Beyond Narcan: Breaking The Heroin Cycle, One Addict At A Time

"It owned me. it ruled my life. I was wherever it was." -- Angela Cicchino, on her heroin addiction

Angela Cicchino says it took being put in jail to break her addiction cycle.

"I had a court date," Cicchino, 26, says in a video produced by the Ocean County Prosecutor's Office. "I woke up that morning and I got high, and I couldn't stop getting high. I was late for the court date."

When Cicchino finally arrived at the courthouse that summer day, she says, she was a complete mess.

"I had long sleeves on because of all the track marks on my arms," she says. "My face was all broken out. I hadn't showered in a couple of weeks."

The judge sent her to jail that day, without bail. It was the turning point, she says.

"If I didn't show up that day, I probably never would have shown up for another court date," Cicchino says in the video. "I was ready to run ... to go far away and hopefully everyone would just forget who I was."

That was in 2011. Today, Cicchino is using her personal experience to try to convince other addicts that they, too, can get clean, and help them navigate a path to do so.

That begins with meeting them while they are still in the emergency room after they've been rescued from an overdose with Narcan, and talking with them in a way that only someone who has been in their shoes can do.

Cicchino is one of a dozen recovery coaches who are part of a two-year pilot program operating in Ocean and Monmouth counties called the Opioid Overdose Recovery Program. The recovery coaches -- all recovered addicts --spend as much time as it takes with the rescued person, encouraging, urging and doing everything possible to convince them to go into a drug addiction treatment program.

The ones who agree are immediately transported to a detox center, and a bed at a long-term treatment center is arranged. For those who don't agree, Cicchino and her counterparts stay in contact with them for eight weeks, on the chance and in hopes they will change their mind and agree to treatment.

The Opioid Overdose Recovery Program, the brainchild of Ocean County Prosecutor Joseph Coronato, has taken nearly a year and a half to put in place. It is being funded by a grant from the New Jersey Department of Human Services, Division of Mental Health and Addiction Services, the Governor’s Council on Alcoholism and Drug Abuse and the state Department of Children and Families.

Barnabas Health, which operates Community Medical Center in Toms River, Monmouth Medical Center in West Long Branch and the Monmouth Medical Center Southern Campus (formerly known as Kimball Medical Center) and has an addiction services component, has partnered with the prosecutor's office to bring the project to fruition.

But it is the dogged efforts of Coronato, who first spoke publicly about the program in November 2014, that have resulted in its inception. The program is first of its kind in the nation, and has created a standardized protocol that the health professionals, law enforcement and government all are following in with one shared goal: to help break the hold heroin has on the populace of Ocean and Monmouth counties.

In 2016 so far, there have been 130 overdoses in Ocean County, of which 30 were fatal, Coronato said. Of the remaining 100, about 50 percent of those revived with Narcan have agreed to go to treatment, Coronato said -- a hopeful sign, but it is so early in the process that it's too soon to draw much in the way of conclusions.

"This is a marathon," Coronato said, "and we're still in the blocks."

Breaking the cycle

When Coronato became the Ocean County prosecutor in March 2013, heroin overdoses were on the rise. He immediately set to work to attack the problem from a law enforcement perspective, directing more resources to investigation of drug dealers, seizing dealers' assets and prosecuting those who provided the drugs that led to a fatal overdose under New Jersey's strict liability laws. He also instituted a number of educational programs.

But in 2013, the death toll from overdoses in Ocean County was the highest in the state: 112 deaths, of which 59 were directly attributable to heroin or heroin in combination with another drug, according to figures released by the Ocean County Prosecutor's Office. Another 49 were attributable to prescription medications alone or in combination with alcohol or cocaine, the prosecutor's office said.

Of the 112 deaths in 2013, 84 of those were people between the ages of 21 and 50, and 73 of them were male. Just six out of the 112 overdoses were people older than 60, the prosecutor's office said.

The trends are similar in 2016 among the 100 people rescued (as of mid-April) by Narcan, Coronato said, with 76 of the revived people among those ages 18 to 44, with another 17 in the 45-64 age group. Those older than 64 are less likely to be found in time to reverse an overdose, he said, because they often live alone. But the problem still is concentrated among those in the younger age groups, he said.

The rapid rise in heroin deaths also led Coronato to push for legislation to allow police officers to carry Narcan to administer to someone who had overdosed. In April 2014, Ocean County began a pilot program that equipped all law enforcement officers with the opioid antidote soon spread throughout the state.

And while Narcan prevented 129 overdose deaths in the county that year, Coronato said police officers told him there was a secondary problem.

"The officers were telling me that they were reviving the same people over and over," Coronato said this week. "We needed to find a way to break the cycle."

