center

“It’s not ‘how do we stop prescribing them?’ It’s ‘how do we make sure that only the people that need them get only the amount they need safely and not any more?’”

Scott D. Petersen, pain management specialist at the Cleveland Clinic’s Avon Hospital

“There’s going to be a new normal in this country... We’re going to work harder to control your pain. We’re going to try and do it with medications that are safer for you.” 14 The Opioid Crisis Exposed

“We’ve seen the negative effects.” Petersen said opioids are used following surgery and in cases of broken arms or legs. But opioids are no longer seen as the first line of pain treatment for cases of muscular pain and chronic pain, he said. “I don’t look at opioids as ‘yes or no,’” Petersen said. “We see opioids as part of a continuum.” Like University Hospitals. the Cleveland Clinic uses what’s called “multimodal analgesia,” a method of pain management that combines multiple medications or techniques. Medications can include local anaesthetics, nonsteroidal antiinflammatory drugs and acetaminophen, as well as opioids. A nerve block or even an ice pack may be used. Pain is often not treated with a single drug, Petersen said. The multimodal approach is effective in relieving pain while reducing side effects, he said. Fewer opioids following surgery, Petersen said, can result in less nausea, less constipation and possibly a shorter hospital stay. “There’s going to be a new normal in this country,” Petersen said. “That new normal is that we’re going to work harder to control your pain. We’re going to try and do it with medications that are safer for you. And we’re going to try and do it with fewer side effects.” Some patients are having a hard time adjusting to not receiving opioids as a first response to their pain, Petersen said. In March 2016, the Centers for Disease Control and Prevention published guidelines stating that opioids should not routinely be prescribed for treatment of chronic pain, which is experienced by 11 percent of Americans. Other therapies and medications should be tried first, the CDC said. Opioids should only be used when benefits are likely to outweigh risks, and the lowest possible effective dose should be used. “The CDC’s recommendation that opioids not be used for chronic pain is based on a lot of evidence that the eventual benefits kind of pale compared to the harms,” Petersen said. Families should clean out their medicine cabinets, Petersen advised, because most people who abuse prescription painkillers don’t go doctor shopping or get them from a drug dealer. Instead they either steal them from or are given them by a family member, he said. ♦

Illicit drugs 101

Knowing the difference between some of the world’s most harmful substances

n the midst of the epidemic, it can be difficult to follow the news with all of the drug jargon swirling about. An easy way to understand these harmful substances is to turn to the Drug Enforcement Agency. In 1970, the Controlled Substances Act was passed which allowed the DEA to classify drugs into groupings (schedules) based on their use in the medical community and potential for abuse. The 2017 edition of the DEA Resource Guide Drugs of Abuse first reviews the basics of the CSA and current drug scheduling...

Schedule

Medical Use

None Some

Severe restrictions

Yes Yes Yes

Abuse Potential

Highest Severe physical or psychological dependence

High

Severe physical or psychological dependence

Commonly known drugs in this category Narcotics: Heroin, Fentanyl analogs Stimulants: Some Amphetamine variants Depressants: GHB Hallucinogens: LSD, Ecstasy/MDMA, Mascaline, Psilocybin Other: Marijuana,* synthetic marijuana (spice, K2), Bath Salts Narcotics: Fentanyl, Morphine, Methadone, Percocet, OxyContin Stimulants: Cocaine, Crack, Methamphetamine, Adderall, Vyvans, Rittalin Depressants: Some barbituates Hallucinogens: Other: PCP

Medium

Narcotics: Suboxone, Vicodin, Codeine products Stimulants: Weight loss drugs phendimetrazine and benzphetamine Depressants: Hallucinogens: Ketamine Other: Anabolic steroids

Low

Narcotics: Stimulants: Depressants: Most benzodiazapines- Klonopin, Xanax, Valium, Ativan Hallucinogens: Other: Sleep medications- Lunesta and Ambien, Muscle relaxer- Soma

Lowest

Narcotics: Cough preparations containing small amounts of codeine Stimulants: Depressants: Hallucinogens: Other:

Moderate physical dependence, high psychological

Limited physical or psychological dependence

From there, drugs are broken down into different classes: narcotics, stimulants, depressants, hallucinogens, marijuana, steroids, inhalants and designer drugs. The report states that “each class has distinguishing properties, and drugs within each class often produce similar effects. However, all controlled substances, regardless of class, share a number of common features.” In other words: all controlled substances produce euphoria and pose the risk of abuse, dependence and subsequent addiction. The new two pages explain these substances a bit more. The Opioid Crisis Exposed 15

Illicit drugs 101 Opioids/Narcotics A class of drugs used for pain relief, these drugs block pain transmission in the brain. The euphoric sensation and severe withdrawals opioids produce are what hooks users. Though some people still refer to all drugs as “narcotics,” today “narcotic” refers to opium, derivatives and substitutes. A more current term for these drug is “opioid.”

Prescription pills

Morphine

Heroin

Fentanyl

Medications that are prescribed by a health care provider to treat pain from surgery, injury or chronic pain. Popular brand names: Vicodin, Percocet, Lorcet OxyContin, Dilaudid.

A non-synthetic narcotic with a high potential for abuse. It is derived directly from opium poppy. It is used for the treatment of severe pain, most commonly in a hospital setting.

An illegal drug made from morphine which comes from the opium poppy plant. It is a rapidly acting opioid, meaning its users feel effects almost immediately after use.

A potent synthetic opioid drug approved by the FDA for pain relief and as an anaesthetic. It is approximately 50 times more potent than heroin as an analgesic.

Marijuana

Depressants

The most commonly used illicit drug in the country, marijuana comes from the hemp plant. The plant’s buds possess the chemical THC which produces its mind-altering effects.

A class of drugs that slows down brain activity. Most depressants are obtained with a prescription and are used to treat anxiety, sleep and stress disorders.

Buds

Concentrations

Sedative-hypnotic

Benzodiazepine

In its most basic form, the buds of the plant are smoked in a pipe, cigarette (joint) or cigar (blunt). Different strains of marijuana can produce either a head or body high.

Marijuana oil or wax is a highly potent concentrated forms of THC. The wax is heated to a high temperature, is turned into a vapor and is then inhaled by the user.

Prescription drugs generally used to treat insomnia and other sleep disorders. The drugs can be habit forming and have potential for abuse. Popular brand names: Lunesta, Ambien, Sonata.

Prescription drugs generally used to treat anxiety disorders. These drugs are misused for their euphoric, sedative effect. Popular brand names: Valium, Xanax, Ativan, Klonopin.

16 The Opioid Crisis Exposed

Illicit drugs 101 Stimulants

Inhalants

This class of drugs increases Central Nervous System activity; making the person using them feel more awake, alert, confident or energetic. Prescriptions stimulants are used to treat ADHD and other related disorders.

Substances that produce chemical vapors that induce psychoactive effects.

Amphetamines

Cocaine

Methamphetamine

These medications are legally used to treat ADHD. Illicitly, the drugs are used to stay focused or awake for extended periods of time. Popular brand names: Adderall, Vyvanse, Ritalin.

An illicit drug made from the coca plant from South America. Cocaine is found as a powder whereas it’s “smokable” form, crack, is found as a solid, white rock-looking substance.

A white powder or crystal that is made in a laboratory. Those who smoke or inject it report a brief, intense sensation, or rush. Meth has highly addictive stimulant properties.

Liquids: paint thinners, glues, office supply fluids Sprays: Any aerosol can Gases: nitrous oxide, whipped cream cans Nitrites: found in preservatives, leather cleaner, room deodorizer

Hallucinogens This class of dissociative, psychoactive drugs alter a person’s perception of reality often bringing about vibrant visions, thoughts and feelings. Hallucinogens are found in plants and fungi or are synthetically produced and are among the oldest known group of drugs used for their ability to alter human perception and mood.

Ecstasy

Mushrooms

LSD

Ketamine

Also known as MDMA or “Molly” this drug is a stimulant and hallucinogen that produces extreme euphoric feelings and energy. It is widely used at parties.

Psilocybin mushrooms are a classification of fungi that are found in tropical regions of the Americas. Those who injest the mushroom are unable to discern fantasy from reality.

The most popular form of D-lysergic acid diethylamide or “acid” is made by soaking blotter sheets in the chemical which users dissolve on the tongue.

A dissociative anaesthetic that can distort perceptions of sight and sound and makes the user feel detached from their pain and environment. It can induce a state of sedation.

The Opioid Crisis Exposed 17

Opioid epidemic costs exceed $1 billion

August 29, 2018 Written by Kevin Kelley

ow do you put a price on the disruption addiction brings to family life, the childhoods lost by those whose parents overdosed and the lives lost to overdoses? Even so, many economists have attempted to measure the cost of the crisis, which claimed more than 350,000 lives between 1999 and 2016, according to the U.S. Centers for Disease Control and Prevention. That figure includes overdoses from both prescription and illicit opioids. Altarum, a Michigan-based nonprofit organization dedicated to solving health problems for vulnerable populations, estimated the cost of the opioid crisis exceeded $1 trillion from 2001 to 2017. If the crisis continues at its current rate, an additional $500 billion will be incurred by 2020. The greatest cost comes from lost earnings and productivity of those who die of overdoses. Altarum estimated that to be $800,000 per person, based on overdose deaths occurring at the average age of 41. This figure also includes lost tax revenue. The total number of years of living lost by those who died of overdoses through 2016 was 1.84 million, Altarum estimated. Health care costs were $215.7 billion from 2001 to 2017, with much of this figure due to emergency room visits to treat and stabilize patients after an overdose. Looking at it another way, the potential benefit of preventing opioid addiction, overdoses and deaths in 2016 alone would have exceeded $95 billion, the Altarum study stated. Altarum also concluded that Ohio’s total economic burden of the opioid crisis is 60 percent higher than the average state burden. In November, a study by the White House Council of Economic Advisers concluded the economic cost of the opioid crisis in 2015 alone, when an estimated 33,000 Americans died of an opioid-related overdose, was $504 billion, or 2.8 percent of the annual gross domestic product. This study’s figures were significantly higher than those in previous studies because it used a different analytical measurement, the “value of a statistical life,” which takes into account the intangible value of a life, beyond lost earnings. “Extensive research indicates that people value fatality risk reduction far beyond the value of lost earnings due to premature death, as earnings do not take into account

18 The Opioid Crisis Exposed

The cost of the country’s opioid epidemic is likely to exceed $1 trillion from 2001 to 2017, and is estimated to cost an additional $500 billion by 2020, according to Altarum, a nonprofit health research and consulting institute. $200 $ Billions (constant 2016 collars)

other valuable activities in life besides work,” the council’s study stated. Meanwhile, economists at the Federal Reserve Bank of Cleveland have substantiated the widespread conclusion that the epidemic arose from the overprescription of painkillers. Counties with higher levels of opioid prescriptions from 2006 to 2016 had substantially lower employment rates among prime-age workers, the economists said. But job losses sparked by the Great Recession of the late 2000s and early 2010s did not significantly increase opioid use, according to the data. That surprised Kyle Fee, a regional community development adviser at the Cleveland Fed. “Overall, this research suggests that opioid abuse is not influenced by short-term labor market shocks but that poor labor market outcomes are highly correlated with prescription opioid availability,” Fee wrote in a study published in May. Mark Schweitzer, senior vice president for the Cleveland Fed, put it this way: “Opioids in your community are bad for labor market performance, regardless as to economic conditions.” A decrease in the labor participation rate due to opioid abuse is essentially the same as an increase in the unemployment rate, Schweitzer said. “It lowers the potential for a location to grow and be more prosperous,” he said. Specifically, the labor force participation rate among those in their prime working years decreased 4.6 percentage points for men and 1.4 percentage points for women between 2007 and 2016 in high prescription rate counties. The declines were greater for

Total and projected costs of the Opioid Epidemic

Projected burden at current rates

$150

$100

$50

$0 2001

2006

2011

2016

2020

* Data between labeled estimated interpolated using constant growth rate. SOURCE: Altarum

those with a high school diploma or less. Fed economists conclude that alleviating the opioid crisis would substantially improve the economy in hard-hit areas. Opioid prescription rates have decreased significantly in recent years due to increased monitoring by state governments and the medical community. But Schweitzer notes the rates are still high compared to 1990s levels, and still higher than national averages. The Fed economists drew no conclusions as to why opioid prescription rates increased so dramatically in some regions. But some studies, he said, point to different prescribing practices based on physicians’ training. The Opioid Crisis Exposed 19

Medical costs surrounding the epidemic has cost the U.S. billions of dollars over the years.

Schweitzer does not dispute that general economic conditions may play a role in opioid addiction. But he notes that not all “rust belt” areas, such as several counties in upstate New York, have serious opioid problems. By contrast, Oregon is doing well economically but has an opioid problem, Schweitzer said. The Cleveland Fed, which serves Ohio, western Pennsylvania, eastern Kentucky, and northern West Virginia, also has been looking at how the opioid crisis has affected specific industries and companies. About half of the small-business executives who serve on the Cleveland Fed’s eight business advisory councils indicated their businesses have been negatively affected, directly or indirectly, by the epidemic. The councils meet quarterly and keep Fed economists aware of current business conditions. Several executives reported difficulties in hiring employees who can pass drug tests. A few said the challenge of hiring 20 The Opioid Crisis Exposed

drug-free drivers in the trucking industry, known for conducting regular tests, has led to increased shipping costs. Leaders in the construction industry said similar problems have caused slowdowns in building projects. Employers often aren’t informed whether a positive drug test is caused by an opioid or another drug, such as marijuana, Schweitzer noted. He also said many potential workers screen themselves out because they know they will fail a drug test. “It’s often that when employees learn there will be a drug test, they turn out to leave after the lunch break,” Schweitzer said. Other executives said some employees did not have drug problems themselves but had to miss work to deal with family members struggling with opioid addiction. Collectively in 2015, the states the Cleveland Fed serves experienced 8,572 overdose deaths – 26 percent of the 33,091 opioid-involved deaths in the U.S., according to the CDC. ♦

Federal prosecutors to target trafficking in Lorain County

July 25, 2018 Written by Kevin Kelley

orain County is one of 10 areas of the country targeted in a new initiative to aggressively prosecute opioid drug trafficking. Operation Synthetic Opioid Surge, SOS, the name of the initiative announced last week, is a collaboration of the U.S. Department of Justice and 10 U.S. attorney’s offices. Like the nine other regions chosen for the initiative, Lorain County was selected for target enforcement because of its high drug overdose rate. In 2014, the Lorain County coroner reported 39 heroin overdose deaths. Last year, the number of overdose deaths related to heroin and fentanyl was 132.

“These drugs have killed thousands of our friends and neighbors and caused pain and heartbreak to their families,” said Justin E. Herdman, U.S. attorney for the Northern District of Ohio. Under the new program, federal prosecutors intend to bring charges in every readily provable case involving the distribution of fentanyl and other synthetic opioids, regardless of drug quantity. Herdman said his office will work closely with Lorain County Prosecuting Attorney Dennis Will and Lorain County Sheriff Phil Stammitti in the initiative, as well as the Drug Enforcement Administration and the FBI. Stammitti said organizations are behind much of the drug trafficking in Lorain County. Just last month, 25 people were arrested after being indicted by a federal grand jury for their roles in a conspiracy to traffic drugs in Elyria and the surrounding area. “These organizations from the street-level dealer to the main source suppliers are drastically having a devastating effect on our communities,” the Lorain County sheriff said in a statement. Montgomery County, which includes Dayton, will also be a focus of Operation Synthetic Opioid Surge. Counties in Tennessee, Kentucky, West Virginia, Maine, California, Pennsylvania and New Hampshire will also be targeted. ♦

The Opioid Crisis Exposed 21

Is there a new trend emerging in this epidemic? July 25, 2018 Graphics by Maureen Bole

A brief history of Ohio’s Drug Overdose Epidemics A number of studies* have charted unintentional drug overdose epidemics in Ohio since 1979. With each new epidemic, the drugs get stronger and the death tolls climb to chilling numbers...

1979-1984

1995-1999

2011-2014

2017

In five years, the first heroin epidemic caused about

In five years, various drug overdoses caused about

In five years, the second heroin epidemic caused about

In two years, the fentanyl, analogs and cocaine epidemic caused about

500 Deaths

1,600 Deaths

10,850 Deaths

4,800 Deaths

2015-2016

1985-1994

2000-2010

In 10 years, the crack cocaine epidemic caused about

In 10 years, the prescription pain medication epidemic caused about

In two years, the fentanyl epidemic caused about

1,900 Deaths

10,600 Deaths

8,750 Deaths

Lacing drugs... how and why does it happen? Lacing drugs, or combining one substance with another, is relatively easy when it comes to cocaine, heroin and fentanyl. Since all three are white, powdery substances, determining what’s in the mix is near impossible without scientific testing. When it comes to heroin, intentionally lacing it with fentanyl is common. The two opioids produce a more potent high that may actually attract users instead of deterring them. But recent reports from the DEA showed that when it comes to cocaine, it is most likely not being intentionally laced with fentanyl. Most of the cocaine they have seized at the border is not laced. So how does fentanyl get into cocaine? As one DEA agent explained, drug dealers don’t clean up after themselves. They attribute most of the fentanyl laced cocaine as “cross contamination” that happens when dealers don’t clean of the table after cutting their fentanyl before cutting their cocaine.

22 The Opioid Crisis Exposed

Fentanyl and cocaine? Isn’t this an opioid epidemic?

Cocaine? Heroin? Fentanyl?

“The explosion of cocaine” 600 500 Overdose deaths

A new graph in the Cuyahoga County Medical Examiner’s Officer’s monthly overdose report charts the influx of recent cocaine overdose deaths, which has surpassed heroin overdoses and even comes close to fentanyl overdose deaths.

400 300 200 100 0

2014

2015

Heroin

2016

2017

Cocaine

2018 Fentanyl

Lacing a stimulant with an opioid ... a deadly combination Heroin laced with fentanyl is unfortunately nothing new to the epidemic. Heroin addicts often know that their drugs may be laced with fentanyl. But a new trend shows that cocaine is being laced with fentanyl as well, something cocaine users are not expecting as it takes their lives.

Overdose deaths 2018

100 80 60 40 20 0 Jan. Heroin

Feb.

March

April

Heroin and Fentanyl

May Cocaine

June

July

Aug.

Cocaine and Fentanyl

Sept. Fentanyl

*Studies: WONDER (NCHS Compressed Mortality File, 1979-1998 &1999-2005) 2006-2017 ODH Office of Vital Statistics, Change from ICD-9 to ICD-10 coding in 1999 (caution in comparing before and after 1998 and 1999.

The Opioid Crisis Exposed 23

OPINION: THE VIEW OF A RECOVERING ADDICT

A different view on the epidemic February 14, 2018 Written by Maureen Bole

can’t tell you how many familiar faces I’ve seen in obituaries or RIP posts on Facebook since I got clean in 2014. Or how many times I’ve seen friends doing well in recovery, then they go out and use once and die. I’ve lost close friends. I’ve hung out with someone and hours later they’re dead. I’ve sat in the ER comforting a friend who just overdosed. After my first close friend died, another told me I should invest in a couple good funeral dresses because I was going to need them. He was right. I think we’re becoming desensitized to death. Has it become all numbers to us now? We see the headlines: ‘30 dead in shooting,’ ‘5 dead after head on collision’ and ‘12 dead in less than a day from overdoses.’ Does it resonate with us that those are lives not just statistics? That isn’t the case for me, but sometimes I fear it is for others. I’ve seen a lot, but none of that can explain how bad this epidemic has become. But we’re gonna try. The purpose of our year-long opioid series that starts today is multi-faceted. First, I really want to start giving back to help with the crisis, and that begins for me with sharing my skills as a graphic designer and reporter to attach impactful images with all the facts and figures. The second is all about people - people I know and people I don’t know, but can feel their pain in my very bones. The opioid crisis is not just facts and figures. It’s people. In our neighborhood. Across the road. In the suburb around the corner. Most of all, I want to provide a different perspective on this epidemic, from someone who sees a lot of it first hand, but - more importantly - someone has lived through its horrors. In the avalanche of publicity focused on opioids and addiction, the addicts’ point of view is not often heard. I welcome any comments, questions or concerns about my journey, and the stories that will be published monthly in this newspaper. Feel free to email me or start your own conversation by writing a letter to the editor. Either way, we love to hear from the view of our readers. So, let’s start the discussion with this: As an addict, drugs aren’t my problem. I am my problem. I’ll explain that more later in the series. ♦ 24 The Opioid Crisis Exposed

part

In the second part of the series, we look at the lifesaving, opioid overdose reversal drug Narcan. ♦ Narcan: Saving lives and buying time for addicts ♦ Project DAWN works to curb overdose deaths by equipping community with Narcan kits ♦ Local first responders share their experiences administering Narcan

naloxone

♦ Opinion: Is naloxone helping or hurting the epidemic?

“I’ve OD’d 8 or 9 times. About half of them I got Narcan. I just go black or all of a sudden I just wake up. It’s a state of nothing. One second you’re there and the next your waking up. Then you feel terrible, throwing up with the worst headache you could ever imagine from not breathing. Of the numerous times I’ve overdosed the most memorable one was when my friends found me half dead in my car. I have no idea how I woke up. They hit me with four doses of Narcan in the hospital that night. I was in and out, I barely remember any of it. But the day after all of that I was back out there using again.” The Opioid Crisis Exposed 25

Narcan: Saving lives and buying time for addicts

March 14, 2018 Written by Kevin Kelley & Maureen Bole

wenty-nine-year-old Garrett. of North Olmsted started using heroin when he was 17. It wasn’t just a slippery slope. It was like stepping off a cliff with jagged rocks at the bottom. Here’s how he described it: “I had an altercation with a drug dealer when 18 and I wound up getting shot. So I stopped using heroin for a year, then I got back into pills and eventually back into heroin. From when I was 21 to 25 my heroin use was manageable, like I still went to work and was able to get jobs. I really don’t know what the tipping point was, but it slowly turned and I started using during the day. I started using real bad again and I kept seeing everyone else around me overdosing and falling out, but it wasn’t happening to me so I didn’t even think I had a problem with drugs. We didn’t have access to Narcan back then, so if someone overdosed we’d just drop them off at Metro and leave.” Narcan. The drug that has saved countless lives and caused a tsunami of controversy. Just ask Dr. Judith Welsh, medical director of the Cleveland Clinic Lakewood Emergency Department. She has administered naloxone, sold under the brand name Narcan, countless times in recent years. But she still remembers the first time she saw it administered as a resident in the early 2000s. “To me, it looked like the hand of God,” she said, recalling how the drug quickly revitalized a patient nearly dead from the effects of an opioid overdose. “It’s extremely dramatic,” Welsh said. “When you see someone who comes in blue, ashen, they look dead frequently. And they’re very close to dead in many cases. Then they’re given Narcan and within 60 seconds, they go from looking dead to completely fine and walking around in some cases. It’s the most dramatic thing we do in the emergency department, I think.” The wider availability of Narcan has been credited with saving numerous lives in recent years as the nation has faced a growing opioid epidemic. Cuyahoga County Medical Examiner Thomas Gilson called the county’s decision to make the drug available to police and paramedics “the best investment the county ever made.” Patented in 1961, naloxone is an opioid antagonist, meaning it attaches to opioid receptors in the brain, preventing drugs like heroin from shutting down the body’s

26 The Opioid Crisis Exposed

respiratory and nervous systems. Within minutes, the drug can restore normal respiration to someone whose breathing has slowed or stopped as a result of an overdose. The Food and Drug Administration has approved three forms of the drug: an injectable form, for which professional training is required; an easy to use, auto-injecting version sold as Evzio; and a nasal spray. In the Lakewood ER, Welsh uses the injectable form. When Welsh first administered the drug, it had to be given intravenously. In addition to restoring normal breathing function, Narcan stops the pain relief benefits of the opioid and can cause withdrawal symptoms in chronically addicted persons, Welsh said. “I had my first stint in rehab in fall of 2013,” Garrett shared. “When I got out, I heard of a lot of people I knew were overdosing and dying, but I still didn’t think it was an issue because it never happened to me. Honestly, I just didn’t care if it did anyways. It didn’t really matter. “I didn’t start falling out and having to have people revive me until a couple years ago, when the dope started to get different. That’s when I would do it and wake up four or five hours later. “I went to treatment three times in a row and none of it worked and that’s when it really hit the fan. “When I was getting high with my girlfriend, when I lived in Wooster, was the first time I really fell out bad. We drove to go get the dope and I knew it was fentanyl and I did too much and didn’t realize it. She went to take a shower and came back downstairs and she said I was completely blue with my eyes wide open slumped over. She called 911 and I woke up in the hospital sick and all messed up. They gave me Narcan obviously.” Medical professionals stress the importance of administering Narcan quickly after the effects of an overdose begin. The nasal spray may not be effective for four to five minutes, but the intravenous version can take effect as soon as 60 seconds, Welsh said. Even though the nasal spray takes longer to work, Welsh sees overdose patients arrive in better condition because they have been given a dose by a police officer.

Naloxone fast facts Naloxone: A synthetic drug, similar to morphine, that blocks opiate receptors in the nervous system. This antagonist is used to temporarily reverse the effects of an opioid overdose in emergency situations. With opioid overdose deaths on the rise, Act 139 was signed into law in 2014. This legislation: ▶ Allowed first responders to administer naloxone to those experiencing opioid overdose ▶ Allowed friend or family members of those who may be at risk for an opioid overdose to obtain a prescription for naloxone ▶ Provided immunity from prosecution for those reporting overdoses through the Good Samaritan provision Naloxone is the generic name for brand names Evzio and Narcan. The FDA approved the first nasal spray version of naloxone in 2015. It was previously an injection. Reversing an opioid overdose is now as simple as spraying the medication into the user’s nostrils. The drug ONLY works for opioid overdoses. It has no effect on overdose from other substances. A drug user cannot get high from naloxone and it is not addictive. Naloxone will not hurt if it is administered to someone who is not in an opioid overdose. It is important that the person experiencing the overdose gets medical attention after naloxone is administered. The substance is only active for 30-90 minutes, therefore it may wear off and the person may go into overdose again. Learn how to respond to an opioid overdose on page 33. The Opioid Crisis Exposed 27

“I’m seeing more people arrive alive,” she said. The nasal form, and even the injectable form that most paramedics have on hand, may not act quickly enough on a patient with circulation problems. “Frequently, if (paramedics) have difficulty getting IV access, they’ll actually drill a spike into an extremity bone and administer the medication directly into the bone marrow,” Welsh said. Patients who have been unresponsive for a significant amount of time before receiving treatment often suffer multiple organ system failures, Welsh said. In such cases, permanent damage may ensue from the overdose that Narcan can’t help. “We’ll get people back, but they won’t be 100 percent now,” Welsh said. Neurological and kidney function may be permanently reduced. Patients may have heart attacks or pulmonary edema, meaning the lungs fill with fluid. “Although Narcan is an incredible drug and does amazing things, if you’re mostly dead, it can’t bring you back all the way,”

Naloxone nasal spray under the brand name Narcan

28 The Opioid Crisis Exposed

Garrett F of North Olmsted

Welsh said. “I think I’ve OD’d 8 or 9 times,” said Garrett. “About half of them I got Narcan. I just go black or all of a sudden I just wake up. It’s a state of nothing. One second you’re there and the next your waking up. Then you feel terrible, throwing up with the worst headache you could ever imagine from not breathing.” Is Narcan giving addicted persons a false sense of security? Welsh says no. The high caused by drugs like heroin – the addiction itself – is the overwhelming motivation of people who use such drugs, she said, with Narcan playing little role in their decision making. Plus, she said, even those whose lives are saved with Narcan risk permanent health problems from overdoses. Those who use dirty needles to inject themselves with heroin or fentanyl often experience skin infections or viral hepatitis, Welsh noted. When Welsh began working as a resident 18 years ago, the standard dose

Hospitalizations are recommended for those who have been revived with Narcan. After a period of time, the drug can wear off and the person can fall back into an overdose.

of Narcan was 0.4 milligrams. Because more powerful opioids, such as fentanyl, are available, 4 milligrams are the initial dose she gives today. She’s seen one case that required 32 milligrams. Some patients will need Narcan administered continually in the form of an IV drip after the initial resuscitation, she added. “Massive doses of Narcan are required to resolve some of these fentanyl overdoses,” Welsh said. Every overdose is different, depending on what drug and how much was taken and how long the patient was down. People who abuse an opioid drug put themselves at risk, Welsh said. I overdosed numerous other times, but the most memorable one was when my friends found me half dead in my car. I have no idea how I woke up. They hit me with four doses of Narcan in the hospital that night. I was in and out, I barely remember any of it. But the day after all of that I was back out there using again. Welsh said she understands why some people might think Narcan has an enabling effect on addicted persons. But medical professionals have a moral responsibility to treat overdoses and give patients the chance to change their lives, she said. Many overdose survivors have taken steps to recovery thanks to Project SOAR (Supporting Opioid Addiction Recovery), of which Cleveland Clinic Lakewood Emergency Department is a partner. The city of Lakewood, the Woodrow Project and the Alcohol, Drug Addiction & Mental Health Services (ADAMHS) Board of Cuyahoga County are also partners in the rapid overdose response program, which launched last fall. Peer support specialists offer patients the chance to enter a treatment program. If a patient declines, a follow-up call is made within the week. After about a year overdosing, being revived and going right back to using again, Garrett was finally facing a lot of consequences. He has had several failed recovery attempts, but concluded it was time to do something different this time. He checked into rehab last October, completed that program and now lives in a men’s sober house. He will celebrate five months clean on March 24. “The only way we can get them clean is to keep them alive,” Welsh said. “You can’t treat anybody that you let die.” ♦ The Opioid Crisis Exposed 29

Where to obtain naloxone Graphic by Maureen Bole

4 Sheffield Lake

611

5 13

Avon Lake

Bay Village

6 7

57 90

1 2

1 PHARMACY SITES Provide Narcan ELYRIA 1. CVS Pharmacy-Target 240 Market Drive 2. Walgreens Pharmacy 100 Cleveland Street 3. CVS Pharmacy 443 Cleveland Street AVON LAKE 4. Walgreens Pharmacy 32798 Walker Road 5. CVS Pharmacy 375 Lear Street AVON 6. CVS Pharmacy 36008 Detroit Road 7. CVS Pharmacy-Target 35830 Detroit Road NORTH RIDGEVILLE 8. CVS Pharmacy 35000 Center Ridge Road 9. Walgreens Pharmacy 33760 Center Ridge Road 30 The Opioid Crisis Exposed

15 8

301

Rocky River 19 Lakewood

Westlake 252

Avon 254 Sheffield Village

North Ridgeville

10 480 80

OLMSTED FALLS 10. CVS Pharmacy 27120 Bagley Road WESTLAKE 11. CVS Pharmacy 30791 Detroit Road 12. Walgreens Pharmacy 25524 Center Ridge Road BAY VILLAGE 13. Walgreens Pharmacy 27251 Wolf Road 14. CVS Pharmacy 625 Dover Center Road NORTH OLMSTED 15. CVS Pharmacy 27713 Lorain Road 16. CVS Pharmacy-Target 24646 Brookpark Road 17. Walgreens Pharmacy 24590 Lorain Road 18. CVS Pharmacy 23351 Lorain Road

20. CVS Pharmacy 19950 Detroit Road CLEVELAND 21. Walgreens Pharmacy 16803 Lorain Road 22. CVS Pharmacy 14025 Puritas Road 23. Walgreens Pharmacy 4281 West 130th Street 24. CVS Pharmacy 13027 Lorain Road 25. CVS Pharmacy-Target 3100 W 117th Street 26. CVS Pharmacy 3171 West Boulevard LAKEWOOD

26 10 71

480

North Olmsted

Olmsted Falls

Fairview Park

252

29 30

27 28

There are two different types of locations where someone can obtain Narcan: LOCAL PHARMACIES: dispense naloxone (just the medication, not a kit) without a prescription. PROJECT DAWN SITES: provide training and naloxone kits at no cost. PROJECT DAWN SITES Provide Narcan kits 1. Lorain Health District 9880 S. Murray Ridge Rd., Elyria 2. Elyria City Health District 202 Chestnut St., Elyria 3. Cuyahoga County Board of Health 5550 Venture Dr., Parma

ROCKY RIVER

27. CVS Pharmacy 15501 Detroit Road 28. Walgreens Pharmacy 14815 Madison Avenue 29. CVS Pharmacy 11706 Clifton Boulevard 30. Walgreens Pharmacy 11701 Detroit Road

19. Walgreens Pharmacy 21010 Center Ridge Road

SOURCE: Ohio Department of Health: odh.gov

4. McCafferty Health Center 4242 Lorain Ave., Cleveland 5. Cleveland EMS 1701 Lakeside Ave. Cleveland 6. FKA The Free Clinic* 12201 Euclid Ave. Cleveland

*-not shown on map

The Project DAWN Narcan kit includes two doses of the nasal spray, a face shield and overdose and CPR instructions.

Project DAWN works to curb overdose deaths with Narcan kits

March 14, 2018 Written by Maureen Bole

he zippered blue bag labeled “Project DAWN,” about the size of a handbag, looks like a regular First Aid kit. Its contents, however, are far more intense than just a few bandages and aspirin. The bag contains a simple-to-administer medication that has the ability to drag an addict back from the brink of death. The Ohio Department of Health followed through on its promise to take action against the opioid epidemic by funding Ohio’s first Overdose Reversal Project. The result is Project DAWN, which stands for Deaths Avoided With Narcan, is a community based Overdose Education and Naloxone Distribution Program, which began in Scioto County in southern Ohio in 2012. Since its inception, dozens of Project DAWN sites have sprung up across Ohio. The The Opioid Crisis Exposed 31

Project DAWN: Saving hundreds of lives... The chart shows the number of overdose deaths over the past five years (note: 2017 numbers are projected). Although these numbers are chilling, they could have been a lot higher without lives saved by Project DAWN.

1200

The death toll in 2017 could have been more than double without Project DAWN.

900 600 300 0

2013

2014

Heroin related overdose deaths

2015 Fentanyl related overdose deaths

2016

2017 Deaths that could have occurred without DAWN

organization arrived in Cuyahoga County in 2013, initially collaborating with MetroHealth Hospitals. It has since expanded to four sites in Cuyahoga County, thanks to agreements with the Alcohol, Drug Addiction and Mental Health Services Board, Cleveland Department of Public Health and Cleveland EMS Headquarters In Lorain County, there are two Project DAWN kit sites, including the Lorain County Public Health Center in Elyria. (Narcan also can be obtained at dozens of pharmacies without a prescription throughout the two counties. Check with your local pharmacy to see if there is a charge.) All Project DAWN kits are free. They contain two, 4-mg nasal sprays of Narcan, a certification card, a quick reference guide flip book and a face shield for CPR rescue breathing. “We provide access to naloxone and we also train those community members on how to properly respond to an opiate overdose.” Emily Metz, explained in a Cover2 Resources (an organization that assists addicts and loved ones find help) podcast. “We provide this medicine in kits for free to our program participants to hopefully curb opioid mortality in our communities.” Metz is the Project DAWN Program Coordinator at MetroHealth Medical Center. She notes that Project DAWN is a harm-reduction program, aiming to negate the most harmful consequence of opioid use - overdose fatalities - by ensuring life-saving Narcan is free and easily accessible. The only requirement to those seeking a kit is that they fill out some confidential forms and undergo a short training session with instructions on how to safely administer and store the medication.

“When we first started out it was the 2 milligrams, where you had to assemble the nasal spray before administering,” said Nicole Carlton, city of Cleveland Commissioner of EMS, whose headquarters is a Project DAWN site. “But because of the fentanyl and carfentanil we increased it to the 4 milligrams. Those are more concentrated and work a bit better.” 32 The Opioid Crisis Exposed

“We roll kits out with the ambulances as well,” Carlton said. “So if we have the time to get it together, we send kits for the family at the scene and the addict themselves.” Metro also has a similar method, sending all of their patients who have suffered and survived an overdose home with a Project DAWN kit. “If you’re coming in for an opioid overdose, you’re more than likely to experience another overdose in the future so we want you to go home with a Project DAWN kit,” Metz said. Statistics show that lives are being saved by providing access to the kits. The chart (left) shows that without Project DAWN and its Narcan distribution, overdose deaths could be double what they were last year. “We’ve asked ourselves do people abuse this medicine?” Metz said. “Do they use more drugs just to be brought back? We did research on this and found that was actually not the case. In fact, individuals who are connected to Project DAWN type programs often reduce their drug use and risky behaviors.” One study showed that a little more than 25 percent of intravenous drug users sought counseling or treatment 30 days after their most recent overdose. “It gives them (addicts) another day, it gives them another chance.” Carlton said. “We have to look at it that way because addiction is not a ‘one time I go into recovery and I’m fixed.’ We’re allowing them to live another day so they can make it to recovery. It’s not an easy road.” ♦

Five steps to respond to an opioid overdose 1. Check to see if they’re responsive. If you suspect someone is overdosing, try to wake him/her. Give him/her a light shake, yell their name if you know it. If they don’t respond, try rubbing your knuckles on his/her chest bone for up to 10 seconds. Michael Catacutan, a trainer at the Cleveland EMS Headquarters, created the acronym PUPS to recognize if someone is overdosing: Pinpoint pupils, Unresponsive, Pale or blue skin color and Snoring or choking noises.

