HOW I FOUND MY RHYTHM WHEN THE MUSIC STOPPED

At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.

….FULL ARTICLE

THE MAN IN A BLUE SARONG

I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.

….FULL ARTICLE

PATIENT “OWNERSHIP”

I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.

….FULL ARTICLE

Use the buttons below to scroll through more great articles from Kentucky Doc Magazine

MORE ARTICLES

Be Sociable, Share!

Share on Facebook Share on Twitter Share on Delicious Share on Digg Share on Google Bookmarks Share on LinkedIn Share on LiveJournal Share on Newsvine Share on Reddit Share on Stumble Upon Share on Tumblr

MORE ARTICLES

CONTACT INFORMATION

© Kentucky Doc Magazine - All rights reserved | Designed & Maintained by PurplePatch Innovations

MORE FROM ROCKPOINT PUBLISHING

KENTUCKY DOC MAGAZINE

HOME | FEATURE ARTICLES | COLUMN ARTICLES |  COMMUNITY NEWS  | DIGITAL ISSUES | ABOUT | CONTACT

medical communities.  What is the role of the health department, specifically our local Lexington- Fayette County Health Department (LFCHD)?


Kraig E. Humbaugh, MD, MPH heads the LFCHD.  As Commissioner of Health and the department’s only physician, he oversees six divisions and 160 full time employees, including a nurse-practitioner, nurses, environmental health educators, and others working out of two Lexington locations – a main building at 650 Newtown Pike and a second facility, largely devoted to Women, Infants, & Children (WIC) education, at 2433 Regency Road.   Dr. Humbaugh reports to the Board of Health, which in turn determines long term planning and future goals for the LFCHD while also insuring that its policies and goals are carried out.  An organizational chart, a list of current Board of Health members, minutes of past Board meetings, and notices of future meetings are posted at the LFCHD website lexingtonhealthdepartment.org.


Dr. Humbaugh stresses that the aim of the health department is to complement, not compete with, other medical services in the community.  “We are not and do not pretend to be a primary care agency,” he says.  “Our real niche is prevention.”  Regarding the opioid epidemic, this chiefly involves harm reduction strategies directed to the subset of opioid-addicted individuals who are injection drug users of heroin or even more potent synthetic opioids. The two main approaches – needle exchange programs (NEPs) and naloxone (Narcan) distribution and training-- are aimed not only at reducing overdose deaths but also at reducing serious infections and other undesirable consequences for the individual and for the community while also serving as a potential first step on the road to recovery and wellness.


In 2015, Senate Bill 182 (“the heroin bill”) was passed by the Kentucky General Assembly in response to a rapid rise in heroin overdose deaths in the state.  The law allowed health departments to distribute new needles to injection drug users in exchange for used needles. Heroin deaths had especially skyrocketed in Fayette County, so the LFCHD had already prepared extensively with government officials, law enforcement personnel, infectious disease specialists, mental health experts, etc.   Operation of the NEP in Lexington was approved by the Urban County Council and the Board of Health by mid-July. and the program began operation less than two months later as only the second such program in the commonwealth (the other being Jefferson County). Its goals were to reduce the spread of bloodborne viruses like HIV and hepatitis C and to reduce the risk of community exposure to these diseases by disposing of used needles safely.  (Previously NEPs elsewhere had been shown to prevent the spread of infection by HIV and perhaps hepatitis C.)  Other important goals were to serve as a center for services for injection drug users, to reduce death from opioid overdoses, and to build client trust to foster referrals to substance abuse counseling and treatment services.  The program is free of charge, anonymous, and supported by law enforcement officials.


Initially the NEP was open for only a few hours one day a week and served 7-8 clients per hour. Now it is open 3 p.m. to 6 p.m. on Wednesdays and 11 a.m. to 4 p.m. on Fridays at the department’s Newtown Pike location, serving over 20 clients per hour (200-220 per week). From its inception on September 4, 2015 through July 25, 2018, the health department’s NEP distributed over 600,000 needles to 3,239 clients on 15,590 visits.  Most clients have been male (59%) from Fayette County (75%), with all adult ages represented (most often ages 26-34 [39%] or 35-43 [30%]). Over 90% of the needles have been distributed on return visits, at which the ratio of needles returned to needles distributed has been 0.90:1.  Returning individuals comprise most of the clientele, but about 15% of visitors to the NEP on any given day are new to the program.


In addition to the actual needle exchange, NEP clients are offered education and optional hepatitis C and HIV testing by the LFCHD’s Disease Investigation Specialists and the staff at AIDS Volunteers of Lexington. Referrals for confirmatory testing are made as necessary. (Kentucky ranks fourth nationally in incidence of new hepatitis C cases, with injection drug use as the predominant risk factor. About 50% of local NEP clients test positive for hepatitis C, which is highly treatable with newer medications. The number of new HIV cases in Kentucky has been stable recently at about 350-360 per year, although there are occasionally clusters of patients seemingly related to injection drug use. About 15% of new HIV patients in Fayette County have injection as their main risk factor for the infection.)