And locking people up -- the way Cicchino was -- wasn't going to be an effective solution, he said.

"We can't arrest our way out of this crisis," Coronato says.

Narcan 2

Since the use of Narcan by both police and EMTs began in April 2014, there have been more than 11,000 opioid overdose reversals in New Jersey, according to figures Gov. Chris Christie quoted earlier this week at a news conference, the Hudson County View reported.

Detractors are quick to scoff, saying that many of those are repeat reversals, and complain that the money spent -- drug forfeiture funds -- is being wasted as a result.

At that news conference, Christie responded saying, "A saved life is a saved life," then added, "That's why the recovery coach program is so important."

Coronato agrees, and has been fighting hard to implement the pilot program to get those reversed by Narcan into treatment.

He first spoke about the plan in November 2014 at a marijuana forum for parents held at Brick Township High School. He referred to it as "Narcan 2," and the rough outline of the plan was for the person rescued by a dose of Narcan to first go into a detox center, and then to a longer-term treatment of 30 to as much as 90 days, to begin to break the cycle.

At the time, Coronato was still in the process of getting all the pieces of the puzzle -- response, treatment beds, and most importantly funding -- in place.

After more than a year of meetings and work, the grant-funded Opioid Overdose Recovery Program was finally launched on Jan. 18 through the Barnabas Center for Prevention, which focuses on addiction treatment. It has standardized the response to an overdose, so that all parties, from law enforcement to the emergency room doctors to treatment facilities, are working together smoothly.

Now, when someone who has overdosed is brought to the emergency room, they are immediately met by a recovery coach who works to convince them to agree to go into treatment. The person also receives a dose of methadone, suboxone or Vivitrol while they are still in the emergency room, to manage the symptoms of withdrawal that a Narcan dose can produce and thereby discourage them from immediately seeking another heroin dose.

The intercepts are taking place in the emergency rooms at Community Medical Center in Toms River, Monmouth Medical Center in West Long Branch and Monmouth Medical's Southern Campus -- formerly known as Kimball Medical Center -- because they are all part of the Barnabas systems, Coronato said.

"We ran into some HIPAA issues" with patient confidentiality in trying to implement the program elsewhere, but Coronato said those are expected to be resolved shortly, allowing the program to then be offered at Ocean Medical Center in Brick, Jersey Shore University Medical Center in Neptune and at CentraState Medical Center in Freehold.

When they agree to go to treatment, they are taken straight to a detox program, and then to an in-patient treatment program, 30, 60 or 90 days long, Coronato said. The treatment is paid for by the grant, he said.

Transportation -- often a roadblock to getting someone into treatment -- is not paid for by the grant, Coronato said. Instead, the county has been using drug forfeiture funds pay for transportation -- they've hired Ubers to drive patients to treatment facilities and paid for plane tickets to out-of-state programs, said Al Della Fave, spokesman for the prosecutor's office, all to ensure the patients who agree to treatment get there.

"We physically deliver them to the program," Coronato said.

Few beds, long waiting lists

Getting into treatment has long been a major impediment to those seeking to break free of heroin addiction. While public perception is that all an addict has to do is decide they want treatment, the reality is that it's not that simple.

For starters, the number of people seeking treatment far outstrips the availability of beds. In a 2010 publication, "The Addiction Treatment Gap Primer," the National Council on Alcohol and Drug Addiction of New Jersey reported that nearly 50,000 people who were seeking treatment were turned away because there were no beds to treat them -- a number that has risen dramatically as the heroin crisis has accelerated in the years since. Many treatment programs in the state have waiting lists that number in the hundreds, the report said.

"Other programs do not even keep waiting lists and simply instruct clients to call back every day to check for openings," the report said.

The 2014 report of the Governor's Council on Alcohol and Drug Addiction's Task Force on Heroin and Other Opiate Use By New Jersey's Youth and Young Adults paints a more stark picture, reporting that the federal Substance Abuse and Mental Health Services Administration estimates that in New Jersey, "only 6 percent of youth and young adults who are in need of treatment for chemical dependence are provided treatment —14,200 out of 234,000."

Coronato said the Opioid Overdose Recovery Program has been instrumental in opening doors to finding beds for those seeking treatment. But it appears to also have had the negative effect of people overdosing to get into a scholarship bed -- even if they have insurance.

"It's a problem," he said.

Once someone is convinced to go into treatment, they are tracked for a minimum of eight weeks, and Coronato said one of the things they are looking at in the program is why some leave treatment while others stay with it.

Very often a battle with addiction has other aspects that have to be addressed at the same time -- a mental health component, a family problem, and even legal problems. If those aren't addressed, making the bridge to recovery can be difficult, he said.