2. Call 911 immediately.

Give the dispatcher your location and let them know you are with someone who is unresponsive and is possibly overdosing.

3. Perform rescue breathing

First check to make sure the victim’s airways are clear and there is nothing in the mouth. Unwrap the face shield in the Project Dawn Kit and place it over the mouth. Tilt the head back, lift chin, pin the nose and begin giving rescue breaths. If you are alone, give two breaths making sure the chest rises. If you have help, give one breath every five seconds.

4. Administer Naloxone

Gently insert the tip of the nasal spray nozzle into either nostril. Press the plunger firmly to administer the dose of Narcan. Continue rescue breathing while waiting two minutes for the medicine to take effect. If there is no response after those two minutes, you may administer another dose of Narcan.

5. Place them in recovery position If the victim begins breathing again on their own, place him/her in the recovery position (on their stomach with a clear airway). Continue to monitor respirations until the ambulance arrives. The Opioid Crisis Exposed 33

Local first responders share their experiences March 14, 2018 Compiled by Jeff Galatin

Bay Village Fire Captain Jim Walts notes that first responders are aware that addicts’ actions affect more than just the addict. One man’s mother told Walts all she had done to try help him. “We gave the Narcan to the man, who was in his 30s and he recovered. He’s had the problem for years. But it was taking a big toll on more than just him. I talked to his mother about him and what she had done for years to try and help him deal with the addiction. She said she had spent thousands of dollars putting him into different rehabilitation programs to try and get him clean. And she talked about all the hours and time she spent trying to provide support and assistance to him. That took away from other parts of her life because she was investing all this time and money in trying to help her son. I really felt for her because she was putting her life’s savings and most of her own life into trying to help him out.”

Rocky River Police Lt. George Lichman said the opioid crisis seems to ebb and flow in his community. “We had incidents when I was young officer and we were aware that there were people who were using heroin or something like it and that they would need something to revive them. It seemed 34 The Opioid Crisis Exposed

to slow down and was not be much of a problem around 2003 or 2004. But a few years ago it really started making a comeback again and now we’re all ready to use that training we’ve had in how to administer it. It’s gone up so much that in November, we changed as a department the amount the officer has with him from 2-4 milligrams. We found that in some cases, a single dose of 2 milligrams wasn’t enough and you have to give them more. “I’ve had to administer it myself once and have had three other times when I’ve been of the officers and paramedics there when we have to give it to someone. I know when they come out of it, they’re usually confused and sometimes agitated or combative. They usually don’t like seeing police or firefighters around them and they just want us to go away.”

North Olmsted The times have certainly changed since Chief Bob Wagner’s first days as a police officer. “When I was a K-9 officer back in 2001, I remember training for possibly having to use Narcan on my dog in case he was exposed to heroin or some opioid when we were checking for drugs. We had Narcan, but it was there to be used in case the dog needed it. If a person would have needed it, it would have been the paramedics who

would have administered it to him. “Now, every officer in the department is trained in how to administer Narcan to a person who needs it. All officers have it with them when they go out. If there’s a call and the paramedics and firefighters are there first, they still will be the ones to administer it. But there have been times we get there first and we give it to the person. Sometimes, that’s not enough and we have to give them another dose, or the firefighters have to give them another dose or two. Some of the people have taken enough of the opioid and even after you bring them out of it, they’ll have enough in their system where they can go right back into it and they have to be revived again.

Sheffield Lake Lt. Wes Mariner was a Marine Corps medic

before joining the Sheffield Lake Department. He believes the problem is ubiquitous. “We certainly get cases and incidents here, just like everywhere else. We’re near Lorain and Cleveland, so you’ve got people from there. But, there are people in town here too. There are hard-working people who get hurt on the job and they take medication to help deal with the injury. Then, some of them get hooked and addicted unfortunately. “We can stay busy with those type of calls. I remember one day last year, where we went to the scene and the person was DOA (dead on arrival) and there wasn’t anything we could do by the time we got there to revive him. Then, the same day we did have two opioid cases where we got there and we were able to use the Narcan and give them some type of assistance. It’s a big part of the job as a paramedic now.” ♦ The Opioid Crisis Exposed 35

OPINION: THE VIEW OF A RECOVERING ADDICT

Is naloxone helping or hurting the epidemic?

March 14, 2018 Written by Maureen Bole

round this time last year, I had a group of super-close friends. We hung out every weekend, went to recovery support meetings together, even shared our locations with each other at all times on our iPhones. Everything was great ... until one of my friends started using again. We were all concerned about him overdosing, getting hurt or hurting someone else. He had used recently in the months prior and had fallen out (overdosed) a couple times already. There was one night in particular though, that one of my other friends and I were extremely troubled with his behavior. We watched on our phones as his location went from the West Side, to East Cleveland, then back to the suburbs, then shut off just to come back on and do it all over again two more times. We were terrified he was going to kill himself - or someone else by driving. We tracked his location to a street in Brooklyn, found his car and planned to wait behind it until he came out of whatever house he was in to drive him home. We waited more than an hour. He wasn’t answering our calls or texts, which was freaking us out because no matter how high he got, he always answered eventually. My friend decided to walk down the street to see if we could hear anything. As she walked past his car, she jerked back around and yelled to me, “He’s in the car.” I immediately jumped out of my car and ran to his. He was slumped over in the driver’s seat. We couldn’t tell if he was breathing. The car doors were locked. We banged on the window frantically, trying to wake him up. Nothing. Panic mode set in as I called 911 to request an ambulance. Just as I finally got a hold of a dispatcher, my friend swiftly hit the window one last time and he woke up. “Thank God. Thank God. Thank God.” We got him out of the car and he struggled to stand. He couldn’t hear us. We just all hugged each other so relieved he was alive and OK. Or so we thought. When I started to drive him home, I knew something wasn’t right. He was throwing up, he couldn’t hold his head up and kept telling me he couldn’t hear right. We decided to take him to the ER. We stayed in the hospital until 6 in the morning. He was given four doses of Narcan to prevent him from continuing to overdose. His oxygen levels took hours to return to normal. He was a mess, but he was alive. The entire night was traumatic for us all. But 36 The Opioid Crisis Exposed

the disease of addiction is insidious, and he was using again in less than 48 hours. That’s the beauty and the curse of Naloxone/Narcan right there. We have this life-saving medication so readily available to us, but many people question: What’s the point if they’re just going to go out and do it again? Why should we treat “repeat offenders” who overdose and have EMS called multiple times a week or even multiple times a day? Is death even a consequence for addict anymore? I can forgive people who don’t know much about the disease of addiction or this epidemic. But for those who do and who ask those questions, why do you think you get to play God? Why should we pick and choose who gets to live and who gets to die? Why would you deny a lifesaving intervention to someone? I recently heard someone compare Narcan to crutches. That we use crutches until we are healed and it’s no different with Narcan. Narcan is available to give addicts another day, another chance. Some may argue, “Well people who shoot heroin choose to do that. People who break an ankle don’t choose that.” Yes and no. The thing about addiction is that after a certain point, using is no longer a choice. It feels like a basic human need, the way that food and water are to normal people. Narcan was invented to help addicts stay alive until they can seek proper help. Recent studies have shown that Narcan programs are driving more addicts to seek treatment rather than enabling them to keep flirting with death. Which is why, for better or worse, Narcan

is a godsend. Everyone should be educated on Narcan and how to react in a situation where someone is overdosing. Everyone should carry it. It can do no harm, only good. It could change your life but most importantly, it can save someone else’s. ♦ The Opioid Crisis Exposed 37

part

In the third part of the series, we examine how the legal system is responding to the influx of drug-related cases. ♦ Drug court programs offer treatment in lieu of prison ♦ Our counties drug court programs and judges ♦ Recovery court program helps dual diagnosis clients

legal system

♦ Looking at drug-related crime in our counties ♦ Project 180 teaches addicts how to have sober fun ♦ Opinion: What drug courts really mean for communities

“Treatment courts are a proven budget solution that stops the revolving door of arrest and incarceration for people with substance use and mental health disorders. They prove that justice is sometimes best served by connecting people to treatment and resources to help them turn their lives around.” 38 The Opioid Crisis Exposed

Drug court programs offer treatment in lieu of prison

April 18, 2018 Written by Kevin Kelley

uyahoga County Common Pleas Judge David Matia is as much of a psychologist, social worker and life coach as he is a judge. It’s the last Thursday of March in Courtroom 17-D in the Justice Center, a day he sets aside for drug defendants. The specialized docket is designed to reduce recidivism by addressing their drug dependency. Those facing felony drug charges are offered an alternative to prison. But they must enter a guilty plea and enter a drug addiction treatment program, attend support group meetings and submit to random drug tests. And they must appear in Matia’s courtroom once a month so he can check on their progress. Those in compliance with the court-ordered requirements are allowed to sit in the jury box, which Matia calls the “honor box.” It’s a reward for taking the first steps toward turning their lives around. Drug Court works best when the emphasis is on rewards instead of sanctions, the judge later explained. The atmosphere is unusually informal for a courtroom. “What’s going on?” Matia asks Rachel, a 34-year-old single mother from Cleveland. Rachel, who spoke from the attorney’s podium, reports that her grandfather recently got her a dog even though she is afraid of dogs. Like the other honor box defendants, Rachel reports how long she’s been sober: three months and 26 days. The other defendants, along with the four case workers, applaud. “Have you noticed anything different?” Matia asks. Rachel says that when she gets tempted to use drugs, she thinks of all the pain drugs have caused her and no longer gets anxious. She hopes to get custody of her daughter again, she adds. “You seem very positive today,” Matia says. “We’re noticing the movement in your mood.” More than 3,000 such addiction treatment courts, including DUI courts, oversee 150,000 people each year in the U.S, according to the National Association of Drug Court Professionals. The organization estimates Drug Courts save up to $27 for every dollar invested and up to $13,000 for every individual who enters a Drug Court program. Seventy-five percent of Drug Court graduates remain arrest-free, compared to 30 percent of those released from prisons, it said. The Opioid Crisis Exposed 39

When a drug-related crime is committed there are several different options for offenders. Here are a few of ways the Cuyahoga County court system works.

Jail or prison Incarceration

Recovery resources are often scarce for incarcerated drug offenders.

Diversion

Re-entry Court

Multiple judges Intervention in Lieu of Conviction This program is typically for first-time offenders. If drugs or alcohol were a driving factor in the offenders committing the crime, they can request IOC. If they successfully complete the treatment program, their case will be dismissed.

Judge David Matia

Judge Joan Synenberg

Non-violent offenders who do not have any trafficking or sexual charge on their docket are eligible to participate in the program. Drug court requirements often include treatment, participation in a 12-step program and urine screens.

This program focuses specifically on offenders who have a dual diagnosis of addiction and other trauma related mentalhealth issues. Requirements mirror those in Drug Court, with the addition of specialized counseling.

Drug Court

Recovery Court

This program was established to “help address the needs of offenders transitioning from prison back to the community.” Re-entry court is based on the Drug Court model and focuses on the specific needs of the offender such as education, employment, housing and treatment.

“Treatment courts are a proven budget solution that stops the revolving door of arrest and incarceration for people with substance use and mental health disorders,” said Carson Fox, the organization’s CEO. “They prove that justice is sometimes best served by connecting people to treatment and resources to help them turn their lives around.” Since Cuyahoga County’s Drug Court began in 2009, 363 people successfully completed the program. Twenty-five graduated in 2017. A 2014 study by Case Western Reserve University’s Mandel School of Applied Social Sciences of 2009-2013 Cuyahoga County Drug Court participants found that 56 percent successfully completed the program. Within 12 months, 8.4 percent of the Drug Court participants, whether they completed the program or not, had been arrested again, compared to 27 percent in a comparison group with similar criminal charges and 40 The Opioid Crisis Exposed

diagnosed drug dependency. And 4.4 Project 180, a group launched by Drug percent of the Drug Court re-arrests were Court graduates to support those in for felonies, compared to 14 percent for addiction recovery. the comparison group. Christopher, who has a stuttering speech Bill Kelly, the Drug Court’s public disorder, said he played a game on his defender, said the approach works smart phone during most of the breakfast because of the dedication of the judge because he was too shy to talk. Under and the case workers. questioning by Matia, Christopher admits “Drug Court is actually a therapeutic he usually used drugs when he was alone. community that’s in the middle of the “We want you to link up with other justice system, and every professional people because being an island is likely around the what led you to treatment table is Drug Court,” the “Drug Court is actually a dedicated to kicking judge said. therapeutic community that’s in the [defendant’s] The mood in the middle of the justice system, addiction to the the courtroom and every professional around curb,” Kelly said. changes quickly the treatment table is dedicated “So we work with when a 23-yearto kicking the [defendant’s] the client to try old Cleveland addiction to the curb. So we work to overcome man named with the client to try to overcome the addiction by Ryan appears the addiction by inspiring them. inspiring them. And before Matia for a because we have violation hearing. And because we have a family a family approach, The week before approach, every client that comes every client that he had gone in becomes a family member and comes in becomes to a hospital’s it works.” a family member emergency room Bill Kelly, the Drug Court’s public defender and it works.” for treatment of Success comes severe abdominal to Drug Court pain and been defendants after a treatment program given morphine and fentanyl without help them get sober. The brain begins to telling the doctor he was in recovery. heal from the drug abuse and they see Ryan - who had been addicted to how life can get better, Matia said in an cocaine, not opioids - had called his case interview outside of court that day. “Their worker before going to the hospital. But whole perspective on life changes,” he Ryan had several previous violations, and said. “They have hope.” Matia isn’t buying his story. In court, Matia asks Christopher, a “You are about the exact opposite of 27-year-old man living in transitional proactive,” Matia tells Ryan. The judge housing in Cleveland, how he enjoyed a imposes a sanction of 14 hours of recent pancake breakfast organized by community service. The Opioid Crisis Exposed 41

The first Drug Court was started in 1989 in Miami-Dade County, Florida. Matia, who has been on the Common Pleas bench since 1999, launched Cuyahoga County’s in 2009. A second Drug Court docket, also under Matia, was created a year ago to focus on defendants who need medicationassisted treatment, such as methadone and buprenorphine, also known as Suboxone. A similar court, called Recovery Court, was established in 2016 under Cuyahoga County Common Pleas Court Judge Joan Synenberg for defendants with a dual diagnosis of addiction and trauma. To be eligible for Drug Court, a defendant must be assessed by a chemical dependency counselor and determined to be drug dependent. Matia said the Drug Court is geared toward those who are likely to repeatedly commit crimes without treatment. Some in the Drug Court already have criminal records. Others are on the IOC track “Intervention in Lieu of Conviction,” meaning the case will be dismissed if the defendant successfully graduates from Drug Court. “So they have the additional incentive of having a clean record,” Matia said. An important requirement of Drug Court is attendance at addiction recovery support group meetings three times a week, along with obtaining a sponsor. “Don’t be too choosy,” Matia tells one defendant who has yet to find a sponsor. “You’re not looking for a best friend. You’re looking for someone who will help you through the [12-step program] and, most importantly, answer the phone when you call.” Before checking with existing defendants, Matia in the morning checked on the status of about a dozen Drug Court defendants and admitted four new ones. Matia accepts guilty pleas from two Willoughby women, dressed in blue prison jumpsuits, in return for admission to the Drug Court program. Bryanna, 24, entered a residential recovery program. Janine, 34, was to enter an intensive outpatient program. She was released from the county jail the next day, a court official said, and overdosed that weekend. She was taken back into custody and is awaiting placement at a residential treatment facility. Like many who go through Drug Court, Bryanna will be given Vivitrol, a drug injected monthly to block opioids from acting on the brain, thus eliminating the euphoria of getting high. Vivitrol can help those entering treatment focus better on recovery, Matia believes. Matia reviews with them the other conditions of the Drug Court program: the support group meeting requirement, random drug tests once or twice a week and two-and-ahalf years of probation, which can be shortened. The judge warns the two women to inform the court if they have a relapse instead of having him find out through urine tests. The goal of Drug Court, he said, is not to throw them in jail but to get them healthy. In all, Matia’s day was spent dealing on a root level. Ohio leads the nation in opioid deaths. The Ohio Department of Health reported a record 4,050 drug overdoses in 2016. Officials hope Drug Court, Recovery Court and Project 180 all will help change that trend - and save lives. ♦ 42 The Opioid Crisis Exposed

Judge says government, medical community must do more April 18, 2018 Written by Kevin Kelley

he federal government and the medical profession need to do more to address the opioid epidemic, says the judge who leads the Cuyahoga County drug court. “All the progress in treating this disease is being done from the bottom up,” Cuyahoga County Common Pleas Judge David Matia said. Matia acknowledges the addiction problem is complex. But he thinks a few simple steps can be taken that would make a big difference. Cuyahoga County Common Hospital systems have not spent enough money Pleas Judge David Matia to establish detox units, Matia said. The medical profession needs to provide more chemical dependency counselors and psychiatrists who specialize in treating addiction, he added. Medication-assisted treatment, the combination of behavioral therapy and medications, is the gold standard for opioid addiction, Matia said. One of the most successful medications in fighting an opioid addiction is buprenorphine. Sold under the brand name Suboxone, the drug works by binding to opioid receptors in the brain without fully activating them, allowing cravings to be satisfied without creating the euphoria that drives addiction. But physicians without credentials in addiction medicine who wish to prescribe buprenorphine must obtain a waiver from the federal government and complete eight hours of training. Then they are limited to treating no more than 100 patients. A 2015 study in the Annals of Family Medicine found that only 2.2 percent of physicians nationwide had obtained waivers to prescribe buprenorphine, and 42 percent of those were psychiatrists. Matia calls the regulations on prescribing buprenorphine “ridiculous.” After nine years of adjudicating the county’s drug court, Matia has concluded that social isolation and mental health problems often drive addiction. “Using drugs is a disease of escape,” he said. Sometimes recreational drug use gets out of hand, Matia said. But the most dangerous “gateway drugs” are a lack of education, isolation and a lack of family support, he said. ♦ The Opioid Crisis Exposed 43

Chronic pain behind many trips to Lorain County Drug Court April 18, 2018 Written by Kevin Kelley

ddiction to pain medication and pain itself are still among the biggest factors driving the region’s heroin epidemic, Lorain County Common Pleas Judge John R. Miraldi said. Miraldi oversees Lorain County’s felony Drug Court, or Recovery Court, as he calls it. At least half of the defendants in his courtroom in Elyria have some pain-related problem, Miraldi said. Defendants tell him their prescription for Vicodin or some other pain medication ran out and Lorain County Common they purchased heroin to deal with ongoing pain. Pleas Judge John Miraldi “One of the biggest problems in recovery is these people are still in pain,” Miraldi said. The defendants are split nearly evenly between men and women, Miraldi said, in sharp contrast to the criminal justice system in general. (According to the U.S. Department of Justice, 15 percent of city and county jail inmates in 2016 were women.) “I have some middle-age women coming up in canes and they’re heroin addicts,” the judge said. Success in Miraldi’s recovery court is defined when the individual is sober for 13 months, employed, re-engaged with his or her family and committed to a support group or program. Since the specialized docket was launched in the fall of 2015, about 100 people have successfully completed its requirements. A big issue, Miraldi said, is how to treat chronic pain without opioids. Some doctors looking for an alternative to opioids have been prescribing gabapentin, an anticonvulsant medication used to treat nerve pain in adults. The medication, sold under the brand name Neurontin, was thought to have a low abuse risk. Gabapentin is not designated as a controlled substance or scheduled drug by the federal government. But in February 2017, the Ohio Department of Mental Health and Addiction Services issued an advisory that abuse of the drug was on the rise. People addicted to opioids take gabapentin to get through periods of withdrawal, the state agency warned, and 44 The Opioid Crisis Exposed

those receiving medication-assisted therapy for addiction with drugs like Vivitrol take gabapentin for the slight high it produces. Miraldi sees gabapentin abuse as a growing problem and has added it to the list of drugs to be screened for defendants in his Recovery Court. Many addicted persons suffer from the effects of physical or sexual trauma, Miraldi said, and are abusing drugs to dull the pain. But the judge said society cannot arrest or jail its way out of the problem. Like judges running other drug courts, Miraldi uses behavior therapy, which seeks

to reinforce desirable behaviors and eliminate maladaptive ones. For Miraldi, the approach is incentives and sanctions. When a defendant reaches another milepost in sobriety, he or she receives applause from those in the courtroom and praise from the judge. Violations are dealt with immediately, possibly with a day or two in jail. The immediacy is important, Miraldi said. “Psychologists say that alters behavior,” he said. And it’s also unusual for the criminal justice system, where a hearing on a parole violation may happen two or three months after the violation. ♦ The Opioid Crisis Exposed 45

Court program helps with dual diagnosis, mental health issues

“I

April 18, 2018 Written by Maureen Bole

never ever in a million years thought that I would be able to be sober because I had tried it by myself and I couldn’t do it. What I needed was guidance, people who are educated about the disease and people who had patience and cared enough about me to help me keep fighting even on the bad days. “With Recovery Court that’s what I got. I don’t go to bed wondering if I’m going to be dead tomorrow. I’m an actual person, with an actual life now. I no longer just exist.” Tabatha Pawlak, 23, is set to graduate from Cuyahoga County Recovery Court in June as an “actual person” rather than the shell of a woman her drug addiction and mental disorders left her just about a year ago. Now a resident of Cleveland, the Lutheran West High School graduate attributes her success in recovery to the program and the team she works with – her probation officer, case manager, public defenders and Judge Joan Synenberg. “How do I file my taxes? There’s a rat in my house how do I get rid of it? How do I get health insurance? They taught me. They always made me feel like someone cared. They advocate for you. You’re slipping? As long a you show willingness, they get you more help.” Recovery Court is a program created by the Cuyahoga County Common Pleas Court to better assist those who are dealing with dual-diagnoses: addicts and alcoholics who also have underlying mental health issues. This program was launched at the end of 2015 and is the first of its kind in the state. Recovery Court currently has 102 participants formally admitted. Judge Joan Synenberg presides over this division of Drug Court and has seen Recovery Court helping addicts make profound changes in their lives. “Mental illness and addiction often go hand-in-hand,” Judge Synenberg stated in a news release. “Not only is treatment critical for those who suffer from both, but helping them recover is ultimately a public health issue as well.” Conor O’Boyle, 25, has had long life of heavy drug use and unresolved trauma. The Rocky River native tried countless methods to get sober in the past, but nothing worked until he came to Recovery Court. “None of it worked for me until I was put into Recovery Court and then found a fellowship I really enjoyed and started working on myself instead of just trying to get sober by osmosis. “They highly encourage or even order you to go to counseling or other outlets to help you get past your trauma in a healthy way and I can’t say enough times just how important that aspect of it was for me.”

46 The Opioid Crisis Exposed

Recovery Court is an intensive program that is tailored to each participant’s needs. Eligible parties undergo an evaluation of their addiction and a psych assessment to determine what kind of treatment they need. Common requirements assigned to Recovery Court participants are treatment (either inpatient or intensive outpatient), at least 3 meetings a week in a 12-step program, 1-on-1 counseling, urine screenings, monthly (or bimonthly) meetings with the Judge, case worker and probation officer. “The difference with this program is that it kept me accountable when I needed it most in early sobriety,” Conor explained. “Also, it provided me with a support group when I was reluctant to step out of my comfort zone and meet new people.” Officials across the country have slowly been realizing that the end to this epidemic doesn’t lie in putting drug offenders in jail or prison. A lot of recent studies have shown that those methods may actually be making matters worse. Recovery Court is giving those who felt hopeless a new chance at a life without drugs and alcohol. The program’s one-of-a-kind approach is addressing the underlying issues of the epidemic and showing its participants how to live a life free from active addiction. “I’ve been to prison, county more times than I can count, more city jails than I can list. I’ve been on probation since I was 12,” Tabatha said. “I’d do my time and when I got out I had no idea how to live without drugs because no one had ever taught me. So I’d go back to the only thing I knew and was comfortable with, getting high. Recovery Court taught me how to live as a normal person.” Added Connor,“Over the last couple months I’ve had like four different people tell me that they didn’t think I stood a chance or that I was the last person they ever expected to get sober. It’s cool to prove them all wrong.” ♦

Tabatha Pawlak, recovery court participant

What I needed was guidance, people who are educated about the disease and cared enough about me to help me keep fighting even on the bad days.”

Conor O’Boyle, recovery court participant

“None of it worked for me until I was put into recovery court and started working on myself instead of just trying to get sober by osmosis.” The Opioid Crisis Exposed 47

Looking at drug-related crime in our counties and beyond April 18, 2018 Graphics by Maureen Bole In the past several decades, officials believed that the solution to the “War on Drugs” was incarcerating drug offenders. After doing so, prison systems saw a boom in population, but society did not necessarily see a decrease in crime.

STATE & FEDERAL PRISONS Drug offenders comprise the bulk of federal prisoners According to the Federal Bureau of Prisons, almost half of inmates in the federal prison system have committed at least one drug offense. A 2015 study by the Bureau of Justice Statistics found that more than half (54%) of drug offenders in federal custody were serving sentences for cocaine or crack. The other half of those incarcerated were for methamphetamine offenses (24%), marijuana (12%) and heroin (6%). The remaining offenders committed crimes involving LSD, ecstasy and prescriptions.

% 46.2 of inmates

“Non-violent drug convictions are a defining characteristic of the federal prison system.”

Incarcerated persons with substance abuse or dependence

More than a million people are in federal prisons for drug possession charges, while less than half a million are put away for sale and manufacturing.

committed a drug offense

100 80 Percent of inmates

Drug-related arrests (in millions)

2.0 1.5 1.0 0.5

60 40 20

0.0 1980

1985

KEY: 48 The Opioid Crisis Exposed

1990

1995

Sale and manufacturing

2000

2005

2010

2015

Drug possession

Jail inmates Dependence

State prisoners Abuse

COUNTY JAILS Who’s in our county jails? To analyze of Cuyahoga and Lorain County jail rosters, offenses* were broken down into nine categories: Top five crimes committed alongside drug offenses

% of drug offenses

Cuyahoga County jails house 2,366 inmates who collectively have 4,050 charges

were committed with another crime 1

Probation/parole violation

Theft

Weapons under disability

Aggravated robbery

Felonious assault

% of drug offenses

were committed with another crime 1

Contempt of court

Driving under suspension

Assault

Theft

Burglary

Lorain County jail houses 415 inmates who collectively have 1,233 charges

What this shows is that drug offenders are highly likely to commit another crime upon their release; especially if the underlying causes of their addiction is not addressed. *NOTE: The crimes listed in each category just a sample, there are many not listed. SOURCES: www.prisonpolicy.org, www.nadcp.org, bop.gov

Drug offenses Possession, Trafficking, Paraphernalia Violent crimes Assault, Murder, Domestic Violence Weapons charges Having Weapons Under Disability Traffic violations Reckless Operation, Driving under suspension Property crimes Vandalism, Theft, Breaking and Entering Compliance violations Parole or Probation Violation, Contempt Sexual offenses Gross Sexual Imposition, Rape, Sexual Assault Disturbing the peace Disorderly Conduct, Menacing, Harassment Financial offenses Passing Bad Checks, Safecracking, Fraud

The Opioid Crisis Exposed 49

Project 180 teaches addicts how to have sober fun

April 18, 2018 Written by Maureen Bole

ddicts and alcoholics seeking recovery seem to all ask the same question - one that may seem irrelevant or even eye-rolling to nonaddicts, but needs to be addressed if recovery is going to be successful: “How am I ever going to have fun again without alcohol and drugs?” One solution is Project 180, an organization that works closely with the Cuyahoga County Drug Court. Project 180 is a support group run by people in recovery for people in recovery. The group was created to collaborate with Drug Court, seeking to help clients and families in the program, but has grown to so much more since its inception in 2015. “We cater to the fun side of recovery, primarily social events,” Project 180 event and social media coordinator Mike Centofanti said. “We do a pancake brunch every month and a half. We have a basketball tournament coming up in May. Some of our bigger events are Light Up the Night and Recovery’s Got Talent.” “Last year’s talent show had a huge turnout,” Project 180 spokesman and event coordinator Brennan Huber continued. “Local food trucks came and supported and we had a lot of community outreach. Everything is put on by people in recovery from the stage crew, to the guys who did the lighting. It’s a total team effort.” Huber, 35, and Centofanti, 25, who both live in West Park, work closely with friends in recovery and the founder of Project 180 to bring these events to life. Both sober themselves, they understand the importance of fun and the hope it gives those who are trying to get clean/sober. Although Project 180 is rooted in Drug Court, the organizations are separate entities. Organizers encourage anyone and everyone to come out and support Project 180 events. Brennan explained that even those who aren’t clean or sober are welcome. They hope to entice them by showing them fun can be had in recovery. All of Project 180’s events are free. “We take a lot of pride in the fact that we’re kind of hands off,” Centofanti said. “We are affiliated with drug and recovery court but no one checks in on these things.” The group is not state funded or funded by the Drug Court system. Project 180 relies on donations to put on these events. “Project 180 revolves around hope,” Huber said. “We show them that there’s hope in recovery. We want everyone to feel a part of; grab on to the ‘we’ of the program. We didn’t get sober to just go to meetings and be in bed by 10, we have fun in recovery. There’s so much more to life than getting high.” ♦ 50 The Opioid Crisis Exposed

OPINION: THE VIEW OF A RECOVERING ADDICT

What drug courts really mean for our communities

April 18, 2018 Written by Maureen Bole

n the past several decades, the number of incarcerated Americans has skyrocketed. As a nation, we make up 5 percent of the global population, yet house 25 percent of the world’s inmates. One study by the National Association of Drug Court Professionals discovered that 1 in every 100 Americans is incarcerated. Why? Is there that much more crime here? Or do we just have stricter laws? It’s a combination of different factors, but one large factor is how we handle drug offenders. It all started back in the ’80s and ’90s with President Ronald Reagan’s “War on Drugs.” Everyone was freaking out about crack-cocaine. President Reagan dealt with the issue in the way he thought was best. Stricter laws were put on the books to lock up drug offenders for possession in small amounts as if they were full-on traffickers. And it worked ... for maybe five seconds. Sure, it got drug offenders off the street, but most of the millions of people being locked up needed help. When they were eventually let out, their unresolved mental and addiction problems were let out too. So what we thought was going to solve the problem actually wound up making everything worse. The released addicts went right back to the only thing they knew, getting high by any means necessary (oftentimes committing more crime to do so). Now, keep in mind, second offenses and beyond came with harsher consequences. Eventually, jails became a revolving door to addicts who weren’t getting the help they needed. Federal and state prisons were overpopulated and boom, our country wound up in a state of mass incarceration. The truth is, imprisonment has little to no positive effect on addicts. The same NADCP study found that approximately 95 percent of prisoners return to drug use after their release and upward of 80 percent commit another crime to do so. Even in our own counties, the top offense that was committed with a drug related crime was a probation or parole violation. In my humble opinion, putting low level and nonviolent drug offenders away did nothing but make the problem worse, cause more crime, failing to look at the underlying issue and ended up costing taxpayers more money. In the past several years, there have been many efforts – better efforts – to fix this problem. “Treatment in Lieu” of conviction and drug court programs began to spring up and things started changing. Crime decreased and addicts were offered the chance to The Opioid Crisis Exposed 51

get the help they needed. I recall reading an article in December about how Ohio’s state prison population had finally dropped below 50,000 for the first time in years. Gary Mohr, the director of the Ohio Department of Rehabilitation and Correction, attributed the population decline to “cumulative efforts in recent years to keep low-level offenders out of prison altogether.” The article continued to say that programs that place nonviolent offenders in treatment accounted for one-third of the prison population decline. I have seen these programs work miracles. I know people in recovery who used for years and never had any willingness to get clean. Or if they did, they didn’t even know where to start. Drug Court placed them in treatment, required them to go to 12-step meetings, held them accountable and gave them purpose. It was great to talk with Tabatha and Conor because they are prime examples of how a little willingness can go a long way in drug and recovery court programs. Those two have been through absolutely traumatic things throughout their active addiction and no one (including themselves) ever had any kind of hope for their futures. But Recovery Court not only gave them that hope, but it gave them back their lives. No wait, it empowered them to take their lives back. And they are now living every moment to its fullest. After interviewing them, I found out that we know a handful of the same people. I used to get high with those people back in the day, but they’re all sober and in the program now. I also discovered that Conor and I partied together before we both got clean but neither of us can remember. Talk about a small world. Nothing brings me more joy than to hear other people have found the same hope I did four years ago. I think it’s amazing that we have the resources today to help addicts get there. So the answer to “What Drug Courts really mean for our communities” is, everything. They are decreasing crime and preventing more from occurring. They are costing taxpayers less money. They are turning addicts into productive members of society. They are giving addicts who are willing to try a new and better way to live. ♦ 52 The Opioid Crisis Exposed

part

In the fourth part of the series, we examine addiction psychiatry ♦ Looking at addiction from a mental health perspective ♦ Understanding addiction in the brain ♦ Debunking the opioid epidemic: 10 myths about addiction

psychiatry

♦ Opinion: Fixing what’s broken: It’s a long road to recovery

“The idea that they [addicts] can make a choice to do something different, not that part of the brain is not powerful enough to override some of these powerful drivers that have been corrupted.”

The Opioid Crisis Exposed 53

Looking at addiction from a mental health perspective

May 23, 2018 Written by Maureen Bole

magine what it would be like to try to make a good choice or decision without having full control of the brain. Knowing what the right thing to do is or what is necessary to get the desired outcome, but not being able to execute it. Imagine what it would be like to make choices, seemingly against one’s will, like the brain has been taken over by some outside force. This isn’t the plotline to the latest sci-fi movie in theatres but instead, outside force. That’s reality for millions of people throughout the county who suffer from mental illness – specifically, the disease of addiction. “It’s a disease because it meets the medical model of a disease,” Dr. Nicole Labor explained during a podcast on Cover2 Resources. “It’s an organ, there is a defect to that organ and then symptoms that come from that defect.” Labor is one of the thousands of medical professionals trying to make a difference in the face of the crippling opioid epidemic. She is an Addiction Medicine Specialist at Summa Healthcare in Akron who has a unique perspective on this field; she is a recovering addict herself. She briefly explained the disease in a podcast interview. “So there is the frontal cortex of the brain and that is our conscious part of the brain where coping skills, stress relief, communication, will power, thoughts, feelings, choice. Then there’s the midbrain, which is a primitive part of the brain that’s entirely subconscious and that part of the brain is responsible for survival. It essentially has three main functions: nourish body, run away from threats and procreate. “What happens in addiction is that the reward system is triggered so much it becomes dysfunctional. High levels of dopamine repeatedly exposed to the midbrain actually causes it to change where the threshold for pleasure becomes much higher. So they need more dopamine to achieve the pleasure they previously had. The midbrain believes the dopamine in that high of a level is what’s necessary for survival. When the midbrain is that active it actually causes the frontal cortex to decrease in function. That is where you value your family, your job, where your morals and ethics are.” Medical professionals across the board are affected by the epidemic, but there are a couple who solely deal with addiction. Christina Delos Reyes, an Associate Professor of Psychiatry & Addiction at University Hospitals Case Western Reserve Medical Center, is helping make a difference in the epidemic by educating primary care physicians about addiction, and by helping addicts first-hand. She explained the chain of command and the difference between the two major medical professions that focus on addiction in her episode of the podcast series.

