Editor's Note: Over the five Saturdays in March, the Clinton Herald is publishing a series about the use and abuse of opioid drugs in Clinton and how those statistics fit into the state and national scope of the opioid abuse crisis. Today's installment is part three of the series.
Amy Berentes is no stranger to the medical field.
She's been vice president of Patient Care Services for 11 years at Mercy Medical Center. She's earned several honors during her career.
And in recent years, she's been seeing the effects of opioid addiction in the Clinton community.
"I don't know if a person not addicted could understand the desperation that comes with those withdrawal symptoms," Berentes said at a recent roundtable discussion with U.S. Rep. Dave Loebsack, D-Iowa. "I can't understand. But it's there. I truly believe it's a monster that is after you and won't let you go."
That monster is something Mercy Medical Center is attempting to prevent from haunting patients who come in for surgeries or other health-related issues. Mercy Medical Center in February began an opioid guardianship committee, featuring about 10 people with specialties, including physicians, pharmacists and surgeons.
The group is eyeing several initiatives, including promoting a physician pledge and utilizing Iowa's Prescription Monitoring Program, an initiative that tracks patients' prescriptions. Group member Christine Swyres, Mercy's pharmacy director, knows that the group's educational mission is broad, but is necessary to nudge a culture change not only for healthcare providers, but for patients, too.
"We have to reframe how we're looking at patients," Swyres said. "We also have to reframe what they should be expecting. Those are huge, huge culture changes. It won't happen in six months or a year. It's going to be another generation of providers before we start to see some changes."
The Clinton hospital's push for reducing access to prescription medication didn't just start last month. The hospital began to see encouraging results late last year.
Since October, Mercy's emergency room has reduced its prescription pain medication by 50 percent. About a year ago, Emergency Department Director Linda Helenthal began seeing problems related to opioids in the emergency room. She started to work with physicians and the CRUSH-plus group on how to better manage pain for patients in the emergency room.
"We started educating the community on our efforts involved in that," Helenthal said. "That's where it started. We were very vigilant over time."
That's an encouraging sign for health professionals, since Clinton County is one of the highest-ranking counties in Iowa for opioid prescriptions per 100 people. Clinton County also is an aging community, with a higher percentage of adults 55 and older compared to the state average.
According to Iowa Department of Public Health figures from 2016, Clinton County was listed in the second-highest category for opioid prescriptions, with 77 to 91.2 opioid prescriptions per 100 people.
Reducing that number is an ongoing task that goes from the head offices of Mercy Medical Center to the physicians who deliver the care.
In 2016, the Centers for Disease Control issued the Guideline for Prescribing Opioids for Chronic Pain, which provides recommendations about the appropriate prescribing of opioid pain relievers and other treatment options to improve pain management and patient safety.
That same year, the U.S. Department of Health and Human Services released the National Pain Strategy, which provides doctors with information on how to improve care and employ safer prescribing practices.
Mercy Medical Center physicians are requested to follow those recommendations.
"We don't believe this has all been the physicians' fault, necessarily," Berentes said. "There was a huge push to control pain. Pain had been on patient satisfaction surveys, and when physicians didn't control pain, people thought there must be something wrong with your pain control. All across the nation, doctors have been rewarded to control patients' pain.
"They had no intention to get them addicted. But now it's happened. Now we have a society full of addict individuals and no way to get them off. We need a way to get these people off these drugs."
Now, with that reward system being fazed out, Mercy Medical Center is focusing more on comfortability, rather than on a pain scale. It's all about finding a balance of not under-medicating, but also not over-medicating, Swyres said.
"The goal of our group is the right pain management for the right patient for the right amount of time," Swyres said. "Medications work in a different way. We're approaching pain from all sorts of different sides. If we can decrease the use of opioids and make other pathways work, that's what we want to do for you. We've started working on a couple of initiatives with those non-opioid types of medications."
Clinton Fire Department Battalion Chief Greg Forari sees the effects of those drugs on a regular basis. He's in charge of training and EMS for the Clinton Fire Department, which runs all the fire and ambulance calls in the city of Clinton.
For more than 20 years, Forari has seen the changing landscape of the drug culture in Clinton. It's not uncommon for the majority of cities to have issues with drugs, Forari said, and Clinton is no exception.
When Forari took over as the battalion chief for training and EMS in Clinton in 2016, he had already started seeing an uptick in opioid-related instances. That's when the Gateway Impact Coalition started to reach out to track the numbers, highlighting what Forari and other firefighters were noticing on the streets of Clinton.
"Now we're at the point today where everybody knows it's out there," Forari said.
Clinton County owns a higher percentage of calls to the Iowa Poison Control Center than the state of Iowa average in relation to prescription opioids and heroin.
Of the more than 24,000 calls that come into the center per year, a little more than 3 percent are for prescription opioids in the state of Iowa, with .1 percent related to heroin.
