Apocalypse Now: Jacksonville's Opioid Crisis

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// by Stella Katsipoutis

“21-week-old white male fetus, mother went to hospital and drug screen was positive for marijuana and cocaine … Next: 43-year-old white male, substance abuse, dead at the scene … Next: 29-year-old white male, found in his parked vehicle in a WalMart parking lot, drug paraphernalia located in the vehicle … Next: 56-year-old white male, found unresponsive in his residence, has a history for abusing heroin and crack cocaine … Next: 42-year-old white male, found unresponsive in his residence, transported to hospital, has track marks from heroin use … Next: 31-year-old white female found at her residence, drug paraphernalia found at the scene, has a history of abusing drugs …”

Catch Dr. Valerie Rao on any given day, and she can rattle off a seemingly endless list of overdose victims that are lying in her morgue. As Jacksonville’s chief medical examiner, she spends each morning sitting with investigators, physicians and her operations manager, deciding who will handle each case. The faster they work, the sooner the victims’ families can pick up their loved ones and leave with their grief. But as of late, the uptick in drug-related deaths across the District 4 counties she serves—including Duval, Clay, Columbia, Hamilton and Nassau—has tested the limits of not only the morgue’s physical capacity, but also Rao’s well-being.

“This is sucking the life out of us,” she said at a Town Hall meeting hosted by Councilman Bill Gulliford in March. “I’ve been sick for the past month, but I cannot take a day off because we are so very busy, so I drag myself to work. We are losing lives, which is terrible. I have to listen to [victims’] families calling me, crying, and I want to cry. We are overwhelmed. Help us. That’s all I’m asking.”

Rao’s impassioned plea is the direct result of an opioid crisis that is infecting the streets of Jacksonville—a festering wound that can no longer be bandaged with denial. The sobering data gathered by the Jacksonville Fire and Rescue Department (JFRD) shatter any disbelief one might have in our city’s growing drug problem: Between 2015 and 2016, the number of overdose victims responded to by JFRD increased from 2,114 to 3,411. In that same timeframe, the number of 911 calls for overdoses has tripled, and the number of drug-related deaths in District 4 has more than doubled from 201 to 464. The majority of victims were Caucasian males between the ages of 30 and 39.

“We’re treating an overdose victim once every six to eight hours,” said JFRD’s Lieutenant Mark Rowley at last month’s Town Hall. “As much as I can tell you about our response to overdose and our firefighters’ struggle to save lives, it parallels in no way to the truly catastrophic loss of life.”

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Chief Medical Examiner Dr. Valerie Rao, left, and JFRD’s Lieutenant Mark Rowley at a Town Hall meeting hosted by Councilman Bill Gulliford in early March // photo by Stella Kastipoutis

Catastrophic indeed. While most of today’s drug users think they’re getting heroin from their dealers, in actuality what they’re buying is fentanyl, a narcotic that is most often illicitly manufactured in Mexico, China and other foreign countries. Since it is 50 to 100 times more potent than morphine, fentanyl gives victims nearly no chance of survival when it is used in conjunction with other substances. According to Assistant Chief W. Mike Johnson of the Jacksonville Sheriff’s Office, because fentanyl and its many derivatives—including carfentanil, acetylfentanil and others—are cheaper and easier to obtain than pure heroin, distributors are now mixing them with small amounts of heroin, cocaine and other drugs in order to increase their profits while still selling a potent product. What buyers don’t know, however, is that distributors are using too much fentanyl in their mixtures, creating deadly concoctions that cause chest rigidity, inability to breathe and swift death—all while the needle is still in the victim’s arm. And to make matters worse, these never-before-seen drug variations are seeping into the market so fast that even experts are struggling to keep up.

“The drugs are literally changing more rapidly than the lab tests can identify them, because those who are responsible for these drugs hitting our streets are changing their formulations very quickly,” says Kelli Wells, M.D., director of the Department of Health in Duval County. “The last report shows some drugs that I’ve never even heard of. Our medical examiner contracts with a toxicology office that processes samples for her because there’s that much challenge in identifying the chemicals that are present.”

How on earth did we get here? It’s a question that hangs over the heads of everyone touched by the growing opioid epidemic. But even though there is no hard-and-fast answer to this question, experts agree that a variety of factors came together to create the perfect storm that is taking the lives of so many people in our community. Some speculate that the unrealistic expectation placed on the medical community in recent years to eradicate all pain in its patients led to the overprescribing of opioids, as well as inadequate patient education about properly using those medications. This, in turn, may have flipped the addiction switch in patients who may or may not have known they were genetically predisposed to getting hooked on the substances.

“We’re getting to a point now where we don’t really tolerate discomfort in our patients,” says Jeremy Mirabile, M.D., medical director of Recovery Keys, an addiction treatment and rehabilitation center in Jacksonville and St. Augustine. “[Doctors think,] here we are fixing bones and giving sight to the blind, so why are people having discomfort?”

