Fall 2017
Cover Story

Crisis on Main Street: When Opioids Hit Home

Treetops sway in the breeze on a balmy late summer afternoon in a small rural community about 30 miles northwest of Pittsburgh. On an attractive campus-style complex just off a highway, several adults socialize on a wooden deck while others toss a ball on a nearby lawn as laughter and chirping birds punctuate a serene quietness.

Since 1972, this former farm has been the site of Gateway Rehab, where medical experts, licensed professional counselors, and social workers help people caught in the grips of the national opioid addiction and overdose epidemic. The public health crisis is dominating national and local headlines as the death toll climbs—every 33 days sees a number of deaths comparable to the terrorist attacks of 9/11.

“It’s a national crisis, certainly, and in Western Pennsylvania, it’s absolutely
a regional crisis,” says Neil Capretto, Gateway Rehab’s medical director and a national authority on the topic. “I’ve watched it develop literally on a day-by- day basis over the last 20 years. When I finished my psychiatry residency in 1985, there were two drug overdose deaths in Allegheny County that year. There were 650 last year. That’s a nightmare. And surrounding counties are seeing similar trends. If we had a serial killer killing 1/10 of that, the National Guard and CNN would be coming in. We do have a serial killer, and it’s addiction. It’s killing our neighbors, our family members, [and] our coworkers, and it does not discriminate by age or ethnicity or where you live.”

Fueled by a rise in the use of heroin and prescription pain medications, opioid abuse has grown quietly into a beastly juggernaut that has thrust itself into the public spotlight. The nation’s foremost public health officials are declaring it the worst drug crisis in U.S. history.

The numbers associated with the impact of opioid addiction and overdose are alarming. Last year, nationwide, the number of overdose deaths caused by heroin (an opiate) outstripped deaths due to gun violence, according to the Centers for Disease Control and Prevention (CDC). On an average day, 91 Ameri- cans die from an overdose of heroin or another opioid and 3,900 people start nonmedical use of prescription opioids. Additionally, heroin-related deaths more than tripled from 2010 to 2015, and approximately 12.5 million Americans abused prescription opioids in 2015.

Closer to home, reported opioid overdose deaths in Allegheny County, Pa., increased from 234 in 2008 to 650 last year, with 480 as of October 29, 2017, according to OverdoseFreePA, a partnership of Pennsylvania communities dedicated to fighting the opioid overdose crisis.

Capretto also highlights a critical need for help for individuals and families impacted by a health issue that demands medical intervention and treatment.

“Social workers are trained and positioned to make a big difference because they are taught to see the bigger picture of not just an individual using drugs but a person in the context of a society with problems and an individual with problems,” he says.

While adult White males are disproportionately represented among the ranks of those addicted to and overdosing on opioids, the crisis cuts across gender, race, age, and socioeconomic lines.

“Capretto, who cochaired a national task force that issued a report on the crisis in 2014, has watched the current crisis unfold over the decades. The needle-injected heroin that once ravaged urban inner-city landscapes in the 1970s eventually became available in cheaper forms imported by drug cartels, variations that could be snorted and over time became a less- expensive, easier-to-get alternative to the prescription pain pills that were the primary causes of opioid addiction among suburban and rural populations.

And so opioid addiction and overdoses “reached a magnitude that was hard to ignore—it hit Main Street, America,” Capretto says. “It’s hard to find anybody who hasn’t been impacted or doesn’t know somebody close to them who has been impacted by the opioid crisis.”

More than a Public Health Issue

Addressing the crisis is a social justice issue in more ways than one and has
a lot to do with the issue of race, says Pitt associate professor of social work and associate dean for research Gerald Cochran. Although opioid addiction
and deaths cut across all social strata, there is a public perception (with which Cochran agrees) that the issue did not receive significant attention and response until the children of upper-class Whites began dying from overdoses.

