LEXINGTON, Ky. (AP) - Like a tidal wave swelling in the distance, Amy Baker saw Fayette County’s spike in fatal overdoses coming.
It was mid March, Baker remembers. Kentucky had just diagnosed its 47th case of novel coronavirus as Gov. Andy Beshear signed an executive order to ban group gatherings, including in-person worship services. The service industry and retailers were shutting down, putting tens of thousands out of work. Those still employed were told to work from home. Everyone was to abstain from getting together, even in small groups. The strong recommendation was to shelter in place until further notice, and to only leave the house for essential needs, like grocery shopping.
“All these things that, a month ago, weren’t an issue are suddenly an issue,” said Baker, the Fayette County substance use intervention program coordinator. “If all the sudden, my work is gone, my (in-person recovery) meetings are gone, my money is gone and my rent is due,” it’s inevitably going to push some in recovery toward relapse, she said. For others, acute stress may push them to use for the first time.
Addiction is often referred to as a disease of isolation, which is why many people in recovery rely heavily on in-person support to stay sober. Revoking that option and replacing it with idle time and forced solitude, then, can pose an especially dangerous threat, Baker said.
Now, a little more than two months later, her grim predictions were confirmed. Fatal overdoses in Kentucky’s second largest city have increased at least 42 percent compared to this time last year, and participation in the local syringe exchange program is higher than it’s ever been.
Between January and late May 2019, 48 people in Lexington died of a drug overdose, according to the county coroner’s office. During that same time this year, the overdose death rate jumped to at least 68, though the figure is likely higher, since some toxicology reports, still pending, have yet to be formally deemed an overdose.
“If this trend were to continue, we would be at more than our peak year, in 2017,” or at least close to it, Baker said. Kentucky’s rate of fatal overdoses hit a record high in 2017, when 187 people in Lexington died, 1,565 statewide.
Health and law enforcement officials across more than 10 Kentucky counties reported similar trajectories in their communities - a swelling of overdoses, if not sustained over the last two months, then periodically surging. Treatment and harm reduction services providers are doing their part to cushion the blow.
And while it’s impossible to pinpoint exactly why, many surmise the state’s outbreak of COVID-19 has something to do with it.
In Louisville, where fatal overdose rates are up 11 percent from last year, Jeremy Byard of Louisville Recovery Community Connections said there are many factors, and the pandemic is one of them. Historically, during other widespread crises, public health or otherwise, “return to use rates go up,” he said, and COVID-19 is no different.
Baker agrees. The pandemic “can’t be held completely responsible, but I can’t help but think it led to some of what we’re seeing,” she said. “Something is happening.”
‘GETTING ANSWERS’
Since data collection takes time and resources, some public health officials could only report what they’d heard week to week from law enforcement and those on the frontlines. In Whitley County, on the Tennessee border, public health director Marcy Rein is working to launch a virtual overdose map, so local officials can better track incidents and outcomes, along with a fatal overdose review committee to retroactively analyze those overdoses and refine the local response.
But for now, it’s word of mouth. During a seven day stretch in mid May, a dozen people overdosed in her county of just under 37,000 - two fatally.
“We might have six overdoses in a month. To have 12 in a week is pretty significant for us,” Rein said last week.
Around that same time, further east in Perry County, local emergency medical services responded to four people who overdosed in a 24-hour-period, each of whom was revived with Narcan, said Scott Lockard, public health director for the Kentucky River District, which includes Lee, Owsley, Letcher, Knott, Leslie, Perry and Wolfe counties.
Lockard said over the last few months he’s also seen “a big uptick in overdoses,” but, again, it’s hard to say exactly why. His district’s seven needle exchanges - some of Kentucky’s “most heavily used rural exchanges” - are also getting ample use. Since January, 111,000 used needles have been exchanged for clean ones.
“I’m not sure exactly what’s going on,” he said. “I know there’s been speculation about pressed fentanyl pills (to look like) Xanax or Suboxone.” Counterfeit pills laced with fentanyl - a synthetic opioid more powerful than heroin - are an issue multiple health and state officials interviewed for this story anecdotally reported to be a growing problem.
Lockard said in his district, it appears that counterfeit pills are, in some cases, replacing methamphetamine and Suboxone as drugs of choice. Anytime this change happens, more overdoses occur, he said. Lockard wonders if the stress of COVID-19 has exacerbated this risk.
“When you’re looking at someone who is in addiction, support networks are so important for them, (and) the pandemic has really, it has changed everything,” he said. “I hope we’re going to be getting answers before we start losing a lot more lives.”
‘MORE THAN A SEASONAL CYCLE’
For someone in recovery, certain triggers can provoke or increase the likelihood for relapse, addiction treatment provider Jim Bush said. He’s vice president of substance use services at New Vista in Lexington.
