Battling an Epidemic - Part Three: What Iowa's parents, doctors and others are doing to overcome opioids' fatal effects The Iowa Harm Reduction Coalition gives out free Naloxone kits as well as risk reduction kits during a mobile outreach event in downtown Cedar Rapids on Monday, April 23, 2018. The organization gives out free Naxolene kits, which can reverse an opioid overdose, as well as risk reduction kits that include sterile water, cookers, ties, antibiotic wipes, band aids and condoms. (Cliff Jette/The Gazette)

Chapter 1: Officials statewide aim to be ahead of opioid overdose issue

The first warm day of the year reached Cedar Rapids this past week, and downtown seemed to come alive again Monday with people making their way into the streets. Among them was Alex Flescher, a staff member with an Eastern Iowa nonprofit to set up a table along Second Avenue SE, lined up with clear plastic tubs and a sign that read: “FREE NARCAN.” Soon, residents who are struggling with addition — whether the drug be heroin, methamphetamine or prescription pills — would stop by the table for the overdose reversal drug Narcan as well as maybe condoms, clean materials for injections or just to talk to the volunteers in a judgment-free environment. “We do a lot of non-judgement, harm-reduction philosophy-based outreach, which is just going out into the community and offering our resources, but primarily just talking with folks, getting to know them, getting to know what their lived experiences are and how we can help them if they’d like it,” said Tiffany Carter, community and volunteer organizer for the organization hosting the mobile outreach. Sometimes, addiction and substance use is discussed in a way that keeps the issue out of sight, in the dark and away from the public eye. But some health care providers are working to bring that conversation into the light. Called the Iowa Harm Reduction Coalition, its main goal is to do just that — reduce harm. Its staff and volunteers work in Cedar Rapids, Iowa City and Des Moines to address the impacts of the national opioid crisis that has caused the death of more individuals in 2016 than the number of Americans who were killed during the Vietnam War, according to the Police Executive Research Forum. And they are not alone. The organization is among several others across the state — including public agencies, law enforcement, private insurance company officials and elected state leaders — working toward the same goal to address the effects of the opioid crisis within the state’s borders. Iowa Harm Reduction Coalition Founder Sarah Ziegenhorn said the nonprofit operates under the assumption substance abuse and addiction cannot be totally eradicated in the population, so the main priority is to prevent the spread of disease and infection associated with injectable drug use, such as HIV or hepatitis C. While they did not wish to discuss it with The Gazette, coalition officials have shared with other media outlets about the work done with another collective, called Prairie Works, that hands out clean syringes and needles to prevent the spread of those diseases — which is illegal in Iowa. During mobile outreach events, Harm Reduction volunteers hand out fentanyl-testing strips, on-site blood tests, paperwork for housing assistance as well as clean injection drug paraphernalia such as sterile water and tie-offs. While doing so, staff and volunteers strive to form relationships and gain the trust of those who use the mobile outreach — so when the time comes they decide to seek treatment for their substance use disorders, the Harm Reduction Coalition can be there to offer help. “It’s really just creating a point of access between a group that can provide resources and a community that’s fairly difficult for many public health sources to access,” Carter said.

Alex Flesher, a team leader with Iowa Harm Reduction Coalition, sets up a table during a mobile outreach event in downtown Cedar Rapids on Monday, April 23, 2018. The organization gives out free Naloxone kits, which can reverse an opioid overdose, as well as risk reduction kits that include sterile water, cookers, ties, antibiotic wipes, band aids and condoms. (Cliff Jette/The Gazette)

Chapter 2: Staying Ahead

In 2016, 63,632 Americans died from drug overdoses, according to the federal Centers for Disease Control and Prevention. About 42,000 involved a prescription or illicit opioid. In Iowa, there were 180 opioid-related deaths in 2016, nearly three times the number of deaths in 2005. Twenty-seven of those deaths in 2016 took place in Linn County, Linn County Public Health Director Pramod Dwivedi said. And yet some nationwide health care experts project the issue only will continue to worsen. Some estimations indicate the death toll from opioid overdose could reach as high as 650,000 nationwide by the end of the next decade, according to STAT, a national health care publication. A recent move by the Linn County Public Health aims to address specific issues within the county, so that the worst of it never comes to the area, Dwivedi said. The Linn County Board of Health recently approved the creation of a steering committee, a collection of nearly 30 individuals that represent local law enforcement agencies, hospitals, health care providers and school districts as well as local and state elected officials, to address the crisis associated with opioid use disorder in Linn County. “The main priority is to make sure that we are penetrating all communities and educating people,” Dwivedi said. “Families, friends, physicians, everybody, so that we can avoid this from happening because they are estimating we haven’t reached the peak yet.” “The whole idea is we’re preparing to deal with the peak, so that situation never arises here in Linn County,” he said. The committee is broken down into four subcommittees that will look at four specific goals: Prevent abuse and addiction

Reduce the number of deaths associated with opioids

Expand access and decrease wait for treatment

Improve community safety At the end of this year, the group will make recommendations on how to best proceed. But none of this can be done without the appropriate funding and resources for local providers and agencies “doing the heavy lifting” on a community basis, Dwivedi said. The steering committee’s next meeting is set for May 4.

