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Background information
The Opiate Task Force was initiated by MGH Revere and the Revere CARES Coalition in June 2004. The Task Force met four times to compile a rapid assessment of the opiate problem in the community and to develop recommendations for addressing it. The individuals who participated in the Task Force meetings include:
Cambridge Health Alliance: Dr. Somava Stout; Dr. David Roll
Cataldo Ambulance: Frances MacDonald, Jeffrey Stewart
Chelsea District Court: Vita J. Aluia, Adult Probation, Steve Siciliano, Juvenile Probation, Judi Lawlor, Adult Probation and Chelsea Drug Court
East Boston Rehab: Patricia O’Hagan
Harvard Department of Anthropology: Maria Stalford, graduate student
Mass Organization for Addiction & Recovery (MOAR): Maryann Frangules
MGH Community Benefits: Joan Quinlan, Director; Revere CARES: Kitty Bowman, Director, Nydia Febres, & Jessie Williams, Assistant Director
MGH Community Health Associates: Ann-Marie Duffy
MGH Revere HealthCare Center: Dr. Liz Miller, M.D., Med-Peds Department (also School Physician Revere Schools), Dr. Roger Pasinski, Director, Dr.Eric Weil, Chief of Adult Medicine (also, Chairman, Revere Board of Health); MGH Revere Mental Health: Dr. Lily Awad, Unit Chief, Jessica Stebbings, Addictions Counselor/LICSW, Lisa Montanye, LICSW
MGH School-based Health Center: Rita Olans, Nurse Practitioner, Marykate Shorter, LICSW, Laureen Fabiano
MGH Youth Zone Drop-In Center: Bill DeMars
North Suffolk Mental Health: Kim Hanton, Carmen Sasso, Margarita Rosario, Rick Karges, CEO
Office of Rep. DeLeo: Representative Bob DeLeo, Jacqueline Woods, and Tasha Poteat
Revere Board of Health: Nick Catinazzo, Director, Carol Donovan, Public Health Nurse
Revere Fire Department: Chief Eugene Doherty, Capt. Jay Picariello
Revere Police Department: Chief Terance Reardon, Capt. Michael Murphy, Lt. David Callahan, DEA Officer, Capt. James Picardi
Revere Public Schools: Dr.Ruth Davis, Director of Comprehensive Health Educatuon and Guidance, Maureen Anzuoni, School Nurse, Peg Sullivan, Counselor; SeaCoast Alternative Academy: Tom Misci, Principal
During the course of the year, information was collected via Task Force meetings; key informant conversations with youth, law enforcement, treatment providers, and probation staff; a focus group of young adults in a drug treatment program; and a public town meeting. The information below represents the collective picture of the opiate problem in Revere followed by recommendations for action.
Decreasing Age of Onset, Increasing Rate of Use
From 2001 to 2003 the rate of heroin use self-reported by Revere High School students and Seacoast students doubled. Self-report rates of prescription drugs use was up as well. (YRBS, Revere Public Schools).
Cataldo Ambulance reported seeing people as young as 14 to16 years and as old as 55 years for overdose/suicide attempt calls. Cataldo representatives stated that the majority of overdose calls are from ages 17 to 32 and the majority suicide attempt calls are for ages 17 to 37. The call volume for advance life support related to opiate overdoses or suicide attempts was 8 to 10% over the past year.
Revere Fire Department reported that 20% of their call volume is for drug overdoses.
Revere Fire Department and Revere Police Department representatives noted that they respond to drug-related, especially opiate-related calls, on every block and in every neighborhood in the city. A city Councilor concurs that nearly every family in the city has someone they care about — a close or extended family member, family friend, or neighbor — who is affected by this problem.
North Suffolk Mental Health’s substance abuse treatment department, reported seeing people using opiates between ages 12 and 53, and noted that they are increasingly seeing younger and younger users.
Treatment providers report seeing mature opiate addicts at 18 years of age with 3 years progressive use beginning with Percocet, then OxyContin, then Heroin starting with 15 years age of onset. Providers also report an even break down between the numbers of female and male clients seen.
School staff report seeing adolescents with prescriptions for Klonopins, and they understand that some parents are letting their kids manage their own medications. Parents, school staff, and others note that these prescriptions may be misused.
There has been a 500 % increase in alcohol and drug related emergency room visits in Boston. The rate of Boston’s alcohol and drug related ER visits are 3 times more than the national average. Boston ranks just below Detroit and Washington D.C. as top major 3 US cities in opiate use.
Patterns of Use
Across Revere, parents, schools counselors, and treatment providers concur that young people who are addicted to opiates all started out using alcohol, tobacco, and marijuana. Most frequently, we hear anecdotes of a late teen heroin user who began drinking alcohol in 7th grade. Youth first start using within a social context with friends. From parents, treatment providers and youth themselves, we hear the following types of scenarios (please note these cases are not real people, but represent compilations of cases from multiple municipalities):
“17 year old honor student, cheerleader, editor of the yearbook and star basketball player is trying to balance all these responsibilities and was introduced to OCs at a party. She was told this would relieve her stress and pressures.”