"You just don't take a wand and wave it (addiction) away," Coronato said.

Those who walk away from treatment are required to go through an exit interview, Coronato said, "so we can find out why. What worked, what didn't work."

"We want to drill down on these things to make the program better," he said.

"People think that after 24, 60, 90 days (in treatment) you've solved the problem," he said. "You haven't. We want to get people from treatment to the recovery phase."

Uncovering true numbers

One of the important aspects of the program, he said, is that officials are now able to really capture statistics on the extent of the heroin problem, based on the reversals and the overdoses.

Heroin overdoses have been on the rise in 2016, Coronato said. With 130 overdoses in the county so far and 30 deaths, the county could very well surpass the number of overdose deaths that happened in 2013, before Narcan use and availability became so widespread. The number of overdose deaths had fallen the last two years, to 101 in 2014 and 95 in 2015, he said, thanks to Narcan. There were 394 Narcan reversals in Ocean County in 2014 and 268 reversals by police in 2015, according to the Barnabas Health website's page on the recovery program.

It remains a critical element, Coronato said.

"Without Narcan, the number of deaths (in 2016) would be 250 or more," he said matter-of-factly. While he said the heroin epidemic is spreading, Coronato also said he believes they are really getting accurate statistics for the first time, thanks to the pilot treatment program.

"Numbers beget numbers," he said, and each layer of numbers makes him want to dig deeper. Among the facts that have become clear: those who are becoming addicted to heroin are not those who've spent their lives in poverty.

"This is a middle class to upper middle class problem," he said.

"I couldn't even tell you a year ago who was being sprayed," Coronato said. "I think we are just uncovering the true numbers."

"We've made strides," he said. Even Narcan itself has undergone an evolution in the two years of its use. It used to come as a kit that had to be assembled and then sprayed into both nostrils of the person being treated. Now a more concentrated formula, prepackaged in a ready-to-use applicator, can be sprayed in just one nostril with the same effect.

But there remains a great deal of work to be done -- not only in the matter of getting addicts into treatment and into recovery, but also in combating the problem where it begins, Coronato said.

"We should not lose sight of the fact that this all starts in the medicine cabinet," he said.

The prescription connection

Prescription drugs -- particularly opioid-based painkillers -- have fueled the rise in heroin use, as those who become addicted to drugs like OxyContin, Percocet and others transition to heroin when they can no longer obtain the prescription pills legally and the cost to buy them on the street becomes too high to maintain their habit.

According to the National Institute on Drug Abuse, "from 1991 to 2011, the number of opioid painkiller prescriptions dispensed by pharmacies tripled, from 76 million to 219 million prescriptions (IMS Health, 2014a; IMS Health, 2014b).

"In parallel with this increase, there was also a near tripling of opioid-related deaths over the same time period."

That realization has led to some, albeit slow, changes in prescribing attitudes.

The Centers for Disease Control in March 2016 issued new guidelines to doctors on prescribing opioid painkillers for chronic pain that is not related to cancer. Those guidelines, which have met some resistance, include opting for non-opioid painkillers as a first choice for treating pain except where a person is being treated for cancer, or receiving pallative or end-of-life care, and prescribing the lowest dose possible to effect pain relief, among others.

St. Joseph's Regional Medical Center in Paterson has taken that to the next level, becoming the first hospital in the country to stop prescribing opioids for pain in the emergency room in most cases.

Coronato's office continues to emphasize education about the role prescription drugs are playing in the heroin crisis. The prosecutor's office hosted a forum aimed at high school athletes and their parents called "Playing It Clean" that brought together star local and New Jersey athletes including Todd Frazier, Ray Lucas, Frankie Edgar and Keith Elias, to talk about the dangers of painkillers, which often are prescribed to athletes, even young ones, in the wake of a sports injury.

The prosecutor's office's "Right Turn" videos, which address both alcohol and drug use and are aimed at students and parents, have been another avenue, as have to prescription drug collection programs and drop boxes that have been installed in most if not all of the police departments in the county.

All the while, drug investigations and enforcement efforts continue, in an attempt to get as much heroin as possible off the streets. But there is a long hill to climb.

"We're making strides (in battling the heroin epidemic), but we are just getting started," Coronato said.

Thanks to the work of recovery coaches like Angela Cicchino, the path to get people into long-term treatment programs and the ongoing efforts to bring all pieces of the community -- law enforcement, health professionals and government -- together, there may be a blueprint for the most difficult aspect of the battle to break heroin's grip. 

"Do I think we'll have this problem solved in two years? No. But I think we're on the right track," Coronato said.

(Addiction educational poster from the Governor's Council on Alcoholism and Drug Addiction)