54 The Opioid Crisis Exposed

“Primary care physicians are at the front lines (of this epidemic) and they have a huge role to play in spotting the early stages of addiction,” Delos Reyes said. “One way we try to help them is by teaching a method we call SBIRT- Screening, Brief Intervention and Referral to Treatment. We are hoping to screen anyone for the disease of addiction like we screen for high cholesterol. We can then make an early intervention before things get so bad they have to come see us. There will never be enough addiction psychiatrists or addiction medicine specialists to treat all that have addiction in the United States. That’s why we need these physicians to do these sorts of screens and early interventions before the illness gets worse.” Delos Reyes continued to explain the difference between the two main types of addiction specialists. Addiction medicine specialists are medical professionals (in any field) who undergo an extra year of training to learn how to properly treat addiction. Addiction psychiatry is a subspeciality that is specifically focused on treating the disease from a mental aspect. She said that both of these focuses are new to the medical community. “Addiction psychiatry didn’t even become a speciality until 1993. It’s a very small percentage of all doctors. If you can imagine there are 500,000 doctors about 4,000 to 5,000 are specifically trained to treat the disease of addiction. Addiction medicine wasn’t officially recognized until the past couple years.” One widely recognized point from medical professionals across the board, regardless of speciality, seems to be that addiction is indeed a chronic brain disease, not a choice. Dr. David Streem, Medical Director of the Alcohol and Drug Recovery Center (Cleveland Clinic, Lutheran Hospital) is one of the many

“It’s a disease because it meets the medical model. It’s an organ, there is a defect to Dr. Nicole Labor that organ and then symptoms that come from that defect.”

“The reality is that the decision/ choice making parts of the brain are some Dr. David Streem of the most demonstrably corrupted by the disease.”

“Addiction and mental illness have never been held to the same standard as other Dr. Christina Delos Reyes illnesses. People are not getting the treatment they need and they’re dying.” The Opioid Crisis Exposed 55

professionals who says addiction must be treated for what it is: a disease, not a choice. “The reality is that the decision/choice making parts of the brain are some of the most demonstrably corrupted by the disease,” Streem said. He explained his point by referencing studies that look at addicted mice. Addicted mice have been known to run to a drug when they see it, even under dire circumstances. Normal mice and addicted mice were both put into a room with the drug present but also smells and sounds of a cat. The normal mouse’s instincts kicked in; it froze then promptly hid. The addicted mouse? It ran across the room to retrieve the drug, regardless of the life-threatening situation. “Now these are animals that don’t make decisions and yet, here is the condition that is overriding the most powerful instinct of self preservation that these animals have,” Streem said. “If addiction is that powerful to make a mouse run into a room with a cat in it, it’s capable of making a human do anything to obtain the drug. “So the idea that they can make a choice to do something different, not that part of the brain is not powerful enough to override some of these powerful drivers that have been corrupted.” The roadblocks for medical professionals and addicts alike don’t stop with the disease itself. Some doctors believe that referring to what’s happening in society with the “opioid epidemic,” may be missing the point. “My biggest concern with the opioid epidemic is the focus on the single drug,” Labor explained. “Ten or 15 years ago there was a cocaine epidemic. There was a big focus on treating cocaine dependence. Then there was a meth problem which we called the methamphetamine epidemic, where we started putting sudafed behind the counter. We focused on those specific drugs. I think the biggest problem is that we as a society are looking at the drug, not the real problem. The real problem is addiction and it’s the same across the board.” “Focusing on opioids we’re taking away from the fact that addiction is a neurological disease, she continued. “I think the focus needs to be on the idea that addiction is a disease and it has little to do with the specific substance; and then focus on treating that.” Streem has a similar viewpoint. He agrees that addiction as a whole should be the focus here, but the opioids are just part of the problem. He believes the sooner all of these problems can be faced, the sooner the general public can get healthy again. “I hope the discussion doesn’t begin and end with opiates,” he said. “I hope it will start here with opiates and end with something else: alcohol, cocaine, tranquillizers and, of course, nicotine. These are all habit forming substances that people have problems with.” There is good news and bad news for addicts. The bad news is that they have a disease that will be with them (in some form or another) for the rest of their lives. The good news is that there is a solution that can be found through abstinence, psychiatry, 12-step fellowships and/or therapy. “If you have the disease, it will always be your default no matter how long you have clean,” Labor explained. “But, if you stay consistent in recovery and stay aware, you have a chance.” ♦ 56 The Opioid Crisis Exposed

A crash course in understanding addiction in the brain

May 23, 2018 Written by Maureen Bole ho remembers the “this is your brain on drugs” commercials from the late ‘80s, where an egg is cracked open onto a hot frying pan? It seemed dramatic, but in reality, it wasn’t too far off. Addiction, particularly to drugs and alcohol, actually compromises the structure and function of the human brain...

Let’s start by defining addiction: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmitters and interactions within the reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors result. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.” — American Society of Addiction Medicine The Opioid Crisis Exposed 57

What structures in the brain are affected by drugs? Although different drugs produce different effects, the same parts of the brain are affected when any drug is taken. Aside from feeling relaxed, energized or free from pain, drugs make users feel an overwhelming ACC PFC euphoria or high. The brain is similar to a complex machine; each part affects the function SCC of the next. Neurotransmitters NAcc are constantly carrying messages OFC between different parts of the Amyg brain. Compromising one area of the brain can complicate or even damage proper function of it’s other parts that control decision making, emotions, judgement, behavior control and memory. When a person takes a drug its effects linger in the brain long after the initial high. These harmful substances actually change the way information travels throughout the brain. Soon, the substance is perceived as something that the user needs instead of something that the user just likes or wants.

Hipp VTA

What do these parts of the brain actually do? Reward System

Inhibitory Control

This group of structures in the brain respond to rewarding experiences by releasing the “feel good” neurotransmitter dopamine. ► NUCLEUS ACCUMBENS: Considered the pleasure center of the brain, the NAcc is stimulated through the release of dopamine during rewarding (or negative) experiences, making memory associations as it goes. ► VENTRAL TEGMENTAL AREA: Also pertaining to reward, the VTA deals with intense emotions and cognition, combining the two to translate motivations.

These areas of the brain play a major role in impulse control and help determine how someone may respond in any given situation. ► PREFRONTAL CORTEX: This region of the brain specializes in decision making, including differentiating between good and bad outcomes, predicting consequences and working toward a goal. ► ANTERIOR CINGULATE CORTEX: Some studies refer to the ACC as the brain’s “gear shift.” It lives between cognitive and emotional centers of the brain; making it an integral part in mediating signals from both.

58 The Opioid Crisis Exposed

How are these four circuits all affected by addiction?

Reward System

Normal brain

Addicted brain

Inhibitory Control

Motivation & Drive

Output

Memory & Learning In a normal brain, positive stimuli (water, food, sex, money, etc.) is determined in the reward system. Leveled communication between these four circuits then determines how a person will make a decision to achieve said stimuli.

Reward System

Motivation & Drive

Output

Memory & Learning In an addicted brain, the reward system is hijacked by drugs. This creates a disconnect in circuit communication, causing the brain to decrease inhibitory control in favor of the instant gratification that drugs provide.

“The stronger the saliency value of the stimulus, which is in part conveyed by the prediction of reward from previously memorized experiences, the greater the drive to procure it.” — The Journal of Clinical Investigation: The Addicted Human Brain: Insights from Imaging Studies

Motivation & Drive

The Limbic System

Areas of the brain where responses are formed by encoding information to determine how behavior should be altered to reach a goal or avoid an unpleasant time. ► ORBITOFRONTAL CORTEX: This area of the brain is frequently associated with decision-making and cognition. Some studies have clear evidence that it is essential for rational thoughts and choices. ► SUBCALOSAL CORTEX: A key area for processing emotional information, the SCC responds to both positive and negative emotional cues to translate them to “appropriate” responses.

The Limbic System is responsible for the control of emotions, learning and formation of memories. ► HIPPOCAMPUS: Dopamine release plays a huge role in the formation of memories and learning in the Hipp. This structure connects feelings from current and previous situations with reactions. ► AMYGDALA: This area of the brain in the center for emotions and memories are combined in the creation of automatic responses. This is where the “gut feeling” comes from.

The Opioid Crisis Exposed 59

How do these circuits communicate? Neurotransmitters Neurotransmitters are chemicals that are released through nerve endings in the brain to communicate messages with other parts of the body. Here are a few specific neurotransmitters that are involved in addiction... ► DOPAMINE This is the main neurotransmitter involved in addiction. It enables the brain to determine rewards and take the appropriate actions to achieve them. ► EPINEPHRINE This neurotransmitter, also known as adrenaline, is more prominent in those with behavioral addictions It is produced in times of stress or excitement. ► SEROTONIN Known for its abilities to regulate mood, Serotonin works to prevent anxious feelings. It also have an influence on learning and memory. Uneven levels of this neurotransmitter lead to anxiety or depressive disorders. ► GLUTAMATE When a situation is particularly pleasing, Glutamate comes into play to remind the brain of it. This neurotransmitter is crucial to learning and memory.

Normal brain

Intoxicated brain

What happens in the brain when excess dopamine is released? When someone uses drugs, an influx of dopamine floods the brain, bringing the feeling of intoxication. The brain on the left shows what it may look like when a person indulges in anything natural that makes them feel good (food, sex, etc.) The brain (above) shows what it may look like after a person uses drugs or alcohol. With long-term use of drugs the brain regulates its dopamine; meaning it produces less naturally because it becomes reliant on the dopamine released from the drug. When the addict stops using the drug, the brain does not know how to react properly to the deficiency. This is how an addiction occurs.

The answer to “why don’t addicts just stop using drugs?” Because it’s not as simple as “just stop.” Their brains have been hijacked; changing it’s function and structure. In due time, addicts can “rewire” their brain through abstinence and new behavior. But those defects in the brain cannot be fixed overnight. 60 The Opioid Crisis Exposed

SOURCES & DISCLAIMER PLEASE NOTE: The information presented in this graphic is based on data from brain imagine studies conducted by a number of publications listed below. There is still plenty that is unknown about the brain and its functions, however, these findings seem to be common across several studies. SOURCES: National Institutes of Health, The Journal of Clinical Investigation, The Journal of Neuroscience, NeuroscientificallyChallenged.com, Brian Research Reviews, HistoricalNewsToday. com, Neuroscience Online, National Center for Biotechnology Information, NeuropsychoTherapist.com, ChooseMentalHealth.net, ResearchGate.net, BoardPrepRecoveryCenter.com, RehabCenter. net, ElementsBehavioralHealth.net

Debunking the opioid epidemic: 10 myths about addiction

May 23, 2018 Written by Maureen Bole here is still so much that is unknown about addiction. Some of this ignorance comes from decade-old beliefs that have just recently began to be talked about in society. Here are some of the most common myths about addiction and the truths that follow.

1. Addiction is a choice, not a disease. The only choice that is made in addiction is the very first time an addict picks up a drug. After that, the decision-making process is adversely affected to the point of dysfunction. “One of the more important things to point out about how the brain is affected by addiction is that a lot of people who don’t do this work, they talk about the role of making decisions. That if they made a choice to use the drug, that they need to just make different choices. The reality is that the decision/ choice making part of the brain are some of the most demonstrably corrupted by the disease.” — Dr. David Streem

2. Addicts need discipline and should be jailed. Addicts have been known to commit crimes in order to feed their addiction. In no way should those crimes be overlooked, but jail/prison is not the key to curing addiction. A graphic from last month’s chapter of the series showed that by creating strict laws on drug use, criminals were actually being created rather than cured. Prison is not the type of environment that is conducive for recovery. Addicts should definitely be held accountable for their actions. But in order to prevent them from happening again, it’s important to teach them how to live without drugs.

3. Addicts can stop using drugs whenever they want to. With the very first drug use, the brain starts to create associations between the drug, motivation and reward. The more an addict uses the drug, the stronger those connections become. After extended use, the brain categorizes the drug (dopamine) in the same category as food, water and shelter. The addict’s brain thinks that the drug in necessary for survival, which partly causes the compulsive use of the substance. The Opioid Crisis Exposed 61

alcohol or used opiates. You know, but the brain where the disease occurs doesn’t know. It will drive the person to seek out dopamine.” — Dr. Nicole Labor

5. “Cravings” are just an excuse for addicts to use again.

4. Drug addiction and alcoholism are two different things. By definition, alcohol is a drug. Although different drugs produce different effects, they all trigger the same neurotransmitter, dopamine, in the brain. Once changes in the brain occur, the specific substance no longer matters. “When you use a substance, any drug, it enters your system and crosses into the brain and binds onto a brain cell. That brain cell then releases chemicals like dopamine. Dopamine is what actually causes the effect. It’s the same dopamine triggered with every drug. It’s actually the dopamine that we’re addicted to and that we crave. It doesn’t matter what substance you use, it’s the dopamine the brain wants. Any drug is off the table for the recovering person. It will release a flood of dopamine and the brain doesn’t know if you drank 62 The Opioid Crisis Exposed

Cravings and triggers are actually the brain’s natural response to drug related stimuli. “The other neurochemical we deal with in the brain regarding addiction is glutamate. Glutamate has to do with memory formation. So when you have a pleasurable experience and dopamine is released, glutamate lays down a memory. Glutamate lays down memory of a pleasurable experience. Glutamate makes associations between people, places and things with pleasure. Even when you put the drugs down, driving past the dealer’s house can initiate a craving. A euphoric recall. People, places and things is paramount to staying clean.” — Dr. Nicole Labor

6. All addicts come from troubled pasts and situations. Many addicts do indeed come from traumatic situations in their childhood/ adolescent years or addicted households, where one or more family members used. This, however, is not true for all addicts. Some addicts come from good families, had a good education, got involved in extracurricular activities. Developmental and environmental factors are only half of the picture. Someone’s risk for addiction is also affected by genetics and psychological/ emotional factors as well.

7. Once an addict detoxes, they should be able to stay clean. Detox is a helpful initial step in the process of recovery, but it is just that, one step. Further measures must be taken to ensure the success of recovery which can include inpatient treatment, intensive outpatient treatment, participation in a 12-step program or other peer support group, therapy, medication assisted therapy, spirituality, etc. “There is good evidence that some of the damage is permanent and some of it can heal over time. Also, understanding how cunning, baffling and powerful the disease can be. How their own thinking and their own judgement can turn out to lead them down the wrong path. Part of that is getting feedback from others who understand that thinking and understand that corruption. This is why sponsorship and support in 12-step fellowships is so important because those folks provide that objective feedback. The disease can fool them and their decision making capabilities.” — Dr. David Streem

8. After a period of abstinence, addicts can drink socially. Addicts who decide to use mood/mind altering substances after a period of abstinence run the risk of unleashing their addiction all over again. Most recovery programs promote total abstinence from drugs for that exact reason. As soon as the brain gets a taste of a substance, no matter the size, years of recovery work can go out the window and an addict can pick up right where they left off before. “Once a cucumber is a pickle, it’s never a cucumber again. Once the brain is broken, it can never fully go back to normal.” — Dr. Nicole Labor

9. Addicts can easily get treatment to be cured of their disease. Addicts will never be cured of their addiction. Like many other diseases, there are plenty of ways to treat addiction, but there is no sure way to cure it. Relapse is always possible. “We don’t have treatment on demand, we have waiting lists. For most other diseases that could kill you, there is treatment on demand, you get service, connected and treatment. For addiction, they come in, overdosed, get revived and sent back out with no help because there are these week long waiting lists. If you have 50K, you can have treatment on demand but that’s the only way to guarantee treatment immediately.” — Dr. Christina Delos Reyes

10. Withdrawal from drugs only lasts a couple weeks. Physical symptoms of withdrawal can be what initially keep addicts compulsively seeking drugs. They don’t want to be physically ill: achy, vomiting, fever, tremors. Those physical withdrawal symptoms last for about a week after ceasing drug use. It’s what happens after those physical symptoms that can make withdrawal so difficult. Post Acute Withdrawal Syndrome can last up to two years after an addict puts down the drugs. PAWS is characterized by emotional and psychological symptoms which can include mood swings, irritability, decreased energy levels, trouble concentrating and having a hard time sleeping. ♦ The Opioid Crisis Exposed 63

OPINION: THE VIEW OF A RECOVERING ADDICT

Fixing what is broken ... It’s a long road to recovery

May 23, 2018 Written by Maureen Bole

y brain is broken. It’s been that way for as long as I can remember. According to medical professionals, I have a chronic brain disease that will be with me for the rest of my life. I’m not defective or morally corrupt, I’m sick. Personally, I believe I was born with the disease of addiction; that drug use is only a symptom of my disease. I’ve always been obsessive, compulsive and a little bit deviant long before the drugs came into play. Even years after the drugs are out of my life, I can still have a pretty messed up way of thinking. I don’t think and reason like normal people do. My first thought is always, ALWAYS wrong. If I don’t think before I act I’m bound to say or do something I’ll regret. Spoiler alert for most people: I don’t have a drug problem, I have a me problem. I AM the problem. One of the rudest awakenings I ever got was when I got clean and the drugs were gone, I was still acting like a messed-up human. My first reaction to everything was to lie, cheat, steal or manipulate. I was so confused as to why I was still acting this way even when I didn’t want to, even when the drugs were gone. It’s because I’m the root of my problems. I had to work on fixing that if I were to have a solid chance at recovery. To those people who say that addiction is a choice, do you seriously think I chose this life for myself? That I wanted to be an addict when I grew up? Do you think I wanted a life where I have to spend a good chunk of my time attending meetings, seeing a therapist and having constant internal battles between good and evil? Hell no. I wanted to be normal like every other 20-something who has brunch and mimosas on Sundays or smokes a little weed at a concert. If I were to do that now, I’d be sniffing out hard drugs quicker than a K-9 unit until I emptied my bank account, lost my job, ruined my relationships and eventually wound up killing myself from the drug use, physical complications from it or suicide. Why would I ever CHOOSE that life for myself? Mental illness isn’t a choice. I can’t “just stop” being an addict. I can’t “just be happy” to deal with my depression. I can’t “just calm down” to cope with my anxiety. I wish it were that simple, but it’s not. It takes a ton of therapy, support from my friends and family, working on myself, spirituality and dozens of coping mechanisms to even break even with my mental illnesses. I can’t control them but I can sometimes control how I deal with them and that’s the best I can do. I hate the amount of stigma that surrounds mental illness. Having a mental disorder

64 The Opioid Crisis Exposed

doesn’t mean you’re defective or weak minded, it means your sick. They’re diseases. We don’t shame people for having other diseases like we do addiction. Look at it like this: Cardiovascular disease affects a major organ, the heart. If someone who eats unhealthy and doesn’t exercise a lot gets heart disease, they are encouraged to get treatment and usually aren’t ridiculed and scrutinized by the public. Cancer is a disease that can affect any organ in the body. If someone smokes cigarettes and gets cancer, they usually get chemo alongside a lot of support from their friends and family. Addiction is a disease that affects the major organ, the brain. If someone uses drugs or alcohol that triggers their addiction they are blamed for “choosing” to have that disease and scorned by society. I’m sorry but what kind of logic is that? Here’s the reality of it: as an addict, I live a disease that wants me to die slowly and painfully. It’s driven me to some of the most self-destructive behaviors on earth. It wants to see me fail at everything. It tells me that I’m not good enough, that no one cares about me. At the same time, it tells me that I’m the most important person in the world and that no one else matters. It’s a constant battle in my mind. My knowledge of recovery is fighting back hundreds of those negative thoughts every single day. It doesn’t rest, it never stops and it never will. If I stop or slack at working on my recovery, the disease voice starts screaming so loudly over the voice of reason that it becomes all I can hear. And listening to it is how people wind up dead. I don’t write about this because I want sympathy, recognition or attention. I write about it because I just want people to understand what we (addicts) go through every day to stay alive. I understand that some of this may be simple ignorance: after years of hearing that addiction was a moral issue some people may have not gotten the memo that it is a disease. That’s why we’re doing this series, to educate our readers about this epidemic and addiction so that we can hopefully move forward as a community with the solution. I hope that society begins to show a little more compassion to addicts seeking recovery. ♦ The Opioid Crisis Exposed 65

part

In the fifth part of the series, we examine the effect addiction has on children ♦ Children of addicts ♦ Facts & figures about the children of addicts ♦ The foster care system ♦ Rosie’s Playhouse

children

♦ The Providence House ♦ Opinion: Who hurts the most

“The addict is chasing the drug and the family is chasing the addict. They become obsessed with trying to help. You can’t chase recovery for them. They have to chase it themselves. We (family members) don’t see ourselves as being sick since we don’t have a disease. But we do mirror what addicts are going through.”

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Opioid addiction is devastating to children and loved ones

June 20, 2018 Written by Molly Callahan

n opioid addiction doesn’t affect just the person using the drugs. A loved one’s addiction can have long-lasting effects on the whole family. Mental health social worker Moira Dugan has seen this in her work. Dugan operates an outpatient opiate withdrawal program for the Visiting Nurse Association in Cleveland. She travels to “sober houses” that people live in after they have gone through detox programs. Dugan’s clients are all 18 or older, but some still carry scars from childhood. One young man was introduced to heroin at age 14 by his uncle, she said. “What I wish he’d had was an uncle telling him ‘There’s scary stuff out there I wish you’d stay away from,’” Dugan said. Other clients enter the countywide program because of their children. “We have quite a few who have young children,” she said. “They got into rehab because they have to support them or they have kids in the county system they want to get back. That’s something I certainly hear. It’s a motivator, for sure. It’s devastating when they can’t get their act together and get their children back.” Children suffer when a parent is “in the throes of addiction,” said Maggie Tolbert, assistant chief clinical officer for ADAMHS. The agency the Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County. “Children in a developmental stage are dependent on parents to teach them how to love themselves and others,” said Tolbert, who also is a psychiatric nurse. “They need help with the basic activities of daily living and an addicted parent may not be available for them to learn those things.” Consequently, the children might learn from people who are ill-equipped to offer guidance, she said, which can lead to unhealthy habits and dangerous behaviors. “This doesn’t mean the parents don’t love the child,” Tolbert said. “They’re addicted. They need help also.” The ADAMHS board, Cuyahoga County Children’s Services and local schools, including some in the Westshore area, are working to help students experiencing physical and emotional problems resulting from a parent or family member’s addiction. They are partnering for mental health first-aid training, said Scott Osiecki, CEO of ADAMHS. “If a parent or child exhibits warning signs, we’re able to direct them to services,” Osiecki said. The Opioid Crisis Exposed 67

Warning signs include being withdrawn, aggressive, moody and losing interest in activities, he said. Children also sometimes become fixated on violent content, Tolbert said. In addition, a child living with an addicted parent might come to school hungry or lack adequate clothing. That child will have trouble learning and might be made fun of by other children. Middle and high school teachers are trained to look for these signs because they might be the first adult to notice them, she said, adding that not all school districts employ guidance counselors. “This is not about labeling children,” Tolbert said. “It’s about making sure they get the help they need.” Resources include free counseling and group activities and other “wraparound services” not covered by Medicaid, Osiecki said. ADAMHS, with funding from the county health and human services levy that voters renewed in May, contracts with several agencies to provide services, he said. The levy provides 60 percent of the agency’s income, Osiecki said. “We would love to do a lot more,” Tolbert said. “We’re driven by how much funding we get.” The urgency of the crisis is seen at the ground level. Social worker Dugan once had a client who detoxed during labor and delivery. “So the baby also was addicted and needed to detox,” she said. For now, the addiction crisis is handled by professionals in the medical, mental health and law enforcement fields, but Dugan expects another profession will become involved as well.

“My prediction is in another three to five years, school teachers will start dealing with the epidemic, the emotional and physical effects,” she said, including children growing up without their parents. “Kids who are born addicted - I can’t imagine how there wouldn’t be long-term effects that will be presenting themselves.” On the other end are the parents of addicted young adults. “Their parents are worrying about whether they’re ever going to see them again,” Dugan said. Sometimes those parents end up raising their grandchildren, which Dugan said was not their plan for their senior years. Dugan’s typical client is a white man between 20 and 30 years old, but he probably started using opioids when he was a teenager, she said. That group includes a high school athlete and a Boy Scout prescribed pain pills after injuries who then became addicted. “Society doesn’t want to hear it, but it can happen to anybody’s kid,” she said. “Kids in these environments are growing up really fast because they’re having to take care of Mom,” Dugan said. 68 The Opioid Crisis Exposed

Besides the VNA program that serves addicted people who want to stay sober, Dugan says society as a whole needs to address the problem, especially to keep families together. People need to use better coping mechanisms for responding to physical and emotional pain, she said, and everyone needs to keep talking about the problem. “The shame and guilt from the community is pretty strong,” Dugan said. “This is a disease. We can’t blame the addict. It’s not a choice.” Children and teens don’t have to wait for someone to act on their behalf. ADAMHS has a 24-hour crisis line that they can call to ask questions and get referrals. That number is 216-623-6888 and the service is available to all Cuyahoga County residents. Residents throughout Ohio also can text “4Help” to 741741, an option that younger people prefer, Tolbert said. Information about ADAMHS and addiction also is available at adamhscc.org/. ♦

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Chilling facts, figures about the children of addicts It’s not news that the opioid epidemic has been wreaking havoc on nearly every part of communities. But most are not aware of how adversely it affects the children of addicts. Here are a few recent statistics about the fate of these children in the midst of the epidemic.

Children of addicted parents and foster care The opioid epidemic i wreaks havoc on the family unit. Parental drug use is a leading cause of why children are removed from their homes.

LORAIN 35%

ASHTABULA 58%

LAKE 20% CUYAHOGA GEAUGA 33% 75%

SUMMIT MEDINA 50% PORTAGE 45% 55% WAYNE 30%

STARK 38%

TRUMBULL 58% MAHONING N/A

COLUMBIANA 44%

The epidemic has put a serious strain on Ohio’s foster care system

Of the children taken into custody in 2015...

PERCENT OF REMOVALS CITING PARENTAL DRUG USE AS THE CAUSE: >75%

51-75%

26-50%

1-25%

No data

50% 28%

had parents who were using drugs at time of removal of those parents were using opioids at time of removal

In the last six years, the number of children in state custody has increased

11%

In that same six years, state funding for state programs has dropped

21%

Babies born addicted

For each child living in foster care, there are 20 being raised by relatives

In Cuyahoga County, documented cases of babies born addicted has been steadily climbing.

40,000

Ohio has more than households where the child’s grandparents are the sole caregiver. Circumstances that lead to this range from economic hardship, substance abuse to death. 70 The Opioid Crisis Exposed

Since many of these households are outside of the foster care system, in most cases, they do not receive extra funding when taking care of their relative’s children. % of these households in Ohio lives in poverty

number of children born addicted

Beyond foster care: Relatives taking custody

500 400 300 200 100 0

2014

2015

2016

Opioid crisis continues to strain the state’s foster care system

June 20, 2018 Written by Kevin Kelley

f you’ve ever wondered what you could do to help battle the opioid epidemic, consider becoming a foster parent. The opioid epidemic is straining the ability of public children protection agencies to care for kids whose parents are struggling with addiction. According to the Public Children Services Association of Ohio, 28 percent of children taken into custody in 2015 had parents using opioids at the time. That figure was 11 percent in Cuyahoga County and 22 percent in Lorain County, but more than 70 percent in several counties in southern Ohio. The number of children in foster care across the state rose from 12,654 in 2013 to 15,510 in 2017, an increase of 23 percent, according to the association. If the opioid epidemic continues at its current rate, the number will be more than 20,000 in 2020. These figures do not include children who have been placed with relatives. But state social workers report that families are increasingly less able to care for children in need because multiple members of a family are often addicted. The number of foster homes available on any given date – estimated at 7,200 – is not rising as quickly as the need. “With the projected increases, we will have children sleeping in county agency lobbies with no available foster family to take them in,” said Angela Sausser, the association’s executive director. This year, Cuyahoga is one of eight counties hit hard by the opioid epidemic to launch a foster family recruitment program thanks to a $1 million pilot program launched by Ohio Attorney General Mike DeWine. The goal of the program is to find a primary related caregiver, with one or two potential backup options, within the first 30 days of children entering the foster care system. Jacqueline McCray, deputy director of Cuyahoga County’s Division of Children’s and Family Services, said her department is looking to expand its network of about 300 foster care homes. The county also contracts with an additional 70 private agencies that provide care. In comparison to many smaller counties in the state, Cuyahoga County has more resources to help troubled families, McCray said. Many of those resources were established in response to the crack epidemic of the early 1980s and the early 1990s, when the county had around 6,000 children in its custody. Today, nearly 2,400 children in Cuyahoga County are in supervised care, the highest The Opioid Crisis Exposed 71

How to get involved: Four ways to help 1. Become a foster parent This is the biggest way to help in the face of this epidemic. Check the end of this story to find out how to become a foster parent. 2. Become a mentor Many youth centers host mentoring programs to help provide supportive adult relationships to at-risk teens and adolescents. 3. Volunteer time Organizations like Cuyahoga County Children and Family Services, Lorain Children Services and the Providence House often hold events and fundraisers. Consider volunteering time to help put on one of these events. 4. Make a donation Children who are removed from their home usually don’t have many belongings to call their own. To help, consider donating items like toys, hygiene products, school supplies, baby items, etc. 72 The Opioid Crisis Exposed

number since 2011, McCray said, adding that the opioid crisis is a major factor in the increase. “Our foster care system is really strained in terms of the number of families available to take kids in,” she said. Every suburb has a need for foster homes, McCray said. “We are always looking for caregivers because we believe that kids need to be in the community that they’re familiar with,” McCray said. “We have kids that come to our attention from infancy all the way through their teens, and we need families that can support not only babies but our older teens as well.” McCray, who has been with the agency for 29 years, said over the past two years, she has seen an increase in parents unable to care for their children because of the opioid crisis. “I don’t think we’ve seen the end, or even the middle, of the entire opioid epidemic,” she said. Parents addiction to other drugs also causes children to enter foster care, McCray said, adding that dependence on cocaine, marijuana and alcohol are even more prevalent in the cases they see. But opioid abuse can have especially dire consequences. “Sometimes your first use is the first and last time,” she said of the drug’s deadly nature. The impact of heroin or fentanyl use can have traumatic effects on children, McCray said. Some children in the county system have witnessed a parent overdose or even die, she said. Scott Ferris, director of Lorain County Children’s Services, said parental substance abuse is nothing new to social workers specializing in child welfare. But he agrees with McCray that opioid abuse can be especially deadly. “What’s different with opioids and heroin is the lethality of it,” he said. “More parents are dying.” A single relapse can lead to death, Ferris said, thanks to the drug’s ability to suppress the brain’s control of breathing. He’s seen too many instances of social workers accompanying a child to the parent’s funeral. This severity of consequences is what’s changed in recent years, he said. In Lorain County, fewer children are in foster homes

The epidemic has put a serious strain on the foster care system with thousands of children of addicts needing care each year.

than four years ago, Ferris said, but more children have been placed in the care of relatives. “We always look for relatives first,” Ferris said of the process of placing children, which is ultimately determined by a court. This often means grandparents, he said, but added that taking in grandchildren can be stressful. “They’re worried about their adult child who has the addiction while still caring for their grandchildren,” Ferris said. Lorain County’s policy is to not place children from different families in the

same foster home. Instead, the goal is to keep children from the same family together and, when possible, in the same neighborhood in which they lived. But those standards require many foster homes. “We are always in recruitment mode for foster homes,” Ferris said. The state licenses foster parents, and the process of getting a license can take from three to six months. Background checks must be done, and the parents must take several classes om topics ranging from child care to CPR. ♦ The Opioid Crisis Exposed 73

Rosie’s Playhouse offers a safe haven for children of addicts

July 25, 2018 Written by Maureen Bole

n the midst of the opioid epidemic, resources for addicts trying to get clean are increasing day by day. There are treatment centers, support groups and other programs for addicts seeking recovery. For spouses, siblings and parents of addicts, there are family support groups and programs. But there seems to be a group of people who don’t really have a place to turn to. Kathleen Stautihar has witnessed this first-hand. “My recovering daughter had a child. I also have another granddaughter whose biological father is addicted and is not present in her life at all. After seeing how much my grandchildren were affected by addiction, I realized that this group of kids (children of addicts) had nowhere to turn,” Stautihar explained. “That’s where the idea for Rosie’s Playhouse came from.” After months of planning, research, assembling volunteers and fundraising, Rosie’s Playhouse launched its first session last Thursday. Rosie’s Playhouse is a volunteerbased, 501(c)(3) nonprofit program that focuses on providing support and a safe place for children ages 5-12 who have been affected by a family member’s addiction. The program was modeled after Hazelden Betty Ford Foundation programs and is the first of its kind in the area. The program features 90-minute sessions once a week for eight straight weeks. Each session consists of a light lecture for the children followed by an interactive activity reinforcing those ideas from the lecture. Rosie’s Playhouse volunteers include curriculum writers, teachers, psychologists, social workers and nutritionists who have all personally experienced the effects of addiction “At Rosie’s Playhouse the kids will learn healthy coping mechanisms and how to express their feelings,” Stautihar said. “We will also have a week on nutrition where they will learn to create their own (non-cook) snacks and meals.” Each child who participates in the program gets a special Rosie’s Playhouse backpack filled with art supplies and books. The books are age-appropriate and illustrated to help educate participants about addiction. The lessons are modeled after 12-step programs but are tailored to fit the children’s needs on a case-by-case basis. “One cool thing we have is called the worry fairy,” Stautihar explained. “It’s a block of wood and when the children place their hand on it, it turns red. The kids whisper their worry while their hand is on the wood and when it turns from red to green, the fairy has taken their worry away. It’s a great symbolic tool for the kids to have to talk about

74 The Opioid Crisis Exposed

Get involved Rosie’s Playhouse is always looking for volunteers and donations.

At Rosie’s Playhouse kids learn to express their feelings, learn coping skills and make friendships. In one exercise, participants wrote “Dear Addiction” letters about what they would say to addiction if they had the chance to talk to it.

Volunteer Rosie Pals: Organizers are looking for committed, patient and compassionate adults to help with the children and behind the scenes. Those who have been personally affected by addiction, are artsy, have been involved in a support group or have fundraising experience are sought to help. Educators: Rosie’s Playhouse is always looking to add K-6 grade teachers for the program. Donations: Those who are interested in donating for Rosie’s Playhouse can make a donation on the program’s website at RosiesPlayhouse. org/Donate. Proceeds help purchase books, bookbags, supplies for weekly activities and snacks for the children. For more information call 216-446-0080 or email Rosies-Pals@ RosiesPlayhouse.org

anything that’s bothering them.” In its inaugural session, Rosie’s Playhouse has six kids participating in the program but can easily take up to 20 children in the future. The program is currently set up in a church in Brook Park, but Stautihar hopes to branch out and become mobile in the future, taking the program to schools and libraries across Northeast Ohio. “The goal of Rosie’s Playhouse is to help these kids have the ability to cope, to not live in fear and to deal with that anxiety they have built up,” Stautihar said. “But if nothing else, it gives them an hour and a half to just be a kid.” ♦ The Opioid Crisis Exposed 75

Providence House cares for children while parents seek help

June 20, 2018 Written by Kevin Kelley

magine being a single mother addicted to heroin who wants to get sober. But you have no one who can care for your kids while you’re in treatment. That’s where Providence House comes in. The crisis nursery in Ohio City cares for infants to 12-year-olds for up to 60 days – 90 days if the parent is in recovery for opioid addiction. Founded in 1981 by Sister Hope Greener, CSJ, Providence House has cared for more than 8,000 children in its 37-year history. Opioid addiction is just one of the crises the facility helps families through. Domestic violence, abuse of other substances and homelessness are among the other problems plaguing parents who bring their children to Providence House. In 2017, the private nonprofit provided Cribs in the Providence House nursery. beds at no cost for 333 children from 158 families. Fifty-eight percent of the children were 3 or younger. Ninety-seven percent of families served were at or below the federal poverty line – an annual income of $24,600 for a family of four. And nearly all – 98 percent – of parents were single mothers. Up to 30 children at a time can be cared for at Providence House’s two buildings on West 32nd Street, just south of Lorain Avenue. Inside the main nursery, one bedroom features four cribs. A nearby room has four children’s beds. Child-sized tables and chairs made of wood are in the center of neat activity rooms. Outside are two colorful playgrounds. A second nursery is dedicated to children with special medical needs. During the school year, children are driven to and from their regular schools. Social workers teach the children ways to control their anxiety levels and deal with the trauma of being separated from their parents. Throughout their child’s stay, parents are required to visit with their children at least twice a week. Sixty percent of the parents bring their children to Providence House after hearing about it from another family that had used it. The other 40 percent were referred by a social service agency. 76 The Opioid Crisis Exposed

The Providence House in Cleveland helps to temporarily house children while parents can get the help.

