Crooked River Counseling

Crooked CROOKED RIVER COUNSELING Fall 2017 issue

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Course Coll ision MUNICIPAL OFFICIALS HEAR GRITTY DETAILS OF MAIN'ES DRUG CRISIS

An unprecedented epidemic: AMERICA IS IN A DEADLY WAR AGAINST OPIOID ABUSE

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Crooked River COUNSELING For more information visit us at WWW.CROOKEDRIVERMAINE.COM 87 S. HIGH ST. BRIDGTON, MAINE 04009 • 207.647.5600 ADDICTION IS A FAMILY DISEASE... ONE PERSON MAY USE IT, BUT THE WHOLE FAMILY SUFFERS.

“It was a wakeup call that we had an enormous problem and I was sticking my head in the sand.” - Craig smith, M.D.

Frum says, “It has been a joy as a CEO to see our medical staff identify a major problem – and here in western Maine it is a significant problem – and figure out a creative way to address it.” The practitioners who are implementing MAT view it as the standard of care for treating OUD. They say it saves lives while increasing the chances patients remain in treatment and learn the skills necessary for long-term recovery. Smith, three other physicians – including his wife, Jennifer Smith, M.D., also a member of the hospital’s medical staff – and two nurse practitioners, prescribe the medication. Crooked River Counseling provides intensive outpatient counseling and group therapy for the patients. About 200 patients are enrolled in the program. Appointments at Smith’s North Bridgton Family Practice are coordinated with patients’ counseling sessions at Crooked River Counseling, just five miles down the road. Crooked River Counseling is located on the hospital’s campus, which the partners say leads to better coordination of the treatment and services.>>>

Death a Day Tackling the opioid crisis in a rural community

With the support of Bridgton Hospital CEO David Frum, Smith partnered with Bell, director of Crooked River Counseling, to set up medication-assisted treatment – or MAT – to treat OUD in his primary care practice. MAT pairs nondrug therapies, such as counseling or cognitive behavioral therapy, with a Food and Drug Administration-approved medication, like Suboxone, to treat patients suffering from OUD. Before the program began in 2009, the only other OUD treatment option was a methadone clinic, which was an hour and 45 minute drive away in Portland. “We got overwhelming support from the hospital,” says Smith. “I was amazed when David and our leadership said, ‘if you are telling us this is a significant problem in our community, we will standby you and do whatever we need to do to care for these patients.’” As part of the program, the 25-bed critical access hospital provides comprehensive maternity care to women with OUD during their pregnancy.

AHA News, Sep 27, 2017 One death a day in Maine is caused by an opioid overdose. Bridgton family practice physician Craig Smith, M.D., a member of the Bridgton Hospital medical staff, is on the front line in the battle against the crisis that is harming people of all ages and all walks of life – not just in Maine but in communities large and small across the country. A Bridgton substance abuse counselor, Catherine Bell, nearly a decade ago approached Smith about prescribing Suboxone, an opiate withdrawal medication, to treat patients with opioid use disorder (OUD). If he did, she would provide counseling to those patients. Smith was reluctant to do so until he realized the OUD crisis had reached his tiny community of 5,000 residents and could not be ignored. Four of his patients died of overdoses in one month, including a 34-year-old mom of two small children. “I was totally unaware they were using it,” he says. “It was a wakeup call that we had an enormous problem and I was sticking my head in the sand.”

>>>“That interconnectedness of services has served us well in putting these pieces together so it is holistically balanced for our patients,” Frum says. “We have constant communication with our providers and we talk about cases all the time,” Bell says. “We tell our clients that the doctor and I are going to do that so we can give you the best possible care.” “Often it is the first time they really tell somebody how severe their use is,” Bell says. “It takes courage to walk through that door.” Smith talks to patients about the stigma. “I tell them that I can’t undo the prejudices some people may have about you, but you can hold your head high and know you are doing the right thing.” Bell notes that more than 90% of her clients “started out with a legitimate medical need to take a prescription,” but at some point lost control. “Recovery is about rebuilding relationships and being a productive member of the community and society,” she says. “They start building recovery-based relationships the moment they walk through our doors.” The program supports pregnant OUD mothers in a net of integrated care that keeps their babies close to home. Despite its modest size, Bridgton Hospital six years ago began delivering babies born to local mothers on Suboxone. The program seeks to remove the stigma associated with the disorder.

