Publisher’s note: This is the third in a multi-part series where the Border Belt Independent looks at what has changed since The News Reporter’s six-part series in 2017 that reported on the opioid crisis and associated mental health issues. Today, Publisher Les High looks at the increase in overdose deaths, particularly during the pandemic, and how overdoses and mental crises strain the resources of the emergency room and EMS.
By Les High
While the COVID-19 pandemic created a devastating level of tragedy in Columbus County, an existing healthcare crisis only worsened: narcotic overdoses.
It’s not just the overdoses but the increase in overdose deaths that concerns healthcare professionals like Dr. John Penrose, head of the Emergency Department at Columbus Regional Healthcare.
“We began to see more people with opioid-related issues and more overdoses and deaths – a lot more deaths,” Penrose said. “There were weeks we’d have five or six deaths.”
In Columbus County, unintentional deaths due to overdoses increased from 17.2 deaths in 2017 to 28.8 deaths in 2020 per 100,000 residents — or by 67%. Nationally, The New York Times reported this week that in the 12-month period that ended in April more than 100,000 Americans died of overdoses, “more than the number of people who died from car crashes and guns combined. The figure marks not only a record high but also a nearly 30 percent increase from the same period last year.” Overdose deaths have more than doubled since 2015.
Drugs like fentanyl and heroin have been particularly deadly, Penrose said.
“There apparently had been shipments of fentanyl and fentanyl-derived substances that were laced in,” he added. “Typically we can reverse a heroin or OxyContin overdose with a milligram or two of Narcan, but we were seeing patients that would require up to 10 milligrams to reverse their overdose. That probably contributed to most of the deaths, when people didn’t exactly know what’s in the product they’re using, they use it when they think they do know, or they’re using alone and don’t have someone to help them.”
Fewer opioid prescriptions
The North Carolina Medical Board has cracked down on rogue opioid prescribers and increased the monitoring of prescriptions, but drugs like heroin and fentanyl often take the place of synthetic opioids like OxyContin.
“The hospital and medical community have put protocols in place to reduce opioid prescriptions,” said recently retired Columbus Regional Healthcare CEO John Young. “The number of opioids has been reduced but you’re seeing an increase in other drugs like heroin and others. It’s been a trade-off.”
“When you’re taking OxyContin, you know exactly what you’re getting, 5, 10, 20 milligrams, whatever it is,” Penrose said, “but with heroin you don’t know the potency or if the drug dealer has laced it with something else.”
“This mixing and matching of drugs makes it even more difficult for us in the emergency department,” he added.
Challenges in the ED
Penrose said overdoses challenge the ER’s resources and enact an emotional toll on the staff.
“We had a couple of young people recently who were known in the community (and died from overdoses),” Penrose said. “The nurses know them and their families. Not only is it time and effort, expense, concern and worry, when the nurses and staff see community members they know die, it hits a little closer to home.”
Penrose wishes more people would take advantage of Narcan, a drug that can be given nasally or injected to reverse opiate overdoses. Narcan was once administered only by paramedics or in the ER. Legislatures across the country, however, have passed laws to make it accessible as an over-the-counter drug to negate the effects of opiates.
“Everybody thinks they’re immortal when they are using drugs, and consequently, they don’t take advantage of Narcan being easier to get,” he said.
EMS on the front lines
Acme-Delco-Riegelwood Fire-Rescue Chief Steve Camlin, who has been chief of the department for nearly 40 years, has seen a lot over the course of his career. One chilling trend, he said, is the steady ascent in substance misuse and psychiatric calls.
Camlin said substance misuse and psychiatric calls once comprised fewer than 10% of the department’s calls; now it’s closer to 25%.
The department is answering fewer opioid calls, he said, but there is a shift to other substances. Even non-narcotic substances like marijuana are being laced with potent chemicals, threatening the lives of patients. A-D-R answered four cardiac arrest calls over the summer and fall where patients overdosed on chemicals mixed in with marijuana, including formaldehyde (a chemical used in plywood and glue).
Camlin said substance misuse and psychiatric calls are often related.
“It’s depression, PTSD (Post-traumatic Stress Disorder). It got even worse in the pandemic,” he said.
The combination of substance misuse and mental health issues puts a tremendous strain on the department’s resources, especially volunteers, Camlin said. Sometimes crews have to stand by for hours only to get cancelled once things are sorted out at the scene by deputies. “That just kills the volunteers who have to get up and go to work the next morning.
“Something’s got to change with the way these calls are handled,” Camlin added.
People seeking help often turn to EMS as a last resort.
“They’re calling in and saying ‘I want to hurt myself’ or ‘I need to talk to somebody’ or ‘I need to go somewhere.’ Then they think we’re going to take them straight to the Oaks (an inpatient psychiatric facility in Wilmington), but we can’t do that,” he said.