Natalie Leek-Nelson, Providence House’s president and CEO, said caring for the children is, in some ways, the easy part of the organization’s job. Making the family healthy and functional can sometimes be more difficult. A big part of the work at Providence House is referring parents to appropriate social service agencies. In the cases of substance abuse, that means recovery programs. Parents recovering from opioid addictions sometimes place their children in the custody of Providence House twice – first while they’re undergoing a medical detox treatment of up to seven days and later in a recovery program lasting several weeks. The fear that they’ll lose custody of their children if they seek treatment often prevents parents from pursuing recovery, Leek-Nelson said. The Rocky River resident’s message is that Providence House can help.

“Our goal is to keep kids safe here and keep the family together by connecting the parent to services in the community,” Leek-Nelson said. Studies have shown that losing custody of a child can have devastating emotional effects on a parent, she said, so the goal is to prevent kids from having to enter foster care unnecessarily. Providence House saw its first cases of patents battling opioid addiction more than a decade ago, Leek-Nelson said, initially from prescription pain medications and later from street drugs like heroin. Leek-Nelson told of a woman who gained custody of three grandchildren after their mother died of a heroin overdose. The children’s father was unable to meet their basic needs as he was recovering from opioid addiction while working a full-time job. The grandmother herself was a recovering addict and had been in a suboxone treatment program. When the stress of raising her grandchildren started to get overwhelming, she was referred to Providence House, which provided respite care for the three children. Providence House houses kids from more than 30 ZIP codes in Northeast Ohio, including several on the Westshore. In 2015-2016, nine children from Lakewood, four from Westlake and three from Rocky River were care for at the Ohio City agency. In 2016-2017, 14 from Lakewood and another three from Rocky River stayed there. Ninety percent of Providence House’s budget is privately funded, through donations and special events. The other 10 percent comes from the state of Ohio. ♦ The Opioid Crisis Exposed 77

OPINION: THE VIEW OF A RECOVERING ADDICT

The children: They hurt the most and have the least control

June 20, 2018 Written by Maureen Bole

ometimes at the close of 12-step meetings, there is a moment of silence. There are a number of introductory words at the beginning of the silence, but the most powerful one I’ve heard is: “Let’s have a moment of silence for the addict who picks up for the first time tonight, the addict who picks up for the last time tonight and the children who have no say in the matter.” I had never thought of it that way until I got clean, how much of a toll addiction has on everyone involved in the addict’s life. It’s a serious problem in the midst of this epidemic. Some children of addicts are forced to mature way earlier than they should. They have to learn how to care for themselves, their siblings and their using parent. Many of them are in and out of the system. A study by the Public Children Services Association of Ohio found that 60 percent of children in the state’s custody under the age of 5 have spent AT LEAST one birthday in foster care. In the worst-case scenario, some children are even born drug addicted from being exposed in the mother’s womb. I could go on, but I think you get the point. The humans who are the most vulnerable and in their developmental stages oftentimes have no say in their fate. Here’s the hope shot: Even though I have heard dozens of horror stories like those listed above, I have also witnessed dozens of happy endings. I know people in recovery who have gotten clean, stayed clean and gotten back full custody of their children. I know people who were barely able to get their children dinner who now are able to get them everything they want for their birthdays. I know people who can show up for their kids today, help them with homework, go to their sports games, tuck them in at night. I even know people whose children were born after they got clean, meaning they will never have to see their parents struggle in active addiction. It’s situations like this that we need to remember when considering children. That recovery is absolutely possible. By making recovery resources and counseling readily available for the whole family unit, we can decrease the amount of at-risk children in the system. Or even better, get the children out of the system and back into their own family. Recently, I watched as a fellow recovering addict’s child hugged her with all his might outside of a meeting and said, “You’re the best mommy in the whole world. I’m so glad you’re not sick anymore.” And that is what we need to focus on. ♦

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part

In the sixth part of the series, we examine the effect additions has on families ♦ Families of addicts ♦ Families involved in treatment ♦ Al-Anon & Nar-Anon

families

♦ Personal accounts ♦ Opinion: Affecting the family

The Opioid Crisis Exposed 79

Families of addicted need to care for themselves, experts say

July 25, 2018 Written by Kevin Kelley

he Centers for Disease Control and Prevention is one of the main federal agencies tracking the effects of the national opioid abuse epidemic. In June it reported that one in seven high school students misused prescription opioids last year. But earlier this month, the Atlanta-based agency was the source of unexpected information about the epidemic. Its director, Robert R. Redfield, revealed that one of his adult children nearly died from an overdose of cocaine mixed with fentanyl. “For me, it’s personal,” Redfield said during a speech to a conference of public health officials. “I almost lost one of my children from it.” Redfield declined reporters’ requests to elaborate on his son’s experience except to say that it’s “important for society to embrace and support families who are fighting to win the battle of addiction ― because stigma is the enemy of public health.” The stigma of a relative’s addiction is one of the problems families are facing in the current opioid epidemic, health professionals report. Parents of an addicted person often experience irrational feelings of guilt and shame, said Ray Isackila, manager of addiction recovery services at University Hospitals. Parents will question whether they did anything wrong while raising the addicted person, he said. “The family’s first response is often shock and denial – ‘This can’t be happening to my loved one,’” Isackila said. An addicted individual will often isolate himself and withdraw from the family, he said. As the drug user attempts to hide the addiction, relatives may deny it exists. “Fear drives people into wanting to believe that the problem isn’t that bad or will go away,” Isackila said. As an addiction gets worse, parents often become angry with their addicted child. “Families become frustrated and afraid and they have this overarching shame that they carry with them day to day,” he said. Depression and anxiety can set in, he added. Like other experts in substance abuse treatment, Isackila said the threat from opioids is more severe than that of other drugs because they can kill very quickly, with any single dose potentially being fatal. Parents often experience grief even while an addicted child lives, Isackila said, as they sense the drugs are changing the person they once knew. They see that their hopes and dreams for their child are being stolen by the addiction, he said.

80 The Opioid Crisis Exposed

“People really surrender their own wellness to the sick addict,” Isackila said. Their very world can come to revolve around whether the addicted family member is safe that day or not, he added. Parents employ various strategies, such as confiscating drugs or withholding access to the family car, in an attempt to stop the child from using. But none of those actions will work if the person is deep in the throes of addiction,” he said. Isackila suggests families in such a situation seek help, either through a support group or private therapy. Either approach can encourage better coping skills that promote rational thinking, instill hope and reduce shame, he said. “The first and most helpful thing they can do is find other families who have gone through this and have come out of this funk and have gotten on with their lives, whether the addicts got clean or didn’t get clean,” Isackila said. He suggested Families Anonymous and Nar-Anon, both 12-step program for relatives and friends of those battling addictions. At meetings, parents quickly learn they are not the only ones going through such problems. That alone can bring an immediate sense of relief, Isackila said. But families are often resistant to attending such meetings, he said, as they cling to the belief that the addicted person can suddenly get clean. Or they think only the addicted family member is in need of help. Members of such support groups are true experts on addiction, he said, and may offer struggling families new approaches that may prove successful. If the addicted person shows no interest in getting clean, Isackila said, the family must come to the hard realization that the drug use will continue no matter what anyone else does. They must then do what is known as “detaching with love,” or stepping away from an addict so his or her behavior no longer causes the same pain. Families who seek private counseling should choose a therapist who specializes in addiction, he said. Dr. Patrick Runnels, director of public and community psychiatry at University Hospitals Cleveland Medical Center, also recommends that struggling families join a support group in which they can talk with other families. Individual counseling can also be helpful to family members experiencing symptoms of depression and anxiety, he said. Families frustrated with addiction need to balance their support of the addicted person with taking care of themselves, Runnels said. Expanding the family support network is helpful, he said. “Addiction tears at the fabric of the family,” he said. An addiction can place great financial burdens on a family, Runnels said, including attorney fees following legal troubles. Stress and anger can even lead to violent behavior, he said. “Generally addicted people tend to be upset and fight a lot more,” Runnels said. “Often you’ll see families afraid to spend time with each other.” The Opioid Crisis Exposed 81

Some families will remain supportive of an addicted child, even when that approach proved ineffective, while other families become angry and take a punitive approach. The addicted person must decide for himself or herself to get clean, Runnels said. But studies indicate strong family and social support lead to higher rates of recovery, he said. Runnels defines a supportive family as one that lets the addicted person know he or she is loved no matter what but does not deny the problem or enable activities that contribute to the addiction. In cases when a parent is addicted, the effects on children can last for years, Runnels said. “Watching a parent be incapacitated, watching a parent do bad things to other people, or watching a parent have bad things happen to them are incredibly traumatic events that have a real long-term impact on young children,” Runnels said. ♦

82 The Opioid Crisis Exposed

Families need to be involved in addiction treatment, counselor says

May 23, 2018 Written by Kevin Kelley

he involvement of an addicted person’s family members is often critical to that individual’s recovery, according to Kevin Berg, an assistant professor in counseling at Cuyahoga Community College. Berg spoke on the ways relatives and friends can help an addicted person during a May 2 program at Tri-C’s Westshore Campus in Westlake. “If we’re talking about good [addiction] treatment in the United States today, we have to include a family component in that,” Berg said. “And it should start from Day 1.” Families will often attempt to maintain a sense of normalcy in spite of a member’s serious addiction, Berg said. “They’ll ignore the substance abuse issue and focus on other things,” said Berg, who holds a master’s degree in social work from Cleveland State University and a master’s degree in sociology from Bowling Green State University. Treating the addiction can shatter that sense of normality and have dramatic ramifications for family dynamics, he said. Those who treat addictions need to work with the family unit as well as the addicted person, said Berg, who previously served as Erie County’s drug courts coordinator. Berg told of a 13-year-old Erie County boy who had been successfully navigating the drug court program when he was arrested for driving without a license at 2 a.m. The reason? He was driving his passed-out mother home from the bar. Erie County social workers then had to treat the mother for alcoholism, which they did. But more still work was needed. “We had to teach mom how to be a mom again and to take control of the [home] environment again,” Berg recalled. “We can’t take the drug-addicted individual, get them clean and sober, and put them right back in that house and say ‘Everything’s good!’” said Berg, who was previously a children’s program specialist at the Alcohol, Drug Addiction, and Mental Health (ADAMHS) Services Board of Cuyahoga County. Family members themselves often need to receive psychological counseling or join a support group to deal with feelings of guilt and anger associated with the addiction, Berg said. Berg suggests relatives and friends encourage an addicted person to enter a treatment program but in a nonjudgemental way. The Opioid Crisis Exposed 83

“Listen and don’t judge,” Berg said. Berg said he does not favor interventions, or gatherings in which the relatives and friends of an addicted person confront him or her about the problem and insist enrollment in a treatment program. Instead, Berg suggests motivational interviewing, an approach in which one attempts to lead the addicted person from indecision toward actions that change behavior and accomplish goals. “We need people to admit, ‘I can get better’ and then let them make that decision,” Berg said. “The problem is it can be a very slow process. That’s OK.” Treatment works, Berg said. But if a person fails to get better after repeated attempts, a new approach may be needed, he said. 84 The Opioid Crisis Exposed

Residential treatment programs can be difficult to get into but are not necessary for every person battling an addiction, Berg said. Family members should also replace negative attitudes that reinforce the stigma associated with addiction with scientific facts on how addiction alters the brain, Berg said. Noting how regular coffee drinkers can become irritable without their morning jolt of caffeine, Berg said it’s an example of how withdrawal from a drug can affect the brain’s neurons. Berg also noted studies suggesting coffee can serve as a type of “gateway drug” for some girls, who see drinking coffee as their first “adult” activity, which can lead them into other adult behaviors. ♦

Al-Anon & Nar-Anon help family members of those addicted

“E

July 25, 2018 Written by Kevin Kelley

veryone seemed to be positive, even laughing, which shocked me. I thought if you lived with addictions or alcoholism, how can you even laugh? There seemed to be this really neat fellowship amongst the people there. I just soaked in everything I could. I was so desperate. I wanted whatever they had.” Diane of Lakewood reminisced on her first Al-Anon meeting 15 years ago. She sought help after her husband’s drinking progressed and he brought up the word “divorce.” Living in constant fear of the unknown and now in a panic, she was referred by her neighbors to the 12-step program to hopefully find some relief. “Before the program, I was afraid of everything. What people thought, what they would do. I was extremely fearful of about everything in my life,” Diane said. “The areas I thought were the most difficult, that I would never see change, have changed.” Diane is one of thousands of people who have struggled watching a loved one battle with alcoholism or addiction. The disease takes a toll on the addict, but it reaches far beyond that. Support groups including Al-Anon and Nar-Anon were formed several decades ago to help addicts’ family members cope. Modeled after 12-step programs Alcoholics Anonymous and Narcotics Anonymous, these support groups place the focus on family members instead of the addict/ alcoholic. These programs provide a safe place for them to share experiences and work through the 12 steps to find serenity in the midst of chaos. “It was nice to talk to people who understood what was going on,” said Kathi of Brook Park, who started the only Nar-Anon meeting on the west side in 2012. “People could relate to that deep ingrained sadness that I had. I knew these meetings were ... going to give me a place to openly talk without being judged.” Kathi went to her first Nar-Anon meeting after the consequences of her daughter’s addiction landed her in prison. During her first couple weeks in the program, she was a bit hesitant about the idea of letting go, but soon got on board. Today she tries to help other families help themselves. “Families are mirroring an addict in their mannerisms,” Kathi said. “The addict is chasing the drug and the family is chasing the addict. They become obsessed with trying to help. You can’t chase recovery for them. They have to chase it themselves. We (family members) don’t see ourselves as being sick since we don’t have a disease. But we do mirror what addicts are going through.” The Opioid Crisis Exposed 85

12 Steps of Nar-Anon 1. We admitted we were powerless over the addict — that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to others and to practice these principles in all our affairs. 86 The Opioid Crisis Exposed

Not everyone understands the concept of the programs for family members. Some people think that attending these meetings might make their addicted family member join a program too, but that doesn’t necessarily happen. “I didn’t think my changing would make a difference,” Diane said. “I thought everyone around me needed to change. But I was looking in the wrong direction. “At first I thought I was there so that the alcoholic would stop drinking. Like if I do the right things, they’ll stop. That was my hope. But that wasn’t what it’s about at all,” she continued. “It’s about changing the way I think, the way I act and the way I look at things. It’s to change those things in me that aren’t necessarily healthy and keeping my side of the street clean. I can’t be responsible for what others do or say. Al-Anon is all about me learning to find a healthier way to live my life, one day at a time.” The 12 steps can help give program members a more peaceful outlook on life. Kathy, of Fairview Park, also came to the program for help with handling her husband’s addictive behaviors and depression. The principles of the steps have taught her how to let go. “When you learn, you learn that you’re powerless over everyone and everything; it takes a big weight off your shoulder because you don’t have to control everything,” Kathy said. “You learn what you can control and focus on that instead.” Programs like Al-Anon and Nar-Anon introduce the concepts of letting go, enabling and detaching with love. “Enabling is like rewarding bad behavior in someone else,” Diane said. “Doing something for someone they should do

for themselves. If you’re doing things for someone because they’re intoxicated, that’s enabling. It’s not healthy for either one of you. It allows them to continue on with their addictions and it makes you angry and resentful of them.” “A lot of people buck the idea of the program at first, (thinking) that letting go means giving up and that’s not it at all,” Kathi said of Nar-Anon. “You can’t keep people alive no matter what you do. The whole idea of this is to find your own inner peace and stop loving people literally to death.” Family groups help members live their best life in whatever situation they’re presented with. Oftentimes this means whether their addict/alcoholic is clean or not. A lot of focus is placed on accepting things the way they are and dropping expectations about how they think they should be. Identifying feelings helps immensely in this process. “What I was feeling was grief,” Kathy said. “I always thought grief was only when someone died. But it was grief for a life I didn’t have anymore or couldn’t have. You want everything to be perfect, but you can’t control another person. I was grieving this perfect marriage I thought I had, but it was falling apart.” Al-Anon and Nar-Anon have no membership fees and anyone is welcome to attend. All three women agreed that if you have someone in your life who struggles with addiction, to give one of these programs a try. “I’ve seen the program working for everyone. It’s never too late to go into those rooms. People think they don’t need it, but it can make such a positive difference,” Diane said. “Even if someone grew up with alcoholism or addiction in their life and don’t deal with it anymore. Even if your child or spouse has passed away. There is still help, there is still hope, fellowship, strength, people who have been through it. There’s always something there to help.” ♦ The Opioid Crisis Exposed 87

A mother and daughter’s battle with addiction When someone is suffering from alcoholism/addiction, it affects more people than just the person who’s using. Family members of the addicted are thrown for a loop for years at a time as they watch their loved one slowly destroy themselves. The narrative below shows my thoughts versus my mother’s thoughts and some of the struggles we endured during the seven years I was drinking and using. - Maureen Bole

The addict: Maureen The point of view of the situation from the mind of the addict.

I can’t believe I got caught AND grounded. This is so lame. Everyone drinks, it was just one night. Ugh. I guess I’ll just have to get sneakier with partying when I’m ungrounded.

My mom thinks that all my friends pressure me, but I like smoking cigarettes. Tonight we’re meeting a girl from our school to get some weed. We’re just trying to have a little fun.

OMG finally I get to make my own rules and do what I want, when I want. It’s time to party!

I think I’ve found the secret weapon for college. I get to party and get high all I want now. When it comes time to study, all I have to do is take one little pill and stay up all night, then I’m good to go.

I didn’t even need to go to the hospital, that was so dumb. It’s hilarious though, they gave me this print-out that tells me to stop drinking and hanging out with friends who do. Good joke! 88 The Opioid Crisis Exposed

The situation A brief explanation of the situation in the mother and daughter’s lives during the daughter’s active addiction, detox and recovery.

April 2008 Mary went out for the night with friends. 16-year-old Maureen had a sleepover with friends and a case of beer.

May 2009 Maureen and her friend (that her parents specifically told her not to associate with) sneak off to hang out again.

August 2010 Maureen begins at Ohio University.

May 2011 After Maureen fails classes her freshman year, Mary tells her if it happens again, she is coming home.

May 2012 After drinking too much at a festival, Maureen winds up in a hospital.

Mother of the addict: Mary The point of view of the situation from the mind of the addict’s parent.

Well, here we go. I mean I knew she would start drinking at some point, I just didn’t think it would be this soon. She’s grounded for the month now. Hopefully she’s learned her lesson

Every time she hangs out with that girl, she comes home smelling like smoke. She’s a bad influence on my daughter. I want to be able to trust her, but I obviously can’t anymore about anything.

I’m terrified. I’m afraid she’s going to drink her life away and there’s nothing I can do to stop her.

Her father and I were ready to pull the trigger if she came home with another F. But this quarter, she brought home straight A’s. I’m so relieved; I think she’s turned the corner, she finally got it.

I got a call today that she’s in the hospital. I’m pissed. I don’t feel sorry for her, I’m not driving down there. She’s in the right place. She can deal with it on her own

I can’t sleep, I’m afraid to sleep. Every time I close my eyes I have these horrible visions of animals trying to attack me or cars crashing into the walls of our apartment. I just want it all to stop.

I think I’m going to puke everywhere. I do not even want to be at this restaurant right now. I did way too many drugs last night. This comedown is totally brutal. I just need more to feel OK again.

I can’t breathe. I need to go home. I’m out of drugs and booze. I don’t know what to do. I just need more. I just need to feel OK for like five minutes.

I just want it all to stop. My heart is racing. I keep gasping for air. I need someone to tell me what to do so I can get through this and get high again this weekend. Maybe I do need help? They made me go to rehab today. They told me I’m an alcoholic/addict. I’m not allowed to go back to school. Hopefully I can sleep tonight.

This is finally happening. After coming back to OU and finishing school clean, I get to walk up to that stage and graduate. Oh God I’m gonna cry. This is the happiest day of my life.

It’s been a crazy journey, but I couldn’t be more grateful for everything that’s happened. In March I celebrated four years clean and sober. Looking back on my active addiction feels like it was a completely different lifetime. Today, I’m able to be present. I can be a daughter today. I’m so lucky to have had the support of my mom through it all.

June 2012 After a trip to Put-in-Bay, Maureen was facing some severe withdrawal at home.

January 2013 On Maureen’s 21st birthday, her parents take her out for dinner to celebrate.

February 2014 Maureen drives home from OU in the middle of the week after having another meltdown.

March 2014 Maureen goes to psychological services to ask for help. They call her mother to tell her the truth about her addictions. Her dad picks her up from school and brings her home. Maureen is diagnosed as an alcoholic with a substance-abuse disorder.

May 2015 After celebrating a year clean, Maureen graduates from college.

I had to call a family friend to ask him what I should do with her. She’s shaking, crying and telling me she’s hallucinating. I don’t know what she took or how to help.

Well, at least she’s legal now. Not like that makes it any better. Her color isn’t right, though. She looks sick. Something is up, but she’s probably just stupid hung over from last night.

She’s in trouble. I don’t think it’s just drinking anymore. She looks horrible; disheveled, a complete nervous wreck. She’s restless, twitching and pacing for hours.

I didn’t know the severity of everything and I’m terrified. Maureen has to sleep with me for the night for five days. Her counselor says that the withdrawal could cause her heart to stop and kill her. She’s a mess and I’m a mess watching her be a mess. But at least she’s at home and safe.

When she first said she wanted to go back to school, I hated the idea. But she did it. I just want to tell everyone, “That’s my daughter. She did it. Today she’s graduating clean and sober.”

The journey has been a difficult one, but being active in a support group has helped me immensely. It has been instrumental in my relationship with my daughter. It has also helped with everything outside of that. I am grateful every day for my daughter’s recovery and my own program. This is a day-by-day process, which is why I’m grateful we have today. The Opioid Crisis Exposed 89

Resource guide for loved ones of addicts/alcoholics Graphic by Maureen Bole 20

Bay Village

Avon Lake Sheffield Lake

611

301

North Ridgeville

Fairview Park

Lakewood

Westlake 252

Avon 254 Sheffield Village

Rocky River

480 80

North Olmsted 252

Olmsted Falls

AL-ANON LORAIN COUNTY ▪ First Congregational United Church of Christ Thursdays at 8 p.m. 36363 Center Ridge Road in North Ridgeville ▪ Cathedral of Life Assembly of God Sundays 5:30 p.m. 5375 Jaycox Road in North Ridgeville ▪ Lake Shore United Methodist Church Mondays at 7:30 p.m. 33119 Electric Boulevard in Avon Lake

CUYAHOGA COUNTY ▪ St. Raphael Church Monday 6:30 p.m. 525 Dover Center Road in Bay Village

90 The Opioid Crisis Exposed

▪ John Knox Presbyterian Church Mondays 7 p.m. 25200 Lorain Road in North Olmsted ▪ Lakewood Presbyterian Church Monday at 7:30 p.m. 14502 Detroit Avenue in Lakewood ▪ Dover Congregational United Church of Christ Thursdays 8:30 p.m. 2239 Dover Center Road in Westlake ▪ St Angelas Church Thursdays at 7:30 p.m. 20970 Lorain Road in Fairview Park ▪ St Andrews Presbyterian Church Thursdays at 7 p.m. 23114 West Road in Olmsted Falls

480

KEY: Al-Anon Meetings Nar-Anon Meetings LCADA Way Meetings

NAR-ANON ▪ Brook Park United Methodist Church Wednesdays at 7:30 p.m. 6220 Smith Road in Brook Park ▪ Medina Community Church Mondays at 7:30 p.m. 416 South Broadway Street in Medina

LCADA WAY FAMILY SUPPORT GROUP ▪ LCADA Way Elyria Men’s Center Tuesdays @ 7 p.m. 120 East Avenue in Elyria ▪ LCADA Way The Key Women’s Center Thursdays @ 7 p.m. 1882 East 32nd Street in Lorain

SOLACE LORAIN COUNTY SUPPORT GROUP Call for meeting times and locations 440-823-6177

There are more Al-Anon and Nar-Anon meetings in Northeast Ohio. To explore more locations, visit: Al-Anon.org Nar-Anon.org and click “Find a meeting”

OPINION: THE VIEW OF A RECOVERING ADDICT

Addiction is a disease that affects the whole family

July 25, 2018 Written by Maureen Bole

hen you’re an addict, there’s only one thing you care about: using. Your single goal is getting high and you do whatever you need to accomplish that goal. People and their feelings don’t matter. Most times, the ones who are hurt most by an addict aren’t the addict themselves, it’s their families. One of the most important days of the week for me when I was in treatment was Tuesdays, family day. On family day, the client’s parents or spouse would come to the three-hour session and work with their loved one and the counselor to begin repairing the damage caused during active addiction. My parents are divorced so I went to separate sessions with each parent. Although very rewarding, these were some of my toughest sessions in treatment. It was so hard for me to see all of the pain I had caused my mom and dad, but it was something I needed to hear. My parents each dealt with my recovery a bit differently. It was recommended that all loved ones seek their own help in a support group of some sort. My mom jumped right in. She was all for working on herself and began attending meetings of her own. My dad couldn’t grasp the whole idea, though. He thought (and still thinks) that it’s my problem and that he doesn’t need his own program. At first, I felt terrible about that suggestion. Like I just put them through all of that heartache and now you’re telling them they have to go to meetings on their own? I soon found out, though, that those meetings had nothing to do with me and everything to do with them. The wreckage reached their lives too and they needed to fix themselves as much as I needed to fix myself. Now, I’m not saying that one parent is better than the other by any means. However, because of those meetings, I do seem to have a better relationship with one of them. My mom and I have learned how to constructively communicate with each other. When faced with controversy, we handle it quickly and easily. We’ve made a lot of progress in the four years I’ve been clean and sober. In the relationship with my dad, we still struggle to deal with issues appropriately. Our communication isn’t always the best. Oftentimes, seeing the solution is impossible because there’s too much focus on the problem. And after four years of honesty and transparency, he still has problems trusting me. There may be deeper issue ingrained in those differences, but I think a lot of it could have been helped by support-group meetings. The Opioid Crisis Exposed 91

part

In the seventh part of the series, we focus on medication assisted treatment methods ♦ Medication Assisted Treatment ♦ What is MAT? ♦ Methadone ♦ Suboxone

M . A . T

♦ Vivitrol ♦ Opinion: Affecting the family

“I don’t believe that medications are the cure for addiction. However, if I break my leg, I need a crutch. I need something to lean on while my bone heals. I still have to go to physical therapy, meet with my surgeon and do all of those things to get my body to heal. For the majority of people on MAT, that’s what it does. It gives them the chance to calm the midbrain down so they can go to treatment and gain the coping skills they need.” 92 The Opioid Crisis Exposed

Medication-Assisted Treatment can help addicts gain traction

August 29, 2018 Written by Maureen Bole

n the midst of one of the worst drug epidemics in American history, many communities are asking the same question, over and over again: “How do we fix it?” The simple answer would be: recovery. By providing recovery resources to addicts, it will be easier for them to get clean. But for opiate addicts, getting clean is far from simple. If an opiate addict manages to get past the severe withdrawal, they encounter the second devil … how to stay clean. For most addicts, they don’t know how to live a life without drugs. After going through detox, they must learn how to deal with life’s ups and downs without drugs. Many spend the majority of their energy fighting the urge to get high. This makes it difficult to focus on anything else, and is why relapse is so common. But with Medication-Assisted Treatment (MAT), some addicts have the chance to focus their energy on more than just abstinence. “Some people argue that medication is just a crutch, it’s swapping out one drug for another,” explained Dr. Nicole Labor, addiction medicine specialist at Summa Healthcare. “As a chemical dependency counselor, I don’t believe that medications are the cure for addiction. However, if I break my leg, I need a crutch. I need something to lean on while my bone heals. I still have to go to physical therapy, meet with my surgeon and do all of those things to get my body to heal. For the majority of people on MAT, that’s what it does. It gives them the chance to calm the midbrain down so they can go to treatment and gain the coping skills they need.” Medication-assisted treatment treats addiction with medication, counseling and other types of support. There are three main types of medication used: Methadone, Suboxone and Vivitrol. Methadone, an opioid that fully activates opioid receptors in the brain, was originally discovered by German scientists during World War II as a pain reliever. It made its way to the U.S. in the 1950s when doctors discovered it could help treat opiate addictions. “They pioneered the concept because they recognized that opiate addicts were terrified of withdrawal,” said Dr. David Streem, medical director of the alcohol and drug recovery center of the Cleveland Clinic at Lutheran Hospital. “So if we can use a longlasting opioid that prevented withdrawal for a long time, we might have more success in treating these folks.” Because of its higher potential for abuse, Methadone often must be obtained from a The Opioid Crisis Exposed 93

clinic. An addict must visit the clinic each day to take their dose of the medication in a liquid or pill form. Suboxone and Vivitrol are two medications that are relatively new to the market (the FDA approved Suboxone in 2002 and Vivitrol in 2008). Suboxone is composed of two main compounds: Buprenorphine and Naloxone. Buprenorphine is a synthetic opioid that partially activates receptors. Naloxone is an opioid antagonist, meaning that it blocks the euphoria from getting high. The medication comes in a pill or a sublingual film that patients place beneath their tongue. “Suboxone is a drug that stimulates opioid receptors, but just a little bit,” said Streem. “Once you get over about 16 mg a day, there is no further stimulation of those receptors.” Vivitrol, the newest MAT medication, comes in the form of an injectable shot administered once a month to patients. Unlike Suboxone or Methadone, Vivitrol is not an opioid. In fact, it makes it mentally impossible for an addict to feel high if they use an opioid. Physical overdose, however, is still possible. With a couple different options, how does an addict choose which medication is right for them? Responsible physicians stress the importance of keeping a good rapport between caregiver, counselor and patient. “The problem I think a lot of people have with MAT is that some physicians aren’t doing it correctly,” Labor said. You hand them cash, they hand you a prescription and tell you to have a nice day. They aren’t looking at the big picture of your life or encourage other aspects of recovery.” “The importance of the collaboration between the prescriber and the therapy program is absolutely critical for all of these treatments,” said Streem. “The doctors who prescribe the medication (at the Cleveland Clinic) meet with the therapy counselors every week and discuss each patient in the program.” Another important aspect of MAT is that the medication is just one small piece to the puzzle. “This is Medication-Assisted Treatment,” Streem said. “What some people forget about, is that they place all of the focus on the medication and they forget about the treatment. The treatment is the group therapy, all of education that goes with it and the routine drug testing.” “After a few years on a medication, I have about the same amount of people in abstinence-based programs clean as I do on MAT,” Labor explained. “And those are the ones who are active in recovery programs.” As one may assume, there is a decent amount of controversy that surrounds MAT. The concept of prescribing a patient an opioid to treat and opioid addiction may seem a bit counterintuitive. “The published peer reviews on scientific results with Medication-Assisted Treatment are pretty clear,” Streem said. “The consequences of choosing philosophy over results could mean the difference between life and death. We here at the clinic choose science, results and life.” ♦ 94 The Opioid Crisis Exposed

What is Medication-Assisted Treatment and how does it work? METHODOLOGY:

Medication

“Medication-assisted treatment is treatment for addiction that includes the use of medication along with counseling and other support.”

Assisted

Treatment

Prescribed Counseling/ Psychiatric medication therapy evaluation

Family & group therapy

N2 N2

- U.S. Department Of Health And Human Services

Addiction Education

MEDICATIONS USED IN MAT: Methadone

Suboxone

Vivitrol

Methadone Long acting opioid

Buprenorphine/ Naloxone Opioid agonist

Naltrexone Opiate antagonist

Methods for administration

54 142

M 2540

Primary form in red

All subsequent information on the chart pertains to the primary form

Liquid

Pill

N2 N2

1170

Film

Pill

Injection

Pill

How does it work? What does the medication do to help in withdrawal/recovery?

Fast facts: ♦ Type of drug ♦ Function ♦ Average dose ♦ Half life* ♦ Risk of dependence ♦ Risk of overdose

METHADONE

SUBOXONE

VIVITROL

OPIOID RECEPTOR

Methadone completely activates opioid receptors in the brain. The medication replaces the euphoric effects of the opioid of abuse and also lessens the severity of cravings and withdrawal.

Suboxone partially activates opioid receptors in the brain. The medication replaces the euphoric effects of the opioid of abuse and also lessens the severity of cravings and withdrawal.

Vivitrol completely blocks the opioids in the brain. The medication makes it impossible to feel any euphoric effects from opioids. However, it does not block effects of other drugs.

♦ Opioid ♦ Opioid replacement ♦ 40 mg to 120 mg daily ♦ 24-55 hours ♦ Moderate ♦ Moderate

♦ Mixed Opioid & Opioid Antagonist ♦ Opioid replacement & Opioid Blocker ♦ 12 mg to 16 mg daily ♦ 24-60 hours ♦ Minimal ♦ Minimal

♦ Opioid Antagonist ♦ Opioid Blocker ♦ 380 mg once a month ♦ 5-10 days ♦ None ♦ None

* The half-life of a medication is the amount of time it take for approximately half of it to clear the patient’s system. www.adsyes.org, www.bluestarmedical.net

The Opioid Crisis Exposed 95

Mediation-Assisted Treatment program components Medications are just one small part of a treatment program. The Alcohol and Drug Recovery Center at the Cleveland Clinic offers a comprehensive treatment program that goes beyond just medication in order to treat addiction:

Psychiatric evaluation Those who suffer from addiction often have cooccurring mental illnesses. Leaving metal illnesses untreated can be the difference between a successful and unsuccessful attempt to find recovery. The Clinic conducts a full evaluation and subsequent treatment to address any underlying mental illnesses.

Individual counseling Both the inpatient and outpatient programs at the clinic recognize that no treatment program is complete without counseling. A few of the components include: ♦ Relapse prevention ♦ Recovery training ♦ Healthy life skills development ♦ Daily self-help sessions ♦ Educational sessions ♦ Family educational sessions ♦ Drug screenings

Medication Patients are prescribed an MAT medication that best suits them and their needs.

Caregiver-counselor collaboration: Each week, the caregiver (doctor who prescribes the medication) and the counselor (the medical professional who oversees the patient in group and 96 The Opioid Crisis Exposed

individual therapy) meet to discuss the progress and well-being of each individual patient to address any struggles they may be facing.

Group therapy Group therapy sessions cover similar topics in individual counseling but on a group level. This encourages patients to connect with their peers in treatment.

Support groups Those in treatment programs are encouraged to attend community self-help groups or 12-step meetings. Similar to group therapy, these meetings enable those in recovery to develop a support group of people who understand their troubles first-hand.

How a methadone clinic helped one addict find recovery

August 29, 2018 Written by Maureen Bole

oan, who lives in Lakewood, thought back to her experience with Methadone back in the mid-’90s. At that time she had be using for 22 years, the most recent four years were when she found heroin. She wasn’t quite ready to get clean at that point in her life, but she was sick of getting sick from withdrawal. She had heard that Methadone helped, so she made her first trip to the clinic. “I would go to clinic every morning,” she said. “We would have to park across the street because you couldn’t get in line in front of the door until exactly 7 o’clock. So we would all be hurting and waiting until 7 o’clock and then it was like cockroaches - a mad dash to the door. When you walk in, it was just massive amounts of people in line, waiting to get to the window and get well. I never tested clean because I was still using heroin on top of the Methadone. When you METHADONE completely activates METHADONE tested positive, you’d have to sit through opioid receptors in the these treatment-like meetings hosted by brain. The medication replaces the euphoric the clinic. So I would go first thing in the OPIOID effects of the opioid of RECEPTOR morning to get it over with, but I would have abuse and also lessens the severity of cravings and withdrawal. a syringe in my pocket ready to go so I could shoot up as soon as I got back to my car.” “I went everyday regardless if I used or not,” she explained. “They couldn’t stop me (from getting the Methadone) even though I was using. The only thing they could do was not give me take-homes and make it a bit harder for me by having to go to the clinic everyday.” During one of her daily trips, Joan met a counselor who introduced her to a 12-step fellowship. But the idea of actually getting clean still didn’t do anything for her. “He really went out of his way to help me by trying to introduce me to Narcotics Anonymous. He would give me meeting schedules and once he gave me a basic text. But all the schedules went into the garbage. I just wasn’t ready.” After about a year’s time at the clinic, Joan began to see her life spin out of control. She was placed on house arrest for embezzling funds from her employer, but still found a way to get out and buy drugs. “I was dragging my 5-year-old son all across the city,” she said. “He would play with the other kids in the courtyards in the projects while I was inside getting high. We would hear gunshots. And I didn’t think anything of it. I was oblivious to the whole thing. The Opioid Crisis Exposed 97

“I remember running through the projects one day, with my ankle bracelet on, chasing some guy who tried to rip me off. And it was times like that that I realized this was getting out of hand.” Although she was resistant to the idea of recovery, the seed had been planted and Joan decided to go to her first meeting. “I started going to meetings because I felt like I had nowhere else to go,” Joan said. “But I was still going to the clinic everyday. “I couldn’t comment at meetings because I was on Methadone, which they considered a mood or mind-altering substance. So they told me to talk to people before or after meetings instead of commenting during them. And I listened because I was desperate. But, at the same time, I argued because I wasn’t doing heroin. So I started to research what Methadone really was. I found out what was in it, that it was an opiate and that I really was high.” After regular meeting attendance for a couple months, she finally decided to get off the Methadone. She spoke to a doctor at the clinic about a 28-day detox program and was appalled by his response. “He told me I wouldn’t make it,” she explained. “That I wouldn’t be able to do it without the clinic. But since I was the one paying for it, they listed to me and began to taper me off of it. I was coming down off of it and I got so sick. The detox from methadone was horrifying. It was an opiate withdrawal but it was more intense than anything I had ever experienced before.” The silver lining was that since she had been going to meetings, she had support from Narcotics Anonymous. Members would come to her house and help her into a bath, take her out for coffee or even just drive up to the airport and watch the planes take off and land. “I was driving around in June, going to meetings, with my heat blasting and a leather jacket on and was still ferociously shaking the withdrawal was so bad.” But she made it through the hard part, got clean and finally had a clear head for the first time since she was 12. Joan made it her mission to stay clean, work a program and help other women who were also trying to get off of Methadone. And she did just that for the next decade and beyond. Today, Joan is “living the dream.” She celebrated 21 years clean back in July and is still an active member of Narcotics Anonymous. She continues to help other women suffering from addiction through sponsorship and sharing in meetings. Even though her experience with the Methadone clinic was anything but successful, she still believes that it was a crucial part of her recovery process.