The stress from an event like a death in the family, for example, can veer someone away from sobriety, Bush said. What’s “unique” about the COVID-19 pandemic is that it universalizes that stress and anxiety so that whole populations, all at once, are contending with the same triggers.
“It’s happening to everybody at the same time,” he said last week. As a result, “we’re seeing more recurrence of use, more relapse.”
Sheena Craiger is seeing it, too. A patient care navigator with Recovery Works, Craiger has lately spent her days on the phone, trying to connect people with treatment services. Since the pandemic hit, her workload has gotten heavier.
Lately, she said, ”I’ve seen a lot of people that had months or years of sobriety and had to get back into treatment somewhere. They’ve lost their job, they haven’t been able to attend meetings or be around the support they used to be around,” she said. “They’ve relapsed, are scared to death and don’t know what to do.”
John Moses, who runs the local syringe exchange through the Lexington-Fayette County Public Health Department, had already noticed a steady incline in overdoses preceding the state’s known outbreak, in January and February. He braced for how the social distancing efforts to curb the spread of the virus would play out in the at-risk communities he cares for.
In his line of work - providing clean needles to people in active addiction, reducing their risk of disease transmission through unclean needle reuse - the surge is clear. In March and April, when the state was on strict healthy-at-home orders, Moses watched as the number of visits to his program soared “historically high,” he said: 1,005 visits to the exchange in January, fell slightly to 973 in February, and ballooned to 1,226 in March and 1,450 in April.
The number of new visitors to the needle exchange during that time increased by 39 percent. More visits, overall, means more used needles returned to be disposed of in exchange for clean ones, which is a good thing, even though the ultimate goal is to usher people into recovery. That volume hit an all-time high, too, Moses said: January saw 40,204 needles returned. That amount swelled to 57,344 needles in April.
Even though March and April’s rate of needle exchange use are the highest they’ve been since the program started in 2015, ebbs and flows in participation are normal, Moses said. But since the program is anonymous - no one’s name, identifying information or reason for visiting is kept on file - getting insight into how often someone visits the exchange, and why, is hard to determine.
“There’s a whole group of functioning people who use drugs on the weekend and go to work during the week,” said Moses, who’s also in recovery. Even though COVID-19 shut everything down, “We don’t know if our normal participants are now coming more often because of the virus, being off work and being at home,” though it seems likely in many cases, he said.
To stave off overdose deaths, even before concrete signs that the pandemic was worsening that likelihood, Moses, Baker and others in harm reduction services across Kentucky began more aggressively pushing naloxone, or Narcan, an opioid antidote that can immediately reverse the effects of an overdose.
Typically in Fayette County, the public health program hands out 20-25 naloxone kits with two doses each a week. Lately they’ve been doling out close to 75 kits, even to people who’ve been in recovery for awhile, Baker said.
“We want to try and get it in the hands of everyone who is at risk,” she said.
‘ADDICTION IS JUST A MONSTER’
When someone overdoses locally and calls 9-1-1, EMS may have to use Narcan to revive them. Overall, the number of EMS overdose calls is on pace with previous years, according to Lexington Fire Department data, but the number of times EMS has administered naloxone so far this year is notably up.
Lexington Fire Department Captain Seth Lockard is part of a small, grant-funded team whose job it is to follow up with this group of people in the days after they overdose and are revived with naloxone. In the age of coronavirus, door knocks and in-person sit downs have been replaced with phone calls and snail mail to try and connect them with recovery services, he said.
Though the rate of overdoses generally increases in the warmer months, Lockard said the spike he’s seeing is more exaggerated, especially compared to last year, which saw a 25 percent reduction in overall overdose calls and Narcan doses administered.
Narcan doses given by fire and EMS have almost doubled since January, from 76 to 147 so far this month, according to Lockard’s data.
“We’ve definitely gone up more than a seasonal cycle,” he said.
Like other spools of Fayette County’s harm reduction web, New Vista is also contending with a surge in people seeking outpatient and residential substance use disorder treatment services.
Usually, the facility sees about 15 new enrollees a month for its medication assisted recovery program, but, “we’re at 26 for May, as of today,” Bush said. Social distancing guidelines make it near impossible to take in everyone, putting providers in a dilemma, knowing that only about 10 to 20 percent of people in active addiction seek out treatment options in the first place.
“We’re trying to decide where that risk lies: if we don’t bring them into care, they have the risk of overdosing,” Bush said. But filling programs to the same capacity as before the pandemic increases the likelihood for infection transmission.
“We don’t usually see this many people seeking services, (and) we can’t obviously bring everybody in,” he said. “What’s the right answer? It’s just tough.”
For Baker, all of this serves as a bleak reminder: “Addiction is just a monster, (and) we have loads and loads of work to do.”
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