In Clinton County, 6 percent of calls in 2015 were about prescription opioids, while it dropped in 2016 to 4.7 percent. Heroin calls totaled .4 percent. The center received 483 calls from Clinton County in 2015 and 514 in 2016.
Clinton County Communications Manager Eric Dau oversees the local information being transferred from the scene to first responders. In 2017, the department handled 70 emergency 911 calls for overdose or poisoning.
"We're definitely getting more overdose calls," said Dau, who has been in communications for 15 years, with seven of those as communications manager in Clinton County.
Because of that increase, staff members have attended training provided by the Gateway Impact Coalition and the Clinton Substance Abuse Council in how to assess the dynamics of a drug overdose.
"The bottom line is we don't want them to worry about being in trouble," Dau said. "We want to have people value life over any consequence."
Having reliable information to relay to first responders is important in creating the first avenue of scene assessment. Addresses known to have overdoses are provided to first responders, but if the caller is truthful about the cause of the overdose, it can provide necessary information to begin treatment.
Maintaining that sense of communication is something that helps firefighters, such as John Crump and Ryan Prior, to establish scene safety.
"Scene safety plays a big part in everything," said Crump, a firefighter for eight years with four years of experience in Georgia. "That's drilled into us from day one. You're constantly trying to keep your head on a swivel to figure out what happened. The longer you do it, the more you can slow down and hone in on what needs to get done."
Assisting with scene safety is an important part of the working relationship between communications dispatchers, the fire department and police. If there is concern for first responders' safety, the police department will be alerted of the situation and will offer backup.
If the caller does not provide much information about the overdose, figuring out what happened doesn't take long, Prior said.
"You learn what to look for pretty quick," Prior said. "The sign with opioid overdose is generally the same. But the situation is not always the same."
That situation is illustrated by the fire department responding to opioid overdoses for patients ranging in ages from 14 to 69 years old in 2017. And while some were accidental, the fire department also responded to 40 patients in 2017 who were using medication as a means to attempt suicide.
"It's not just going in with tunnel vision," Crump said. "It could be a serious medical issue, that maybe they mixed medication somehow, and you go in and help them out. It's not just illegal drugs."
Adding to the opioid abuse mix is the increased use of fentanyl, a potent painkiller. According to government figures released in 2017, 2/3 of last year's drug deaths were from opioids, with fentanyl deaths doubling in just one year.
Police and fire officials said they have yet to see evidence of fentanyl in Clinton. However, just 60 miles north in Dubuque, a man was sentenced last year to 20 years in prison for selling heroin and fentanyl resulting in death.
Saving those who have overdosed has been a more regular occurrence in recent years for the Clinton Fire Department.
Reversing an overdose
Naloxone, commonly referred to by its brand name of Narcan, is a common discussion topic among those with knowledge of the opioid epidemic. It is a medication used to block the effects of opioid overdose. Narcan can work within minutes of being administered, taking a person who has overdosed on a prescription opioid and heroin into a state of consciousness.
Forari said that he knows of four overdose calls in the last year that naloxone was used prior to first responders' arrival. Of the 14 active pharmacies in Clinton County, three — Walgreens, Mercy inpatient and Hy-Vee — stock naloxone, according to information from the Gateway Impact Coalition. Hy-Vee offers naloxone without a prescription and is available in nasal spray, as well as injection form by request.
In 2017, the Clinton Fire Department administered naloxone on 49 patients. The bad news is that is higher than naloxone deployments in 2015, which stood at 37. The majority of naloxone usage in 2017 was on people who overdosed on heroin.
The good news is that it dropped significantly from 2016 when it was administered 62 times. Similar jumps were recorded in Camanche, too, with the use of naloxone five times in 2015 to 12 in 2016. In 2017, those numbers had dropped to three in Camanche.
The use of naloxone doesn't come without controversy. A study published this month by Social Science Research Network claimed that broadening access to naloxone encourages riskier behaviors with respect to opioid abuse and the increased access is actually increasing opioid abuse. Leslie Mussmann, prevention director with the Area Substance Abuse Council in Clinton and Jackson counties, disagrees.
"I don't know of anybody who would openly say, 'well so and so had a really bad week of eating and didn't track their food and so they had an insulin issue and they were going to have a diabetic coma or something like that,' and you wouldn't provide them with the insulin they needed," Mussmann said. "No one would say they don't deserve to have that insulin because they made those poor choices. We look at substances that way all the time."
The opioid-related issues in Clinton is creating increased supplies of naloxone in Clinton Fire Department vehicles. Firefighters now carry three times the amount of naloxone than 2016, upping the quantity of 4 milligrams to 12 milligrams in each of the six fire department vehicles.
But while the number of patients needing naloxone diminished from 2016 to 2017, the amount used per patient is increasing.
"It used to be used 1 or 2 milligrams, maybe three, and people would be functioning and answering questions," Forari said. "Now we're giving two, maybe four, then a third dose. We're seeing (the drugs) as more powerful and potent."