Gone Too Soon

I attended the wake of a young woman this week. I’ll call her Carla. She was 20 years old, petite, pretty, sweet and smart. I had known she was a biology major but didn’t know that she was also a skier and golfer. I learned this from the photos displayed at the funeral home where Carla was pictured as a baby through late adolescence; smiling, happy and obviously well loved by her family and friends. By all appearances Carla had a bright future. Sadly, it was not the case. Although I don’t know the details of her death, prevailing assumptions and rumors are that she died of a drug overdose.

What I do know is that Carla was a patient in a medication assisted treatment program. She was a recovering heroin addict who made good progress in treatment, had negative drug screens for opiates and attended both individual counseling and weekly recovery groups. There was no indication that she wouldn’t be successful and achieve her life ambitions. But she was sidetracked. Carla dropped out of treatment unexpectedly and prematurely. We heard that she was jailed for a time for unknown cause and she did not return to treatment upon her release. She mostly likely died of a heroin overdose that was mixed with Fentanyl.

Our medication assisted treatment program counts seven deaths among our patients over the past five years. That may seem like a large number of fatalities for a small rural clinic but death rates are much higher in larger clinics. Most often we learn of a drug related death after they leave treatment. Only one of the seven deaths occurred when they were in treatment. That person died of natural causes, although years of addiction may have taken a toll on her medical health. For this reason, I get anxious when patients leave treatment prematurely.

I’m told that the highest rates of overdose deaths occur shortly after release from incarceration or discharge from a treatment facility. People who are addicted to opiates may relapse to the same amount of opiates that they had previously used. But after a period of abstinence, as little as three days, their tolerance is down, which increases their risk of overdose death. Carla had received education on Narcan, an opiate reversal drug. She was given a Narcan kit that included two pre-filled nasal syringes. However, Narcan is only effective if someone administers it to you. Even with Narcan, it is best that someone call 911 for assistance. Depending on the amount of opiates that they ingested, two Narcan doses may not be sufficient. I heard of one person who was given five doses of Narcan and the patient died in spite of medical care.

Fentanyl is becoming a major drug of abuse and is associated with increasing deaths. It was designed for end of life and cancer treatment. It is a synthetic substance that is cheaper, easier to produce, it is generally mixed with heroin and more quickly distributed. As a result, it’s potency along with heroin is responsible for the overdose epidemic. Most drug dealers don’t even know whether, or how much, Fentanyl is contained within heroin. Because it is hidden, and more powerful, many people who are dependent upon opiates are drawn to it and are susceptible to overdose.

The majority of jails and prisons in this country do not allow the administration of a medication such as Methadone, Suboxone, or Vivitrol. It is the opinion of this writer that it is inhumane to allow someone to suffer withdrawal while incarcerated. A small percentage of people have died while undergoing withdrawal in the judicial system. For this reason, some jails may allow a 30 day detox from opiates in order to avert powerful withdrawal during incarceration. In most cases, when an individual is released, it is often to return to their previous drug environment, rather than take firm steps to get them back into treatment. One study demonstrated that former inmates are released to environments that strongly trigger relapse to drug use and places them at higher risk of overdose death. Additionally, felons have more difficulty securing housing and employment. They are less likely to have the ability to either pay for treatment or have access to transportation to treatment.

Often, addicts who overdose are transported to a hospital. For people who have overdosed and received successful, life-saving medical treatment, the majority do not get the appropriate follow-up care. It is recommended that hospitals partner with programs or practitioners who can and will prescribe medications such as Methadone, Suboxone or Vivitrol. Lacking a relationship, they should provide assistance to patient access for immediate treatment where they can get these medications. However, one study of overdose patients who leave hospitals indicate that less than 17% receive these medicines. Instead they were given prescriptions for anti-depressants (40%), anti-psychotics (16%), and benzodiazepines (14%). In more than 7% of cases, patients who had overdosed were given both an opiate and a benzodiazepine which is a dangerous mix in that they can cause respiratory failure.

So why would a smart young woman relapse to opiates? She was an informed person who personally knew of others who had died of overdose deaths. This might have made her cautious. She had Narcan, the overdose reversal medication, that may have saved her life if someone had been available to administer it. Was she likely unaware that her heroin may have contained fentanyl? For all these reasons, Carla should have known better and lived to an old age.

So why did Carla act against her best judgment? Addiction is a disease that negatively effects brain functioning including memory, decision making and judgment. Her disease, created an impairment in brain chemistry and neuropathways, and allowed her to take a risk, rather than seek self preservation. Most people have a survival instinct that alerts us to danger and allows quick reaction to escape it. Yet, opiate addicts are drawn to danger, like moths to a flame. Is it not evidence of disease that a drug addict will relapse in spite of the knowledge that they could die by overdose? Drug addiction is a disease, not simply a choice.

So what can we do to avert overdose deaths? We can ensure that people who are opiate dependent receive the appropriate treatment; change our prison system to allow addiction medication both during and upon release from incarceration; make Narcan readily available to anyone who is prescribed opiates; and offer overdose patients appropriate medication upon discharge from the hospital. If the hospital is not equipped to prescribe these medications, they should affiliate themselves with a treatment program. We should have a better monitoring and referral system for anyone who leaves treatment prematurely. If these measures are in place, lives will be spared. People like Carla will live to achieve her dreams.

Rest in peace, sweet Carla.