“The methadone was the start of my surrender process,” Joan said. “The mental, spiritual, physical and emotional pain I experienced; I was completely bankrupt in all of those areas. “I don’t regret anything. It was all part of my journey, whether I liked it or not.” ♦ 98 The Opioid Crisis Exposed

Suboxone assists in learning to cope with opioid addiction

August 29, 2018 Written by Maureen Bole

very recovering addict is different. Each has a different story, a different journey and different ways to deal with/conquer the demons. What may work well for one addict may not for another. But what seems to be an important factor in medication-assisted treatment is the addict’s desire to get and stay clean. “My first attempt to get clean was with Suboxone at 22,” said Carla of Parma Heights. “But I didn’t take it properly. I’d sell it or just not take it because I still wanted to get high. I wasn’t ready to quit and never gave the Suboxone the chance to work. I just took it to get my parents off my back.” Carla first experienced the euphoria of opiates at age 16. Although she didn’t start using heavily until 20, she remembers that the euphoria was a treasured memory for the four years before she began abusing them. SUBOXONE “When I failed at the Suboxone, the docpartially activates SUBOXONE opioid receptors in the tor recommended to my parents that I go brain. The medication to treatment. I went to Glenbeigh and was replaces the euphoric OPIOID effects of the opioid of RECEPTOR using again the week I got out,” she said. abuse and also lessens the severity of cravings and withdrawal. “From there on out, it was rehab, get clean for a second, use, rehab again until I caught a case in 2015.” For addicts who don’t have the desire to get clean, Suboxone can be what helps them find their bearings in recovery and find a new way of life. But if they continue old behaviors and illegal activity while taking the medication, like Sean, of Cleveland, did, their chances to find recovery aren’t too promising. During his active addiction, Sean sold drugs to support his habit. He was charged with Driving Under the Influence at 18 and was sent to treatment. Instead of listening to the information about recovery, he paid more attention to what drugs everyone else was on. He noticed that heroin was popular and began selling it. “One day I tried it (heroin) to see what it was like and started using it 1 or 2 times a week for about a year,” Sean said.”Then it progressed. I have had long periods of sobriety 1-2 years but would usually start using cause I would usually fall back into dealing.” In another treatment program, Sean was prescribed Suboxone as part of a medicineassisted treatment program. Addicts tend to have the need for instant gratification. So The Opioid Crisis Exposed 99

when the medication didn’t work the way knew that rehabs alone weren’t working. Sean expected it was, he quickly found I wanted to give it an honest try. I paid loopholes. for it with my own money. Miraculously, I “The last time I was on Suboxone (about woke up after a couple days on it and felt three years ago), I got on it because I so much better. I actually didn’t want to overdosed and just didn’t want to keep get high.” doing dope,” he said. “But it didn’t take Around this time last year, Sean began away the cravings, so I started using dope to surrender as well. He explained that he here and there, then would take the was sick of doing the same old things. Suboxone when I didn’t have money for “I have wanted to stop for years but alheroin. But then I started using so much ways got pulled back,” Sean said. “I know heroin that the Suboxone wouldn’t help a lot of it had to deal with the fact that I and would just send me into withdrawal. was addicted to the fast lifestyle of selling So I stopped taking the Suboxone and drugs. That’s why this time around I told would sell it to buy myself no matter more heroin.” what I’m not going “I actually wanted to get clean Around that back to that.” this time. I knew I needed help. I same time, Carla “I decided to call knew that rehabs alone weren’t was catching her detox to try and working. I wanted to give it an first charges after get in,” he conhonest try. I paid for it with my an overdose and tinued. “It was a own money. Miraculously, I woke was placed in the Sunday night and up after a couple days on it and Cuyahoga County I thought there felt so much better. I actually drug court prowas no way in hell didn’t want to get high.” gram. She stayed I would get in that clean for most of night but the lady the program but asked me if I could felt as though she was struggling to do so make it there by 11 p.m. I said yes. Even the entire time. though my roommate was waiting on a In December of 2017, she had an ecdelivery of about an ounce of heroin and topic pregnancy and had to have surgery. a half ounce of cocaine I told him I didn’t “That whole thing just destroyed me,” care anymore.” Carla explained. “I walked out of the Sean went to detox that night and hospital and went straight to get high. heard of an inpatient treatment program Thank god that relapse was only about a at the Methadone clinic. He explained month.” that he wanted to try something new this In January of this year, Carla decided time around. And this time, that someenough was enough. She was ready to thing new is working for him. get clean and gave Suboxone another try. “I have been ready before to get off of “I actually wanted to get clean this heroin, but I feel the methadone really time,” she said. “I knew I needed help. I helped tremendously. I think Methadone 100 The Opioid Crisis Exposed

Suboxone, a popular brand name MAT drug, is often taken by dissolving a small film under the tongue.

can help people who have been struggling for years to get and stay sober,” Sean said. “I’ve been sober over a year. “I have no cravings and things have been going great.” Sean is now a single father to his son and has a relationship again with his mother. He visits the clinic six days a week to take his Methadone. Next month he will be returning to his old job as an ultrasonic inspector, which he went to school for. It’s nice having a normal life. Well, at least what I consider normal,” Sean added. “I’m definitely grateful for Methadone and I know my mom and son are too.” After nine months on the Suboxone program, Carla has remained clean for the longest amount of time in her life and is beginning to taper off of the medication. “I learned that with Suboxone, you gotta give it a little time to work,” Carla explained. “It takes four or five days for you to really start to feel better and you gotta take it the right way. Not cut corners like so many people and I used to do.” “It took away that obsession that’s so very hard in the beginning,” she continued. “It took away that white knuckling feeling. I finally had time to focus my energy on other stuff rather than just fighting the urge to not get high everyday. I can focus on work, taking care of my daughter, so many other things. In addition to that, it’s helped me get adjusted to a new lifestyle without drugs.” ♦ The Opioid Crisis Exposed 101

Vivitrol: Not one-size-fits-all MAT option

“T

August 29, 2018 Written by Maureen Bole

here’s just so much thrown at you at once (when you first get clean), it’s too much to handle. There’s only so much you can immerse yourself into the program (12-step) at that stage. You’re in an awful place. I just wanted to use all the time and I knew I wasn’t going to be able to fight it by myself every day, all day long.” Melissa, 26, of Lakewood recalls the beginning months of recovery. After almost a decade of using drugs and four years of heavy Percocet abuse, she know something needed to change. “I was so screwed up emotionally,” Melissa explained. “I knew something had to give or I was gonna die otherwise. I was scared.” After getting honest with her therapist about getting help, Melissa learned about the Vivitrol shot. The shot is a full opioid blocker, making it impossible for addicts to get high VIVITROL on any opiate. For Melissa, it was very helpful completely blocks the VIVITROL in the beginning stages of her recovery. But opioids in the brain. The medication makes that’s not the case for all addicts. it impossible to feel OPIOID “When I first tried it, I didn’t want to be any euphoric effects RECEPTOR from opioids. However, addicted to heroin anymore. That was it,” it does not block effects of other drugs. Allan, 30 of North Olmsted explained. “I did it (the shot) for six months before I started substituting. Cocaine, alcohol, benzos. I was still looking for something. The thought of using never went away and that’s when I sought out other things. I just had to go to get something else since I couldn’t do heroin.” That was Allan’s first attempt at getting clean in 2010. Since then, he has tried the Vivitrol shot on three other occasions. But it did not seem to help his situation. “It didn’t work for me because I just went to other drugs,” he explained. “The blocker works. It’s impossible (to get high on heroin). I tested it, I tried.” Allan’s third attempt at the shot was through the court system. He could either serve jail time or get the Vivitrol shot and do treatment. He chose the treatment route and it worked long enough for him to get involved in a 12-step fellowship. After stopping the shot after six months, he used again, violated his probation and was faced with the same choice: jail or treatment.

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Vivitrol, a relatively new MAT drug, is administered by a medical professional once a month through injection.

“I chose the Vivitrol,” he said. “They took me right from jail to get the shot. And that night I was smoking crack. I just wanted to get out of jail so I could use.” After his last attempt at MAT. Allan realized that something needed to change and had to figure out a “new plan of attack.” And that new plan was wholeheartedly giving a 12-step fellowship a try. “I got a sponsor, met other people who are clean and learned what they did to stay clean. It’s worked for millions of other people. I just had to believe it could work for me too.” Melissa completed the full 12-month Vivitrol program just shy of her one year clean celebration. During that time, she also made huge strides in her 12-step recovery program. “Today, my life is 100 times better,” Melissa said. “I did a lot of things in recovery I can fall back on. I have a support group, coping mechanisms and I know what to do in those situations now.” Both Melissa and Allan have over 18 months clean now and are still active members of their fellowship. “The drug was not the problem. It (Vivitrol) can be beneficial, but it won’t work alone,” Allan explained.. It blocks drugs. That’s all it does. It doesn’t teach you how to cope with things, be responsible, live your life. That’s where the program comes in” ♦ The Opioid Crisis Exposed 103

OPINION: THE VIEW OF A RECOVERING ADDICT

Addressing some of the pitfalls of MAT

August 29, 2018 Written by Maureen Bole t face value, medication-assisted treatment (MAT) programs seem like a viable and effective weapon in the fight against the opioid epidemic. But with all of the benefits of these programs, there are pitfalls apparent after reading the stories in this month’s edition of “The Opioid Crisis Exposed.” No. 1: Not all MAT medications work the same for all addicts. Each addict is unique and therefore, each MAT program must be tailored to fit that person’s needs. Where Suboxone may work wonders for some (like Carla), it may not have the same benefits for others (Sean). Where Methadone is the crutch for addicts who have used for more than a decade (Sean), it may just be an enabler for others (Joan). No. 2 If an addict wants to get high, they’re going to get high. Regardless of MAT. This is apparent in Allan’s story. Although he was getting the Vivitrol shot, a complete opioid blocker, he still found a way around it. While it worked as a deterrent in Melissa’s experience, it was nothing but a small barrier for Allan. He knew that he wouldn’t be to be get high from his drug of choice (heroin) so he turned to other drugs and alcohol instead. This brings me back to the point that addiction is a disease. That it’s not as much the drug that matters, but the high. The desire to feel numb. No. 3 MAT medications can be abused, but lawmakers and physicians are fighting to prevent that from happening. Methadone clinics operate the way they do for a reason. The medication they provide does have potential for abuse. Nowadays, doctors have also implemented more rules and regulations when it comes to prescribing Suboxone to prevent patients from abusing or selling their medications. In addition to these regulations, most MAT programs place high importance on developing a relationship between the prescriber, counselor and patient. They can address issues as they arise and exhaust all options to prevent those seeking recovery from abusing their meds. No. 4 The medication is just one small part of the program. The simple theme throughout the stories this month is obvious: Support is key. All five of the recovering addicts mentioned went through a treatment program in conjunction with the administration of their medication. For those who embraced those programs, the medication seemed to work more effectively. For those who did not, the medication did not do them much good. BUT, in all of those instances, they were introduced to 104 The Opioid Crisis Exposed

treatment and 12-step programs. Those programs and support groups planted the seed so that later down the road, when they did become fully ready and willing, they knew where to turn. No. 5 Twelve-step fellowships usually have stark opposition to those on MAT. This is the elephant in the room in medicated-assisted treatment. Unfortunately, many fellowships recognize Suboxone and Methadone as “mood- or mind-altering” substances. Members often ask MAT patients to not share in meetings for this reason, because they are considered to be under the influence. This gets sticky. Communication is crucial in any program. MAT addicts may feel ostracized. Addicts should work closely with a sponsor to overcome these issues. The bottom line is that MAT can be life-saving. Although it is absolutely not the solution to their problems, it can be an integral part of the road to a clean life. Many have found recovery through MAT; many have found it with abstinence alone. But what seems to be the defining factor in any successful attempt at recovery are support groups and/or 12-step fellowships. Next month, we will look further into these recovery groups in honor of National Recovery Month. ♦ The Opioid Crisis Exposed 105

JOIN THE VOICES FOR RECOVERY invest in health, home, purpose, and community

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West Life’s observance of National Recovery Month

“

Each September, the Substance Abuse and Mental Health Services Administration (SAMHSA) sponsors National Recovery Month (Recovery Month) to increase awareness and understanding of mental and substance use disorders, and celebrate the individuals living in recovery. Now in its 29th year, the 2018 Recovery Month observance focuses on urban communities, health care providers, members of the media,and policymakers, highlighting the various entities that support recovery within our society. The 2018 Recovery Month theme, “Join the Voices for Recovery: Invest in Health, Home, Purpose, and Community,” explores how integrated care, a strong community, sense of purpose, and leadership contributes to effective treatments that sustain the recovery of persons with mental and substance use disorders. The observance will work to highlight inspiring stories that help thousands of people from all walks of life find the path to hope, health, and wellness. In addition, the materials support SAMHSA’s message that prevention works, treatment is effective, and people can and do recover.” - Substance Abuse and Mental Health Services Administration (SAMHSA) As members of the media, we’re doing our part to help celebrate National Recovery Month this month, and every month of this series, by helping to educate the public about addiction and celebrate the success and happiness those in recovery have found. Although this project is focused around the opioid epidemic specifically, it’s important to note that most of the issues and hardships throughout this series stem from substance use disorder. This disorder is recognized as a mental illness by The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) and medical professionals across the country. National Recovery Month goes beyond the realm of addiction and looks at all mental disorders as a whole. The 2010 National Survey on Drug Use and Health found that nearly half of people suffering from addiction have co-occuring mental illnesses, or dual diagnosis. Finding recovery is imperative to all duel diagnosis patients; failing to tend to a co-occuring mental illness can threaten their prosperity or even their life. Most coverage of the epidemic is bleak: death tolls rising, families torn apart, children being ripped away from their homes, addicts winding up incarcerated. In this month’s part of the series, we feature stories of courageous people who have overcome their addictions and found a new way of life in recovery. This month, we focus on the success stories of those who suffer with substance use disorder and other mental illness. This month, our focus is telling stories that evoke feelings of hope in the midst of a seemingly hopeless crisis. The Opioid Crisis Exposed 107

part

In the eighth part of the series, we focus on National Recovery Month ♦ Recovery’s Got Talent ♦ Mental Illnesses ♦ Mental Disorders 101 ♦ Mental Health & Treatment

recovery

♦ Cover2 Resources ♦ Opinion: Mental Illness

Hundreds gathered in Lakewood Park for the annual ‘Light Up the Night for Recovery’ event. The event, which included speeches and the release of sky lanterns, honored those who have been lost and those who are still sick and suffering.

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Matt Jefferies and Scott Lewis perform a cover of the song ‘Drown’ by Bring Me The Horizon at the second annual Recovery’s Got Talent show Saturday, Sept. 22 in Pepper Pike. The duo won first place in the competition for their performance.

Hopelessness turned into passion: Recovering addicts take center stage at annual Recovery’s Got Talent show

October 3, 2018 Written by Maureen Bole

ecovery from drugs and alcohol often means starting a new life. Those in recovery are stepping out of their comfort zone to prevent themselves from falling into old habits and addiction. The upside, other than health? Many are able to regain their hopes, dreams and life passions. Talent and personality are back after being hidden in the shadows of addiction. “I never would have been able to do this before getting sober. I didn’t care enough about anything,” said Erica Long, 26, of Cleveland. “Being sober, I gained a purpose. If I trust in the process and do what’s asked of me, I can gain and build beautiful The Opioid Crisis Exposed 109

Anthony Gregorio took third place in the talent show with his piano and vocal rendition of ‘Can’t You See’ by the Marshall Tucker band.

relationships and live a better life.” Long was one of 11 participants in recovery from addiction in Project 180’s second annual Recovery’s Got Talent event Sept. 22 at the Lillian & Betty Ratner Montessori School in Pepper Pike. Project 180, a group of people in recovery, works with the Cuyahoga County Drug Court to host events throughout the year for drug court clients and their families. Recovery’s Got Talent is one of their more popular events. “My favorite part about this is that I get to learn about each of them,” said Katie Patton. She was chosen to be a judge for the competition because of her strong ties to the women’s recovery community in Cleveland. Patton is the director of the Jean Marie, a sober living house for women located in Brook Park. “I ask them to pick a couple things to talk about. Like who inspired them to do their talent,” Patton continued. “I love to bring as much out in them for everyone else. I love to get the audience to get to know them like I do.” Contestants bustled around backstage before the competition began, completing their interviews with the judges and rehearsing their acts. Four judges each had two or three contestants they were to judge individually before collaborating on the winners later in the evening. Two contestants performing together, Matt Jefferies and Scott Lewis, met during their stay at the Lantern, a men’s recovery house in Cleveland. Both of them have been into music since they were children and have continued to pursue that during their recovery. 110 The Opioid Crisis Exposed

“We’ll be performing a song, a cover of ‘Drown’ by the band Bring Me the Horizon,” Jefferies said. “The lead singer is also in recovery and he wrote the song in treatment. We were gonna do an original, but since crowd reaction is part of the judging, we decided to go with something that was a little bit more relatable. It is a competition. We do have the chance to win some money. But the biggest thing is that we’re out here promoting recovery; that we can still have fun in sobriety.” As the clock ticked closer to 7 p.m., the Ratner School auditorium filled up with drug court clients, recovery house clients and friends and family of contestants. The lights dimmed as one of the Project 180 organizers made his way to center stage to get the night started. Each contestant was brought out on stage and asked to answer several questions before their performance. Most contestants shared the deep meaning that their performance had for them. Anthony Gregorio began the evening with his piano and vocal rendition of “Can’t You See” by the Marshall Tucker Band. He explained that the song meant a lot to him in his own journey to find recovery for what he couldn’t see before. For the second performance of the night, Bethany Stanley chose to sing “Lay Me Down” by Sam Smith in honor of her best friend, who passed away from the disease of addiction six years ago. John Seitz came out to the stage with an amplifier and his guitar to perform an original song he composed called “Good Time.” He has been playing music for most of his life, and explained that for him, it’s a form of therapy itself. Stand-up comedian Ken Dodson paced back and forth onstage as he told jokes about situations that most addicts have been through. With 21 days sober, Andy Girgis took the

Martial arts master Kyle Petrosky holds a position during his Grand Champion Bo Staff Kata routine.

John Seitz hypes up the audience during a performance of his orginal composition ‘Good Time.’

Erica Long spins a light-up hula hoop for the talent show.

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stage with his guitar. Girgis is a self-taught musician who explained that his mom was his inspiration. He performed a flawless rendition of the reggae band The Green’s “Something About It.” Erica Long came onto the stage with her lit up hula hoop, a skill she has been perfecting for about five years. The stage crew cut the lights as the Electronic song “Crave You” by the Flight Facilities filled the room. Long twisted and spun the hoop to the music, creating a spectacle of bright lights for the audience. Long’s best friend in recovery, Ashley Mansell, followed with her own vocal rendition of Christina Perri’s “Jar of Hearts.” “Music feeds our souls. I actually didn’t plan to participate, but then they talked me into singing,” Mansell explained. “I don’t know how it’s going to go, but what I do know is that I love music and sharing it with everyone. Someone told me to just trust myself and if I do that, then I know it will come from the heart.” Singer Jamie Meade followed with one of her favorite songs by rock band Evanescence “Bring Me to Life.” She explained that the tune was her go to. “This song has gotten me through everything: divorces, relationship problems, deaths. But more importantly, this song is how I met my husband. I was singing karaoke and he heard me. My dad said not to bring him home, so I married him and had two kids,” Meade laughed. Guitarist and singer Des explained how recovery brought him to wanting to change his name from his legal name, Chris. His grandfather, who has been in recovery longer than he’s been alive, gave him a poem titled “Desiderata” which really resonated with him. Des decided last minute to perform an original song he composed called “Blue October.” Jefferies and Lewis took the slot for the second to last performance of the evening with their rendition of “Drown.” The duo stepped to the front of the stage with their guitars, belting out the lyrics to the song and remaining perfectly in sync. The final act of the night, martial arts expert Kyle Petrosky performed his Grand Champion Bo Staff Kata routine. The term kata refers to the detailed patterns of movements practiced in martial arts while the bo staff is a traditional martial arts weapon used in conjunction with those movements. Petrosky let out booming shouts as he completed a standing backflip across the stage before picking up his staff and mesmerizing the crowd. At the conclusion of the acts, it was time for the judges to deliberate. Third place went to pianist Anthony Gregorio, second to comedian Ken Dodson with the singing and guitar duo Jefferies and Lewis taking home the first-place win. “Just showing the amount of talent and skills of people in recovery is outstanding, Lewis said. “People in the rooms are just some of the most talented and passionate people I’ve ever met. And for us to be able to showcase that is really important. It’s good, healthy competition but what it’s really all about is getting together to celebrate our sobriety.” ♦

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A story of battles with mental illness and journey to recovery October 3, 2018

Written by Maureen Bole arlene, 18, of North Olmsted, knew from an early age that something wasn’t right with her. Something always felt off. She was diagnosed with ADHD when she was little, but that wasn’t her only battle. She always felt like something was missing, that she needed a way to escape from reality. She felt like she found those ways during her freshman year at North Olmsted High School.

“My friend and I discovered self harm and started cutting together,” Darlene said. “I

started doing that before I found drugs, but it’s funny how that kind of crossed over into my drug use. After I started using drugs, I stopped with the cutting a lot. I really only did it when I didn’t have drugs. Just so I would have something. It was like I was always The Opioid Crisis Exposed 113

missing something and needed a way to yet. So I still used throughout it.” escape.” Darlene was also still cutting. She had Darlene started her high school career several incidents where she cut too deep strong, excelling in all of her classes. But and wound up in the hospital to get after she began to act out, her grades stitches. One night she took a whole botsuffered and so did her attendance. tle of pills, just wanting all of the madness “I aced the first semester of freshman to stop. But the end goal wasn’t necessaryear, then started failing classes,” she ily suicide; it was more of an impulse. said. “I started to go to school high, if “I didn’t want to let something (cutting I even went at all. I skipped a lot. Or I and using) go that I’d done for so long,” would go in late with a fake pass.” she said. “It was hard to give it up. It was Things continued to spiral. At 15, more of missing that than wanting to kill Darlene used self harm and drugs to myself. I didn’t feel right and I felt like that cope with her feelings. She continued to would fix it.” rebel from the rules of her school and her After a couple of hospitalizations, she mother. decided to make “My mom was an honest attempt “I didn’t want to let something mad at me beat getting clean. (cutting and using) go that I’d cause I snuck out She found some done for so long. It was hard to the night before,” serenity through a give it up. It was more of missing Darlene said. “She 12-step program, that than wanting to kill myself. left me a voicemail getting a sponI didn’t feel right and I felt like and was super sor and going to that would fix it.” mad at me, so I meetings. But she didn’t want to go was still having home because I trouble controlling knew she would yell at me. I was scared. her self harm and crushing depression. So I just didn’t go home. I ran away to The hospitalizations continued, but for Kentucky with a couple people I was her next several trips, she was transportusing with. One of the guys I was hanged to a psychiatric hospital where doctors ing out with was in college and went to put her on various medications to try to school there.” fix her problems. They tried medications After she returned home, the school for bipolar disorder and major depressive filed truancy against Darlene for skipping disorder, but soon after each release, school so frequently. She began to exDarlene wound up back in the hospital plore other options for her education and for the doctors to try again. her mother enrolled her in an adolescent “It was about a year of going to different treatment program. doctors and programs trying to figure out “I was brought into treatment after that, what was wrong with me,” she said. but I just wanted to still have fun,” she Then doctors finally found the right said. “I wasn’t ready to let go of all of that medications to help Darlene with her 114 The Opioid Crisis Exposed

depression and mood disorder. Life slowly began to improve. She left North Olmsted High School for Ombudsman Educational in Berea, a high school focused on getting students back on track to graduate. Darlene began to excel in academics again. She continued attending 12-step meetings and talking with her sponsor. She also got her first job, at Subway. Darlene decided she wanted to start studying to be an emergency medical technician. After completing her sophomore year at Ombudsman, she spent half the day there and the other half at Polaris during her junior year. During her senior year, she completed a half day at Ombudsman and the other half at Cuyahoga Community College. This past March, Darlene graduated with her EMT certification. “What made me decide I wanted to be an EMT was from my own trips to the hospital,” she said. “They (the EMTs) helped me more than anyone else, especially when it was the ride from the hospital to the psych hospital. I just wanted to help people like they helped me.” Darlene landed her first EMT position with the same company that transported her to the hospital when she was struggling. Today at 18, Darlene has her career (which she hopes to expand to a fully certified paramedic in the future), a good relationship with her mother and sister again, is going on three years dating her boyfriend (whom she met in the hospital) and will celebrate three years clean this November. “I’ve done so much more with my life than I would have if I would have continued to use,” she said. “I wouldn’t be anywhere near where I am right now.” She encourages those struggling with mental illness or addiction, or struggling to understand it, to ask for help and to never give up. “Not a lot of people understand it,” she said “I always hope that people will take the time to try to understand what we go through. But even as hard as they try, they won’t get it like we do. Until you live through it first hand, you’ll never fully comprehend it. But educating people about it is a start. “With mental health, it gets better. It may take a while, but don’t ever lose hope. It will get better.” ♦

The Opioid Crisis Exposed 115

A crash course on common mental disorders Each year the Substance Abuse and Mental Health Services Administration (SAMHSA) publishes a listing of common mental disorders to further educate the public about behavioral health. Here are 8 of the most prevalent disorders:

Major Depressive Disorder A mood disorder that consists of a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure. Depression can negatively affect behavior and cause physical and emotional problems such as problems with sleep, eating, energy, concentration, self-image or recurrent thoughts of death or suicide.

Substance Abuse Disorder Occurs when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home. A diagnosis is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.

Post-Traumatic Stress Disorder (PTSD) Can develop after exposure to a terrifying event or ordeal (traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, and military combat), persistent frightening thoughts and memories of the ordeal, sleep problems, feeling detached or numb.

Bipolar Disorder This is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. Moods range from periods of extremely “up,” elated, irritable, or energized behavior (known as manic episodes) to very “down,” sad, indifferent, or hopeless periods (known as depressive episodes). 116 The Opioid Crisis Exposed

Mental Health by the numbers

1 in 5

adults experience mental illness

HALF of adults will experience mental illness during their life

Of adults who suffer from a mental disorder:

HALF of all mental disorders begin by age 14

6% have two disorders 6% have 3+ disorders

1 in 17

youths have a mental health disorder

Only 41% with a mental disorder received professional health care or services in the past year.

Generalized Anxiety Disorder Generalized Anxiety Disorder is characterized by persistent and excessive worry about a number of different things. People with GAD may anticipate disaster and may be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worry or may expect the worst even when there is no apparent reason for concern.

Attention Deficit/Hyperactivity Disorder (ADD/ADHD) A chronic condition including attention difficulty, hyperactivity, and impulsiveness. ADHD often begins in childhood and can persist into adulthood. It’s symptoms include inattention or difficulty staying focused; hyperactivity or constantly being in motion or talking and impulsivity, meaning often not thinking before acting. It may cause difficulty at school or work.

Schizophrenia A serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and thought disorder (unusual ways of thinking), as well as reduced expression of emotions, reduced motivation to accomplish goals, difficulty in social relationships, motor impairment, and cognitive impairment.

Obsessive Compulsive Disorder (OCD) Obsessive-Compulsive Disorder (OCD) is a common, chronic, and longlasting disorder in which a person has uncontrollable, intrusive reoccurring thoughts (obsessions) and/or repetitive behaviors that are engaged in to reduce anxiety (compulsions) or a combination of both; unable to control anxiety producing thoughts and the need to engage in ritualized behaviors. The Opioid Crisis Exposed 117

Physical, mental health needs now integrated with addiction treatment

October 3, 2018 Written by Maureen Bole any physicians, therapists, social workers, health insurers and even patients themselves have becoming increasingly aware of the need to treat opioid addiction with an integrated approach. The need for an integrated team approach to opioid treatment and recovery, particularly medication-assisted treatment, has been advocated by Caroline Carney, chief medical officer for

Magellan Healthcare. “Such an approach may include relapse prevention medications; group and individual counseling; physician visits for medication management; mental health therapy; and psychiatric treatment for co-occurring disorders,” Carney wrote earlier this year in the The American Journal of Managed Care. Health insurance providers and pharmacy benefit managers are helping members fighting addiction better access long-term support and better integrate behavioral and physical health, according to a May survey by the global consulting firm Deloitte. “Health plans recognize that a more comprehensive approach is required to address the opioid epidemic,” the report stated. “This involves different types of interventions across the three main pillars of the prescription life cycle: identification, prevention, and treatment and recovery.” Recovery Resources is one area health care provider specializing in addiction treatment that has adopted the integrated approach. “We want to treat the whole person,” said Ken Holt, a licensed social worker and therapist at Recovery Resources, which has offices in Lakewood and the Midtown and Old Brooklyn neighborhoods of Cleveland. After an initial assessment by a therapist, a client struggling with an opioid addiction is typically referred to counseling, both in individual and group sessions. “Group counseling is very important because you need the peer support in recovery,” Holt said. “You can’t do it alone.” Addicted people can learn a lot from hearing other people’s stories, he added. A physical exam is also often scheduled to address any illnesses or conditions brought on by the addiction. “Often there’s a really large need for dental care,” Holt said. Addicted people often neglect their self care and hygiene once drugs take over, he explained. A mobile dental unit, provided by Northeast Ohio Neighborhood Health Services, visits

118 The Opioid Crisis Exposed

Recovery Resources locations weekly to provide screening and make referrals for additional treatment. The integrated approach has become increasingly common in the past five to 10 years, Holt said. Nine out of 10 clients at Recovery Resources like the integrated approach, according to Holt’s estimation. “They talk about how convenient it is to have their primary care doctor, their psychiatrist and their mental health counselor all in the same building,” Holt said. “We’re all able to share records and we’re able to coordinate their treatment.” Recovery Resources offers a dualdiagnosis program for persons dealing with both addiction and psychiatric

problems. One track is for those whose primary problem is the addiction, with their mental health needs as secondary. The other is for those whose primary challenge is a mental illness, with addiction problems secondary. Common co-existing mental illnesses occurring in people seeking addiction treatment are depression, anxiety and trauma. Some studies indicate that more than 90 percent of people with addictions have experienced some kind of trauma as a child, Holt said. In many cases the individual will use drugs to self-medicate the psychological problems, he said. Some people are reluctant to address deep-seated trauma, Holt said. “You can’t push them,” Holt said. When The Opioid Crisis Exposed 119

demands or ultimatums to continue treatment are made in an aggressive way, the person will often discontinue treatment, he said. Patience and encouragement on the part of the therapist is often required, Holt said, with treatment options offered one step at a time. For example, if a person needs a physical exam, medication-assisted treatment and counseling, only a counseling session is initially scheduled Recovery Resources uses motivational interviewing, an approach in which the therapist attempts to lead the addicted person from indecision toward positive changes in behavior and the setting of goals. “Engagement is what’s most important,” Holt said. “Once they’re engaged, we can start planting seeds and help them grow. “When one has an internal sense of motivation, a behavior change is much more likely to continue and be maintained when you finish treatment,” he said. Psychiatrists specializing in addiction disorders can treat co-existing mental illnesses with medications such as antidepressants, as well as offer medication-assisted treatment for the addiction. In medication-assisted treatment, drugs such as Suboxone and Vivitrol act upon opioid receptors in the brain to reduce cravings or prevent the euphoria created by opioids. Because numerous studies have shown the effectiveness of medication-assisted treatment, it is increasingly seen as the standard of care for opioid addiction. “It reduces relapse and it reduces [an addicted person’s] involvement in the criminal justice system,” Holt said of medication-assisted treatment. Some in the 12-step recovery community, with its focus on total abstinence from drugs, see it as substituting one drug for another. But that’s been changing in recent years, said Holt, who oversees Recovery Resources’ medication-assisted treatment and intensive outpatient programs. “People are starting to see the research, the evidence, the success stories of people using medication as prescribed to help their opioid addiction,” he said. Holt emphasized that medication-assisted treatment should not be used as a standalone therapy and must be done in conjunction with some form of counseling. He said one reason it’s been stigmatized is that some physicians had prescribed the drugs without requiring counseling or support group participation. Counseling sessions will often use cognitive behavior therapy, which helps people address problems by modifying dysfunctional thinking and behavior. Another form of psychotherapy, called acceptance and commitment therapy, encourages people to stop avoiding or suppressing negative emotions and instead accept them as appropriate responses to life’s events. In the latter therapy, Holt said, a person experiencing discomfort or grief would be encouraged to see that emotion as an appropriate response to the death of a loved one. Such “mindfulness” skills are sometimes needed, he said, to accept the highs and lows that life brings without trying to alter them with drugs. ♦ 120 The Opioid Crisis Exposed

Cover2 Resources continues to expose the opioid crisis

October 3, 2018 Written by Maureen Bole

n 2015, the McNeil family lost their dear son and brother, Sam, to a heroin overdose. The McNeils thought they had the whole addiction thing figured out and were doing all they could to help Sam. “We were blindsided when Sam died,” Greg McNeil, Sam’s father said. “It was only then that we realized, how woefully unprepared we were to help Sam in his battle.” After Sam’s death, McNeil launched a podcast series called Cover2 Resources to help educate others about addiction in order to properly deal with the opioid epidemic running rampant in Northeast Ohio. The podcast episodes interview professionals as they share their expertise of the opioid crisis. Topics include exploring safer pain management options (other than opioids), treatment centers, harm reduction programs, drug court programs, relapse, detox, addiction psychiatry, overdose, law enforcement, sober houses, prevention and much more. The goal of Cover2 is to provide the general public with the all of the information possible about the epidemic and how, as a community, to get through it. After almost two years of podcasts, Cover2 recently released their 200th episode. “We produced our first podcast about “People, Places and Things” making a difference in the opioid epidemic 26 months ago,” McNeil explained. “To mark the occasion of our 200th episode, we wanted to recognize some extraordinary people and programs we’ve profiled along the way.“ McNeil revisits a few of his memorable interviews from the previous 199 episodes including Cuyahoga County Drug Court Judge David Matia and 10 other programs, professionals and stories across the Midwest and the East Coast. “We plan to continue highlighting the people and programs that are working to fight the opioid crisis through our podcast series,” McNeil said. “And whenever possible, connect the people behind the programs with leaders in other communities” All Cover2 episodes are available free of charge and can be found through Google Play Store, iTunes, Stitcher, Soundcloud or by visiting the organization’s website at Cover2. org/podcasts Cover2 Resources is a 501 (c) 3 supported through tax-deductible contributions and private donations from listeners and sponsors. To learn more about Cover2 or to make a donation visit Cover2.org. The Opioid Crisis Exposed 121

OPINION: THE VIEW OF A RECOVERING ADDICT

We are not our mental illnesses, addictions

October 3, 2018 Written by Maureen Bole

ach September, SAMHSA (Substance Abuse and Mental Health Services Administration) encourages communities around the country to observe National Recovery Month. The goal is to promote recovery and related stories of those who have overcome their mental illnesses and addiction in their daily lives. The message is that resources are available, community leaders and medical professionals are working together to find new solutions, and through those solutions recovery is possible. In addition to being a recovering addict, I also suffer from generalized anxiety and major depressive disorders. On a good day, I don’t even think about those issues. But most days, it’s an uphill battle to combat them both. My life is characterized as a series of panic attacks and what I like to call depression holes. For anyone who doesn’t know what a panic attack feels like, I’ll share my experiences. My panic attacks can be brought on by anything and anyone at anytime. Mostly, though, they are rooted in stress, fear of inadequacy and running out of time. My moderate panic attacks are characterized by small fits of panic where I usually need to stop and control my breathing before it gets out of control. I feel a sense of impending doom, like I’m in a room and the walls are closing in more and more until they suffocate me. With severe panic attacks, I have a hard time breathing at all. The last time I had a severe one, I couldn’t inhale. My friend had to coach me back into breathing while I tried to use my rescue inhaler. My hands and face often go numb from oxygen deprivation and I cry and struggle to breathe. My depression often triggers my anxiety as well. It’s like they work hand-in-hand to cripple my life moment by moment. When I’m deep in a depression hole, I feel purposeless. All I want to do is sleep. When they’re really bad, sometimes I feel like my heart actually aches. Not in a chest pain kind of way, but in a way that my negative feelings are so powerful that I feel heartbroken. My depression takes away all motivation to do daily tasks or complete projects. Occasionally it manifests itself as anger or rage, where I quickly lose my patience with situations and people around me. And of course there’s my addiction. Luckily, I’ve lost the desire to use drugs or alcohol to “solve” my problems. But the disease is still there, lurking, waiting for me to slack in my recovery so it can take the reins again. My addiction wants to see me fail. It wants me to be a manipulative, self-centered, close-minded, insane person who will make her

122 The Opioid Crisis Exposed

own life unmanageable one bad decision at a time. And believe it or not, all of those times don’t involve drugs or alcohol. My mental illnesses play a pretty large role in my life, but through recovery and working with a therapist, I have learned how to manage them. I take medication, work my steps, attend meetings, sessions with my therapist and meditate daily. Although I cannot prevent myself from having these mental illnesses, I can control the way I react to and handle them. There is a lot of stigma attached to mental illnesses and addiction. Many don’t comprehend the struggles individuals who suffer from these ailments endure. Even more don’t understand that it is possible to live a productive, fulfilling life with these ailments. If there’s one thing, however, I hope readers get from this month’s opioid series package, it’s this: We are not our mental illnesses, addiction or drug of choice. It’s not all that we are. I think there is too much emphasis on “What drugs did you do?” or “What mental illnesses do you have?” and not enough attention placed on recovery. The participants in Recovery’s Got Talent are a perfect example of my beliefs. They are musicians, singers, hula-hoopers and stand-up comedians. Being in recovery is just a part of their lives, but a part that has allowed them to explore their passions again. For Darlene, she is diagnosed with a mood disorder and suffers from addiction but today, she’s an EMT, a present daughter, a faithful girlfriend and a good friend. In my case, yes I suffer from several mental illnesses. But they do not define me. I am not my disease. I am a person, just like you or your neighbor. I am an addict, but I am also a journalist, a designer, a part of the electronic dance music industry, a good daughter, a loyal friend, a productive member of society, an active member of the recovery community and so much more. I think that once society starts viewing mental illnesses as what they are, brain diseases, some of the stigma will dissipate. We cannot control our mental illnesses, but we are responsible for our own recovery. I hope this month’s package helps change perceptions. We are so much more than our diagnoses. ♦ The Opioid Crisis Exposed 123

part

In the ninth part of the series, we focus on prevention programs for today’s youth and resource officers. ♦ Prevention ♦ Drug use warning signs ♦ Stopping before starting ♦ Why do kids do drugs?

prevention

♦ Community Resource Officers ♦ Opinion: Prevention can work

“The basics of what we do, is we teach skills to people: communication skills, healthy relationship skills, personal and emotional regulation skills, stress management, social and emotional learning skills. Our job is really to help people be who they truly are by helping them learn these valuable skills that they’re going to carry over to all aspects of their life. It’s not all about alcohol and drug education. It’s also about self management.” 124 The Opioid Crisis Exposed

Students’ drugs of choice: Alcohol, pot, vaping

October 31, 2018 Written by Maureen Bole

fficer Scott Fortkamp said he’s not seeing evidence of heroin or other opioid abuse among students at Westlake High School, where he’s been the school resource officer for 17 years. But it’s something he’s always worried about. The Westlake police officer said opioid abuse among Westlake students appeared to peak 10 years ago when three students were arrested for heroin-related crimes. But Fortkamp said he learned that a high school student sought professional treatment two years ago after using heroin. Alcohol and marijuana appear to be the drugs of choice today among students who abuse substances, Fortkamp said. This past spring, a student was arrested after a vaping device with marijuana residue was found in his car, he said. Fortkamp reported a couple of instances when students were caught with marijuana or drug paraphernalia The Opioid Crisis Exposed 125

on campus last school year, as well as a couple of instances spring, a student was arrested after a vaping device with marijuana residue was found in his car, he said. Fortkamp reported a couple of instances when students were caught with marijuana or drug paraphernalia on campus last school year, as well as a couple of instances of students being caught with alcohol on the high school grounds. The 22-year police veteran hopes media coverage of the epidemic has made students aware of how deadly heroin and other opioids are.

