Experts are calling heroin use the worst drug epidemic the United States has ever seen—and the numbers certainly bear this out.

The UN Office on Drugs and Crime's 2017 World Drug Report, which examines the health impacts of opiates, cocaine, cannabis, amphetamine, and other substance abuse across the globe, finds heroin is the deadliest drug worldwide, especially in the United States. The organization reports that in the states, there are more than 1 million heroin users and deaths have increased five-fold since 2000.

More alarming is the fact that these numbers are expected to continue skyrocketing, predicts Pennsylvania physician, Dr. John P. Gallagher, who chairs the Pennsylvania Medical Society's opioid task force. He suggests that as efforts to combat heroin and opioid use escalate across the U.S., so too will overdose deaths.

Work is ongoing to close the opioid and heroin pipelines, which will prevent new people from becoming addicted, explains Gallagher. However, he adds that those already hooked on these dangerous drugs will be led toward the use of more potentially deadly ones, such as fentanyl and carfentanil. Drug dealers are increasingly using carfentanil, a drug used to tranquilize very large animals such as elephants, to cut heroin, he says.

The presence of these harmful substances in heroin is leading to an increase in overdoses, Gallagher adds.

"In 2016, the country had 60,000 drug overdoses; 85% of those were to opioids," he explains. "That's not the worst part. Studies show it will be another seven years before the changes we are making now will have an impact, and it is estimated that another 500,000 people will die before we hit a peak and the numbers start to go down. In fact, we may actually see an increase in heroin deaths before overdose deaths start to decrease."

Pennsylvania's experience with this epidemic is not unlike that of any other state in the nation. Jennifer Smith, acting secretary of the Pennsylvania Department of Drug and Alcohol Programs, reports the state saw 4,642 overdose deaths in 2016, an increase of 37% from the year prior. "We are on track to see at least another 35% jump in 2017," she adds.

The Keystone State has begun work in a variety of channels to stem the tide of this epidemic. One measure has been to arm police officers with the opioid-reversing drug Narcan.

"If they die in an overdose, we will never get a chance to treat them," says Gallagher. "We are trying to keep people alive so that they can seek therapy down the line."
Smith adds, "Police officers may very well be the first on the scene. You want to be able to provide this life-saving drug as quickly as possible while waiting for medics to arrive."

Doing the Right Thing
The Hermitage (PA) Police Department has 30 officers who police the City of Hermitage's approximately 16,000 residents as well as an influx of people who come to the city daily to visit its large retail areas. The department also polices the communities of Weiland and Clark, which collectively have approximately 2,000 residents.

While the jurisdiction hasn't seen as large a heroin problem as, say, Philadelphia, it is seeing its share of heroin overdoses; more than Hermitage Police Chief Eric Jewell feels comfortable with. He explains, "We're like anywhere in the country; we are having too many overdoses. But even one is too many."

This sentiment led Jewell to research adding Narcan, the brand name of Naloxone hydrochloride, to every Hermitage police officer's duty bag. This drug blocks opioids from acting on the body and reverses their effects within minutes.

In his research, Jewell uncovered a memorandum of understanding sent to Pennsylvania's district attorneys by Gary Tuggle, U.S. Drug Enforcement Agency Special Agent in Charge. This document warned that the heroin epidemic was everywhere and presented safety concerns to both the public and police officers. The memo went on to encourage law enforcement to obtain and deploy Narcan.

"I read the memo and reached out to Gary and said, 'If you're encouraging Narcan's use, is there anything you can do to help me?'" Jewell recalls. His request led to the DEA dispatching a diversion investigator and two agents from its Pittsburgh office to train Hermitage officers on Narcan deployment.

Though it's too soon to report hard numbers on how many saves Hermitage officers are responsible for, Jewell says his officers have already used Narcan and it has saved lives.
Smith adds that the numbers of saves are staggering across the state. Since 2014, the Pennsylvania Department of Drug and Alcohol Programs has been notified of 3,845 reversals by police but she says there are likely more.

Protects the Public and Police
Though Narcan saves have been well documented, its use by police still encounters a mixed bag of responses across the nation.

Before defending its use for other reasons, Jewell stresses one important fact—carrying Narcan protects officers from harm.

Gallagher explains fentanyl and carfentanil are extremely harmful to humans, even in small doses. In some cases, the heroin at the scene can be so lethal that touching or inhaling it can lead to a fatal overdose. In fact, he reports in Westmoreland County, PA, Narcan was recently administered to an officer who overdosed after inhaling fentanyl in the air.

Tuggle supports this finding, stating, "If you ingest or inhale even minute amounts of carfentanil, it can have deadly consequences."

Even so, police officers are not paramedics, say nay-sayers. Most departments do not allow police to carry Epi-Pens for this reason, so why should they be allowed to administer Narcan, these opponents ask. "It has been, and still is, a big debate among police officers and police chiefs. There is a big divide on Narcan's use," admits Jewell.

However, Tuggle points out that for every person who dies from an overdose, there are five to 10 people who survive, partly due to increasing Narcan use. "As more and more police departments and local governments adopt the practice of using Narcan, we're saving a lot more lives. If we weren't using it, we'd have a lot more fatal overdoses than we do."

Many departments argue that it's also hard to justify Narcan's use when officers are administering the drug to the same people over and over. It's a sentiment Tuggle understands well as he points out that just last week there was a young pregnant woman in the Kensington area of Philadelphia who was revived twice in less than an hour. "She went back to the same area, gained access to the same heroin, then overdosed and had to be revived again," he says. "That is just how powerful this addiction is."
Gallagher adds, "We hear stories about police resuscitating the same people again and again, and my argument is, 'If this was your son, how many times would you resuscitate him?'"