Meanwhile, public health issues that primarily affect less-privileged social groups haven’t received the same urgent response, “which is problematic right now in the United States” given recent flare-ups of racial division, Cochran contends.

In the thick of the response are social workers, who witness the ravages and devastation as they work at the forefront of aiding those affected.

“I left school with basic group and individual counseling skills and the understanding of addiction as an illness,” says Ellen Corona, clinical manager at Gateway Rehab’s Green Tree location since 1999. “My degree prepared me to become a therapist at Gateway 32 years ago. At the time, opioid use was not nearly as prevalent as it is now. While we have always educated our clients about the disease concept of addiction and taught them that addiction can be fatal if left untreated, I don’t think anything could have prepared me for the large numbers of clients we’ve been losing to overdose deaths in the last few years.”

Corona’s role is a whirlwind of activity: orienting, training, and supervising staff, interns, and volunteers; providing case consultations; solving problems; performing daily documentation audits of electronic medical records; monitoring staff and managed care authorizations; conducting routine safety and emergency management drills and inspections; and coping with client deaths.

“I think the current opioid overdose epidemic is one of the most serious health crises this country has ever faced,” she says. “We have lost clients of every race, gender, and socioeconomic background. Almost every day, a client comes in and mentions someone dying. People are losing someone all the time. It’s scary and it’s sad. It has reinforced my belief that opiates are too accessible and that alternatives for pain management are needed.”

The crisis has compelled Gateway Rehab and other service providers to think beyond the traditional abstinence-based model of recovery from addiction.

“It became clear in the last few years that the traditional model was not successful with many of our clients addicted to opiates,” says Corona. “Our clients were dying. That was a very powerful realization that caused me to have a shift in my thinking about what we could and should be doing differently.”

A big result was the introduction of medication-assisted treatment, which involves the use of medications such as Revia and Vivitrol alongside long-standing approaches to treatment such as education, intensive therapy, and 12-step programs like Narcotics Anonymous.

“Many of our staff have struggled with this shift, as have many in the recovering community,” says Corona. “For me, I believe that every day we keep someone [who is] addicted to opiates alive and functional is a win.”

The opioid epidemic is an unusual drug crisis in that it significantly impacts all age ranges. While fatal overdoses increased nationally among all age cohorts from 2010 to 2015, according to CDC, the greatest increase was among adults ages 55–64, and the highest overall rates were in the 45–54 age bracket.

Those facts underscore a need for special attention to older persons addicted to opioids, says Daniel Rosen, David E. Epperson Professor of Social Work at the University of Pittsburgh, who has an interest in studying addiction in the aging population.

“Older adults who have been overprescribed pain medications are at particular risk,” he observes, noting that more than 15 percent of opioid overdose deaths in Allegheny County since 2008 have been people age 55 and older and that nearly one-fourth of such deaths in the county in 2016 were adults ages 45–54.

“Limited resources exist for addiction treatment for older adults, and it is a vulnerable population that is often socially isolated,” Rosen points out. “In order to adequately address the opioid epidemic, multiple social service and health care agencies will need to be adequately trained to screen for and treat opioid misuse.”

In addition, he recommends that social workers in various social service settings be trained to address the opioid epidemic and its nuances. “There is a ripple effect across the human service sector from foster care to older adult services that are being impacted by this crisis. Social workers, with their training in interdisciplinary care and collaboration, are well poised to play a critical role in addressing this epidemic.”

Social workers, Corona adds, can address the problem before it gets to the point of dealing with broken families, workplace problems, and other repercussions of addiction, overdose, and death. A key component is becoming educated about addiction “so as to recognize the signs and symptoms and make appropriate referrals for treatment as early as possible,” she says.

Social workers tend to serve many roles, and the opioid crisis is testing that ability, observes Cheryl Cooper (MSW ’00), a therapist at JADE Wellness Center in Monroeville, Pa., which provides outpatient treatment and has been addressing opiate addiction since its opening in 2010.