Sudden changes in a teen’s behavior are a major warning sign of drug abuse, Fortkamp said. He advises parents to be vigilant and not be afraid to check their child’s room and media devices. Don’t be your kids’ best friend,” he said. The National Association of School Resource Officers notes that no formal registry of such school-based officers exists. But the Alabama-based organization estimates that between 14,000 and 20,000 SROs are in service nationwide. The purpose of a school resource officer is to provide a safe learning environment, foster positive relationships with youth and develop strategies to resolve students’ problems, the organization says. Officer Keenan Cook is the resource officer covering Westlake’s elementary, intermediate and middle schools. He warns those younger students that heroin and other opioids are so dangerous they can 126 The Opioid Crisis Exposed

kill after a single use. Cook, a 13-year police veteran, warns students at Lee Burneson Middle School that “juuling,” another term for vaping, can lead to cigarette smoking. JUUL is the brand name of an electronic cigarette sold by PAX Labs. “It’s setting them up for addiction to tobacco products later on,” he said. Cook, who has helped teach the D.A.R.E. (Drug Abuse Resistance Education) program to the school district’s third-, fifth- and seventh-graders for the past six years, said establishing an early, positive connection between students and police is important. A third-grade student approached Cook after class last year to recount how a

few years before, she nearly died after drinking a bottle of cough syrup she had come across in her house. Cross asked her to retell her story to the class to underscore the dangers of drugs. Fortkamp and Cook said juuling is a growing problem. The vaping device looks like a computer flash drive and can be charged in a USB port. A 2016 study by the federal Centers For Disease Control and Prevention found that more than 2 million U.S. middle and high school students had used e-cigarettes within the past 30 days of the survey, including 4.3 percent of middle school students and 11.3 percent of high school students. The CDC warns that e-cigarettes contain harmful substances, including nicotine, heavy metals like lead, volatile organic compounds and cancer-causing agents. Fortkamp said juuling was first noticed at Westlake High School about two years ago and increased last year. Starting this week at North Olmsted High School, Officer Jim Carbone will issue citations to students possessing vaping devices. That means students and their parents will have to face a judge in Cuyahoga County Juvenile Court if caught with such items. Carbone, the resource officer at North Olmsted High School for 17 years, said a similarly aggressive approach several years ago against cigarette smoking on campus was successful. All North Olmsted High School students were recently shown a video warning of the dangers of vaping. “They’ve been forewarned,” Carbone said. Carbone said vaping became a problem last school year. Underage alcohol use among students has continued over the years at generally the same level, Carbone said. But opioid or heroin use at the school has not been an issue recently, he said. That does not mean Carbone is naive about the opioid threat. In recent years, he has attended the funerals of about a dozen North Olmsted High School graduates who died from opioid overdoses, he said. Carbone still mentors former students, some of whom have battled opioid addiction. They reported that their opioid use did not take place during their high school years. But some, he said, began abusing prescription medications obtained from friends or the family medicine cabinet. Overall, Carbone said prescription medicine abuse among students is a minor problem compared to alcohol and marijuana abuse. Carbone, who was recently named Ohio’s school resource officer of the year, said his colleagues have recently launched an email chain to share information about patterns of drug abuse. But the main goal of a school resource officer, he said, should be to establish a sense of trust with the community’s teachers, parents and students. Carbone does this through a constant presence at the school and extracurricular activities. He also periodically addresses science and health classes in grades seven through 10. Carbone’s message to the students is this: “You really police this school. You have to decide what kind of school you want.” It has not been uncommon for a student to tell Carbone of a friend who has begun The Opioid Crisis Exposed 127

abusing drugs. In such cases, Carbone calls the student to his office and confronts him or her with the information. Often, he said, the student will admit to the drug use. Carbone then contacts the parents, and the school tries to provide the family with the resources necessary to address the challenge. But in some cases, Carbone said, the parents become defensive and go into denial. Carbone believes marijuana use among students is on the rise. And he believes that the growing number of states that have legalized the drug is a contributing factor. “We have given them an excuse that it’s OK to use it because there are so many benefits,” he said. Calvin Cross, the school resource officer at North Ridgeville High School, is also concerned about the effect legalization is having on students. He worries legalization will increase students’ interest in marijuana and think using it is not risky. Criminals who have become addicted to other drugs have told Cross legalization is a bad idea because marijuana was the first drug they began abusing. Marijuana and alcohol appear to be the drugs students are most likely to start abusing, Cross said. Last year, Cross said a high school student was arrested for possessing what police said were gummy bear candies containing THC, or tetrahydrocannabinol, the active 128 The Opioid Crisis Exposed

chemical found in marijuana. Police believe he purchased them online from a state where marijuana is legal. But such arrests are rare, Cross said. “It doesn’t occur as often as people might think,” he said. Cross said recent studies indicate the majority of students who abuse drugs do so outside of school. “Kids know if they were to abuse drugs at school, the chances of getting caught are pretty high,” Cross said. “They don’t take that chance.” Cross said he’s seen no recent evidence of opioid abuse among North Ridgeville High School students. And he said while cigarette smoking isn’t a problem, juuling is a new phenomenon in North Ridgeville as well. “They think it’s safer to use than tobacco,” Cross said. But the oils used in vaping can contain nicotine or THC. Much of Cross’s time is spent doing what other school resource officers do – developing a rapport with the staff and students and serving as a deterrent to violent attacks. He sometimes mediates student conflicts, which are often fought on social media. “Every situation is different,” he said. Last year, Cross and the North Ridgeville Police Department investigated a New England man who contacted a girl at the high school online asking her to email him nude photos of herself. The department forwarded its evidence to the police where the man lives, Cross said. ♦

8 reasons why teens use drugs, alcohol Middle school and high school can be challenging times for adolescents. The Partnership for a Drug Free America has studied reasons teens start using drugs, alcohol and tobacco products and compiled the top 8 reasons they start:

1. Their peers

Teens often start using or drinking because their friends or people they associate with are doing it and it’s available to them.

2. Popular Media

With drug and alcohol use so rampant in music, TV shows and movies, some teens want to indulge like their idols do.

3. Escape/ Self-Medication

If teens don’t have a healthy outlet to channel negative emotions, they may turn to drugs or alcohol to make them feel better.

4. Boredom

Getting drunk or high gives teens “something exciting” to do.

5. Rebellion

Many middle/high schoolers feel the urge to rebel against their parents’ wishes during adolescence. Some do so by partying.

6. Instant Gratification

Drugs and alcohol produce a euphoric effect that can serve as a go-to for teens looking for a quick fix and happiness.

7. Lack of Confidence

Just as adults may use alcohol as a “social lubricant,” teens are prone to do the same to lower their inhibitions.

8. Misinformation

Even with the wealth of knowledge available about the risks of using drugs and alcohol, some teens disregard that information and think consequences will be minimal. The Opioid Crisis Exposed 129

Knowing the warning signs of teen drug use So many parents nowadays fear that their kids will turn to drugs for one reason or another. Especially with the opioid epidemic in full effect, that fear is even greater. Most parents know what it looks like if their kid comes home drunk, but do they know what it looks like when their kid is high? This graphic helps parents recognize the warning signs that their teen may be experimenting with something harmful. For more information or to see photos of these items, visit getsmartaboutdrugs.gov or drugfree.org.

How you kno kids are o

Here is a quick flags that an may be exp with d

Hallucinogen use | LSD, PCP, MDMA, mushrooms Warning signs:

▪ Dilated pupils ▪ Excessive sweating ▪ Loss of appetite ▪ Teeth grinding ▪ Jaw clenching ▪ Sleep problems ▪ Enhanced mood followed by severe depressive episode ▪ Dry mouth ▪ Tremors ▪ Panic or paranoia

Paraphernalia: Most hallucinogens don’t involve any specific tools to take the drugs. Therefore, it’s important to know what these drugs look like to spot their general use. See pages 16-17 or use the links listed above for photos.

Keywords:

▪ Drugs names: Acid, boomers, X, E, rolls, candy, hits, tabs, doses or sheets “Candy flipping” ▪ “Hanging out with” Lucy (LSD), Molly (MDMA), Dimitri (DMT) ▪ Talking about a journey, going on a trip

Stimulant use | Prescription pills, cocaine, crack, meth Warning signs:

▪ Hyperactivity ▪ Trouble sleeping ▪ Loss of appetite ▪ Weight loss ▪ Dilated pupils ▪ Aggression ▪ Paranoia ▪ Nosebleeds or congestion ▪ Overheating or excessive sweating ▪ Delusion, confusion 130 The Opioid Crisis Exposed

Paraphernalia:

▪ Rolled up bills or cut up straws ▪ Flat surfaces or small mirrors with white residue ▪ Needles or syringes ▪ Small spoons ▪ Glass pipes or lightbulb ▪ Razor blades or plastic cards (not in wallet)

Keywords:

▪ Pills: Adderall Ritalin, Vyvanse, Concerta ▪ Crack: Rock, hail that girl, stone ▪ Cocaine: Blow, white girl, snow or powder ▪ Crystal meth: crank ice, speed, chalk ▪ 8-ball or ball ▪ Point, line, bump

General teen drug use Warning signs:

• Irritable, hostile • Severe mood swings • Headaches • Persistent cough • Slurred speech • Glazed eyes • Lack of coordination • Drop in grades • Resisting discipline • Frequently asking for money or stealing • Isolating • Making excuses or lying constantly • Changes in friends, appearance

Paraphe

• Lighters • Small ba • Pipes: Us smoking • Foil: Use makeshif to melt d • For snort Tiny spoo rolled-up mirrors, blades or • For shoot Syringes, cotton ba tube, bel

What else to look out for...

Here are a couple other harmful teen drug-use trends for parents to keep an eye out for: Inhalants: Common household products can be abused by huffing (breathing in) to give the user an immediate high. These products include glue, paint thinner, nail polish remover, computer duster, gasoline, spray paint and whipped cream dispensers or “whippets.” Cough Syrup: When taken in large doses DXM, the primary ingredient in cough syrup, can produce a euphoric high and hallucinations.

w do ow when on drugs?

Benzodiazepine, Tranquillizers, Sleeping Pills: Popular prescription medications like Xanex, Valium, Klonopin, Ambien, Lunesta which are used to treat sleeping and anxiety disorders are commonly abused. These medications are highly addictive and should be kept out of reach. Vaping: With the prevalence of e-vapor alternatives to help adult cigarette smokers quit, a new epidemic has emerged with teens. Although the amount of carcinogens is lower in these products, the nicotine levels are still very high; making them very addictive.

k guide of red n adolescent perimenting drugs.

Marijuana use | Marijuana buds, wax, edibles, hashish Warning signs:

red flags:

ernalia:

aggies sed for drugs ed for a ft pipe or drugs ting drugs: ons, straws, p bills, razor r cards ting drugs: , spoon, alls, pen lt

Keywords:

• Getting lit, messed up, faded, turnt, etc. • Going to pick up, cop, meet up, etc. • Metric system: - Ounce (zip or O) - Quarter (¼ ounce) - Eighth (⅛ ounce), half quarter, slice or ball, 8 ball - Gram (or dime) - Point (0.1 gram) • Pill doses (in mg): - XR, ER, XL (extended release) - 5s, 10s, 20s, etc.

▪ Glassy, red eyes ▪ Slurred speech ▪ Dry mouth ▪ Uncontrollable laughter ▪ Increased appetite ▪ Lack of motivation ▪ Fatigue ▪ Difficulty focusing ▪ Disrupted memory ▪ Slowed or poor coordination

Paraphernalia:

▪ Rolling papers ▪ Bongs or pipes ▪ Tiny metal screens ▪ Blow torch ▪ Grinder ▪ Apple with holes in it (used as a pipe) ▪ Items used to mask the smell: Incense, deodorizer or a toilet paper roll with dryer sheets in it

Keywords:

▪ Hanging out with Mary Jane or buds ▪ Meetings at 4:20 ▪ Hearing unusual terms used to identify a specific strain (i.e. Lemon D, OG, Purp, Northern Lights) good-quality (kush, fire, chronic) or poor quality (reggie, dirt, mids).

Opiate use | Prescription pills, heroin, fentanyl Warning signs:

▪ Fatigue ▪ Loss of appetite ▪ Unexplained weight loss ▪ Constricted pupils ▪ Excessive scratching ▪ Nodding out ▪ Constipation ▪ Flu-like symptoms (fever, sweating but shivering)

Paraphernalia:

▪ Missing spoons, finding spoons with burn marks on the bottom ▪ Needles or caps from syringes (orange or blue piece of plastic) ▪ Belts, pieces of metal, mangled seat belts in car (used as a tie off)

Keywords: ▪ Prescription: Opana, Percocet (percs) Vicodin (vikes), codeine (lean) ▪ Heroin: Smack, horse, that boy ▪ Fentanyl: China Town, poison ▪ Shoot or shoot up ▪ Getting well or getting straight

The Opioid Crisis Exposed 131

Stopping before starting Prevention efforts and programs inform and educate about alcohol, drugs, healthy behaviors

October 31, 2018 Written by Maureen Bole

ather than cope with the world around them, some people seek an escape through drugs or alcohol. It’s not difficult for those methods to become habits or the main coping mechanism. It’s even more likely (and more dangerous) for teens and adolescents, whose brains are still developing. In February 2017, the Partnership for a Drug-Free America compiled the top eight reasons teens start doing drugs, based on studies and surveys. Escape and self-medication, rebellion, instant gratification and lack of confidence were cited as reasons teens turn to drugs, tobacco and alcohol. How does society help prevent this? Experts advise providing resources to help young people with those underlying problems, a strategy that includes drug prevention programs. “There’s a lack of awareness and knowledge of how drugs and alcohol affect people in the long run,” said Jose Flores, associate director of prevention at LCADA Way, a recovery organization that serves Lorain and Medina that helps individuals and families dealing with drug and alcohol abuse. “This is a society of instant gratification, in adolescents and adults. If we continue down that road and don’t provide something to offset that, our society will become diseased.” LCADA Way offers prevention programs tailored to meet each school or organization’s needs. They are used in 12 of the 14 Lorain County school districts. What makes its programs unique is personalized programming, attention to the underlying causes of drug and alcohol use and education about the risks of using substances as coping mechanisms, Flores said. “The basics of what we do, is we teach skills to people: communication skills, healthy relationship skills, personal and emotional regulation skills, stress management, social and emotional learning skills,” Flores said. “Our job is really to help people be who they truly are by helping them learn these valuable skills that they’re going to carry over to all aspects of their life. It’s not all about alcohol and drug education. It’s also about self management.” Flores said that without those skills, people resort to alcohol and drugs to fix these interpersonal problems. They don’t know how to self-regulate their emotions.

132 The Opioid Crisis Exposed

Every year, the Bay Village Kiwanis has an anti-drug, alcohol and tobacco poster contest for area students. Winners from the 2018 contest pose here with their posters.

“So what they wind up doing is turning to some form of escapism, whether it’s food, sex, drugs, alcohol,” he said. “ And in our program, the skills they learn can carry across a multitude of addictions.” In Cuyahoga County, D.A.R.E (Drug Abuse Resistance Education) programs are prevalent in most public and private schools. The mission and vision of D.A.R.E. is to create “a world in which students everywhere are empowered to respect others and choose to lead lives free from violence, substance abuse and other dangerous behaviors.” The organization does this by placing local law enforcement officers into schools to lead lessons for students in kindergarten through 12th grade. Programs are tailored for elementary, middle-school and high school students. The curriculum is based on Socio-Emotional

Learning Theory, which identifies “fundamental, basic skills and developmental processes needed for healthy learning.”These skills include self-awareness, responsible decision making, communication skills and handling challenges. The Opioid Crisis Exposed 133

What do they teach in school prevention programs? One of the programs the LCADA Way brings into schools is Botvin LifeSkills Training. The program has proven effective in helping youth to remain drug-free, to reduce or stop using drugs and to avoid high-risk behaviors such as violence and gambling. Here is a quick glance at the scope and sequence for the program for grades 8 and 9: ►Drug Abuse - Causes and Effects: Analyzing risk factors; personalizing and generalizing information on risk of use and abuse. ►Making Decisions: Decision analysis; recognizing options; application of decision-making process ►Media Influences: Analyzing and resisting media influences, in general and specific to drug use. ►Coping with Anxiety: Anxiety selfassessment; building and reinforcing repertoire of healthy stress reduction techniques. ►Coping with Anger: Recognizing anger, its causes, and consequences; identifying reasons and techniques to control anger. ►Social Skills: Practicing greetings and brief social exchanges; differentiating between superficial, informational, and “deep” conversations, and practicing “deep” conversation skills. ►Assertiveness: Analyzing situations; identifying and practicing effective responses; saying no, making requests, asserting rights, expressing feelings; verbal and non-verbal assertive skills. ►Resolving Conflicts: Analyzing conflict resolution choices; applying life skills (anxiety and anger reduction, decision-making, communication, social, and assertiveness skills) to resolve conflicts ►Resisting Peer Pressure: Further practice in applying assertive skills in peer situations; identifying and responding to persuasive tactics 134 The Opioid Crisis Exposed

Community members’ support can help instill these skills and beliefs in youths. Reiterating and showing youngsters these ideals outside of the classroom could motivate them to live productive, healthy lives. Each year, the Bay Village Kiwanis encourages Bay Village Middle School students to craft posters with positive messages to fight drug, alcohol and tobacco use. The Kiwanians believe it’s important for kids to learn about the harmful effects of drug and alcohol use. First-, second- and third-place prizes are awarded to students with the strongest messages and most dynamic art while 18 other students receive Judges Choice awards. This year, Elizabeth Carney won first place for her poster that reads, “Don’t let smoking burn you…” with an illustration of a hand where some of the fingers were drawn in as burning cigarettes. Other winners included Sarah Kah’s poster of a person getting lost in a pool of pills with the message “Why fall in the first place?” and several posters showing the message “Be smart, don’t start.” All of these programs share a holistic approach to teaching prevention. They create a safe environment for youths to develop life skills that are critical for a prosperous and healthy future. However, there is no definitive way to gauge the success of prevention programs. “You really can’t measure the quality of a prevention program by what didn’t happen,” Flores said. “If we do our job right, people don’t have issues. Or their issues are minimized or more manageable because of the skills they learn from us. Looking at that, we think, ‘How do we measure that?’ We don’t in the moment. In the future you will.” Flores recalled a recent encounter with a student: “Whether you know it or not, the things you taught me, the things that we talked about made a difference in me staying out of trouble and staying off of drugs. Now people probably don’t tell you that, but I’m telling you that,” the student said. “For me, why I do what I do is because I really care about people,” Flores said. “I really care about these kids. And I want to help them be better. And I love doing it in my community. It’s really gratifying for me.” ♦

Meet our community’s resource officers

“S

October 31, 2018 Written by Maureen Bole chool resource officers are sworn law enforcement officers responsible for safety and crime prevention in schools. SROs serve as educators, emergency managers, and informal counselors. — The U.S. Department of Justice

AVON

David Layne School: Avon Middle School How long at school: 3 years Previous job: Patrolman Favorite part about being a resource officer: Getting to know all the students and being there for them whenever they need help or guidance.

Patrick Sullivan School: Avon High School How long at school: 5 years Previous job: Beachwood police Favorite part about being a resource officer: I find it very rewarding working at the schools, helping the students navigate their way. What I find amazing is the teamwork and commitment that is displayed on a daily basis.

AVON LAKE Brian Hurd School: Avon Lake High School, Erieview Elementary, Redwood Elementary and St. Joseph Parish School. How long at school: 11 years

Previous job: Detective Favorite part about being a resource officer: I enjoy working with the kids and provide real-life experiences so once they graduate they are better prepared in college or in the career of their choice. It is important for kids to build relationships with officers so they have someone they can trust and talk to anytime if they need help or are having problems.

Robert Walborn School: Learwood Elementary School How long at school: 1 year Previous job: Patrolman Favorite part about being a resource officer: I enjoy the positive interactions with the students. When most people think of police encounters such as getting pulled over for speeding they think of it as a bad thing, or they are getting in trouble. Therefore it’s nice to be able to interact on a daily basis with students without the negative connotations. It’s also rewarding to feel like you’re making an impact in their lives even if it’s just helping them with a minor problem they may be having. The Opioid Crisis Exposed 135

NORTH OLMSTED Jim Carbone School: North Olmsted City School District How long at school: 18 years Previous job: Patrolman Favorite part about being a school resource officer: A school resource officer’s job is education, enforcement and counseling. My favorite part is counseling. I enjoy and take pride when students reach out knowing they can go to any adult in the school. I take the counseling very seriously and know how important it is to make an impression because it might be the difference between a good or bad decision that might last a lifetime.

NORTH RIDGEVILLE Calvin S. Cross School: North Ridgeville High School How long at school: 7 years Previous job: Patrolman Favorite part about being a school resource officer: Building relationships with the students and staff in an effort to create a positive and safe environment.

ROCKY RIVER Mike Bernhardt School: Rocky River High School How long at school: 7 years Previous job: Patrolman Favorite part about being a resource officer: Having the opportunity to positively impact the youth in our community as they ready themselves 136 The Opioid Crisis Exposed

for life after leaving our community and go on to college and beyond with life lessons that can help to make them the best people in whatever direction they go on to as our future citizens and decision makers in our society.

Matthew Blazer School: Rocky River Middle School How long at school: First year Previous job: Patrolman Favorite part about being a resource officer: Working with kids every day and building relationships between juveniles and the police.

SHEFFIELD Keith Pool School: Sheffield-Sheffield Lake schools How long at school: 6 years Previous job: Lorain County Correctional Officer Favorite part of being a resource officer: Helping students stay focused on getting the ultimate prize, their high school diploma, while making sure they stay out of the legal system.

WESTLAKE Scott Fortkamp School: Westlake High School How long at school: 18 years Previous job: Patrolman Favorite part about being a resource officer: The relationships you build with students and staff. It’s the people you will always remember most.

Patrick Foye School: Lee Burneson Middle School How long at school: 1 year Previous job: Patrolman Favorite part about being a resource officer: The youth that we interact with today are the future of tomorrow. I look forward to interacting with them in positive environment and keeping the schools safe.

Ted Morley School: Dover Intermediate School How long at school: First year Previous job: Lakewood City Police Neighborhood Policing Favorite part of being a resource officer: Having just started this new stage of career, is looking forward to interacting with parents, staff and students. ♦

What SROs may help with The U.S. Department of Justice lists some activities that school resource officers may be involved in: ►Handling requests service calls in schools ►Conducting safety and security assessments ►Developing, implementing safety plans, strategies ►Responding to unauthorized persons on school property ►Serving as liaisons between the school and other police agencies, investigative units, or juvenile justice authorities when necessary and consistent with applicable civil rights laws and privacy laws; ►Serving as a member of a multidisciplinary school team to refer students to professional services within both the school (guidance counselors or social workers) and the community (youth and family service organizations) ►Building relationships with juvenile justice counselors to help connect youth with needed services ►Developing and expanding crime prevention efforts for students ►Developing and expanding community justice initiatives for students The Opioid Crisis Exposed 137

OPINION: THE VIEW OF A RECOVERING ADDICT

Why prevention works, and why it didn’t for me

October 31, 2018 Written by Maureen Bole

hen I was in fifth grade at St. Mary of the Falls school in Olmsted Falls, a D.A.R.E officer came to our school to talk about the risks of alcohol, drugs and tobacco. I remember some of the lessons, the discussions, writing a paper about what I learned about and even taking a pledge to remain drug free. Obviously that didn’t work out as planned. Honestly, I don’t remember learning about how to cope with my issues or life skills that were talked about in this week’s articles. Maybe that was a part of the program I zoned out on or maybe those components weren’t covered back in 2002. But either way, the words didn’t penetrate. I did stay drug and alcohol free until my freshman year. And there were a number of reasons why I started: I thought it was fun, I wanted to rebel and I used it to feel better about myself. When it came to drugs, I wanted to experiment and see what it felt like. I heard all of the risks and side-effects of drugs and instead of deterring me, they enticed me. I disregarded all the health and mental risks because I thought I was invincible. I thought that stuff only happened to other people, that it would never happen to me. In high school, I heard more about those risks. And they got to me a little bit more that time around. But again, I brushed them off. When I would get in trouble, I would wind up in prevention classes again with the same messages. It was like I thought it was all a big joke. I remember being in one prevention class that I had to go to because I got caught drinking by my high school. There were seven of us in that class who clearly didn’t want to be there. Coincidentally, all seven of us wound up at the same house party that weekend after a football game. Going into college, the reasons I drank and did drugs began to change from fun to necessity. I started doing them to cope with my life, for self-confidence and to just feel numb. I thought that if I educated myself about drugs and alcohol, learned all I could about them, that I could control it. And I thought I was controlling it. But in reality, they were controlling me. I got high to get up, to go to class, to study, to go out, to sleep. I needed a drug or a drink for everything I did. When I wanted to celebrate, I partied. When I was sad, I did drugs until I felt numb. When I was angry, I used them to blow off steam. Honestly, I thought prevention had failed me. But it was I who failed at prevention. If I 138 The Opioid Crisis Exposed

would have listened and taken what the instructors were saying more seriously, maybe I wouldn’t have started. Maybe if someone told me I would lose a lot of my friends, lose interest in all of my past times, fail classes and have to drop out of college right before graduation, I would have stopped. But I was so hard headed, it may have not made a difference. But it would have helped to have more access to learning healthy coping mechanisms and ways to handle stress. That’s information I really could have used because I feel like 80 percent of what I heard was “Drugs and drinking are bad, don’t do them.” I wasn’t told what to do instead. All prevention programs can do is give kids the tools, skills and knowledge they need. But it’s the kids who determine what they do with all of that. They either use it to stay drug free, or they ignore it and wind up on a downward spiral like I did. Of course there are some in-between, who drink and do drugs and wind up without an addiction. What youth have today that I didn’t have in my early adolescence are a multitude of prevention programs and resources. Programs that are available to them in school, after school, throughout the summertime for all 13 years of their education. And those programs are different now. They focus on every aspect of prevention from learning healthy coping mechanisms and communication skills to drug and alcohol education. These programs are telling kids the risks of drugs and alcohol, and also telling them how to cope. They’re trying to instill confidence in them so when they’re faced with that choice to drink or do drugs, they choose to say no. And they make that choice for themselves, not because someone told them what to do. ♦ The Opioid Crisis Exposed 139

part

In the tenth part of the series, we focus on methods to reduce the collateral damage of the epidemic ♦ Harm reduction ♦ What is harm reduction? ♦ Community Outreach

harm reduction

♦ Law enforcement ♦ Opinion: ‘Get over it’

“This needs to stop. We need to do something to help. There are some people in the community who think they aren’t affected. If you think it doesn’t affect you, you are mistaken.”

140 The Opioid Crisis Exposed

Harm reduction: Controversial, yet necessary for the epidemic

December 5, 2018 Written by Maureen Bole

here are several different methods of addressing problems within the opioid epidemic. Prevention programs strive to stop the problem before it starts with education; detox and treatment programs work to get a using addict clean and help them find a new way of life. Harmreduction programs fall somewhere in the middle. The goal of harm-reduction programs has been around for decades. Most initiatives started outside of the United States but have slowly made their way to our country as the opioid epidemic has intensified. One popular harm-reduction program, now present in both Cuyahoga and Lorain counties, is a needle or syringe exchange. These programs offer a place to dispose of used needles and receive new, clean syringes. “Being a part of the needle exchange, at first I was like everyone else. ‘That’s enabling drug users I don’t want to do nothin’ like that. I don’t want a job like that.’ But then they broke it down for me, the purpose of being out here is to stop the spread of HIV,” said Chico Lewis, with the Circle Health’s Needle Exchange program in Cleveland. “Once I got educated about the program and had the proper training, it was more understandable.” The main goal is to prevent the reuse of needles to curb the spread of HIV, hepatitis C and other blood borne diseases that are spread between intravenous drug users (IDUs). It also provides for safe disposal of used syringes. Recent data shows that this specific program may be accomplishing that goal. The Ohio Department of Health published a report documenting a 56 percent drop in new HIV infections associated with IDUs since 2012 in Cuyahoga County. The Circle Health Needle Exchange program offers more than just clean needles. The agency provides injection supply bags, instruction and education for safer injection, condoms, fentanyl test strips, referrals for doctor and dental visits and ultimately, referrals to detox or treatment centers. Lewis is on a first-name basis with many needle exchange clients. He believes it is important to build trust and help them know they’re not alone. “The whole object is to build a relationship with them so we can get the client to the point that they can get some type of help.” The Opioid Crisis Exposed 141

One of the goals of harm reduction programs like needle exchanges is to keep hazardous waste out of public areas and waste disposals.

This year in Lorain County, a group of philanthropic and community organizations joined forces to create a coalition to combat the epidemic. Their September progress report showed that although their main focus has been on establishing a recovery center, they are also looking into a syringe exchange program in the county. “In Lorain County between 2012 and 2016, the number of people infected with Hepatitis C increased by 522 percent from 99 people to 616 people,” reported Health Commissioner Dave Covell in a report on harm reduction. “To protect the public’s health, we are developing solutions to curb this dramatic increase of Hepatitis C in our community.” “When considering the health care, treatment, and criminal justice costs associated with the opioid epidemic are $50 million in Lorain County alone, harm reduction programs like syringe exchange make good human and economic sense for everyone in the community,” the report said. The group has already received approval and funding for a syringe exchange and plans to open the program in the near future. This reporter did not receive a response from the coalition with further details. Although syringe/needle exchange programs seem to be the most popular form of harm reduction in the wake of the epidemic, they are not the only methods. Many agencies have been actively dispensing Narcan (covered in the March package of the opioid crisis series), the opioid overdose reversal medication, in order to prevent overdose deaths. Medically-assisted treatment (methadone clinics, Suboxone, Vivitrol- covered in the August package of the opioid crisis series) is also seen as a harm reduction tactic by some as it provides addicts with a prescribed, low dose opioid (or opioid blocker) to keep them away from the street drugs. 142 The Opioid Crisis Exposed

A tactic that has not yet reached Ohio are consumption rooms, or safe injection sites. These sites are places where addicts can obtain clean needles and do their drugs under the watch of a trained medical staff. Studies from this method of harm reduction in other countries have shown a decrease in overdose deaths, public drug use, spread of bloodborne infections and improper disposal of needles. However, in the U.S., this method is highly controversial and organizations who start them may face consequences from the justice department. Although the main goal of all of these programs is to minimize the potential harm caused by using drugs, the ultimate goal is to get addicts the help they need. Syringes can be exchanged at the Circle Health Clinic on Euclid Avenue. Although both locations are in urban area, Lewis’ clients come from all over Cuyahoga and surrounding counties to exchange. During the interview, Lewis had two clients looking for a set of clean needles for the weekend. When asked for their basic information and zip codes, both clients stated 44012, the Avon Lake zip code. Lewis gave them their kits and suggested they also have overdose kits on hand over the weekend. He asked the couple if they needed anything else before they left and before sending them on their way he reminded them: “Whenever you two are ready, I know of a good detox program going on.” The interview with Chico Lewis was adapted from Episode 5 of the Cover2 Resources Podcast conducted by Greg McNeil. ♦

Where do harm reduction methods fall on the spectrum? One thing that many experts and medical professionals can agree on is that when it comes to addiction and treatment, it’s important to meet the addict where they’re at. Services and programs are tailored to help keep those who are using alive, as safe as possible and eventually, clean throughout their process to find longterm recovery. There are a variety of methods used to make this possible: HARM REDUCTION These methods are meant to minimize the harms that stem from drug use and to help keep users safe and alive with hopes they seek out treatment. ▶ Syringe exchange: Injection drug users (IDU) can obtain clean supplies, fentanyl test strips and instruction on how prevent infection. -Goal: To keep IDU’s free from infection or disease transmission that may occur from sharing or using dirty needles. ▶ Project DAWN: Naloxone kits and training are provided to drug users and community members. -Goal: To prevent overdose fatalities. MEDICATION-ASSISTED TREATMENT MAT programs offer a helping hand to those who are seeking recovery and need some extra help. ▶ Suboxone, Subutex: These medications help drug users ease out of their physical dependence by tapering the presence of opioids out of their system gradually. ▶ Vivitrol: This medication completely blocks opioids so the addict would not be able to experience a high if they use. -Goal: To act as a “crutch” for those in treatment until they are strong enough in their recovery and psychologically to stand on their own. The Opioid Crisis Exposed 143

What is harm reduction? “Harm reduction refers to policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs.” — Harm Reduction International

BROAD GOALS: • To keep people alive and encourage positive change • To improve drug laws/ policies and law enforcement practices (see facing page). PREVENTION

Stopping the problem before it starts

• To provide access to the best quality evidence-based programs and methods • To ultimately prevent or end illegal drug use

HARM REDUCTION

TREATMENT

Reducing the collateral damage of the problem.

