By Crystal Wallin, EMS1 Contributor
The waves of the river lap up against the beauty of the downtown streets and graceful lines of the buildings that cluster along the bank like elegant beings. The bluffs benevolently watch over the three colleges, two hospitals and the shady tree-lined streets laid out in grids between them. Groups of students walk to coffee shops, businessmen discuss strategic plan implementation over lunch outside the Irish pub downtown. You can get a scoop of homemade ice cream from a quaint shop at 16th and Market or spin a pottery item down on Pearl Street, attend a rock concert a couple blocks from the mighty Mississippi or take a horse and carriage ride among the thousands of lights in Riverside Park.
It’s a city that feels like your hometown, a city that values farm-to-table restaurants, farmer’s markets and eclectic shops, education and family events. The county has an incredible rate of compliance with advance directives in its citizens – over 90 percent – and the health care is recognized nationwide.
But beneath the dappled sunny side of La Crosse, Wis. is an insidious and ugly underbelly of another reality – namely, the use of prescription drugs for unintended purposes has bred a growing number of addicted individuals.
Examining the origins of heroin and illicit substance abuse
Looking back on the origins of this abuse, La Crosse area ED Physician Chris Eberlein recalls the early days of providers being told of a non-addictive narcotic to assist their patients with pain medication needs. Purdue Pharmaceuticals was manufacturing a new drug, soon to be a household name – OxyContin, or oxy.
Around this same time, the pain scale became a commonplace way of quantifying patients’ pain levels. The push to identify and treat pain coincided with the new wonder narcotic, and a giant increase in prescriptions written for opiates was born. Research offered by Purdue Pharmaceuticals promised that less than 1 percent of patients prescribed oxy would become addicted. Peer reviewed studies seemed to back the company’s claims.
Dr. Eberlein addresses this topic with passion, having seen prescription opiate abuse become devastatingly commonplace. Now, Dr. Eberlein wears a variety of hats. He’s the medical director for Tri State Ambulance, the area’s largest prehospital provider. Tri State covers a complex geographical area, from rural Amish country to the urban downtown of La Crosse itself.
Dr. Eberlein has been known to contact the local news stations, requesting airtime to warn of a particularly potent batch being evidenced in the trucks of Tri State and the local ERs as overdose rates spike. His concern isn’t just limited to the community; he also holds the position of medical director of the Region 4 Healthcare Coalition. The Coalition is comprised of emergency management, public health, EMS and hospital representatives from a number of counties in southwest Wisconsin.
Dr. Eberlein recently spoke of the impact seen once Wisconsin’s Prescription Drug Monitoring Program became mandatory for providers. No longer able to doctor hop, shopping for multiple prescriptions from providers who were unaware of one another’s prescriptions, the now-addicted patients found themselves up against an invisible but effective wall.
Those addicted turned to heroin initially. The overdoses changed, the demographic along with them. No longer filling prescriptions easily at the corner drugstore, now the street level movers of this new drug of choice brought dangers previously unseen. Beyond the understood risks inherent with narcotic abuse – most notably dangerously slow respirations, or total respiratory arrest – now the criminal element was added into the already volatile mix of addicts seeking new ways to meet their never-ending need.
Tri State Ambulance director Tom Tornstrom shares data on overdoses requiring naloxalone (Narcan) in a timeframe spanning 2007 to 2016. The chart shows the spike seen by street medics and ED staff alike.
Explains Dr. Eberlein, “it’s cheaper to synthesize opiates overseas than to produce a crop of poppies to create heroin. The large fields necessary are a larger target for the DEA. Labs with manufacturing capabilities, complete with chemists and skilled crafters, are manufacturing large quantities of Fentanyl and, more recently and dangerous, Carfentanil.”
He goes on to explain that the above listed opiates and others like them can have 10,000 times the volume compared to a bundle of heroin. One kilo of a recent bust in Canada was sufficient to overdose 30 million people. A grain of Carfantenil – the size of a sugar or salt crystal – is enough to overdose a person.