“Private high school senior, captain of the football team [had] a serious knee injury and was prescribed OxyContin for the pain. Friends informed him he could get $1/ milligram. He wonders what could be the draw that someone would pay him $80 for one pill. He is told to chew the pill and break the time release…He now has a $360 a day habit and is stealing from his wealthy parents.”
“A 16 year old is balancing work and school. Friends suggest that she snort an OC and her night of work will become total pleasure... Now she is selling herself to maintain an IV heroin habit.” (Source Kim Hanton, North Suffolk Mental Health, testimony at Opiate Town Meeting 2/1/05)
Source of Drugs
Revere Police Department’s Drug Enforcement Officer reported the vast majority of OxyContin arrives via mail, either Fedex or other delivery channels. At this time it is being shipped up from Florida and sold by young adults, mostly in their early 20s, to one another. (May 2005)
A lesser source of the drug, but one of which community leaders are more commonly aware include physician prescriptions and left over drugs in family’s medicine cabinets.
Finally, drug treatment providers and others reported that Buprenorphine, a new and promising drug that treats Opiate addiction without allowing for a “high” if misused, it now being sold on the street now. People addicted to opiods are using “Bupe”, as they call it, to hold them over and avoid withdrawal until they can get their next supply of Oxycontin.
Dual Diagnosis, Overlap with Mental Health
Parents, treatment providers, psychiatrists, and youth who are using themselves speak of the connection between mental health problems and addiction. Mental health providers noted that any depression predisposes one to substance abuse problem. Mood disorders are under-diagnosed, and self-medication with alcohol and drugs is common. Child psychiatrists across the nation are “rare as hen’s teeth”, and local wait times to see a child psychiatrist may be 4 to 6 months. Young adults in treatment suggested that depression makes some young people more likely to begin using opiates, that depression may be a result of using opiates, and that it may be an obstacle to getting clean.
Lack of Perception of Harm
Parents in Revere believe that alcohol and marijuana are the “lesser of two evils” compared to other drug use. There appears to be consensus among community leaders that a lack of consequences for young people who are apprehended on first time offenses related to underage drinking reinforces the problem. Children in Revere report first use of alcohol in middle school. (YRBS) Treatment providers and others also suggest anecdotally that the time span between onset of alcohol use and onset of harder drug use is shrinking. It seems that too many youth are moving more quickly from alcohol or marijuana to harder drugs, including OxyContin.
OxyContin is seen as “classy” or “chic.” The high price of the drug gives it an allure. “OxyContin to heroin is like Heinekin to Budweiser,” said one young man in a treatment program. There is also widespread misbelief that “It’s okay and cannot hurt you if comes from a prescription from a physician,” said another person in treatment. Still another noted, “Kids look up to people who supply it; almost as heroes.” Once the network of dealing is set up, it easily expands. (Focus group 2004)
People begin by chewing or snorting OCs. When crushed, the time release feature of the OxyContin pill is bypassed bringing on the high. Users progress to snorting heroin once they no longer can pay the high prices of OxyContin ($1/milligram or $80 for an 80 milligram pill). Kids say, “I’m not a junkie if don’t do needles”. The clients in treatment told us that virtually everyone winds up injecting heroin after a while. (Focus Group 2004)
Identification & Screening
It is extremely difficult for any parent to recognize and admit that their child has a problem with drugs. This is in part due to shame and stigma of addiction and in part of the difficulty of identification.
Over and over again, parents who came forward to share their stories about children who are addicted or who died from overdoses told us that surmounting the shame of addiction within their household was one of the biggest barriers to seeking help. Most parents don’t want neighbors, friends, and even other family members to know that their child uses prescription drugs or heroin. In talking with approximately seven families, it appears that families struggle to overcome the shame and stigma for a period of about 3 years prior to acknowledging the addiction among member(s) of their family. Parents also talk about not wanting to identify the subtle symptoms of drug addiction with their kids, and this is more so when they do not know where to get help. In short, for a child who begins drinking in 7th grade and begins using hard drugs in 9th grade, it may take until they are 18 or 20 for their family to reach out for help beyond their nuclear family circle.
All members of the Opiate Task Force agree that parents need to know telltale signs of use including missing checks and money disappearing from their bank accounts, as well as the very subtle changes in behavior, mood, activities, and peer relations that are too easily chalked up to “teens being teens.” It has been suggested that if a parent suspects their child may have a problem, they should take them to get a professional drug and alcohol screening and apologize later.
Juvenile Probation noted that drug testing for Oxycontin is not yet approved, and current drug tests do not pick up Oxycontin. Also, Oxycontin leaves the body within 24 hours, no tracers. Federal legislation to add tracers to the drug has not been supported by drug manufacturers.