Camlin isn’t sure what the solution is. Doctors need to play a major role, he said, but adverse childhood experiences like domestic violence, sexual abuse and molestation contribute to anxiety and mental trauma in kids that lead to serious issues later in life.
“We need to find the root causes first,” Camlin said.
‘Easier to get than pills’
Whiteville Rescue Unit Chief Shannon Strickland said paramedics aren’t getting as many synthetic opioid calls since 2017, but there are more heroin overdoses and heroin-related deaths.
“They say heroin is easier to get now than pills,” he said.
Like Acme-Delco-Riegelwood, Whiteville Rescue has seen a stunning increase in overdose and mental crisis calls, which Strickland estimates comprise about one third of the department’s calls.
Strickland got involved with EMS in 1985 and has been chief at Whiteville since 1995.
“We had a lot of calls related to alcohol back then,” Strickland said. “Now it’s drugs.”
Most departments, including Whiteville, are seeing a spike in heroin overdoses that result in deaths. The pandemic made everything worse.
Strickland surmised that more people are using drugs to fight depression and deal with other issues. This was especially the case when the nation went on lock down.
“They couldn’t get out of the house,” Strickland said, “and the walls started closing in.”
Substance misuse and mental health crises are often intertwined, making treatment difficult. Strickland said the increase in these calls also saps manpower and other resources, especially since law enforcement officers must be on the scene before ambulance crews are allowed in.
“It’s dangerous,” Strickland said. “You have to protect your people.”
The department does what it can to help patients recover once the medical emergency is over. Strickland hopes to get a new batch of pamphlets provided by Celebrate Recovery, a Christian 12-step program for people who struggle with all habits and hardships like addiction. The pamphlets list resources and encourage people to seek assistance.
Strickland said he finds that many people who overdose are initially receptive to overtures by EMS crews to seek further care, but he suspects most don’t follow through.
“They have to want to get help,” Strickland said. “We do what we can to encourage them.”
Strickland said that mental health services are better than they were because there are more providers, but that EMS departments would like to have more training on how to deal with substance misuse and mental health crises. Trillium, the lead mental health agency in the county, sent a representative to speak to the department once about the topic, but no one has been back.
Finding treatment facilities for people with substance addiction and mental health issues is an ongoing battle. The ED almost always has people being held in rooms pending transfer to in-patient substance misuse or mental health care facilities. Waits can be days or even weeks.
“It’s not just the opioids themselves, it’s the whole spectrum of behavioral health that meshes with it that has put this strain on us,” Penrose said. “Even during covid times, we’re trying to hold patients here because there was no room in the hospital and we’ve got that whole section with four, five, six behavioral health patients. They’re not being placed in the appropriate settings because these (behavioral care) places are filled up. There’s this backward bottleneck across the state. Everybody is being affected by the same thing.”
Young said the state has moved to more community-based mental health solutions “because there was this feeling that some of the in-patient facilities weren’t helping people get better, but now we see there is a huge need for in-patient psychiatric care as demonstrated by the long waits to get patients admitted to existing facilities.
“We need those options back,” he said. “It’s overwhelming.”
Dr. Evangeline Gonzalez, a hospitalist at Columbus Regional Healthcare, said more community-based and in-patient psychiatric options are needed.
She describes the local situation as “not good….It takes so long to find resources for the patient.”
Medication-based treatment, which includes the use of less potent narcotics like Suboxone to help patients navigate through withdrawals, is only one option, she said.
Gonzalez believes more patient contact with counselors and therapists is critical to help those who are motivated to get off drugs.
“It will ebb and flow,” she said, “but we need more access to psycho-social treatment than medication treatment.”
Limited treatment resources for substance misuse and mental health crises will continue to perpetuate the cycle of overdoses and deaths, Penrose said.
“Many of the people who go to rehab generally don’t do it successfully, and that’s another issue,” he said. “Until we get some sort of universal health system that includes behavioral health and rehab services, I don’t know that it will add that much more success than what we can currently do.”
How effective are mental health and substance misuse resources in Columbus County?
“I appreciate that the people are doing all they can but they have limited resources, too,” Penrose said. “They’re so overstretched and have such limited resources they themselves feel overwhelmed, so maybe they’re trying to move patients along a little faster than would be successful for them…but it’s not good.”
“Until the pandemic subsides,” Penrose added, “and until we get back to more of a new normal in terms of people getting back to work and developing their self esteem and being able to take care of themselves and their families, our issues are going to continue.”
The Border Belt Independent (borderbelt.org) is a nonprofit, online newsroom that provides in-depth reporting in Bladen, Columbus, Robeson, and Scotland counties, often in collaboration with the six newspapers that serve the region.