Free risk reduction kits are given out by the Iowa Harm Reduction Coalition at a table during a mobile outreach event in downtown Cedar Rapids on Monday, April 23, 2018. The kits include sterile water, cookers, cotton, ties, antibiotic wipes, band aids, vitamin c and condoms. (Cliff Jette/The Gazette)

Chapter 3: Legislative Elements

Wellmark Blue Cross and Blue Shield, the Des Moines-based private insurance company, also has implemented an opioid medication management program through a partnership with its pharmacy benefit manager CVS Caremark. Officially in place as of April 1, the program limits opioid prescriptions for acute, or short-term, pain to seven days for first-time users. The focus of the program, said Wellmark Chief Pharmacy Officer Matt Hosford, is to “limit the excess quantities (of opioid medication) in the community” to prevent misuse. The program would not affect those who take the medication for chronic conditions, Hosford explained. Despite ongoing efforts, Iowa still lacks the appropriate initiatives, according to a 2018 report on the opioid epidemic from the nonpartisan federal advocacy organization National Safety Council. The report identifies six key actions states should take to reduce the loss of life, which includes increasing access to treatment, improving data collection and treating overdoses with naloxone, and a Good Samaritan law. The National Safety Council stated Iowa failed to meet four of these actions, and only has policies in place for two of recommendations: mandates for prescriber education and opioid prescribing guidelines. For Iowa to receive a passing grade, and for the state to see change, “a legislative element is really important,” said Dwivedi of Linn County Public Health. Dale Woolery, associate director of the Iowa Governor’s Office of Drug Control Policy, approved what he called a “comprehensive” bill that will take on opioid addiction and abuse. The bill has a multitude of components to approach the opioid crisis from a number of angles. The legislation, House File 2377, passed through the House and was moved to Monday for the Senate. “A lot of it deals with enhancing the prescription-monitoring program, either how it’s administered or how it’s used,” he said. The bill would require prescribers to check the monitoring program before writing the prescription to determine whether that patient may be doctor shopping — going doctor to doctor to obtain more opioid prescriptions. The bill also requires automatic registration for all opioid prescribers and dispensers, including veterinarians, Woolery said. “It’s trying to do, I think, a more effective job of accounting for opioids and other controlled substances that are being prescribed and dispensed in Iowa,” he said. A prescriber report card — a measure proposed by the Office of Drug Control Policy — also will be featured in the bill, Woolery said. That will allow medical professionals to take an annual look at their prescribing activity and compare it with other professionals in a similar discipline — an orthopedic surgeon could compare her prescribing activity with other orthopedic surgeons, for example. Also included in the bill is a provision to track Naloxone — a drug used in an emergency to counteract the effects of an opioid overdose — in Iowa. By having information on where Naloxone is being administered, law enforcement conceivably could determine if there is a “hot spot” for a new drug dealer or drug type, Woolery said. A Good Samaritan provision also is included in the bill which Woolery said will encourage 911 calls in the event of an overdose by offering immunity from criminal prosecution. Woolery said the provision isn’t for people suspected of committing a violent crime or drug dealers, but rather someone who possesses an illegal substance and is with someone overdosing. “It’s trying to keep people from running scared and leaving people to die,” he said. The bill isn’t a “silver bullet,” but it’s a start, Woolery said. “This type of legislation has the potential of moving us forward significantly to prevent addiction and saving lives from overdose,” he said. Some useful approaches to the opioid crisis don’t need legislation, however, Woolery said. Parents can talk to their children about the right way to use and dispose of medication. People can report suspicious drug activity that they see and keep authorities notified of “bad prescribers,” Woolery said. “I think that counts for a whole heck of a lot and it doesn’t require a legislative session.” Comments: (319) 368-8536; michaela.ramm@thegazette.com About this story Gazette healthcare reporter Michaela Ramm shares where the idea for this series began, and how she reported on this complex series of stories. We are dedicated to being transparent in our reporting processes. Read more at thegazette.com/trust. Was this information: Helpful Not Helpful

Pamphlets on hepatitis C are available at an Iowa Harm Reduction Coalition mobile outreach event in downtown Cedar Rapids on Monday, April 23, 2018. The organization gives out free Naloxone kits, which can reverse an opioid overdose, as well as risk reduction kits that include sterile water, cookers, ties, antibiotic wipes, band aids and condoms. (Cliff Jette/The Gazette)

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