Lack of Capacity in Service System
In the Revere Public Schools, outreach and education cuts have occurred because health grants were eliminated. This means health education, including alcohol and drug education is limited in the schools.
Law Enforcement and first responders report that their systems are becoming overwhelmed with problems associated with opiate use, especially as age of first use drops.
Across the state, the number of adult detox beds was cut in half as a result of the income roll back years ago and the decline in state revenue just as the economy slowed down.
The few youth residential programs that exist have 6 month waiting lists, and are generally considered inaccessible by members of the Task Force.
All in all, it was noted that very limited treatment options exist for young people 17 and under. There are a few male detox beds through Department of Youth Services (DYS), but no female beds within DYS. Juvenile probation notes that despite all their efforts to access treatment services, youth often detox on their own or in juvenile detention.
Parents detail putting up thousands of dollars to admit their child to a residential program because of insurance barriers. One parent was forced to pay $9000 up front for a bed in a residential program on the South Shore/ Cape. He was told by program staff member that if his child ran, he would not be refunded the balance of his deposit.
Outpatient treatment exists locally, but providers report that retention is a huge problem with young people. Without consequences such as incarceration, youth will not follow through on treatment. Youth report that they will only attend treatment when they are “made” to go to, and only for as long as they are “made” to go.
Bupenorphine (Suboxone), a promising new treatment for opiate addiction, has proven to be a good option for young adults. Yet current FDA regulations define a provider by their Federal Tax ID number, and place a cap of 30 patients for any provider prescribing it. This means all of the MGH system can only legally serve 30 patients. There is a Federal bill to amend or remove the cap, but it is stuck in committee currently. Of the Massachusetts delegation, only Rep. Markey and Rep. Capuano have signed on to sponsor this bill. (May 2005)
Treatment providers concur that youth treatment with Suboxone alone will not suffice. A combination of evidenced-based counseling with intensive outpatient or outpatient treatment is more effective. Of course, increasing capacity in the youth residential system is another area of need identified. Evidence-based treatment approaches would include, but are not limited to Motivational Interviewing, Motivational Enhancement, and other Cognitive Behavioral Therapy approaches.
Role of Physicians and Pharmacists
Physicians report how challenging it is to verify that requests for additional prescriptions or higher levels of pain relievers are legitimate. One doctor noted, “I don’t treat pain with narcotics, but I am going to make mistakes because I can only take patients coming in a couple times, saying “I can’t stand the pain” before I give them a prescription. My role is to help patients with their pain.”
MGH Revere Adult Medicine instituted a new policy in the fall of 2004 eliminating the prescription of OxyContin except for extreme cases, such as end stage cancer, and when the physician and patient have explored all other pain management options. In addition to the policy, the practice has brought in a pain management specialist for professional development trainings.
It was agreed among Task Force members that medical providers need education regarding addiction and alternative pain management techniques.
Task Force members also identified the need for pharmacist education and awareness.
II. Final Recommendations
Community Awareness & Education
Goal: Decrease the time it takes for parents to recognize their child’s addiction and to reach out for help and support (from 3 years to a matter of months).
Recommended strategies:
Town Meeting on OxyContin and heroin
Parent education on signs & symptoms
Physician education on alternative pain management techniques
Pharmacist education
Social marketing messages to reduce stigma of addiction
Strong messages and opportunities promoting alternatives to drug use
Consistent “no use” messages from parents, schools, police, and physicians
Improvement in marketing of treatment options and development of a centralized listing of both public and private resources for youth and families who need to access treatment or other services
Outreach to hard to reach populations including out of school youth, students who don’t see doctors and diverse communities such as non-English speaking parents, newcomer or first generation immigrant youth
Enforcement
Goal: Increase consequences for first time offenders picked up for alcohol and drug-related offenses, including use of substance abuse screening and assessments, treatment, and drug testing.
Recommended strategies:
Create juvenile drug court
Educate probation officers to make counseling and treatment a criteria
Consistent enforcement among parents, police, schools, physicians
Increase drug unit staff with Revere Police
Intervention & Treatment
Goal: (1) Increase access to and retention of youth within treatment programs; (2) Decrease parent/ family isolation and increase support services for parents, siblings, and other family members.
Recommended strategies:
Create a parent-to-parent network and increase parent involvement in system
Create more parent and sibling support groups
Create network of youth resources, a “safety net” for kids at risk, including mental health and addictions treatment
Increase both treatment options and access to treatment for youth 17 and under, especially intensive outpatient treatment programs or adolescent SOAPs
Use of evidence-based treatments methods such as Motivational Interviewing, Motivational Enhancement, and Cognitive Behavior Therapy
Reach out to recovery community and work with Peer Leaders
Increase Alateen groups in the area and specifically develop AA groups run by youth for youth. (Anecdotally, a number of families have said that NA groups have not worked out. Too often they are a place for where the youth go to get drugs.)
The Revere CARES Coalition and local partners continue to make progress toward these goals. For more information, please contact Jessie Williams at (781) 485-6404.
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