The Bangor region continues to pull itself out of the depths of the opioid epidemic, but more work remains as people turn to far more lethal drugs, providers continue to adapt their approaches, and a major nonprofit gears up to expand drug prevention efforts, according to health care and social services officials in the Bangor region.
Last July, about 75 people gathered in Bangor with the then-gubernatorial candidates as part of the Bangor Daily News’ One Life Project to discuss and vote on the initiatives that they thought were most important and urgent to address the opioid epidemic.
They decided the top regional priority should be preventing drug use, followed by supporting people in recovery — a potential indication that people recognized the work that had already happened to expand access to medication-assisted treatment and reduce the volume of prescription opioids.
The work is ongoing. Opioid-related deaths are still high. There are untold future consequences for employment, housing, children and families. So while some key statistics are encouraging, it’s too soon to know whether the region has reached a turning point, said Patty Hamilton, director of Bangor Public Health and Community Services.
“I want to see more of a downward trend,” Hamilton said. “You really need to see trends over time, and we really haven’t had enough time.”
Here is an update on a number of regional initiatives and indicators on the status of the opioid epidemic, which on average claims one life every week in Penobscot County.
Treatment
Since 2015, the number of providers offering the medication Suboxone to treat opioid use disorder has more than doubled at a subset of health care providers in the region, and the number of patients prescribed Suboxone by those providers has nearly quadrupled. Suboxone is the brand name for a prescription medication, containing buprenorphine and naloxone, that is used to treat people addicted to opioids.
The increase in providers licensed to prescribe Suboxone will allow Penobscot Community Health Care’s center on Union Street in Bangor to offer same-day access to the medication by June, representing a significant change from several years ago when patients had to wait six months.
The chart below includes numbers from Penobscot Community Health Care, St. Joseph Healthcare, Bucksport Regional Health Center and Northern Light Acadia Hospital over time. It does not include numbers for other Northern Light Health facilities over time.
However, currently there are 34 Suboxone providers and 268 patients at four local Northern Light Health internal and family medicine practices, according to Amy Kenney, a system spokesperson.
This month, another provider plans to enter the field. Groups: Recover Together, a for-profit chain of addiction treatment clinics, is opening a location at 877 Stillwater Ave. in Bangor where it will prescribe Suboxone and provide weekly counseling, said Cooper Zelnick, executive director of the company. It already provides the services in nine other locations across Maine, and serves people with MaineCare, the state’s Medicaid program, in addition to those with commercial insurance.
The increase in access to treatment has corresponded with a decline in prescription opioids, such as oxycodone and hydrocodone. Out of 11 area ZIP codes, the ZIP code 04474, which encompasses Orrington and part of Winterport, saw the sharpest decline in prescription opioids between 2014 and 2017, measured in average daily morphine milligram equivalents.
The region started seeing a decline in opioid prescriptions before a new Maine law took effect in early 2017 to limit patients’ doses and cap prescriptions at seven days for acute pain and 30 days for chronic pain. That decline appears to have hastened after the law’s implementation.
As providers in the area have revised their approach to prescribing opioids, they have also changed how they help babies born with neonatal abstinence syndrome, which is the term for a group of problems experienced by babies withdrawing from drugs that they’ve been exposed to in the womb. They may have tremors, diarrhea, seizures, high-pitched cries and other symptoms.
Several years ago, Northern Light Eastern Maine Medical Center used a numeric system that weighed the signs and severity of babies’ withdrawal to judge whether to administer pharmacologic treatment, such as methadone. A high score would indicate the baby was experiencing significant withdrawal and could benefit from medication, said Dr. Jay Hagerty, medical director and lead physician of the hospital’s newborn intensive care unit.
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Now, if babies can eat, sleep and be consoled reasonably well, even if they have withdrawal symptoms, the hospital is less likely to administer medication. A number of environmental changes — keeping down noise, using pacifiers when appropriate, having a consistent caregiver when possible who can pick up on the child’s cues — have also helped, Hagerty said.
If babies are having trouble eating, sleeping and being consoled, the hospital may give them small, intermittent doses of morphine. If they need more, it would offer methadone.
“It’s not that [the previous approach] was bad, but what we know now may be better,” Hagerty said.