Finding the solutions to the problem.

Harm reduction falls somewhere in between prevention and solutions, with the ultimate goal of getting drug users into treatment. Note: IDU stands for Intravenous Drug Use(r)

METHODS: SYRINGE EXCHANGE A service where IDUs can bring used needles, safely dispose of them and obtain new, clean needles. GOALS: • Prevent the spread of bloodborne diseases • Proper disposal of dirty needles • Provide referrals to counseling or treatment

NALOXONE PROGRAMS

DRUG TESTING KITS OR STRIPS

SAFE INJECTION SITES

A strip that allows users to test their substance to ensure it is what they think it is.

Facilities where addicts use illegal drugs under medical supervision.

GOALS: • To help drug users avoid taking more dangerous substances • Prevent accidental overdose • When reported, can help researchers follow trends in illicit drug markets

GOALS: • Prevent public drug consumption • Provide overdose intervention • Prevent the spread of bloodborne diseases • Provide referrals to counseling or treatment

N2 N2

MEDICALLYN2 ASSISTED N2 N2 TREATMENT N2

COMMUNITY OUTREACH

Providing medication to reverse the effects of an opioid overdose.

The prescribing of low dose opioids or opioid blockers.

An organization of community members working together to help in an epidemic.

GOALS: • Counteract permanent damage to the central nervous system • Prevent overdose deaths • Keep addicts alive, ideally, for them to seek treatment in the future

GOALS: • To prevent the use of street drugs • To curb possibility of overdose • To serve as a crutch for addicts to get through the beginning stages of treatment

GOALS: • To help addicts feel like they’re a part of; not alone • Provide education and information • Provide referrals to counseling or treatment

144 The Opioid Crisis Exposed

LOCAL HARM REDUCTION FIGURES: 12

The Needle Exchange

IDU Infections

4,000

The number of clients who use the needle exchange in 2016.

8 6 4 2 0

50,000

The number of syringes exchanged in the program every month

By sharing or reusing needles, infections can be contracted or develop in IDUs: Blood borne • HIV • Hepatitis B • Hepatitis C Bacterial • Cellulitis • Skin abscess • MRSA • Staph • Sepsis

10 Percentage increase

While the rate of new IDU associated infections has been climbing steadily in Ohio, it has been decreasing in Cuyahoga County. Experts contribute this decline to the Needle exchange program in Cleveland.

2012

2013

2014

2015

State of Ohio

2016

2017

Cuyahoga County

Project DAWN

Community Outreach Programs

MATs

The number of times a life was saved with Narcan in five years. Note: These are instances, not individual people

of individuals targeted by Project SOAR in the first three months of 2018 initiated services

increase in the amount of money Medicaid spent of Medication-Assisted Treatment from 2014 to 2016 in Ohio

1,685

57%

43%

of individuals who accepted help from Let’s Get Real Inc. are involved in some level of recovery treatment

1780%

FALSE OR FACT? • Harm reduction methods may keep users stuck in their addiction: Fact, however, studies have concluded that most methods have a high success rate of connecting addicts with treatment when they’re ready. • Harm reduction methods encourage illegal drug use: Fact, however, the premise of all methods is that using drugs is harmful, but the problems (disease, infection, death) IDUs face can be lessened. • Harm reduction methods undermine prevention methods: False. Harm reduction programs were created to help those who already have a drug problem; to curb the consequences to society and the using addict.

• Harm reduction facilities are harmful for the community: False. Studies have shown that syringe programs help keep dirty needles out of public place and open waste receptacles. It also makes it less likely for drug users to shoot up in public places like bathrooms or in their car in a parking lot. • Harm reduction legislation makes it too easy for drug users to get high without consequences: False. Some of these laws and criminal punishments can actually be detrimental to the overall wellbeing of the drug user. The ultimate goal of these regulations should be to eventually rehabilitate, instead of imprison, the at risk individual. The Opioid Crisis Exposed 145

Community Outreach organizations make a difference in epidemic

December 5, 2018 Written by Maureen Bole

ccording to data on the Cuyahoga County Medical Examiner’s monthly report, the current drug epidemic our communities are facing is the most deadly in state history. Lawmakers and officials have been scrambling for solutions, but many community members have taken matters into their own hands. Community outreach programs and organizations mix prevention, harm reduction and treatment solutions in their efforts to reach addicts who are still suffering. The goal of these programs is to meet addicts where they are, and guide them to treatment. One program, SOAR (Supporting Opiate Addiction Recovery), is a groundbreaking rapid response program in Lakewood. The program operates through peer support, instead of law enforcement or medical professionals. SOAR is partnered with the ADAMHS Board of Cuyahoga County, Cleveland Clinic Lakewood Emergency Department and Woodrow Project. Those suffering with addiction (from any city) can walk into the Lakewood’s Fire station No. 1 (on Madison Avenue just east of Warren Road.) or the Cleveland Clinic - Lakewood Emergency Department for help. All individuals who agree to go will be immediately admitted to treatment. SOAR peer support volunteers also meet with individuals who have recently overdosed while they are still in the Lakewood ER to discuss treatment options. These “specialists” are usually recovering addicts who have are well into their “clean time.” Also, any Lakewood resident who overdoses will receive a home visit within days of their hospital release. Gina Bonaminio, a 24-year-old Amherst High School graduate, is working as a SOAR peer outreach specialist. An outspoken voice in the Ohio recovery scene, said she does this to encourage others to speak up and to combat the negative stigma of addiction and mental health. Shortly after graduating high school, Bonamino started using heroin. She also became addicted to opioid painkillers after jaw surgery. She noted that around 2011, law enforcement started cracking down on pills, which lead many addicts to switch to heroin. “For me, it wasn’t a decision,” said Bonaminio. She was constantly sick and needed to go to work, so she felt she had no choice. “I had a chronic disease in my head,” she said, adding that she was lucky enough to 146 The Opioid Crisis Exposed

Volunteers of Assist Communities and TAP United create care packages to distribute to recovery facilities during the holidays.

never have overdosed. She’s been clean since 2015. Although she finds helping people to be rewarding, she added, “We’re literally sprinting to catch up to this (epidemic), and we’re not even close.” Let’s Get Real Inc., another program utilizing peer-support, has expanded significantly since its inception in 2013. The group recently moved to their the former Dombrowski-Riddle Funeral Home building in Lorain to accommodate the growth. The organization offers a weekly meeting for families and children with an addict in the family. It works with law enforcement and willing agencies to provide outreach and support for those who have overdosed. Similar to SOAR, addicts can also go to any Lorain County Police Station to ask for help. A statecertified peer-support volunteer (who must be someone in long-term recovery) will be on call 24/7.

The results speak for themselves. “Forty-three percent of the people accepted our assistance are in detox, treatment, recovery housing or reconnecting with 12-step and sober support,” director Kim Eberle said. Volunteers also follow-up, making sure addicts are on the right path, even driving them to probation appointments for drug tests. Aside from the state-certified peer specialists, Let’s Get Real Inc. is comprised of volunteers who want to give back and help make a difference. The Opioid Crisis Exposed 147

The relationship between volunteers Recovering Children & Education) to do and addicts is integral. But another just that, and more. link that seemed to be missing was the Addiction has run rampant in relationship between these advocates Elefteriou’s family. She was married to an and stakeholders who bring treatment addict for 13 years. Now divorced, her exresources to the community. husband is still using. She took custody of Grassroots organizers like Jim Coyne of her nieces when they were adolescents Assist Communities (formerly Assist Avon because her sister is an active addict. Lake), have long maintained that rapport Her brother is an alcoholic. Addiction through pulling resources together into has even gripped the lives of her own a centralized database and through a children. better use of technology, some of these “I have four kids, two of them are gaps in service can be filled with existing my own, two of them are my nieces,” resources. Coyne believes that through Elefteriou explained. “Three of the four of help from volunteers, local solutions can them were addicted to opiates. They are be found for local problems. all in recovery now.” In addition She explained to acting as a that after fighting “There is strength in numbers. clearinghouse her own personal Instead of trying to decide whether for recovery battle with it’s a choice or its a disease, why resources and addiction and don’t we decide to work together information, Assist seeing how it to find an answer.” Communities could adversely Rene Elefteriou founder of the BA Force also launched the affect the lives of C.A.R.E package her loved ones, program several she felt like she years ago. In conjunction with TAP had to do something. United, Assist creates care packages “It doesn’t discriminate, it’s in all of our to distribute to sober home and other communities. You cannot hide it,” she recovery facilities across the area during said. “Families cannot feel ashamed. the holidays. The organization is now Silence is deadly. You have to speak out working with the United Church of Christ and let others know in the community in Avon Lake to continue the “blessing that there should be no stigma. These bag” initiative in Lorain County and are our sons, daughters, mothers and beyond. fathers. You don’t have to like an addict, Another goal of community outreach but remember, these are human being organizations is to break the stigma who have families that love them.” that is associated with addiction and Elefteriou and the BA Force seek to the epidemic. Rene Elefteriou of Parma help families who are also affected started an organization called the BA by addiction or who have lost a loved Force (Battling Addiction Families Of one. She helps refer people to detox or 148 The Opioid Crisis Exposed

Volunteers of the BA Force pose for a quick photo after their addiction awareness walk.

treatment centers and talks to family members of addicts on the phone frequently. The BA Force hosts a walk every September which draws hundreds of people. The walk brings together a lot of other community outreach groups as well. “I started BA Force because I want to continue to help people and families,” she said. “This needs to stop. We need to do something to help. There are some people in the community who think they aren’t affected. If you think it doesn’t affect you, you are mistaken.” Elefteriou believes that if everyone can put their differences and opinions aside, that a solution can be found. “There is strength in numbers,” she said. “Instead of trying to decide whether it’s a choice or its a disease, why don’t we decide to work together to find an answer.” The interview with Rene Elefteriou was adapted from episode 124 of the Cover2 Resources podcast. Nicole Hennessy contributed to this story. ♦

Get involved Become a peer support specialist, Safe Passages guide, outreach volunteer, organize or participate in a rally or make a donation. Conact the organizations to find out how you can help fight the epidemic. Project SOAR katherine.kurtz@lakewoodoh.net BA Force baforce4addiction.weebly.com Let’s Get Real Inc. letsgetrealinc@gmail.com Assist Communities join@assistcommunities.org Safe Passages madam@olmstedtownship.org Hope over Heroin 844-HOPE-777 The Opioid Crisis Exposed 149

Law enforcement officials step up response to crisis

December 5, 2018 Written by Maureen Bole

ommunity volunteers aren’t the only ones making strides to combat the addiction epidemic. Law enforcement officers across the Westshore and its surrounding communities have joined forces to help make a difference as well. The Westshore Enforcement Bureau Drug Task Force (WEB) concept was established decades ago, but has recently shifted its focus to opioids. WEB is a multi-jurisdictional unit whose outreach includes Bay Village, Lakewood, North Olmsted, Rocky River, Westlake and Fairview Park. Officers in these communities are specially trained to respond to crisis situations such as natural disasters, snipers, bomb threats and now the opioid epidemic. Earlier this year, WEB launched a quick response team in partnership with MetroHealth Medical Center’s Office of Opioid Safety – a program started in July of 2017. The plan is to send out a social worker and WEB officer to the home of anyone who overdoses. Now that WEB is stepping up with its outreach program, all of these programs are slowly creating a regional network. The city of Parma will also join forces with WEB. Jeff Capretto, special agent in charge of WEB, also sits on the board of Cuyahoga County’s drug court. He makes it a point to attend successful participants’ drug court graduations. People in drug court go through a period where they have to prove they’re in recovery instead of facing criminal charges, after which they graduate from drug court. Another trend in law enforcement action against the epidemic is an initiative known as PAARI or the Police Assisted Addiction Recovery Initiative. PAARI was created in Massachusetts in 2015 to help opiate addicts get treatment rather than “using the power of arrest to combat the problem.” After identifying heroin as a major public health issue affecting their communities, the Berea and Olmsted Township Police Departments have partnered with PAARI to organize their own outreach initiative. Safe Passages, the local PAARI program, is a quick response team that works through the two police stations to help escort addicts to treatment. Safe Passages is now active in 10 communities across Northeast Ohio. ♦

150 The Opioid Crisis Exposed

OPINION: THE VIEW OF A RECOVERING ADDICT

It’s a crisis: Don’t tell me to get over it

December 5, 2018 Written by Maureen Bole

recently was reading about media coverage of the opioid crisis. Most of those commenting were positive and grateful for the information. But some comments opened my eyes, including: “Continued drug coverage. Get over it! It’s their choice.” Get over it? Get over it. It’s their choice? I’m sorry, sir or madam, but have you even read about how this is a declared public health crisis? About how addiction is a brain disease? Of the excruciating journey of recovering addicts who have been through hell and back to reclaim clean, productive lives? Let me tell you why I can’t “get over it.” When I was a little kid, I didn’t want to be an addict when I grew up. When I drank for the first time in high school, I had no idea it would be the beginning of eight years in the grips of addiction. I did not CHOOSE to be an addict. I did not CHOOSE to lose friends and fail classes. I did not CHOOSE to wind up in the hospital several times. That’s not the life I wanted for myself. But at the time, it was the only type of life that my brain could comprehend. Using was as important in my brain as basic survival needs. I take that back. On most days, my brain told me that using was MORE important than eating, sleeping, having a safe place to sleep and my health. Please explain to me how that was my choice? “Well you CHOSE to do drugs and drink,” is the response I hear most. Sure, I did. But so do thousands of other people. Maybe I wouldn’t have started if I knew that’s what my future would turn into. But since I’m not psychic and I was 14 years old when I started drinking (which also counts as getting high, it’s just more socially acceptable), I had no idea I was an addict. And even if I did consistently “chose” to continue drinking and doing drugs, does that mean I deserved to die? I am 26 years old. I have been to more of my friends’ funerals than I have my friends’ weddings. I have seen my friend’s mother, father and sister sob over their 28-yearold son/brother’s casket. I have seen my friend’s daughter and husband completely numbed by their mother/wife’s untimely death. Should they “get over it?” You want to tell the parents who lost their children prematurely that it was their kid’s choice and to get over it? You want to tell the kids who are now orphans because their parents overdosed together that it was their parents fault and to get over it? You want to dismiss the grief of the hundreds of families in our communities who will go through The Opioid Crisis Exposed 151

the holidays without a loved one? Because THAT’S who you’re talking to when you’re saying “get over it.” This is the most deadly epidemic to hit our counties in history. Drug overdoses continue to be the leading cause of injury-realted death in Ohio. In our country, someone dies from an overdose every 12 minutes. This epidemic has cut short the lives of hundreds of thousands of people and broken millions of families. I commend the dozens of organizations, community leaders, religious community members, medical professionals, lawmakers and law enforcement officials who have taken the initiative to combat the scourge of opioids and now cocaine, especially to the organizations mentioned in this month’s stories. It gives me hope to see how many more people are staying focused on the solution. I stand with the thousands of Ohioans who are trying every day to make a difference. I’m proud of that. I’m proud that I am able to have this opportunity to speak up for people who cannot speak up for themselves. If it weren’t for the people who went out of their way to promote recovery and treatment I wouldn’t have had a chance at the life I have now. If I would have given up and crumbled under the power of my addiction, you would be reading my name in the listing of addicts who died from an overdose instead of in a column titled “The view of a recovering addict.” No, I will not get over it. Because my life and the lives of the thousands of using addicts still suffering in our communities are worth the fight.♦ 152 The Opioid Crisis Exposed

part

In the eleventh part of the series, we focus on treatment programs and methods ♦ Treatment plans ♦ Road to find recovery ♦ Coalition to end the epidemic

treatment

♦ Getting clean, giving back ♦ Opinion: Surviving the horrors

“A lot of what we talk about in our early recovery treatment programs involves education, the nature of addiction and how our judgment and decision making has been very subtly, yet powerfully corrupted by the addictive disorder. Recognizing that addictive thinking before a full-blown relapse occurs is so critically important.” The Opioid Crisis Exposed 153

Individualized treatment plans give addicts a chance at new life

February 6, 2019 Written by Maureen Bole

he opioid epidemic is a living breathing monster, with ever-increasing drug potency, younger addicts … and deaths. The faces and treatments have both changed. “Twenty years ago, most of our patients were 40-50-year-old alcoholics,” said Orlando Howard, director of outpatient services at St. Vincent Charity Medical Center Rosary Hall in Cleveland. “Today, the average age on our wing is 27. Twenty years ago, we admitted five to seven opiate addicts a week. Today it’s five to seven a day.” The start of the long-term recovery journey begins by cleansing the bodies, but withdrawal is scary for many addicts. Dr. David Streem, addiction specialist at The Cleveland Clinic, explained that the medical detoxification program at the Clinic strives to prevent debilitating withdrawal. “When people suffer from withdrawal symptoms, that doesn’t determine how they do,” Streem said. “There’s no benefit from experiencing that discomfort. It’s just suffering for no real value. We want people to be clear headed and feeling physically well so they can focus on the hard work ahead of them.” Although getting an addict through withdrawal is an important component that, if untreated, could lead to their continued drug use and possible death, it is not the only piece of the puzzle. “Detox is not the answer,” Howard said. “You stay in detox for five to 10 days. If you get out and don’t follow it with any other kind of treatment, the chances for staying clean are unlikely. Those who enroll themselves in an inpatient or intensive outpatient program followed by a non-intensive outpatient program and/or sober living, we’ve found that they are more successful.” Streem explained that when an addict has been using for an extended period of time, parts of the brain become dependent on the stable level of that drug; meaning that the brain has physically changed by chronic exposure to the drug and that change has caused those parts of the brain to become insensitive to the drug. When the use of the substance is abruptly stopped, the brain becomes hyperactive, which affects areas of the body controlled by the brain. This is how withdrawal symptoms occur. But beyond initial withdrawal, the brain is still altered from the chronic abuse. Which is why extended treatment is so important. After making it through withdrawal, individuals seeking recovery have a number of options for extending their treatment plan (see page 10 for details). These treatment plans

154 The Opioid Crisis Exposed

are individualized based on the person’s drug use (duration, quantity, etc.), co-occurring mental health disorders, physical health problems and social support. Common components in these programs include group therapy, education, relapse prevention and individual therapy. “A lot of what we talk about in our early recovery treatment programs involves education, the nature of addiction and how our judgment and decision making has been very subtly, yet powerfully corrupted by the addictive disorder,” Streem said. “Recognizing that addictive thinking before a full-blown relapse occurs is so critically important. “The second thing we spend a lot of time talking about is getting a better understanding of how we feel our feelings,” he said. “Many people who come into treatment say they don’t have feelings anymore, which isn’t true, but they feel like they don’t understand how to perceive them and how to describe them. Helping patients develop a better understanding of how to perceive what actual feelings they’re experiencing teaches them to apply the tools we help them to develop much more effectively.” Howard agreed that extended treatment plans and long-term recovery are crucial for success. “They are giving their brains time to heal,” Howard explained. “Their brains have been hijacked and rewired by drugs. Treatment gives the brain time to heal. Addicts need time to work on their thinking. Staying in treatment long term will allow them to do that.” Unfortunately, relapse is all too common. “The average person in opioid addiction treatment will go through treatment five times before they achieve sustained sobriety,” Streem said. He also notes that an individual’s previous attempts to get clean should not be seen as failures. “What we’re very interested in at The Cleveland Clinic is trying to understand how to identify, describe and measure the benefits that patients get from each of their treatment programs even if they don’t achieve sustained sobriety as the postscript to each of those programs,” he continued. “When you ask people who do have sustained sobriety whether or not they got anything positive from each of their treatment programs, they will most always say they learned something valuable from each program. But if you only look at whether they relapsed or not, in the case of someone who has been through five treatment programs, that the the first four programs were failures and the fifth as a success. And that really misses our opportunity to understand why they needed five treatment programs.” After treatment programs are completed, the work is still not done for an addict seeking recovery. It is a daily battle. Most treatment programs recommend involvement in a 12-step fellowship, participation in long-term recovery, to continue that battle to avoid relapse. “This is a chronic relapsing disease. As long as treatment is continued, they have a chance,” Streem said. When asked what was meant by the term “long-term recovery” Howard, a recovering addict himself, responded, “As long as I’m breathing, I’ll be in recovery. I will never graduate.” ♦ The Opioid Crisis Exposed 155

Rough road to find recovery The stigma most of society has toward addicts is that they are hopeless individuals who have character flaws that can’t be cured. “Why don’t they just stop using?” The unfortunate truth is that it is not that simple. Actively using addicts would love to “just stop,” but they can’t. Addiction is a physical and psychological disease that deprives the addict of the choice and ability to stop using on willpower alone. Although there isn’t a cure for addiction, there is hope for addicts to change their ways and escape the grips of their fatal disease. With a structured treatment plan and the aid of medical professionals and support groups, addicts can actively work on retraining their brain. Those who were hopeless can find relief from their disease in long-term recovery, but the road to finding freedom from their addiction isn’t an easy one.

Living with addiction is like being a puppet. Every move is controlled by the obsession and compulsion to use.

COMPULSION

Using drugs becomes the main focus of the addicted person’s life. Family, jobs, school, etc. take a back seat to chasing their drug of choice.

DETERIORATION

A drug user quickly loses control to their addiction. They no longer feel that unparalleled euphoria. Instead, they use to feel normal.

Most persons have to seek outside help for their addiction since most cannot stop on sheer willpower alone.

TIME AND LENGTH

COMMON SYMPTOMS

First stage: Lasts 5-10 days More physical withdrawal symptoms occur during this stage.

▪ Tremors ▪ Muscle aches ▪ Cold sweats ▪ Insomnia ▪ Nightmares ▪ Loss of appetite ▪ Nausea, vomiting ▪ Heart palpitations ▪ Shallow breathing ▪ Shakiness ▪ Anxiety

WITHDRAWAL/DETOX Before going into treatment, the substance(s) must work itself out of the person’s system. Severe symptoms from the absence of the drug occur during this process.

REHABILITATION An integral part of getting clean are treatment programs. These rehab programs are structured into different levels* to help ease the recovering person back into society abstinent from drugs. 156 The Opioid Crisis Exposed

INPATIENT TREATMENT A rehab program that lasts 30-90 days. The client temporarily resides at a facility for the duration of their program for daily treatment sessions.

When someone uses drugs for the first time, they feel an unparalleled euphoria. This first feeling is often the reason some addicts move on to stronger substances for a better high.

OBSESSION

A drug user begins to become preoccupied with getting high and finding drugs. Their tolerance steadily increases.

POST-ACUTE WITHDRAWAL

ACUTE WITHDRAWAL

SEEKING HELP

FIRST USE

TIME AND LENGTH Second stage: Lasts for about 2 years More psychological, emotional withdrawal symptoms occur during this stage.

COMMON SYMPTOMS

RELAPSE

▪ Mood swings ▪ Poor concentration ▪ Disrupted sleep ▪ Vivid Dreams ▪ Low enthusiasm ▪ Low energy, fatigue ▪ Limited focus ▪ Depression ▪ Irritability, hostility ▪ Stress sensitivity ▪ Panic attacks

TREATMENT

Structured treatment programs function in a variety of settings and intensities. The purpose of these programs is to take a holistic approach to treating a person’s addiction.

IOP* TREATMENT

AFTER CARE

A rehab program lasting 6-8 weeks, of structured 3- to 5-hour long daily group treatment sessions.

after IOP offering extendend-care sessions once a week. These sessions can often continue as long as the addict needs them.

A rehab program

A relapse can happen at any point if a person is not taking the necessary precautions to maintain their recovery outside of the treatment setting.

By actively seeking recovery, an addict can free themselves from their obsession and compulsion to use and find freedom.

SOBER LIVING Some individuals in recovery choose to live in a halfway house during/after treatment.

OTHER SUPPORT GROUPS

There are hundreds of support groups for addicts in the country that are not based in the 12-steps. One of the more popular alternatives is SelfManagement and Recovery Training or SMART. This program focuses more on scientific approaches to conquer addictive behaviors. The nonprofit’s approach to behavioral change is built around a 4-Point Program: (1) Building and maintaining the motivation to change. (2) Coping with urges to use. (3) Managing thoughts, feelings, and behaviors in an effective way without addictive behaviors. (4) Living a balanced, positive, healthy life.

12-STEP PROGRAMS

STEP 1: We admitted that we were

powerless over our addiction, that our Members of these fellowships share their experience, strength and hope with each other through meetings, lives had become unmanageable sponsorship and other events so they may solve their STEP 2: We came to believe that a Power common problem and help others to recover from greater than ourselves could restore us to alcoholism and other addictions. The program, sanity. known as “The Twelve Steps” provides a framework for self-examination. A recovering addict will work STEP 3: We made a decision to turn our will and through all 12-steps with a sponsor’s guidance. our lives over to the care of God as we underThose seeking recovery through a 12-step stood Him. program are often encouraged to embrace the “fellowship” by making new friendships STEP 4: We made a searching and fearless moral inand associations with others who are ventory of ourselves. also choosing the path to recovery. STEP 5: We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

*Note: Not all recovering persons STEP 6: We were entirely ready to have God remove all these participate in this specific structure of treatment. Some patients may defects of character. only need outpatient treatment where others need more STEP 7: We humbly asked Him to remove our shortcomings. care in residential. The steps listed are from STEP 8: We made a list of all persons we had harmed and became willing to Narcotics Anonymous. make amends to them all. Step wording varies slightly between STEP 9: We made direct amends to such people wherever possible, except fellowships.

when to do so would injure them or others.

STEP 10: We continued to take personal inventory and when we were wrong promptly admitted it. STEP 11: We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. STEP 12: Having had a spiritual awakening as a result of these steps,we tried to carry this message to addicts, and to practice these principles in all our affairs. FAMILY SUPPORT GROUPS

It can be helpful for family members of those in recovery to seek help for themselves also. See the list of resources on page 180 for family support groups.

TAKING CARE OF MENTAL HEALTH

A crucial component to prosperous recovery is to tend to any dual-diagnosis.

HEROIN ANONYMOUS

COCAINE ANONYMOUS

DUAL DIAGNOSIS: COMPLICATING RECOVERY FOR ADDICTS It’s crucial for those seeking recovery to also seek treatment for any cooccuring mental disorders, or a dual diagnosis. Studies from the National Alliance on Mental Illness, half of those who have a substance abuse problem also suffer from another mental illness. The most common disorders found in dual diagnosis people are anxiety, depression and bipolar disorder.

As a person in recovery comes to know their inner workings, they can begin to find new, healthy coping mechanisms to help them live without using drugs.

Not tending to other mental health concerns can pose a serious risk for relapse. In 12-step programs, these other disorders are considered “outside issues;” meaning that 12-step programs are meant to help an addict find relief from addiction, but outside help (therapy, medication, etc.) must be sought when managing mental health disorders other than addiction.

ABSTINENCE

In order to have a chance at staying clean/sober, a person in recovery must abstain from using any mood, or mind-altering substances, including their drug of choice.

ALCOHOLICS ANONYMOUS

NARCOTICS ANONYMOUS

SUPPORT GROUP

Most treatment programs require patients to attend support group meetings outside of treatment.

CHANGE

Eliminating drug use is just one small part of ongoing recovery. A recovering person must make changes to their lifestyle, learning how to deal with problems in new ways.

The Opioid Crisis Exposed 157

Philanthropic coalition working to bring resources to Lorain County

February 6, 2019 Written by Maureen Bole

ail or the emergency room? That is the dilemma facing law enforcement and crisis facilities as the opioid crisis has continued its destructive march forward, ebbing and flowing with intensity. Underlying issues that caused the addictive behavior often went unaddressed, sabotaging attempts to get clean and sober. One local group of philanthropic organizations and community members has been working to develop a more comprehensive treatment model in Lorain County. “In the summer of 2017 we brought together some different agencies in the county working on the epidemic,” said Dr. Don Sheldon, board member of the Nord Foundation and a medical professional. “It was clear to us at that point as a board, that the biggest crisis facing our country was the opioid epidemic. We decided to attack it.” Soon after, the Altarum Institute was brought in to do a full assessment of Lorain County. “We knew we had a problem but we wanted to know how bad it was,” Sheldon said. “Tell us how big the problem is, how big the burden is, what we’re doing, what we’re not doing, where the holes are in care.” By the end of 2017, Altarum published its analysis for the Nord Foundation. Not only did the institute lay out the hard numbers of how the epidemic was affecting the county, but also how to tackle the issues. The recommendations were broken into six “strategies,” the first being to “further develop efforts to encourage multiple stakeholder involvement and collaborative decision-making.” And with that, the Philanthropic and Community Coalition to End the Opioid Epidemic was established. “Our first goal was to get our arms around the problem,” Sheldon said. “We had to define it, quantify it. If you can’t properly identify the problem you can’t fix it. We identified several areas of significant need. One is, we needed better coordination between the agencies. Not that they aren’t already working together, but we needed to kick it up a notch.” The coalition’s main goal is to use the information, data and strategies from Altarum to protect the community of Lorain County “from further human devastation and the significant economic burden of the opioid epidemic.” The coalition is comprised of major organizations and agencies across Lorain County including The Nord Family Foundation, the Community Foundation of Lorain County, the Black River Education and Wellness Foundation, the Road to Hope House Inc., The Nord Center, Lorain County Public Health, Lorain County Board of Mental Health, LCADA Way, Firelands Regional Medical Center and the Alcohol and Drug Addiction Services (ADAS) Board of Lorain County. 158 The Opioid Crisis Exposed

Philanthropic and Community Coalition to End the Opioid Epidemic progress

Community Assessment Recommendations Further develop efforts to encourage multiple stakeholders’ involvement and collaborative decision-making Action taken: The philanthropic coalition was formed to work in conjunction with existing agencies in Lorain County. Develop a full continuum of accessible care and related services including prevention, detox, treatment, recovery and harm reduction Action taken: The coalition is working on several plans to address these five points: ► Prevention: Bring additional programming to school systems to establish more uniformity. ► Detox, treatment & recovery: Bring nonexistent services (sub-acute detox, men’s residential treatment, etc.) to the county, research best practices on where to house

them and link them with existing services and agencies. ► Harm reduction: Needle exchange program will launch in Wellington at the end of February. Institute an education component Action taken: The coalition plans to create a multi-faceted anti-stigma campaign to educate the public about addiction and mental health. Review current national, state policies Action taken: Coalition members have made a number of site visits across the country to observe best practices for a full continuum of care. Develop a system of data collection Action taken: A Lorain County data dashboard has been established on the coalition’s website.

Work teams in the coalition were established in March 2018 as the group began to get to work. The month prior, a group from the coalition began site visits around the country to observe other treatment models and best practices. “We’ve tried to be consistent with communications. Any site visits we do, best practices we find we try to bring that back and make that a part of the conversation. That’s really important from a communications standpoint,” said Cindy Andrews, president and CEO of the Community Foundation. “We’ve created work teams charged with a task who then come back and report to the coalition. We don’t need to recreate, but we wanted to see what’s working. And through our site visits to maybe take a piece from this model and that model.” Some of the issues brought to the coalition’s attention were the holes in care and how to prioritize those needs. Sheldon said the holes include the number of detox beds, psychiatric support, residential beds for recovery and some best practices other communities have, such as needle exchange programs, methadone clinics and medically assisted treatment were necessary for Lorain County’s prosperity in the midst of the epidemic. “One thing that came up several months into our process was not only how we can get these agencies together but how we can bring multiple services under one roof,” Sheldon said. “That’s where the concept of the Golden Acres building came up.” Golden Acres, a vacant former nursing home on North Ridge Road in Elyria, was the focus of the coalition for most of 2018. The group had visions of putting many of the services the county needed under one roof in this facility. Originally built as a tuberculosis The Opioid Crisis Exposed 159

sanitarium, the structure had a good base for a treatment center, but still needed plenty of work. The coalition figured it would take a couple million dollars to get the facility to an operational level, not including the funds it would take to get it up and running with staff and resources. “Golden Acres came into play in April,” Andrews said. “As we continued to march down that path we discovered that the cost to make that facility what we wanted it to be kept growing and growing.” Hitting a wall with funding, Issue 14 was put on the ballot in November 2018. The 0.3- mill additional levy was planned to help fund “Recovery One,” the new name for the one-stop recovery center on the Golden Acres site, for five years. The levy would have raised $2 million annually for the center. Issue 14 failed, with 52 percent voting against it. The group coalition began to regear its discussion. What drove the discussion previously was fitting services into a structure. But now the focus is more on what are the best and most necessary services and what is a centrally located, fiscally responsible solution to house those services. “We’ve talked about the model for a continuum of care,” Andrews said. “Because, when it comes down to it, it’s not about the facility, it’s about the model.” One model that the coalition has found along its site visits is the concept of “onedoor access.” This model features one physical door, that is open 24/7 to receive patients with addiction and mental health problems. “From there, the person is assessed on three major components: where are 160 The Opioid Crisis Exposed

they on the addiction spectrum, on the behavioral health spectrum and on the social side: family support, job, means of paying, etc.,” Sheldon explained. “From there, that information is devised into an individualized treatment plan.” A primary goal for the coalition is how to combine treating addiction and mental health treatment plans. “It really is that assessment across the county,” Andrews said. “The coordination of care is really one door, but moreso, getting back to what each individual needs.” “Initially when we were looking at the big project we were thinking that we have all of these needs, let’s put them all under one roof at Golden Acres,” Sheldon said. “But now we’re looking at the critical core of front door as a project, not to ignore the residential and recovery. They may or may not be co-located. We just took the big idea and broke it down into smaller pieces so we can hopefully have more success.” The group also is opening a harmreduction clinic in Wellington, centralizing prevention presentations in school systems and working on a countywide anti-stigma campaign. The coalition plans to have a more concrete look on the continuum of care concept by the end of the month. It hopes to develop a system that someday becomes a model for the rest of the state. “It’s about having respect for the individual,” Andrews said. “And it’s no different from what you would do with any other disease.” Progress reports, project data and donation information can all be found on the coalition’s website at www.endtheepidemiclc.org. ♦

Getting clean and giving back After overcoming addiction, two friends return to the treatment center that helped them get clean to help others find hope

February 6, 2019 Written by Maureen Bole

or most high school teenagers, day-to-day life usually consists of school, extracurricular activities, hanging out with friends and doing homework. But for 17-year-olds Cami, of Westlake, and Kalie, of North Royalton, their days were consumed with driving to East Cleveland to buy drugs and get high for one more day. Although the two didn’t know each other at the time, their addictions began in a similar fashion. It didn’t take long for the girls, who already partied frequently and hung around with the wrong crowd, to get caught up with heroin. After using other drugs for a couple years, Kalie was introduced to pain pills at 16 after suffering a softball injury. After reconstructive surgery, she couldn’t play softball anymore. She lost her grandfather and two uncles within a couple weeks. The pills quickly switched from a pain remedy to her way of self medication. Pills soon became too expensive, so in 2013, at age 17, she started using a cheaper drug – heroin. For Cami, it started by getting drunk at a party when she was 15. She recalled the feeling from that night, saying that was the first time she felt like it took away all of her problems and insecurities. Her addiction continued to progress as she began seeking out different friends and a better high. “I grew up in Westlake and, at the time, the nickname for my high school was ‘Heroin High,’” Cami explained. “The group of kids I started hanging around with were using it and I got curious. I was 17 and went to a bonfire with my friends and wanted to try it. And as soon as I did it I just thought, ‘This is what I’ve been looking for and it’s going to take away all the pain I feel inside.’” After less than a year using heroin, Kalie saw her grades slip, she was skipping school and she got arrested, forfeiting her chance at walking with her class at graduation. That summer, she made her first attempt at getting clean. She started to detox at home before heading to inpatient treatment. “I wanted to die,” Kalie explained. “I remember begging my mom to make it go away. I was so sick with cold sweats and the shakes. I would go from the bath to the bed and I was so weak that my mom had to help me in and out of both.” The Opioid Crisis Exposed 161

Cami and Kalie worked to overcome their addictions and now work at the same treatment center that helped them get clean as counselor aides.

