Heroin: the hidden price
In the late 1880s, the modification of natural substances in pharmacological sciences was important work. Pneumonia and tuberculosis were then the leading causes of death worldwide, and in an effort to alleviate the suffering of so many sick and wasting people, Germany's Bayer Corporation introduced a fast-acting pain-killer it called "heroin."
Doctors at the time had hoped heroin would be more effective and prove less addictive than its immediate predecessor, morphine. Such was not the case.
Five years after first opening its doors for the treatment of people addicted to heroin, New York's Bellevue Hospital admitted 425 such patients. That year was 1915.
Today in 2015, hospitals, police and emergency responders are beleaguered by the continually growing presence and use of the drug, but nobody can discern exactly how much trouble it's causing.
"It's a real problem," said Dr. Duane Siberski, an ER physician at Reading Hospital who often sees several overdose-related cases a week. "The ease of obtaining heroin … it's known to be cheap. Access is there." He said emergency workers are always alert to the signs of drug use during their evaluations, especially when the patients are not breathing or are mentally depressed – clear signs, but ones that may have any number of causes. Identifying heroin users for proper treatment isn't always easy. And cataloging a database for hospital use or state or national statistics isn't going to happen any time soon.
"There's a perception of, 'Oh, it's a downtown thing,'" Siberski said, "but the demographic is changing. It's the white kid from the suburbs [using heroin]. Heroin doesn't really pick and choose poverty." Siberski explained it's tremendously difficult to grasp who is being hurt by heroin; those saved by first responders often refuse a hospital visit, and even in their own record keeping, hospitals must organize their patient information by the most immediate problem.
For instance, Siberski said an abscess from frequent injections or a psychiatric diagnosis may have root causes in heroin abuse, but the records wouldn't have a red flag indicating that's the case.
"The primary health issue when they enter the ER is how they're recorded. The presenting complaint may be 'not breathing, unconscious' … but without doing a data dredge on all the charts that come through here it's almost impossible," Siberski said. "We have to do a certain amount of profiling. When we hear, 'Somebody's blue and not breathing,' and [the patient] is 70 years old, we usually assume a cardiac event. If they're 20 and not breathing it's probably heroin."
Eastern Pa. EMS Council Director John Kloss said when drugs are involved, first responders are likely to arrive at the scene of a 911 call to find the patient alone and in dire straits, having been abandoned by friends afraid of legal ramifications or panicked by the overdose. It's one of many reasons he feels that as much as drug addiction is an individual problem, it also reflects shortcomings in education and societal support.
"I don't know where you begin to measure the financial impact, the social impact, the cost to the health care system," Kloss said. "It's not just the drug of choice, it's a drug that has long-term effects on your liver, your cardiac production … just so many other bodily functions that it's more than just that 10-minute high. It leads to a lifetime of clinical challenges for these individuals."
Additionally, Kloss said EMS personnel often must contend with the criminal element or frightened residents and the threat of bloodborne pathogens. Exposure to bodily fluids and loose needles is often complicated by the patients themselves. Providers take precautions, he said, but once overdose patients wake up they don't know where they are or may be angry the treatment has ruined their high. "They may be depressed or they become uncontrollable. And it's also what was mixed with [the heroin]; was it Fentanyl, methamphetamine or something that's going to take them from a depressed mood to a Superman syndrome? It's not uncommon to be assaulted in the pre-hospital arena.
"It's a fine balance."
Siberski said longtime ER staff know when new dealers are operating or a new synthetic variation of the drug has hit the streets because the overdose cases rapidly increase. He said regular users usually end up in trouble when such changes occur. "We ask them when they had their last hit and how much it was – they'll tell you. They usually know what they're doing."
Kloss cites Pa. House Act 139, in the works since 2013, as a means of catching up societal responsibility with the need to save lives. It amends the 1972 controlled substance bill to include language immunizing from prosecution anyone who calls 911 or transports a person suffering a drug overdose, even if he or she possesses paraphernalia or is under the influence.
Both medical and legal professionals are hoping the changing law and greater availability of medicine will impact the final, sad result; drug overdose-related deaths.
Lehigh County Coroner Scott Grim said the exact number is difficult to pinpoint, for reasons mentioned earlier and the presence of other toxic substances often found in the dead, but it has increased by half since 2010. In that year 47 overdose deaths were ruled accidental, with each year since rising above 60 or 70, and the highest being 81 in 2013.
"We have seen a tremendous increase in drug-related deaths in Lehigh County, which is tragic," Grim said. "It is most difficult and saddening to have to notify a loved one that their child, brother, sister and/or spouse had died and then advise them that the death was due to drugs, whether prescription, illicit or a combination of both.
"Unfortunately, the drugs are easily accessible to almost everyone today. In the coroner's office, we see the end result, the final result of an individual's life, regardless of the circumstance," Grim said. "It wears on us as human beings. However, our responsibility and duty is to determine a cause and manner of death and to try to bring some closure to the next of kin."
Northampton County District Attorney John Morganelli said he and the law enforcement community wishes to avoid that most tragic conclusion. Even given his office's mandate, he said he supports wide use of medicines such as Naloxon, more commonly called Narcan, and laws giving some legal breathing room to someone calling for medical assistance for an overdosing companion. "I prefer a call [to EMS] to prosecuting people," he said.
"We're trying to send out the word; if it's a choice between life and death, prosecution is secondary."
The distribution of Narcan kits throughout the state to EMS and police entities has begun largely through a sort of grant through Capital BlueCross, Morganelli said, but not all counties want them because of the additional training and documentation involved.
Siberski said the program is targeting high-risk counties such as Carbon and Schuykill.
But as Kloss explained, distributing a miracle cure for the miracle cure may only encourage abuse by addicts willing to plunge over the edge if they know a Narcan injection will bring them back within heartbeats.
The fact is we can't rely on medicine to protect us, our communities and the ones we love from heroin. It's a shared responsibility in education and even compassion.
"It's society's problem," Kloss said.