About 15 to 20 years ago, says Mirabile, medical credentialing companies began to reimburse doctors and hospitals based on patient surveys, which asked each patient to rate how well they felt their pain was treated. “So doctors began to liberally prescribe [opioids] and never really screened people. Somewhere between 10 and 20 percent of patients has some form of substance abuse disorder and, therefore, are vulnerable when they’re given painkillers—such as opioids—to control their mild to moderate pain. That puts them at risk for having a painkiller problem in the future. So in a way, we kind of made the disease show itself.”

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Kelli Wells, M.D., Director of the Duval County Department of Health // photo by Agnes Lopez

Kelli Wells, M.D., Director of the Duval County Department of Health // photo by Agnes Lopez

Paul Stasi, director of resource development at the City Rescue Mission in Jacksonville, explains that the number of opioid pain reliever prescriptions has skyrocketed from 76 million in 1991 to 207 million in 2013—and almost 100 percent of the global opioid supply is currently being consumed right here in the United States. “According to the Centers for Disease Control and Prevention, 78 Americans die every day of an opiate drug overdose,” he says. “Over half of those deaths are [from medications] prescribed by doctors.” And despite the best efforts of ethical physicians who follow proper prescription protocol, more and more improperly trained doctors are handing out opioids, while fewer and fewer are accompanying scripts with adequate counseling for their patients.

“What’s happening is, in some cases, [doctors] are giving [patients] 90 pills, without any real guidance on what to do when they don’t get pain relief with one, two or three [doses] a day,” says Wells. “No guidance about other modalities that can be tried, no holistic approach to control it, and then an unrealistic expectation that the patient is not going to have some pain. If you have, say, a legitimate back issue, you’re going to have some pain every day. If we don’t do a great job in the office of saying, ‘This is a narcotic, you can get addicted if you use it every day for the next 30 days, and you will feel withdrawal symptoms when you stop it,’ then we’ve got a problem. We need to reset our expectations. Our expectations should be that this is one of your tools to use for pain control, in addition to massage, heat, cold, stretching, acupuncture, meditation, etc.”

To add fuel to the already rampant fire, those who are already in the throes of addiction have scant access to the resources that are necessary to manage and overcome their disease. For example, when addicts find themselves in the emergency room due to a drug-related complication, or in jail due to a crime they committed while under the influence, they receive temporarily life-saving detox services; however, they are given very little education or referrals to rehabilitation programs that promote lasting positive change for their addiction. The result: As soon as they are discharged, their chances of relapsing are near 100 percent, according to Wells.

“If you incarcerate these folks and do a forced detox during that time in lockup, but don’t put any services around them to stay clean, the second they’re free they’ll use again, and then the cycle starts all over again,” she says. “In some communities [around the country], they’re progressive enough that rather than lock the addict up after they’ve clearly committed a crime in order to support their habit, they go to rehab. That’s where I think we may be missing a complete intervention strategy.”

However, even when those suffering from addiction who do wish to seek help and check themselves into a treatment center, their path to recovery is even further blocked by selective insurance policies and deep state-mandated budget cuts for mental health and addiction services.

“People with substance abuse problems who have private insurance get a selection of care that is pretty diverse; they can go almost anywhere [for rehabilitation],” says Mirabile. “Someone who doesn’t have insurance [or is covered by Medicaid or Medicare can] basically only go to state-funded facilities—such as Gateway and River Region in Duval County—and the number of people these facilities can serve is directly affected by budget cuts from the state. If [the patient’s] plan doesn’t pay much, it’s unlikely that they’re going to reach a place that has multidisciplinary, doctorate-level staff with more experience, more training and that is potentially able to deal with more withdrawal complications. And for certain people, that can mean the difference between life and death.”

That was exactly what happened to Jacksonville resident Steven Maldonado’s son, Jonathan, who passed away last year from a drug overdose. After months of searching, Steven was unable to find a treatment facility that would accept the family’s Medicaid coverage—which was all they could afford. Those facilities that did accept Medicaid told the Maldonados that they had to wait, simply because the facilities didn’t have enough capacity to accept new patients. “River Region is packed, their counselors work so hard and they have so many people under their wing that they just can’t attend to everybody,” Steven said at Councilman Gulliford’s Town Hall last month. “Gateway is always full; if you call them, they say keep calling back. When you call the 800 number, they refer you to facilities that have beds, but then they want you to have Humana, Aetna or Blue Cross Blue Shield. If you say you have Medicaid, nobody takes that. We called for three months straight before Jonathan died.” Jonathan was 20 years old.

Law enforcement, emergency services and other organizations throughout the city of Jacksonville are honing in on their efforts to attack the drug issue from every angle. In the past three months, JFRD spent $113,000 to equip every fire engine and rescue truck with Narcan, a medication that reverses the effects of opioids during an overdose and jumpstarts victims’ breathing again. “In addition to ensuring that every apparatus in the city has Narcan, we’re also making sure that they have a paramedic onboard and advanced airway equipment,” says Rowley. “So we are doing our best to equip our finest with the equipment needed to take care of people suffering from addiction.” JSO also provides a drop box at the entrance to the Police Memorial Building on Forsyth Street, where anyone can—and is strongly encouraged to—anonymously drop off unused prescription drugs from their medicine cabinets, preventing them from potentially reaching the hands of children or a loved one who might have an addiction problem.