Before the hospital adopted the maternity care program, Jennifer Smith observes that “our obstetric nurses were caring for these women their entire pregnancy, then sending them to larger hospitals to deliver their babies. All of our [obstetrics] nurses are now trained in Neonatal Abstinence Syndrome scoring, which is a withdrawal scoring system for newborns exposed to opioids or [Suboxone].” She says “Bridgton Hospital is one of only a few rural hospitals in the state providing this level of care for opioid-dependent mothers and I am proud to be a part of it.” Craig Smith adds: “We are a community hospital and I wasn’t sure how that would go over. But we got tremendous support from the hospital and multiple departments to make sure we could take care of moms who needed to be here and care for their babies.” Smith has watched patients turn their lives around, go back to work, reconnect with their families and dramatically reduce their risk of dying from an overdose. “We can’t do it alone,” he says. “The police can’t do it alone. But we can come together as a team when the community says this is a problem and we need to fix it.” Too few treatment facilities, qualified personnel and limited insurance coverage are barriers to widespread adoption of MAT programs like the model implemented in Bridgton. But hospital CEO Frum said his small rural community’s experience in tackling the OUD epidemic demonstrates that where there is the will there is a way to overcome those barriers. “There are barriers, but that is what led us to create this integrated, creative local solution that has saved people,” he says. “They otherwise would have been lost and that is why we do it.”

“The police can’t do it alone. But we can come together as a team when the community says this is a problem and we need to fix it.” - Craig smith, M.d.

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An unprecedented epidemic: AMERICA IS IN A DEADLY WAR AGAINST OPIOID ABUSE

“It actually runs parallel,” he says. “I think (overprescribing is) a mistake that the medical profession clearly now sees.” Shocking Things You Never Knew About 'The Golden Girls' Today, thanks to government mandates, better education and extensive training, physicians are more cautious when prescribing the use of opioids for the treatment of chronic pain like back, bone or headaches, chronic pain syndromes like fibromyalgia, or dental procedures. This is largely due to a lack of evidence indicating that in these instances, opioids can “help people to feel less pain, be less disabled and function better,” says Dr. Fiori. The research that is currently available in this regard “is very controversial,” he says. But just as one supply route started to be cut off, another, much more dangerous painkiller has become accessible: synthetic opioids. Manufactured in laboratories, these new designer drugs, commonly known as fentanyl and carfentanil (which is actually an elephant tranquilizer) are more potent than their predecessors — and potentially more deadly. “Fentanyl is 100 times more powerful than morphine, and 50 times more powerful than heroin,” says Lindsey Vuolo, associate director of health and law policy at the National Center on Addiction and Substance Abuse (NCASA). “And that is what has caused the surge in deaths — there was a 72% increase in overdose deaths from synthetic opioids between 2014 and 2015.” Synthetic opioids are predominantly being used and abused “east of the Mississippi (River),” she adds. According to the CDC, the areas of the country seeing the most

“The way that this epidemic is particularly unique is that it has really impacted suburban and rural areas.” -Lindsey Vuolo, associate director of health and law policy at the National Center on Addiction and Substance Abuse (NCASA).

BY: JORDAN GALLOWAY NEW YORK DAILY NEWS Tuesday, September 26, 2017, 1:36 PM

“100% of those deaths are preventable.”

For starters, a drug known as Naxolone is able to reverse an opioid drug overdose when administered in time. It’s now available at pharmacies in New York City (go to nyc.gov/health/map for a list of participating locations) and can be paid for through insurance or out-of-pocket (cost starts at $45). Community programs throughout the city will also provide it free of charge; they can be located by calling 311. Prevention, especially among children and young adults — people ages 18 to 25 have the fastest growing rate of drug use, specifically opioids — continues to be a first wave of defense and the best long-term solution for stemming the tide of substance abuse. But advancements in drug and alcohol treatments, as well as greater accessibility thanks to substance abuse rehabilitation being covered under the Affordable Care Act, are making it easier and more affordable than ever for people dealing with substance abuse issues to find help. “Assessments are very fast,” says Dr. Nordstrom. “It’s a 45-minute investment of time that can literally save your life.”