Prevention
In terms of prevention, a major social services organization based in Bangor recently received clearance from the federal government to spend promised funds to help children who have suffered the consequences of the opioid crisis, to stop the cycle of trauma from continuing.
In October 2018, Penquis announced it had won a $632,037 three-year grant from the U.S. Department of Justice to address gaps in services for children in Penobscot and Piscataquis counties.
Now that it’s received the official go-ahead, it has hired a program manager, Derek Hurder, to oversee the grant, said Tamar Mathieu, who directs family enrichment services for Penquis. Hurder is the communications coordinator for the local organization Families And Children Together, which is closing.
When he starts May 13, Penquis will begin its work to involve other community groups, businesses, faith groups, the public and, in particular, youth themselves, in figuring out where the biggest needs are and what they can do to support youth, whether through mentoring and tutoring, basic supplies, or social options to bring kids together.
There are a number of other prevention efforts underway, including before- and after-school programs and extracurricular activities, that aim to give kids healthy alternatives to drug use and reduce absenteeism, said Hamilton, with Bangor’s public health department, which has staff who help businesses and schools set policies around alcohol, tobacco, marijuana and drugs.
“Even if you can delay initiation, you’ve taken a big step,” Hamilton said, because it reduces the likelihood someone will develop an addiction.
Recovery
The Community Health Leadership Board, a collective of local health and social services leaders, that Hamilton helps lead, has been planning how to revise the area’s response to people after they overdose.
It learned about Huntington, West Virginia, which started an initiative to follow up with every overdose survivor within 72 hours, often at their homes, to connect them with the resources they may need to get well, such as recovery coaches. It’s helped the city cut its drug overdose rate in half.
The CHLB is looking at how to organize and fund such an initiative in the Bangor region, Hamilton said.
Right after an overdose, when people are most likely to encounter emergency personnel, they are usually not thinking about stopping using. “But within 24 to 48 hours, if they’ve had the opportunity to reflect on what’s happened, that might be a much better time to make an intervention or at least offer an intervention,” said Jonnathan Busko, the medical director of St. Joseph Hospital’s emergency department.
Local leaders also had their eyes on a bill, LD 993, to fund a recovery center with $1 million per year to expand support services to people in Penobscot and Piscataquis counties. The legislative health and human services committee voted that it ought not to pass the full Legislature.
Challenges
Over the last few years, the region has expanded access not just to treatment but also overdose-reversing naloxone. The Health Equity Alliance alone gave out about 700 kits last year and about 500 the year before, said Kenney Miller, the organization’s executive director.
Local emergency responders have used the opioid overdose antidote to save lives, administering it 131 times last year.
But overdose deaths remain high, largely because of the emergence of the synthetic opioid fentanyl, which is 100 times more potent than morphine. Fentanyl caused 77 percent of all opioid-involved deaths in Maine last year.
However, the total number of overdose deaths appears to have started to fall, driven by a large decline in pharmaceutical opioid deaths (such as those caused by oxycodone and hydrocodone) of 37 percent, according to figures released by the Maine attorney general and chief medical examiner in April.
In 2018, there were 354 drug fatalities in Maine, compared with 417 in 2017. Penobscot County overdose deaths are down slightly as well — 53 last year compared with 65 the year before.
Between 2011 and 2017, the number of overdose deaths in the state nearly tripled, launching Maine into the top 10 states in the country with the highest rates of opioid-related overdose deaths.
The city of Bangor put together a map to show where overdoses and overdose deaths occurred in 2017. The public version is not detailed, to protect privacy, but it shows that most overdoses happened in the downtown area, from the vicinity of Broadway in the east, extending to Parker Street in the west, and north along Ohio Street and the Kenduskeag Stream.
“It shows us where we need to concentrate our efforts,” Hamilton said. More than that, it illustrates how a wider swath of issues that affect the downtown, such as homelessness and poverty, can overlap with the challenge of addiction.
Indeed, a qualitative survey that the Community Health Leadership Board gave to 114 people with opioid use disorder in the Bangor area this fall found that participants still face significant barriers to recovery. Some included lack or costs of insurance, need for inpatient treatment and for treatment close to home, and help with supportive services such as housing and child care.
“It all goes back to the social determinants of health, which is really where the prevention work will happen. If you don’t address trauma and health and housing and all of those things, we’re going to continue to be where we are or worse in the years to come,” Hamilton said.
Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com.