While the manufacturers are highly intelligent to produce such a potent product, the distribution personnel are often less educated – herein lies another problem. Cutting the shipment, diluting it properly, is dependent upon the street-level distributors. An addict cannot reasonably assume that a purchase made on Wednesday is equal to the potency of a purchase made on Monday. Using the same volume can have deadly consequences.
The Task Force takes shape
A group of local stakeholders began to assemble, sharing a common goal; identification of needs/concerns, and implementation of initiatives specifically designed to meet those community goals. Stakeholders in the task force include the:
- County administrator, board chair and clerk
- Human services and the health department
- The medical examiner
- Local news media
- AIDS resource center representatives
- The county sheriff and police department representatives
- The ambulance director
- A professor from one of the local colleges
- The superintendent from the local school district
- The director of the region’s council on addictions
- Dr. Eberlein and nurses
The mission statement reads, “the goal of this effort is to create a self-sustaining coalition task force of community stakeholders to identify and implement community-based strategies that reduce the public health burden of heroin and other illicit substance use in La Crosse County. Our intention to pilot this initiative is to: save and protect lives, reduce illegal and prescription drug substance misuse, improve overdose interventions, improve early intervention to treatment and recovery, provide education to the community about heroin and prescription drugs and to reduce the burden on the criminal justice programs.”
Initiatives the task force has spearheaded include medication drop-offs within the community, where individuals can safely turn over expired/no longer necessary medications. In an effort to head off sharing needles, the free needle exchange was formed. Survivors of heroin abuse combined with members of the task force, giving presentations to the community about the realities of being addicted and then closing with the inspiring message of recovery.
Opiate overdose toolkits were created and distributed. Perhaps most helpful, the members created a map of recommendations and strategies, committing to regular meetings where further interfacing kept them cohesive, effective – and engaged as a multidisciplinary team. A list of resources and contact information was created, distributed and made available online.
Changing the culture behind the drug problem
Slowly, sometimes painstakingly so, the initiatives came together. It’s a work in progress, they’ll tell you here in this river town. But what’s important is that the problem is identified, and the members are committed to effecting a change. The culture and climate behind the drug problem is bound to change, but the participants are in it for the long haul.
The takeaway point here for law enforcement and prehospital providers is twofold. First, be aware that overdoses can necessitate higher amounts and repeated doses of Narcan. Second, be aware of any unidentified crystals on a scene, on a uniform, near a cut or inadvertently inhaled. Field providers can find themselves in a dangerous situation themselves and require large doses of Narcan themselves.
There’s no doubt that in towns near and far, the same scenes play out. Someone’s child, someone’s parent, the neighbor next door – addicts fit no cookie cutter. Ultimately, Purdue Pharmaceuticals found a one-time fine levied against them, the total $600 million. They paid the fine, a drop in the bucket for a company whose profits averaged $3 billion dollars/year for the past 20 years.
The next time you see a pain scale in your provider’s office, the back of your truck, on your ePCR – remember the big pharmaceutical company who promised a non-addictive narcotic. But remember too how a tree-lined college town nestled up against the coulees with the waves of the Mississippi lapping up on its shores stood up and said, “we won’t give up. We’ll stand up and together, we can all make a difference.”
In a time of instant results and demands for transparency, division and rhetoric, sometimes what it takes to succeed is the quiet determination of those involved to not stand by silently, but to join shoulder to shoulder and fight for what matters.
Kudos, La Crosse. Thank you, to each and every stakeholder of the heroin drug task force.
We see you.
About the author
Crystal Wallin, NREMT-P, CCEMT-P, is a dual licensed Minnesota and Wisconsin paramedic who began as a volunteer responding in her personal vehicle. She is a preceptor and field training officer with Gundersen Tri State Ambulance in La Crosse, Wis., and a nursing student.
She served as an executive council board member of the Wisconsin Southwest Regional Trauma Advisory Council and as the EMS representative on the Wisconsin Healthcare Coalition board for Region 4.
She is the featured writer for the Professional Ambulance Association of Wisconsin, and blogs monthly at Standby for Tones. Crystal lives with her husband Kurt and their combined six children in Prairie du Chien, Wis.