In a paper published earlier this year, it was estimated that the total economic toll of the opioid crisis in the U.S. since 2001 has exceeded $1 trillion dollars, including a whopping $93.8 billion alone in 2016 – a figure projected to reach approximately $200 billion for the year 2020.  So, it is important to ask whether needle exchanges and their ancillary services are cost effective.  The answer appears to be a resounding “yes.”  Consider that the LFCHD’s needle exchange program budget is around $100,000- $150,000 for fiscal year 2018.  Compare that to the CDC’s estimates of the average cost of treating just one case of hepatitis C ($32,000-$56,000) or the cost of a lifetime of HIV treatment for a single patient ($379,000).


Another important ancillary service of the LFCHD is harm reduction via the distribution of naloxone (Narcan) kits, each containing two doses of the often lifesaving opioid antidote in the form of a nasal spray.  The second of the two doses can be utilized 3-5 minutes after the first if the initial response seems insufficient.  The drug is essentially harmless if someone’s difficulties turn out to be due to something other than an opioid overdose.   Training in the use of the naloxone kit is easy, requiring about 15-20 minutes at most.  Nearly 1,600 of these kits, which can cost up to $140 each if purchased privately, have been obtained at great savings and distributed by the LFCHD through partnerships with organizations like the UK College of Pharmacy and the Kentucky Injury Prevention and Research Center (part of the UK College of Public Health).  Hours for naloxone education and distribution are Fridays 11 a.m. to 1 p.m. at the LFCHD’s Newtown Pike location.  Quantities may be limited.    


Another vital health department ancillary service is on-site referral to substance abuse counseling and treatment.  The client is not required to sign up for this to continue in the NEP but is offered the opportunity to voluntarily pursue this course of action.  Thus, the health department’s harm reduction programs can also serve as an entry point to psychosocial support services and pharmacological treatment – a chance for individuals to turn their lives around when they feel ready to take that next big step.  The LFCHD itself does not have the means to provide this tertiary preventive service, buy it can arrange treatment through experienced partners such as the city’s Social Services’ Substance Abuse and Violence Intervention program, Chrysalis House, and bluegrass.org.  Since April 2016 the LFCHD has made over 135 treatment referrals.


Absent an unexpected, huge influx of money, even the most optimistic public health experts foresee little likelihood that the opioid epidemic can be significantly controlled before the mid or late 2020s.  The number of people receiving proper treatment is minuscule compared to the number of individuals newly presenting with opioid use disorders. Meanwhile and in the future the health department will continue to play a vital role in preventing complications and facilitating the treatment of individuals caught up in this public health crisis.


References: 


Not a day passes without some story in the media about the devastating opioid epidemic in this country.  Often the item concerns the latest government statistics that show an ominous worsening of some indicator of the crisis – such as a CDC report that estimates that there were more than 42,000 drug overdose deaths in the U.S. in 2016 alone, a figure that was projected to reach 72,000 deaths in 2017, representing a deadly drug overdose about every six minutes.


Invariably Kentucky ranks among the worst states in these statistical analyses, even though the commonwealth has often been a leader in its approaches to the opioid problem, such as the pioneering use of online prescription drug monitoring with the Kentucky All-Schedule Prescription Electronic Reporting (KASPER) system and our state’s requirement of continuing medical education regarding controlled substances in order to maintain a license to practice medicine. In 2011 Kentucky pharmacies dispensed 371 million opioid units.  The following year, with passage of House Bill 1 by the General Assembly, the state’s physicians, nurse-practitioners, and dentists for the first time were required to use the KASPER system before prescribing an opioid.  In 2017 that number of prescribed opioid units was down to 278 million – a decrease of 25%.


So how did the U.S. (and Kentucky) end up in this opioid crisis?   America likely will always have some problem with drug abuse disorders.  The current epidemic is notable principally for the rapidity of its rise, the large number and broadly inclusive demographics of its victims, its particular infectious disease accompaniments, and

BY THOMAS J. GOODENOW, MD

the pronounced lethality of its newest abused drugs of choice.  It began three decades ago and has manifested itself in three continuing, overlapping, and increasingly lethal waves of drug overdose deaths.  The first wave began around 1999 and was associated with a marked rise in authorized prescriptions for natural and semi-synthetic opioid pain relievers such as hydrocodone and oxycodone, used medically and non- medically.  A second wave followed around 2010 and was associated with a slight slowing in the availability of prescription opioids accompanied by easier availability of cheaper and more potent heroin. The most recent wave had its onset about 2013 and is associated with surging use of inexpensive, readily available, synthetic opioids, such as fentanyl and carfentanyl, that are many times more potent than heroin.  The recently released “2017 Overdose Fatality Report” from the Kentucky Office of Drug Control Policy reflects the latest trends in drug use in Kentucky and each of its individual counties, including increasing fatal roles for fentanyl and for mixtures of other controlled substances such as prescription opioids, benzodiazepines, and (somewhat resurgent) illicit methamphetamine.


Management of this epidemic will require a concerted, multidisciplinary effort involving the public, the government, and the expertise of the scientific and

THOMAS J. GOODENOW, MD

Dr. Goodenow practiced medicine for 42 years, the last 37 as an endocrinologist at the Lexington Clinic