America’s been waging a war on drugs for decades, but it’s never faced an adversary as deadly as the current opioid crisis. “Virtually all experts agree it’s the worst drug epidemic we’ve seen for 40 to 50 years — it may be the worst drug epidemic ever,” says Peter Provet, president of Odyssey House, a drug and alcohol rehabilitation center in New York City. “Opioid overdose is the No. 1 cause of death under 50 years old.” What makes opioids — a class of drugs intended to relieve pain that includes both prescription formulas like morphine, oxycodone (OxyContin), hydrocodone (Vicodin) and codeine, as well as illegal versions like heroine — so dangerous is both their addictive quality and their accessibility. The number of opioid overdoses involving prescription painkillers alone has quadrupled since 1999, according to the Centers for Disease Control (CDC) — and so did the sale of prescription drugs. That’s no coincidence, says Michael Fiori, director of addiction services for Mount Sinai-Beth Israel Medical Center in New York City.

significant increases in opioid overdoses are the Northeast and the South. Individual states hit the hardest include Connecticut, Florida, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Washington and West Virginia. But overall, opioid usage is skyrocketing across the country — opioids were involved in more than 33,000 deaths in 2015, according to the CDC. And unlike earlier drug epidemics, this current one is no longer concentrated in urban areas. “The way that this epidemic is particularly unique is that it has really impacted suburban and rural areas,” says Vuolo. And while addiction is an indiscriminate disease, according to the latest statistics, the highest rate of increased overdoses is occurring in Caucasian and Native American populations. “I think a lot of people were surprised by those recent statistics,” says Dr. Fiori. Something else that’s very different about this drug epidemic? “Men are (still) more likely to die of an overdose than women, but that gap is closing,” he says. “And it’s not clear to me why the rates of overdose are increasing in women.” One thing that is clear is that “any use of opioids right now carries the risk of overdose,” says Ben Nordstrom, MD, chief clinical officer at Phoenix House, a nationwide holistic drug and alcohol treatment center. But there is hope, Nordstrom adds. With proper medical intervention,

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Rate of fatal car accidents involving prescriptions opioids surges collision course

“Findings from this study may help put a spotlight on the adverse effect of prescription opioids on driving safety,” Li said. “The results also suggest that the health consequences of the opioid epidemic may go far beyond overdose fatalities.” Mothers Against Drunk Driving (MADD) is also “concerned about the rising use of opioids across the nation and the effect these drugs have on the safety of our roadways,” said Colleen Sheehey-Church, the organization’s national president. “There is no doubt that drugged driving is a serious problem.” Sheehey-Church believes that driving while intoxicated with painkillers or alcohol can be avoided by personally ensuring that a friend or family member with addiction is kept from driving. “The risk associated with driving under the influence of opioids affects all road users,” “Our focus is always on impaired driving, no matter what form of impairment,” she added. “There are many organizations that deal with addictions and contacting one would be a good step.” “The growing use of illicit drugs and abuse of prescription drugs makes our work at MADD even more difficult,” she said. “So, education, legislation, technological development and support of law enforcement are more important now than ever before.”

“The risk associated with driving under the influence of opioids affects all road users,” said co- author Dr. Guohua Li, a professor and director at the Center for Injury Epidemiology and Prevention at Columbia University. “The issue of drugged driving should be a cause for concern to all of us.” “Consumption of prescription opioids in the U.S. has increased markedly in the past two decades,” he said. “It’s a major driver of the ongoing opioid epidemic, which is widely recognized as a national public health crisis. The impact of the opioid epidemic on traffic safety, however, is understudied.” The researchers looked at 20 years worth of statistics from the Fatality Analysis Reporting System and scouted drivers who died in West Virginia, Rhode Island, New Hampshire, Illinois, Hawaii and California. These states consistently monitor and test for substance use in car-related accidents that result in fatalities. “The study was based on six states that routinely test for drugs in 80 percent or more of all drivers who are fatally injured in motor vehicle crashes,” said co-author Stanford Chihuri, an epidemiologist at Columbia University College of Physicians and Surgeons. “In addition, the study only included drivers who died within an hour of the crash in order to avoid potential bias from opioids administered after the crash.”

After analyzing nearly 37,000 drivers, almost a quarter were found to have a substance in their system and 3 percent of these results were linked to prescription opioids throughout the two-decade span. This data exposed that the number of opioids detected in fatal car accidents increased from 1 percent in 1995 to 7.2 percent in 2015. “With regards to drugged driving, women are more likely to be affected than men — 4.4 versus 2.9 percent, respectively,” Li said. “Our data indicate that fatally injured female drivers are significantly more likely to be under the influence of prescription opioids at the time of crash than fatally injured male drivers.” “Consumption of prescription opioids in the U.S. has increased markedly in the past two decades,” Chihuri believes that the use of the prescriptions opioids found in fatal accidents may be from the nonmedical use of unused postoperative meds and from nonmedical use obtained illegally. He added that improving the epidemic will require health care professionals to inform patients of the possible dangers of driving under the influence of prescription opioids based on the type and dosage.