“We very often wear a number of different hats,” notes Cooper. “We are case managers, educators, [and] prevention specialists. We [wear all those hats] for all of our clients. I think the advantage that social workers have over licensed professional counselors is we have more knowledge and avenues about how to access those core basic needs of a client. People come to us with a lot of needs. If someone doesn’t have food or shelter, no amount of therapy in the world will fix the addiction. Basic needs have to be met, like health insurance and a safe place to live.”

Due largely to the opioid crisis, JADE has expanded to facilities at three locations in Allegheny County. Like Gateway Rehab and other licensed treatment facilities, JADE goes beyond medical solutions by providing daily individual and group sessions led mostly by licensed professional counselors and social workers as well as occasional overdose prevention lectures by medical staff members.

When the opioid crisis began to emerge publicly as a major news event, Cooper was among those who wondered if the problem was receiving greater attention because it had evolved from being a problem primarily in poor Black urban neighborhoods to a plague on White middle-class suburban communities.
That unanswered question has faded to the background as she draws on her social work education at Pitt and 23 years in the addiction field to help people recover.

“I’ve never seen it this bad,” Cooper says. “But I love what I do. I focus on the positive outcomes, rather than dwell on the negatives, because if I did that, I would drown—because almost daily, I hear about an overdose death.”

Federal help has increased for Cooper and others in the trenches. Medicaid expansion under President Barack Obama’s Affordable Care Act, as well as the standing order for naloxone (Narcan) signed by Allegheny County Health Department Director Karen Hacker in 2015, increased access for many without insurance who otherwise could not afford treatment. The standing order allows any licensed pharmacy in the county that chooses to participate to dispense naloxone to individuals at risk of a heroin- or opioid-related overdose or those who may witness one. And last spring, the U.S. Department of Health and Human Services announced it would award $485 million in federal grants to all states and U.S. territories to address the crisis. In August, following a report issued by the President’s Commission on Combating Drug Addiction and the Opioid Crisis, President Donald Trump declared the problem a national emergency and pledged more money to federal agencies and states to implement the panel’s recommendations, which included making overdose antidotes more widely available and waiving some health regulations to ease access to intervention and treatment.

The heightened attention and increased resources in recent years have been hailed by those in the field.

“We cannot arrest our way out of this problem,” Gateway Rehab’s Capretto warns, echoing other experts. “It’s a public health crisis, which involves many things.”

At the Gateway Rehab flagship facility in Aliquippa, Pa., which opened in 1972, Capretto works with multiple patients each day, as about 300 addicts are admitted each month. Administration was moved to a building in a nearby town six years ago so that the space could be transformed into a 28-bed inpatient detox center, which usually is filled and has a

waiting list by early afternoon. The campus has another building with 42 beds for youths and young adults in treatment, with a total of 192 beds in three buildings.

Overall, Gateway Rehab has nine outpatient satellites in Western Pennsylvania that serve about 1,500 active patients. Most are opioid-addicted clients, some as young as 14 and a few in their 70s, says Capretto.

“I never imagined it would reach this magnitude,” he confesses. “A lot of people thought I was overexaggerating. I think people thought it didn’t affect them, that it was happening to other people—then that [notion] started falling apart.”

Creating an Environment of Recovery

Capretto sees hope in a holistic, multipronged approach that incorporates education for prevention, better training for medical professionals about how to treat pain, physician databases with prescription tracking, adequate treatment resources, long-term follow-up for patients, and law enforcement working to curb the amount of heroin and fentanyl flowing illegally into the United States.

Efforts to make Gateway Rehab in Aliquippa a healing environment are apparent to visitors. Amenities include a small store, cafeteria, gymnasium, library, chapel, and enclosed garden courtyard. Natural light that spills through large windows is hoped to dispel the darkness into which so many there have been plunged.