Police are in the lifesaving business, says Jewell, who maintains administering Narcan is simply the right thing to do. "Though they might overdose two to three times in the same day or week, it's not for me to decide who lives or dies. We cannot arrest people into rehabilitation. And, we cannot help them at all if they die," he says.

Smith agrees: "The reversal is a really important step in getting someone into treatment. If you cannot keep them alive, you certainly cannot get them into treatment."
However, she stresses it is incredibly important for officers to possess the necessary skills to convince overdose survivors to seek medical help. Currently, overdose victims do not have to go to the emergency room after Narcan treatment.

"We're like anywhere in the country; we are having too many overdoses. But even one is too many." —Chief Eric Jewell, Hermitage (PA) Police Department. Photo: Getty Images.

She advises officers to employ Motivational Interviewing (MI), a psychotherapeutic approach that attempts to move an individual away from a state of indecision or uncertainty and toward finding motivation to make positive decisions and accomplish established goals. Some attributes of MI include expressing empathy, asking open-ended questions, keeping a positive/forward focus, and linking talk to action (not just saying they want treatment, but getting them to act). 

"The benefit of police learning this technique," she says, "is that they are present during that critical window immediately following an overdose event with the ability to capitalize on the feelings of what just transpired. If we can get the overdose survivor to the emergency department for an evaluation, we buy a little more time to talk with them about treatment and allow them to meet with certified recovery specialists."

Responding to Reservations
Liability and cost are two additional concerns that must be overcome for police departments to begin carrying Narcan, admits Gallagher.

The State of Pennsylvania has addressed the liability concern with its Good Samaritan Act, which states that any emergency responder administering Narcan is immune to prosecution should an adverse reaction occur. To qualify for immunity, these responders must take two hours of online training offered by both the DEA and the Pennsylvania Department of Drug and Alcohol Programs. This training certification counts toward an officer's continuing education credits.

In Hermitage, all officers received Narcan training from the DEA and local EMTs. The department also fashioned a policy regarding Narcan use and officers had to pass an online certification test. In addition, because the state requires departments to have a prescription from a medical doctor to use the drug, Gallagher wrote a script for the department.

Applicable training covers the symptoms of opioid use, the administration of Narcan, the follow-up after its use, documenting the event, and more, says Jewell. He explains, "With any type of drug use, particularly intravenous, we are concerned with bloodborne pathogens and contagious diseases and officers need to know how to protect themselves. They need to know that the victim could hurt themselves or officers if they are combative as they come out of their high. They need to turn them on their sides and move them away from others as a means of protection. We don't want to have to charge them with assaulting a police officer when we are just there to save their lives."

Cost has been an ongoing issue, and is one that Hermitage overcame by obtaining its supply from the Pennsylvania Department of Drug and Alcohol Programs, which had received a $600,000 donation from Capital BlueCross and a few other sources to distribute Narcan to first responders.

The cost of this drug has plummeted in recent years. When it first came out, it was only available in an auto-injectable form, and this carried a very high price tag—up to $5,000 per dose, he says. But today, Narcan is available in an aerolized form that can be squeezed into a person's nostril, much like Flonase. This version of Narcan costs approximately $40 a dose.

Though the price has come down, there still can be a cost to financially strapped agencies. In Pennsylvania, Smith is seeing departments cover the expense in several ways. Some departments, she says, have built it into their budgets. "They've decided it's important enough that they're going to continue funding it."

But in areas where there is more drug use, such as in Philadelphia, this isn't realistic. In those places, Smith says donations from charitable organizations are keeping the supply plentiful and the programs going. Pennsylvania Gov. Tom Wolf recently put $5 million in the budget for the Pennsylvania Commission on Crime and Delinquency to purchase or replenish supplies of Narcan. "This $5 million isn't just limited to police. It's available to police, first responders, treatment providers, libraries, churches, and other community organizations," she says.

Cost is also kept in check if police are properly trained in its storage, adds Gallagher. Narcan is stable to from -4 degrees to 120 degrees Fahrenheit. He recommends officers carry it in their response kits, and bring it into the station after their shifts end as opposed to leaving it in their squad cars.

"Our officers are responsible for putting it into their duty bags with their other supplies and bringing it out to their cars at the beginning of their shifts and back in to the department at the end of them."

A Community Effort
Just as it takes a village to raise a child, it takes the work of the entire community to stem the tide of heroin use and overdose deaths, according to Smith.

"It's so important that all these pieces work together," she says. "Without the support of law enforcement carrying Narcan; without the support of the health systems who see these folks in their emergency departments and physicians' offices; without the support of the criminal justice system allowing these individuals to seek the treatment they need instead of being put into jail; without the support of treatment providers and without community resources little will be
accomplished.

"We need that shared vision, to assist these people in getting the help they need so that they can live a life of recovery," she says. "If just one piece is missing, such as law enforcement just isn't interested, the whole process just kind of falls apart."
Tuggle agrees, noting, "This is not just a Pennsylvania problem, this is a national problem. It's not just a public safety issue, it's also a public health issue, so public safety and public health have to work together to tackle this problem."

Ronnie Garrett is a freelance writer based in Fort Atkinson, WI, who has specialized in writing about law enforcement since 1995.

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