“There is no doubt that drugged driving is a serious problem.”

AMERICA’S OPIOID EPIDEMIC continues to manifest itself in a new report that reveals a drastic sevenfold spike in the number of fatal car accidents involving opioid prescriptions. Columbia University researchers present this data at a time that when the use of prescription drugs like hydrocodone and oxycodone has increased four times the rate, going from 76 million in 1991 to almost 300 million in 2014, they stated.

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Why Waiters Drink And why it matters

In Las Vegas, many bar and casino workers become addicted not only to substances, but also to the gambling services their employers provide. Many employers do not restrict their workers from gambling in their establishments. Addiction is a disease, and in some ways, it is contagious. As much as we might want to imagine we are, none of us are completely immune. My dearest friends are those I toiled alongside in horrible restaurant jobs. We share with manual labor industries like construction and mining the physical toll of our work, but also the continued sense that our work is less-than. In my first restaurant job at 18, I observed my older co-workers drinking together after shifts as I folded napkins and polished silverware. The social nature of food service can mean it becomes easy to define substance abuse behaviors as “typical” rather than problematic. Incorporating substance abuse prevention information into training materials, and providing insurance with access to mental health care, could help. Industry executives must realize that although far removed from them directly, the staff ’s substance abuse has compounding effects on the bottom line through workplace injuries, absenteeism and low employee morale. My co-worker who was let go after that drunken night eventually found another job. Today she works in sales. But not everyone in food service can or will pick another career. If leaving the industry entirely is the primary path toward recovery, then we are not actually solving our problems. We are running away from them.

My former co-worker once drank so much during a waitressing shift, she stumbled through the restaurant with her intoxication on full display to guests. Even the chaos of the service rush couldn’t hide the state she was in. By closing she was fired. After work that night, a group of us consoled her at the casino sports book, where we often congregated for an after-hours ritual. Over drinks, cigarettes and video poker, we traded our best war stories. Together, our minds and bodies recovered from the physical exhaustion and emotional stress of service. We told our friend that everything would be fine. After all, she wasn’t the first employee to be under the influence on the job. One manager regularly arrived to work with alcohol on his breath. Some bartenders taste-tested enough cocktails to maintain a steady buzz throughout their shifts. We knew which servers, cooks and managers relied on cocaine to get through the long hours that restaurant life demanded.

According to the report, the industry currently has the highest rates of substance use disorder, at nearly 17 percent of its workers.That percentage is especially jarring when you consider that the restaurant industry is the second-largest private-sector employer. According to the Bureau of Labor Statistics, jobs in food service will soon outnumber those in manufacturing. But without union representation, these jobs are usually accompanied by poor pay, inconsistent schedules and no medical insurance. High turnover means that when substance abuse behaviors do interfere with job performance, workers can be easily, and immediately, replaced. Plus, the problem goes all the way to the top.The same report on substance abuse found that across all industries, one in 10 managers is abusing controlled substances. Middle management is arguably the most overworked in food service; in high-end bars and restaurants, managers often make less than their service staff, while working longer hours with no overtime pay. Because food service jobs are increasingly a foundational part of our economy, it is even more crucial to think about what happens to the people who work them. There remains a false assumption that restaurants are staffed by college students and 20-somethings, making it easy to pass off substance abuse as a result of unmotivated employees or the immaturity of a younger work force. But an increasing portion of food service workers, particularly in cities like mine, are in the industry for the long term. With more metro areas relying predominantly on restaurants for employment, more workers will find themselves in food service based on economic necessity and limited employment opportunity. I’ve personally managed to avoid drinking and drug use. On more than one occasion, however, I found myself walking back to my car after a shift, disappointed in the amount of cash tips I fed, like Monopoly money, into a video poker machine.

For anyone who has worked in food service, these anecdotes are likely familiar. According to a 2015 report from the Substance Abuse and Mental Health Services Administration, the food services and accommodations industry is among the top fields for alcohol and illicit drug use, alongside construction and mining. Naturally, food and beverage work is accompanied with an easy access to alcohol. But with the addition of late-night hours, long shifts without meal breaks and dark rooms full of people drinking, it is no surprise the environment often nurtures addiction. Because food service jobs are increasingly a foundational part of our economy, it is even more crucial to think about what happens to the people who work them.