Heroin and opioid painkillers—including prescription ones—act similarly on the brain, and using even one opioid painkiller as pre- scribed can increase a person’s chances of getting hooked on the medication or heroin. Death rates from legally prescribed opioids grew 4 percent from 2014 to 2015, according to CDC, a rate that suggests some success in efforts to reduce overprescribing by doctors. However, during the same time period, use of illegally obtained opioids such as oxycodone, methadone, and fentanyl—the drug involved in the

2016 death of pop star Prince that is 50 times stronger than pure heroin— grew an alarming 74 percent from 2014 to 2015.

Patrick Bibza, a Pitt student who interned at Gateway Rehab under Corona’s super- vision, decided to join the fight against the opioid crisis by earning a master’s degree in social work with an emphasis on mental health, particularly drug and alcohol treatment. The journey began with his own struggle with opioid addiction.

After graduating from high school in a small community about 30 miles northeast of Pittsburgh and prior to earning a bachelor’s degree in behavioral health from Point Park University, Bibza joined the U.S. Navy. A week before his deployment in 2008, he sustained a severe knee injury that required two surgeries. During that time, he had his first use of an opiate in the form of a doctor-prescribed pain medicine. Bibza pinpoints that event as the beginning of a long struggle with addiction.

“I saw a lot of substance abuse in and out of the service,” he says, adding that he has witnessed numerous relatives and friends struggle with opioid and various other types of addiction.

Complicating the matter was Bibza’s personal fight to resist the lure of alcohol, which he hopes to do on a broader scale as he witnesses the powerful effect of media images on youth perceptions of drug use and drinking.

“Alcohol has always been something exciting to me, easily available, thrown in your face,” he says. “I developed a core belief that in order to have fun, you need to drink. That message is sent to lots of kids who don’t know the consequences.”

During Bibza’s second internship at Gate- way Rehab, he assisted with group therapy for adolescents each day and cofacilitated an adult therapy group once a week.

“The biggest thing I’ve come to learn and completely agree with is that addiction is a disease,” says Bibza.

He counts at least 10 friends, all under the age of 25, who have died from a drug overdose. And with every funeral comes a growing desire to help prevent more overdose deaths.

“I want to see my friends stop dying,” he says. “Every time I go to a funeral, I wish I could have helped them. What confuses them is that [addiction] is their choice, but it is a disease. I have someone very close to me who is in recovery and doing extremely well. Her story started as most do, with the overprescribing of pain medication and without a step-down system from the meds or proper addiction education or therapy. It gets to the point where people aren’t getting high to cope any more, they are buying and using just in order to survive and not be ‘dope sick.’ A lot of people don’t understand just how bad that feeling is and how long it lasts, but also there is always the very real possibility that [what] you are about to use will kill you.”

Bibza is angered by negative public perceptions and stigma about addiction and those who grapple with it. His view, shared by experts in the field, is that compassion, treatment, and support are the cures rather than disdain, disparagement, and imprisonment.

“If you haven’t been there, you don’t know what they’re going through,” says Bibza. “A lot of addicts do terrible things, but that’s not who they are. It’s the drug, not the person. One thing I hear a lot about addicts is, ‘They just need to stop.’ It’s not just stopping but doing other things.”

It’s doing the kind of things that Gateway Rehab, JADE, Pittsburgh Mercy, and similar agencies help to provide. It’s doing the kind of things that Bibza hopes to offer one day on a large scale. As a recovering addict, he says, he has to avoid bars, con- certs, sporting events, and other places where alcohol is served—and he knows many people who have to avoid those venues as well.

Armed with education and experience, he says that his life calling is to establish “hundreds if not thousands of centers that allow addicts to come together and watch sporting events, shoot pool, and throw darts—do the things that they love doing but without drugs and alcohol being shoved in their face.”

There is necessarily much focus on the disease of addiction, says Bibza, but he wants to start “a disease of recovery. Recovery needs to be fun. There isn’t a place for people in healthy recovery to live their lives. There should be places where addicts can come together every day and help each other and enjoy life again.”