Cami’s disease also progressed quickly. After using heroin for a couple months, she was expelled for getting caught with drugs. She sought treatment after her expulsion because even with such severe consequences, she couldn’t stop using. Unfortunately for both, their first treatment experience wasn’t the end of the story. They wound up relapsing, time and time again after attempts to get clean. Each relapse took them to lower places, as their diseases pushed them to make absolutely irrational decisions with no regard for consequences to feed their addictions. Both recognize that they didn’t take treatment seriously their first 162 The Opioid Crisis Exposed

couple times; that they were intolerant to suggestions and wound up going back to the same groups of people when they got out. “I was hopeless at that point. I thought I was going to die with a needle in my arm,” Cami said. “I felt like it was impossible for someone like me to get recovery.” After three long years of using, getting heavily involved in crime and catching criminal charges, Cami and Kalie wound up in treatment together in 2016 in Ashtabula County. Both girls had been in this particular treatment center twice before. But each time they returned, they

were welcomed back with open arms from the treatment center staff. “When I walked in there that time, I felt like an elephant got off my shoulders,” Kalie explained. “I was so broken and that’s how I gained the willingness to do whatever it took to stay clean. I knew there was a better way of life and I wanted it.” This time was different for both girls. They got honest, really opened up about some of their past traumas and let the treatment center staff help them where they needed it most. A lot of the staff were recovering addicts themselves, allowing them to personally relate to the struggles Cami and Kalie had throughout their active addiction and previous attempts to get clean. The girls successfully completed the inpatient treatment program together, becoming great friends in the process. They each moved into three-quarter way houses, completed Intensive-outpatient programs, after-care programs and immersed themselves in Narcotics Anonymous. Both girls had finally found recovery through their tireless efforts, celebrating a year clean together in 2018. In late November of 2018, Cami and Kalie were contacted by the treatment center where they got clean together. There were positions available as counselor aides. Ecstatic, the girls applied for the positions, interviewed and soon walked back through the doors of the treatment center with employee badges, instead of patient wristbands. “I remember being a patient there and how much the CA’s helped me,” Cami said. “They talked through everything with me and helped see things in a different way. I always wanted to be that for someone someday in the future. And now I can make that impact in someone’s life.” As CAs, the girls help facilitate 12-step meetings, help with admissions, drug screens, monitor and talk with the patients to let their counselors know if someone is struggling. “I’m able to really relate to the patients,” Kalie explained. “I’ve been in all of the different mindsets so I’m able to meet them where they’re at. I know what it was like to be at the bottom and completely hopeless. I just want to help people like people helped me. There was just something in my soul that drew me to it.” “I’ve been through a lot in the past 10 years in regards to my using and I’ve gained a lot of knowledge on what to do and what not to do,” Cami said. “I’m just grateful that I made it out alive so I can offer my experience, strength and hope to other people.” After years of feeling lost, completely broken and hopeless, Cami and Kalie use their experiences to carry a message of hope and freedom to the patients of the treatment center each day they go into work.

“I’m able to give back to the place that started me off, showed me love and made me believe that I was worth it,” Kalie said. “And now I have the opportunity to do that for all of the people coming in.”

The Opioid Crisis Exposed 163

OPINION: THE VIEW OF A RECOVERING ADDICT

Surviving the horrors of withdrawal to find recovery

February 6, 2019 Written by Maureen Bole

n March 18, 2014, I woke up at my drug dealer’s house in a panic. I had slept through my morning class again, crippling my attendance grade. My friends were all mad at me from my recent volatile behavior. I had drained my bank account again. But worst of all, I was out of drugs and booze. I was coming off a three-week long binge and I had nothing left to take the edge off. I had to get high, I had to get this feeling to go away. I went home and found the little bit of drugs left. I used it, even though I really didn’t want to. But it wasn’t enough. It wasn’t close to being enough to get high. So I tried to sleep it off. But I couldn’t stay asleep. I kept jolting back into consciousness, gasping for air with a shooting pain through my chest. My heart kept stopping, which sent me into a crippling panic attack. I couldn’t feel my fingers. I couldn’t breathe. Now my heart was pumping so fast I felt like it was gonna beat right out of my chest. I just curled up into the fetal position and viciously shook until I was able to calm down enough to go get help. I walked up the street to psychological services and got honest about my drug use for the first time in my life. As soon as I sat down on the couch in the psychologist’s office, another panic attack ensued. She wanted to call my parents. She said I needed to go to rehab. I couldn’t drop out of Ohio University now, I sobbed. I was supposed to graduate in six weeks. But I needed those feelings to go away. I felt like everyone hated me. I hated myself. I felt like the walls were closing in on me and there was nothing to stop the impending doom I felt crushing my very existence. After an hour of panic attacks and crying, I finally let her call my parents. My dad left Cleveland to come pick me up at school. I stayed in the fetal position in the back seat of the car the entire three-hour ride home: sweating profusely, trembling, coughing. I kept forgetting where I was and what was going on. He stopped and tried to have me eat something. As soon as I smelled food I vomited in the parking lot. My parents were stunned by my appearance. In addition to my horrific behavior as I continued to detox my eyes were sunk in, I had lost 20 pounds, my skin was yellow, hair thinned and I smelled of drugs and alcohol no matter how many times I bathed. When I got home to my mom’s I crawled into bed with her as she hugged me and I continued to shake and cry. I was exhausted but I couldn’t sleep. That’s when the hallucinations started. Blood-thirsty tigers pacing around the bed, cars crashing through the wall of our apartment – horrific scenes that seemed all too real in the dead of night.

164 The Opioid Crisis Exposed

The next day, the delirium was absolutely debilitating. The tremors and heart palpitations got worse, which I didn’t even think was possible. I stayed curled up in that same ball with a death grip on my childhood Pooh bear stuffed animal and blankie absolutely hysterical as each episode of sheer terror came and went. I had an appointment at a treatment center for an evaluation that afternoon. At 22, I refused to leave the house without Pooh and blankie. I was a complete wreck, reverting back to the comforts of my childhood to try to make it through each crippling second. When I got to the treatment center, they wanted to admit me into inpatient. They said that the withdrawal symptoms from my long-term alcohol abuse could provoke a grand mal seizure or heart attack. But I was scared. I couldn’t fathom being away from my parents at this point. The compromise was that I wasn’t to leave their sight for the next five days of my detox at home so they could make sure I wasn’t slipping away to my untimely death. I was enrolled in Intensive Outpatient Treatment that day; a six-week long program for three hours a day, four days a week. Part of the agreement was to also go to three 12-step meetings a week outside of treatment. The woman (who became my counselor) explained to me that I was an addict, that I had a disease that has no known cure other than long-term recovery. She continued to tell me that it was a day-by-day process and each day it would get a little easier as long as I didn’t get high. But to get there I had to be ready. I had to be done. I had to become willing to make changes in my life. And in that moment, I was hurting so bad. I was so broken. I was willing to do whatever anyone said to just make the pain go away. I saw a magnet on my counselor’s desk that read “Let go or be dragged.” I told her I liked it because I could relate to it, so she gave it to me. Today, that magnet hangs on my desk at work: a humble reminder of that day. I never want to forget that message or the way I felt that day at the peak of detox, being admitted into rehab. The date was March 19, 2014, the first day I didn’t get high in years. And little did I know, it was the first of 1,422 days I wouldn’t get high. That was the day I decided to let go instead of letting my addiction continue to drag me to death. And I haven’t thought twice about that decision since that day. ♦ The Opioid Crisis Exposed 165

part

In the twelfth part of the series, we focus on treatment programs and methods ♦ Barriers to the epidemic ♦ A year of the epidemic ♦ The series in review

s y n o p s i s

♦ Opinion: Fighting the stigma

“The more we can drive policy and reimbursement structures to support coordinated or integrated care, the more we are going to see an impact in a patient’s overall health.” 166 The Opioid Crisis Exposed

Treatment costs, delays can hinder treatment for addiction

April 3, 2019 Written by Maureen Bole

lthough the 2010 Affordable Care Act expanded health insurance coverage for substance abuse disorders, many persons with addictions face hurdles paying for treatment, according to doctors and counselors. And the adoption of medically assisted treatment of opioid use disorder, increasingly considered the standard treatment by addiction experts, has been inconsistent. Many addicted persons lack health insurance when the first seek help, reports Ken Holt, a clinician with Recovery Resources, an outpatient mental health agency with offices in Lakewood and Cleveland. In such cases, the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County can provide funding for the initial stages of treatment, Holt said. But that doesn’t pay for prescription drugs or medication management appointments, he said. Recovery Resources helps many clients apply for Medicaid, and coverage can be backdated Holt said. And the agency has experts who help people navigate the health insurance maze. The purchase of the agency by MetroHealth System, Cuyahoga County’s public health system, in October has provided more resources. But other Ohio counties don’t have as strong a support system in place for those fighting addiction, Holt said. In such cases, components of a treatment plan may have to be delayed, he said. Faced with such delays, a person may abandon treatment, he explained. “Motivation can vary from one week to the next,” Holt said. Treatment is more likely to be successful when all components begin at once than if a 30-day wait is required for health insurance coverage to start, he said. The working poor with minimum wage jobs may not qualify for Medicaid, Holt said, or may be underinsured and therefore unable to pay the out-of-pocket expenses of addiction treatment. “Those are the individuals I really worry about,” Holt said. An April 2018 Kaiser Family Foundation report said the Medicaid program covers a disproportionate share of opioid addiction treatment. Among nonelderly adults with opioid addiction, those with Medicaid are significantly more likely than those with private insurance or those who are uninsured to receive treatment, the report said. According to 2016 figures, 43 percent of addicted persons with Medicaid received treatment, compared to 21 percent with private insurance and 23 percent with no insurance. The Opioid Crisis Exposed 167

Another Kaiser reports said the cost of treating addiction and overdoses was eight times higher in 2016 than in 2004, rising from $300 million to $2.6 billion. The average inpatient cost in 2016 for opioid addiction treatment was $16,104 annually in 2016, up from $5,809 in 2004. That same year, $2.3 billion in addiction and overdose services was covered by insurance, while $335 million was out-of-pocket expenses. Dr. Shawn Ryan, the past president of the Ohio Society of Addiction Medicine and founder of BrightView, a outpatient addiction medicine practice in southern Ohio, said the high deductibles charged by private insurance plans can stop people from getting treatment. “If they have a $5,000 deductible that can be a huge barrier,” Ryan said. “They may not be substantially motivated to seek help.” Ryan is a strong advocate of medically assisted treatment, or MTA, the use of three FDA- approved medications (buprenorphine, naltrexone and methadone) to relieve physiological cravings and normalize body functions. “We’ve known that medication assisted treatment is the right decision for patients with opioid use disorder for a decade,” Ryan said. “Medication assisted treatment is absolutely the standard of care for opioid use disorder.” In its November 2017 report, the President’s Commission on Combating Drug Addiction and the Opioid Crisis reported the use of MAT is been associated with reduced overdose deaths, retention of persons in treatment, decreased heroin use, reduced relapse, and prevention of the spread of infectious disease. Yet there’s been some resistance to MAT in the medical community. A January 2019 study from researchers at the Johns Hopkins Bloomberg School of Public Health found that only 36.1 percent of addiction treatment facilities offered MAT for opioid use disorder in 2016, up from 20.0 percent in 2007. The President’s Commission identified insurance barriers to MAT, such as “failfirst” protocols that require that a patient try counseling before MAT, as well as prior authorization requirements that can delay the start of treatment. But Ryan said private insurance companies have been removing prior authorization requirements. 168 The Opioid Crisis Exposed

MAT should be used in combination with counseling and behavioral therapies to provide a “whole-patient” approach to the treatment, according to the Substance Abuse and Mental Health Services Administration, an agency of the U.S. Department of Health and Human Services. But according to the Society for Behavioral Medicine, many treatment programs fail to integrate the behavioral component of MAT. “Programs that deliver only the medical component are essentially providing partial treatment and are subsequently likely to have poorer outcomes and higher relapse rates,” the organization said in a 2018 policy statement. A shortage of qualified behavioral treatment specialists contribute to the problem, the statement said, but limited insurance coverage is a more pervasive problem. Although the Affordable Care Act broadened a 2008 law requiring insurance companies to cover mental health conditions in the same way as medical and surgical care is covered, reimbursement for psychological treatment is often less than for other specialities, Ryan said. Enforcement of the insurance parity law is difficult because the rules are complicated, he said. From a patient’s perspective, travelling to four or five different locations for the various services involved in addiction treatment can be burdensome, Ryan said. “The more we can drive policy and reimbursement structures to support coordinated or integrated care, the more we are going to see an impact in a patient’s overall health,” Ryan said. ♦

Only 1 in 4 with opioid use disorder getting treatment Six-hundred thousand Americans received treatment for an opioid use disorder in 2017, according to the federal Substance Abuse and Mental Health Services Administration, up nearly a third from 2016. Yet only about one in four people - 28.6 percent with the disorder received speciality treatment, the U.S. Surgeon General’s office said. Only about 12.2 percent of adults who need treatment for a substance use disorder receive any type of speciality treatment, according to “Facing Addiction in America: The Surgeon General’s Spotlight on Opioids,” published in September 2018. And 45.5 percent of people with a substance use disorder also have a mental disorder, yet only about half receive treatment for either disorder. The stigma associated with drug abuse make people less likely to seek help, the report said. Other contributing factors cited include the cost of care and a lack of drug abuse screening in general health care settings. And some with an alcohol or drug problem simply feel they do not have a problem, the report added. The Surgeon General noted four specific challenges to combating the opioid crisis: • The substance use disorder treatment system is underprepared to support care coordination; • The primary care system has been slow to implement medication-assisted treatment (MAT) as well as prevention, early identification, and other evidence-based recommendations; • The existing health care workforce is already understaffed and often lacks the necessary training and education to address substance use disorders; and • The need to protect patient confidentiality creates hurdles for sharing of information. The Opioid Crisis Exposed 169

The epidemic in review In 2018 the CDC stated that accidental overdose was the leading cause of death for adults younger than 50 in the United States. Its studies also show that life expectancy is down, which can be attributed in part to the epidemic. Although the Midwest remains the hardest hit by the epidemic, it’s still a problem that’s faced at a national level. According to the National Survey on Drug Use and Health, in 2018 in the United States: - 140 people died every day from an opioidrelated overdose -10.3 million people misused prescription opioids, 20% of those were new users - 808,000 used heroin, 10% of those users picked up the drug for the first time this year

As one of the states at the epicenter of the crisis, Ohio is seeing death tolls slightly decrease as it continues the battle. The map below charts the number of overdose deaths that occurred in each city featured. Lorain (32) and Elyria (30) had the highest number of incidences in Lorain County and Lakewood (23) and Parma (27) had the highest number for the suburbs of Cuyahoga County. Cleveland, with the most county residents, recorded 287 overdose fatalities in 2018.

SHEFFIELD LAKE SHEFFIELD VILLAGE

AVON LAKE

AVON

LORAIN

VERMILION AMHERST

ELYRIA BROWNHELM

NORTH RIDGEVILLE

SOUTH AMHERST

HENRIETTA

170 The Opioid Crisis Exposed

NEW RUSSIA

OBERLIN

CARLISLE

EATON TOWNSHIP

GRAFTON

O T

The epidemic in Ohio Through the end of 2018, the state remains among the five states with the highest rates of overdose deaths at 32.9 deaths per 100,000 residents, according to the U.S. Centers for Disease Control and Prevention. Fatalities in Cuyahoga County have been higher than the state rate for the past several years.

AY VILLAGE

CLEVELAND

LAKEWOOD

ROCKY RIVER

WESTLAKE

NEWBURGH HEIGHTS

FAIRVIEW PARK NORTH OLMSTED

PARMA HEIGHTS

BEREA OLMSTED FALLS

PARMA

STRONGSVILLE

SEVEN HILLS

VALLEY VIEW INDEPENDENCE

MIDDLEBURG HEIGHTS BROADVIEW HEIGHTS

COLUMBIA

GARFIELD HEIGHTS

BROOKLYN HEIGHTS

BROOK PARK

OLMSTED TOWNSHIP

CUYAHOGA HEIGHTS

BROOKLYN

NORTH ROYALTON

Number of overdose deaths by city where the fatality occurred

KEY

11-15

16-20

1-5

21-25

6-10

26+

The Opioid Crisis Exposed 171

Lorain County 2018 in the county:

DEMOGRAPHICS

70 OVERDOSE DEATHS 23 OVERDOSES PER 100,000 RESIDENTS DOWN 47 PERCENT

Age 30 25 20 15 10 5 0

For the first time in years, deaths are down in the county.

Gender

Youth (15-24)

Young Adults (25-40)

Adults (41-55)

Seniors (56-70)

Elderly (71 +)

Male

Female

MOST COMMON DRUGS INVOLVED IN FATALITIES 10 Number of cases drug found in

Lorain saw an influx of fentanyl and cocaine in toxicology reports in 2018, especially in the late summer and fall months. Heroin prevalence still remains a problem for most of the year.

8 6 4 2 0

Jan.

Feb.

Mar.

April

May

June

Heroin

Fentanyl

July

Aug.

Sept.

Oct.

Nov.

Dec.

Cocaine

NARCAN DISTRIBUTION

POLICE BLOTTERS: DRUG-RELATED CRI

Over the past five years, opioid-related deaths have declined. The drop can be partially attributed to the spike of Narcan kits distributed in the community.

The chart below was compiled after analyzing 52 we the number of drug-related incidents (possession, O trafficking, etc.) that occurred. The figures reflect all methamphetamine, prescription pills, etc.) but do n

500 400 300 200 100 0

2014

2015 Deaths

172 The Opioid Crisis Exposed

2016

2017

2018

Narcan kits distributed

Number of drug-related police blotter reports

Number of deaths or kits distributed

600

60 50 40 30 20 10 0 Avon

Avon Lake

Sheffield North Lake Ridgeville

Sheffield Village

Cuyahoga County DEMOGRAPHICS Age

Gender

30 25 20 15 10 5 0 Male

2018 in the county: 560 OVERDOSE DEATHS 46 OVERDOSES PER 100,000 RESIDENTS DOWN 23 PERCENT

Female

Youth (15-24)

Young Adults (25-40)

Adults (41-55)

Seniors (56-70)

Elderly (71 +)

For the first time in years, deaths are down in the county.

MOST COMMON DRUGS INVOLVED IN FATALITIES Number of cases drug found in

100 80 60 40 20 0

Jan.

Feb.

Mar.

April Heroin

May

June

July

Fentanyl

Aug.

Sept.

Oct.

Nov.

Dec.

Cocaine

In Cuyahoga County, fentanyl remains the most prominent component in overdose fatalities. In 2018, the presence of cocaine in toxicology reports spiked at alarming rates.

NARCAN DISTRIBUTION

eeks police blotters in 2018. The figures show OVI, paraphernalia, overdoses, stolen pills, l drug violations (heroin, marijuana, cocaine, not include violations from alcohol intoxication.

In Cuyahoga County, Project DAWN tracks all documented Naloxone saves. The middle line shows what the death toll would be without those saves. 3000

60 Number of deaths or kits distributed

Number of drug-related police blotter reports

IME

50 40 30 20 10

2500 2000 1500 1000 500 0

0 Bay Village

Fairview Park

North Olmsted

Rocky River

Westlake

2014

2015 Deaths

2016

2017

2018

Narcan kits distributed

The Opioid Crisis Exposed 173

A year of the crisis in review: What’s working to fight the epidemic

April 3, 2019 Written by Maureen Bole

recent study from the Centers for Disease Control in Atlanta pointed to drug overdose as the leading cause of death for people under the age of 50 in 2017, stating that overdoses take more lives than car crashes or guns. There is no community immune from the effects of this epidemic. Every city in our readership has faced the economic burden, crime and death in their own back yard. Over the past year, this newspaper has been following the epidemic here at home and how the work by community leaders, law enforcement and government officials are having an impact. This is our last installment. Here is a synopsis of what we’ve covered over the past 12 months:

Pain management The opioid crisis’s roots are in the overprescribing of prescription pain medication about a decade ago. Regulations were established when caregivers were seeing patients become addicted to their medications from their surgeries or back pain. In the medical world today, opioids still have a place in pain management, but are used more judiciously. Randy Jernejcic, chief medical officer at University Hospitals Ahuja Medical Center, stated, “It’s not ‘how do we stop prescribing them?’ It’s ‘how do we make sure that only the people who need them get only the amount they need and not any more?’”

Narcan Arguably the most valuable tool in saving lives, Narcan has become well-known in the past year. Narcan, or Naloxone, can reverse the effects of an opioid overdose in a matter of minutes. It is available without a prescription at more than two dozen pharmacies across our readership area and is now carried by every EMT and police squad in Lorain and Cuyahoga counties. The Lorain County Health Department also held training sessions at public libraries this year. For the first time in nearly a decade, overdose deaths were down in Cuyahoga County in 2018, according to the medical examiner. In Lorain County the more Narcan kits were distributed, the fewer overdose fatalities were seen. Although Narcan doesn’t solve the epidemic, it helps to keep people alive long enough to find solutions. 174 The Opioid Crisis Exposed

Drug Courts After the influx of inmates held on drugrelated charges, officials recognized that penitentiaries were not the best place for people to get help. Studies and data analysis show that inmates are highly likely to commit another crime upon their release from jail or prison if the underlying causes of their addiction are not properly addressed. Drug court programs were developed in Lorain and Cuyahoga counties to give offenders a choice to pursue a rigorous program of a year or more or face jail time. The judges who preside over these cases, David Matia, Joan Synenberg and John Miraldi, have helped give addicts the push they need to find long-term recovery.

Addiction psychiatry For years, addicts were seen as morally deficient individuals instead of having an actual illness. Medical professionals interviewed over the past year seem to agree that recognizing addiction as a brain disease is a crucial component in fighting the epidemic. Addiction affects four main parts of the brain, making it difficult, if not impossible, for actively using addicts to make rational choices. By developing treatment plans that help rewire these ways of thinking, medical professionals help give addicts a chance to make productive decisions and help them find their way to recovery.

Family support The reach of the epidemic goes far beyond just those addicted. Often the people who are affected most by addiction are the families of addicts. The foster care system has been

flooded with children who are removed from homes with drug use cited as the cause: 75 percent of cases in Cuyahoga County and 35 percent in Lorain County. Grandparents of those addicted often take custody of their grandchildren in these situations. A new program, Rosie’s Playhouse, was launched in July by Kathi Stautihar for children of addicts to learn healthy coping mechanisms and express their feelings in a safe environment. Since addiction is recognized as a “family disease,” it’s important for the whole family to seek help. Hundreds of husbands, wives, mothers and fathers of addicts across Lorain and Cuyahoga counties have sought this help through Al-Anon and Nar-Anon family support groups. Weekly meetings help them to find their identity and independence regardless of what their addict or alcoholic is doing. Alateen and Narateen support groups are also available for adolescent family members of addicts and alcoholics. The Opioid Crisis Exposed 175

Medication Assisted Treatment (MAT) When describing MAT, some medical professional liken addiction to breaking an ankle. When you break an ankle, sometimes you need to use crutches until your ankle has healed and can be walked on again. When people suffer the disease of addiction, sometimes they need medication to help cope with day-to-day life and give their brain some time to heal. Three popular forms of medication that assist with addiction treatment are: Methadone, which fully activates opioid receptors in the brain to replace the effects of the opioid of abuse to lessen the severity of cravings; Suboxone, which partially activates opioid receptors in the brain to replace the effects of the opioid of abuse to lessen the severity of cravings; and Vivitrol, which completely blocks opioid receptors in the brain, making it impossible to feel any euphoric high when using opioids. Doctors note that there is no “one-size-fits-all” MAT and that every addict is different. However evidence-based practices show that incorporating MAT into a treatment plan can help guide a person with addiction to long-term recovery.

Co-occurring mental disorders Medical professionals note that another important component of any treatment program is properly diagnosing and treating any co-occurring mental illnesses addicts may have. By leaving these illnesses untreated, an addict is at high risk for a relapse and possible death. 176 The Opioid Crisis Exposed

Prevention Educators and law enforcement officers have been working together to help educate youth about the dangers of using drugs, alcohol and nicotine. Shying away from the old methods of “Just Say No,” today’s programs not only teach children and adolescents about the consequences of using drugs, but also help them develop healthy coping mechanisms and advance their emotional intelligence to help prevent them from turning to drugs to fix their problems. Resource officers have been placed in most area schools to help students and diffuse or prevent issues.

Harm reduction “Isn’t that promoting drug use?” and “How is that productive when addicts don’t face consequences?” are the biggest questions that follow harm-reduction strategies. But these methods have one simple goal: to reduce the harm of the epidemic. Narcan and MAT drugs are two popular harm-reduction tactics; not seeking to solve the crisis but to keep people alive. Another popular, yet controversial, method is syringe exchange programs. These exchanges, now active in Cleveland and Wellington, encourage addicts to bring in used needles to trade them for clean ones for free. Needle exchanges help keep these harmful syringes out of public waste receptacles and curb the spread of blood-borne illnesses such as HIV and hepatitis.

Community outreach In the midst of the epidemic, community members and leaders across Cuyahoga and Lorain counties have established programs, organizations and coalitions to battle the crisis. These programs are innovative for communities, as they seek to meet addicts where they are at and help where they’re needed. They recruit the help of community members to help addicts along their journey. Project SOAR, Let’s Get Real Inc., the BA Force and Assist Communities are four impactful community outreach organizations across both counties. The Philanthropic Coalition of Lorain County, composed of leaders and teams from 10 major county agencies, to assess and devise action plans to combat the epidemic.

Detox and treatment One driving factor that keeps addicts using so much and so frequently is the uncomfortability of withdrawal symptoms. Going through a medically assisted detox can help an addict get through the initial pain of withdrawal, but is just the beginning of their recovery. Without enrolling in a treatment program (inpatient, intensive outpatient or counseling), staying abstinent, making environmental changes and attending support group or 12-step meetings, an addict runs a high risk of relapse.

Long-term recovery Arguably the best solution to end the epidemic would be for addicts to seek long-term recovery. All of the previous methods and components are crucial in the fight, but alone are not the total solution. By working a daily program of recovery, thousands of addicts have been able to live productive and successful lives. Many then seek to help those who are still suffering. It’s a long road, but it’s possible. ♦ The Opioid Crisis Exposed 177

OPINION: THE VIEW OF A RECOVERING ADDICT

Fighting the stigma of addiction together

April 3, 2019 Written by Maureen Bole

n the year of covering the opioid crisis strides have been made, lives have been saved and solutions have been found. But the fight against the stigma surrounding recovering addicts is still present, and can be a huge factor in seeking recovery. When they were telling me during my evaluation at treatment that I was an addict and I would have to do something to combat my disease every day (one day at a time) for the rest of my life, I thought of it as a curse. I was stuck in my own “woe is me” pity party for weeks. I was grieving the loss of my previous lifestyle. I felt like I was having all of the fun parts of being a 20-something taken away from me. No more parties? No more bar hopping with friends? What was I supposed to do now? It took me awhile to realize that I wasn’t a normal 20-something. I didn’t do, think or act like “normal” kids my age. I took everything to an extreme and those extremes were literally killing me. Aside from the “grief” of losing my old lifestyle, I was also filled with a lot of fear and shame. I knew I was different. I was the person that most people in society look down upon. So when I first got clean, I hid my recovery every chance I could. I told my college roommates to tell all of our friends I was working when I wasn’t at a party. I had my mom telling white lies to my family as to why I wasn’t at functions. I lied to my coworkers about why I couldn’t go out for happy hour. I didn’t dare share anything about it on social media. Why? Because I was ashamed. I was afraid of being judged. I isolated myself a lot in that first couple months because of that fear and shame. I felt like an outcast of society more when I was new in recovery than I did when I was actually using. Probably because I was so high all the time I didn’t feel much of anything, but that’s beside the point. While fighting for my life in recovery, stigma was just one more burden to add to my fight. Some days, the stress of hiding it was the straw that broke the camel’s back and it drove me to thoughts of using. I felt like I was living this horrible double life again, except this time I wasn’t hiding my using I was hiding my recovery. It wasn’t until I had about six months clean that I thought to myself, “Why am I trying so hard to hide this?” I was finding pride in what I was doing and in turn, pride in myself. That fear of what others thought about me waned because I knew deep down that I was finally doing the right things. I was finally living an honest and worthwhile life. My

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transparency slowly began to change. Today, I’m proud to be an addict. I’m proud to be in recovery. And I don’t mind telling that to anyone. I don’t hide anymore (obviously, or you wouldn’t be reading this column). By being in recovery and working a 12-step program I have the chance to better myself everyday I stay clean. I look at my behaviors, motives, assets and defects. I’ve learned how to be grateful for everything in life, even the bad times. Fighting through the stigma and speaking up about my recovery was such a turning point in my journey. I finally felt free. Here at West Life, we decided to publish this column every month to show a different side of the epidemic; the view of someone who’s been through the throes of active addiction and has lived to tell their story. But what I’m also hoping this column has done is shatter some of the stigma surrounding recovery. I’m your neighbor, your child’s friend from high school, the girl your daughter played softball with when she was young, your coworker’s daughter. I’m just like you, I just have a few more demons inside to fend off than most people. So, as a community, let’s start treating addicts with the love, support and respect we would show anyone else. Let’s not create one more problem for them than they already have. Let’s lend encouraging words when they need it. Who knows, it may even help to save a life. It helped save mine. The Opioid Crisis Exposed 179

Addiction help & resource guide TREATMENT

Searching for treatment centers and programs individually can be exhausting. The resources listed below provide the most reliable and comprehensive lists of facilities and programs in Northeast Ohio. The Emerald Jenny Project In memory of Jennifer Emerald Ayars, this site was created to help people struggling with addiction find treatment services in Ohio. emeraldjennyfoundation.org ADAS of Lorain County The Alcohol and Drug Addiction Services Board of Lorain County is an agency that specializes in contracting alcohol and drug treatment and prevention services. lorainadas.org/provider-agencies/ The ADAMHS Board of Cuyahoga County Provider Network Guide This is a comprehensive listing of facilities that are contracted by the ADAMHS Board to provide addiction and mental health services. adamhscc.org/en-US/provider-network-guide.aspx The LCADA Way This non-profit provides more than 40 recovery related services for individuals living in Lorain, Medina and surrounding counties. thelcadaway.org 2-1-1 A free community service for information about social, health and government resources 24 hours a day, every day. Simply dial 2-1-1 or browse online directory for a comprehensive list of prevention and treatment options. www.211oh.org

SUPPORT GROUPS FOR ADDICTS Alcoholics Anonymous A fellowship of alcoholics that focus on recovery from alcoholism through the 12-step model and group support meetings. 1-800-835-1935 www.aacleve.org Narcotics Anonymous A fellowship of addicts that focus on recovery from addiction through the 12-step model and group support meetings. 1-888-GET-HOPE www.wagsna.com SMART Recovery This group meets and works through a four-point program to help all types of addicts find recovery. 1-800-477-6291 nar-anon.org

SUPPORT GROUPS FOR FAMILIES Al-Anon & Alateen A fellowship of relatives and friends of alcoholics who help each other by working the 12- steps and attending group meetings. 1-888-425-2666 clevelandal-anon.org Nar-Anon & Narateen A fellowship of relatives and friends of addicts who help each other by working the 12-steps and attending group meetings. 1-800-477-6291 nar-anon.org SOLACE Lorain County A support group for families who are impacted by substance abuse. 440-823-6177 lorainadas.org/about-solace-lorain-county

COVER2 RESOURCES PODCAST: COVER2.ORG During the course of the Opioid Crisis Exposed project, Cover2 Resources served as an invaluable resource for West Life. The podcast was founded by Greg McNeil and his family after they lost their son/brother to a heroin overdose in the fall of 2015. Cover2 Resources using an educational approach to connect those touched by Opioid Use Disorder with resources that can literally save a life. Their mission is threefold:

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-To shine a spotlight on the best resources in the State of Ohio to fight this growing epidemic. -To shine a spotlight on the best service providers in the State of Ohio who are working to change the lives of users and prevent new addictions before they occur. - To develop and deliver preventative educational programs that will stop opioid addictions before they even happen.

Sources Local ▶ Cuyahoga County Opiate Task Force opiatecollaborative.cuyahogacounty.us ▶ The Cuyahoga County Medical Examiner’s Office: Cuyahoga County Heroin Initiative medicalexaminer.cuyahogacounty.us/en-US/CCHeroinInitiative.aspx ▶ Lorain County Medical Examiner’s Office ▶ Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County adamhscc.org ▶ Project DAWN opiatecollaborative.cuyahogacounty.us/en-US/ Project-DAWN.aspx ▶ The Philanthropic Coalition of Lorain County endtheepidemiclc.org ▶ LCADA Way thelcadaway.org ▶ Ohio Department of Health odh.ohio.gov ▶ Take Charge Ohio takechargeohio.ohio.gov ▶ Ohio Department of Mental Health and Addiction Services mha.ohio.gov ▶ Recovery Ohio recoveryohio.gov ▶ Cleveland Clinic Alcohol & Drug Recovery my.clevelandclinic.org/departments/ neurological/depts/behavioral-health/ alcohol-drug-recovery-center ▶ The Centers (formerly Circle Health Clinic) thecentersohio.org/services/addiction ▶ MetroHealth Office of Opioid Safety metrohealth.org/office-of-opioid-safety ▶ Harm Reduction Ohio ▶ Cuyahoga County Jail, Sheriff’s Office ▶ Lorain County Jail, Sheriff’s Office ▶ All area police departments (Avon, Avon Lake, North Ridgeville, Sheffield Lake, Sheffield Village, Bay Village, Fairview Park, North Olmsted, Rocky River, Westlake) ▶ Cuyahoga County Special Drug & Recovery Court cp.cuyahogacounty.us/court-resources/ specialty-courts/ ▶ Lorain County Recovery Court courtofcommonpleas.loraincounty.us/ departments/adult-probation/recovery-court ▶ Let’s Get Real Inc. www.letsgetrealinc.org

National ▶ Substance Abuse and Mental Health Services Administration (SAMHSA) samhsa.gov ▶ National Recovery Month recoverymonth.gov ▶ Centers for Disease Control and Prevention cdc.gov/drugoverdose/epidemic cdc.gov/nchs/fastats/drug-use-illicit.htm ▶ U.S. Department of Health and Human Services https://www.hhs.gov/opioids/about-theepidemic/opioid-crisis-statistics ▶ Partnership for a Drug Free America drugfree.org ▶ National Institute of Drug Abuse drugabuse.gov ▶ Drug Enforcement Agency www.dea.gov/factsheets ▶ National Institute of Mental Health nimh.nih.gov ▶ American Psychological Association www.apa.org ▶ Harm Reduction International www.hru.global ▶ Federal Bureau of Prisons bop.gov ▶ The Journal of Neuroscience jneurosci.org ▶ National Society of Drug Court Professionals nadcp.org ▶ Drug Policy Alliance DrugPolicy.org ▶ Prison Policy Initiative prisonpolicy.org Studies ▶ The Journal of Clinical Investigation - The addicted human brain: insights from imaging ▶ Forward Thinking on Drugs: Evidence-base for harm reduction approaches to drug use ▶ WONDER (NCHS Compressed Mortality File, 1979-1998&1999-2005) 2006-2017 ODH Office of Vital Statistic ▶ Public Children Services Association of Ohio Opiate Survey, April 2016 ▶ Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. ▶ Monitoring the Future national survey results on drug use, 1975-2017: Volume I, secondary school students.

Many of the photos used in this e-book are stock images obtained with WestLife’s subscription with Getty Images.

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