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Municipal officials hear gritty details of Maine’s drug crisis As part of the Maine Municipal Association's annual convention, front-line responders spoke about what they see daily and what

“Yesterday, we had a fellow that we saw three times in a six-hour period,” he said. “Every time, he re-dosed himself in terms of heroin. The third time he was given an option — go the to the hospital or go to jail, because we were going to chase this guy forever. There are no easy answers.” Not all overdoses result in deaths, but the death toll from opioids is rising. In 2016, 376 drug-induced deaths were reported statewide, according to the Expanded Maine Drug Death Report for 2016, funded by the Office of the Maine Attorney General and compiled by Marcella Sorg, of the Margaret Chase Smith Policy Center at the University of Maine. That number is a 38 percent increase over the deaths reported in 2015.

they hope can be done. BY JESSICA LOWELLSTAFF WRITER

For more than an hour, Walsh and Lt. John Kilbride, of the Falmouth Police Department, spoke to about 65 municipal and law enforcement leaders at a session of the Maine Municipal Association’s annual convention about the state’s opioid crisis about what they see every day. A number of those officials had addiction stories of their own to tell of friends and family members who have become addicted to heroin, fentanyl and carfentanyl. Walsh said when he first starting working in Portland in 1977, he and his co-workers encountered heroin occasionally. Now he and his team know that when they come on shift, it’s not if but how many overdoses they will see that day, in front of schools, on Interstate 295, in homes and on the street.

AUGUSTA —The people on the front lines of the response to Maine’s opioid crisis are doing everything they can when they’re confronted addicts and overdoses, but it’s not always enough for the addicts, their families or even their co-workers. “I keep thinking it’s going to get better, because how could it get any worse? But it is. It is getting worse,”Terry Walsh, deputy chief of the Portland Fire Department, saidWednesday.

Of the deaths in 2016, 88 percent were accidental overdoses. Most deaths were caused by two or more drugs, and two-thirds of all deaths were caused by nonpharmaceutical opioids.

“Law enforcement knew a long time ago that you can’t arrest your way out of the problem,” Kilbride said. “We knew that when we were arresting someone and we took the drugs off them, they were high as a kite. We weren’t treating them at all. We were dealing with the problem at hand.” The state’s jails have become the biggest detoxification centers for the state. In Cumberland County, where the jail population is typically about 400, about 80 percent of the inmates are there as a result of substance abuse. “There is no clear pathway from detox on through to treatment,” he said. Kilbride praised initiatives such as Operation Hope, sponsored by law enforcement and others in Scarborough, under which addicts can come to police for help. “They have worked with insurance companies and treatment facilities out of state to provide help to more than 200 people,” he said. But not every law enforcement agency can do that, he said, and Maine has few other options for treating addiction in the state. For him, the answers lie in treating addiction as a disease and providing education about drugs. “I want to read a quote to you,” Kilbride said. “I wrote it down because it was upsetting to me. Attorney General (Jeff) Sessions said: ‘Create and foster a culture that is hostile to drug use.’ This is the leader of law enforcement. … He’s so far off-base. He doesn’t get it that it is a disease of the brain that can capture an 18-year-old who took oxycodone when he had his wisdom teeth out and he’s dead three years later, two years later. If our attorney general doesn’t get it, who does at the federal level?” Drug abuse is like diabetes, he said. If you have it, you have to manage it, and the way to do that is with suboxone or methadone, he said. That’s what saved a member of his own family who became an addict. He stressed the importance of education and the leadership role of municipal officials to help get the message out to schools and encourage their law enforcement agencies. For Patricia Brochu, Old Town’s city clerk, jails are not the answer. “It doesn’t matter what kind of family you come from,” she said. “It doesn’t discriminate.” he

She said it’s sad that she’s hoping that the member of her family who is addicted would be arrested to have an opportunity to go through detoxification. “There’s not enough in-patient facilities to help these people,” she said. “Jail is not the answer. They are not criminals. They are turning into criminals to feed their addictions.” The discussion was part of the first day of Maine Municipal Association’s annual convention at the Augusta Civic Center. Other sessions on Wednesday included updates on best

practices in municipal infrastructure projects, addressing change and

challenges in budgets and taxes and managing weather-related risks to coastal communities.

- Terry Walsh, deputy chief of the Portland Fire Department

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