Drug Free Duval, a local coalition that strives to ensure freedom from substance abuse, has put together a task force whose sole purpose is to mobilize health solutions and initiate community-wide change in substance abuse behaviors. “One of our co-chairs, Jodie Grace, has done astounding work in the area of reducing when folks who work in a hospital setting are stealing drugs for their own use or to sell,” says Susan Pitman, Drug Free Duval executive director. “One of the goals we have is to implement that throughout all the hospitals in the region and eventually the nation. We also have really complex policy goals to increase physician use of the Prescription Drug Monitoring Program.”

Jeremy Mirabile, M.D., medical director of Recovery Keys // photo by Agnes Lopez

Jeremy Mirabile, M.D., medical director of Recovery Keys // photo by Agnes Lopez

Joe Jamison, a certified addiction counselor at Recovery Keys—and a recovering addict who has dedicated his life and career to helping other addicts stay healthy and drug-free—urges anyone suffering from addiction to pick up the phone and call a treatment facility for help, no matter their situation. “Just a simple phone call to an agency is going to be anonymous; it’s not going to be judgmental, it’s not going to interrogate,” he says. “But it gives the addict a barometer of how far down the road they are and gives them a way back with the help of someone else.”

While individual local efforts are slowly gaining momentum, more work still needs to be done in order to find an effective solution—and because that will involve multiple layers of intervention across multiple disciplines, every facet of the community has to work collaboratively in order to make even the slightest of dents in Jacksonville’s opioid crisis. “I think the thing that we’ve got to do, obviously, is engage the entire community,” says Gulliford. “It can’t be piecemeal; it has to be a concerted, all-inclusive effort to address this problem. We’ve got a multitude of different entities working toward a solution, and they never communicate. We as a community need to get together and continue this dialogue, set some goals and move forward.”

Several possible solutions to the issue have already begun to be tossed around by various experts: For instance, Wells says she would like to see hospital ERs staffed with peer advocates who can counsel detox patients, assess their readiness for recovery and link them to care—tasks that emergency room doctors are too overburdened to take care of on their own. Mirabile, on the other hand, believes that—rather than taking a backend approach to the issue and focusing on providing post-overdose help to victims with Narcan—more proactive action needs to be taken by family physicians to screen their patients, spot addiction and help treat it before it spins out of control. He suggests that the screening tool used by the Substance Abuse and Mental Health Services Administration (SAMHSA)—a simple one-page questionnaire also known as SBIRT, which stands for “screening, brief intervention, and referral to treatment”—be integrated into the lineup of tests primary care doctors conduct on their patients during their annual wellness checkups. These ideas—and more that have been brought to the table—are all feasible; but in order for them to come to fruition, they need to become a part of a broader discussion and plan of action.

“The city government, the city leadership, the Department of Health…we can certainly play a role in convening the conversation. But I wouldn’t want us to put together a community intervention that is sanitized enough that everyone can palate it,” says Wells. “Instead, I want it to be bold and threaten our boundaries. Because that’s what it takes. People who are addicted to opioids aren’t living any sort of normal life. And so we can’t, from our safe spots, devise interventions that are going to help them. We have to be able to push our sleeves up and get a little uncomfortable, have conversations that challenge us, because it’s a big problem. It’s bigger than us, and we’re not going to be able to solve that from behind our desks.”

According to Wells, looking beyond any biases about addiction and seeing it for what it is: a disease that is rooted in a person’s biology—and deserves just as much medical attention and care—is crucial if success is to be attained. “It’s almost as if [the addict] has diabetes and he acts differently when his blood sugar level is 500 or 700,” says Mirabile. “He can’t bring that number down on his own because his pancreas isn’t working right, so he needs insulin, he needs medicine, he needs help. There’s very little an addict can do about his condition because it’s embedded deep in the survival center of the brain, so he reflexively uses drugs and alcohol in place of food, water and even relationships.”

Mirabile likens the brain’s reward center to a gas tank, and explains that everyone is born with a different amount of fuel: the feel-good neurotransmitter dopamine. Addicts are born with an inherently low level of dopamine, and so they instinctively seek activities or substances—such as drugs or alcohol—that make them feel better.

“We intuitively think that if [an addict] wants to be well, then he should try harder and not be addicted anymore. But that’s why it’s called addiction,” says Wells. “If it were easy to quit, we wouldn’t be having most of these conversations. The addict is looking for that next high, and that doesn’t make him a bad person; it only makes him an addict. When the medical examiner sounds the alarm that her morgue is full, then we as a community have a responsibility to answer to that. Because every patient she touches represents a family who’s lost a loved one. And in this case, it’s something that is entirely preventable. I don’t know what else we would need to rally around if not that. We are at a critical moment, and what we do from here is incredibly important—and it translates directly into lives saved.”