FRAMINGHAM (AP) >> It all starts with a $20 to $30 purchase.
That's the average street price of heroin today, according to Framingham Police. But if that one purchase is a bad batch, too strong, or if the user injects too much, that's all it takes to cause an overdose. Although the proliferation of the overdose-reversal drug Narcan — the market name for naloxone — has saved innumerable lives, more than 1,000 people are dying a year in Massachusetts from heroin and other opioid overdoses. When you crunch the numbers, that overdose costs a whole lot more than $20.
As Framingham Police Chief Ken Ferguson can attest, emergency workers in every community are responding to more and more overdoses. Gov. Charlie Baker recently announced a new $250,000 "Make the Right Call" initiative — a campaign to encourage people to call 911 if somebody is overdosing.
According to the Massachusetts Department of Public Health, in 2015 emergency personnel statewide responded to 11,884 opioid-related incidents, up from 6,315 in 2013. Of those incidents, naloxone was used 9,127 times. In 2,976 of those incidents it had to be given to the patient more than once.
"Addiction to heroin is a sickness and we respond when people are sick," Ferguson said.
Framingham Police recently announced a partnership with the Police Assisted Addiction and Recovery Initiative, which will include the addition of a full-time clinician to the department. When police respond to an overdose, the clinician will follow up with the patient or the patient's family to encourage and help them to get treatment for addiction.
So what happens when the 911 call comes in that a person is overdosing? According to Ferguson, police and EMTs don't always know if it's an overdose or not. Frequently, calls come in as generic "medicals" where first responders are unsure what they'll find. Police tend to be first on the scene.
All 132 Framingham officers now carry Narcan whenever they are on patrol and they are all trained to use it. In Framingham's case, the department funded its Narcan stock with a $15,000 grant from the Department of Public Health. Although some police departments in the state have not yet made the leap to carrying Narcan, more are getting on board. In March, Hudson Police were among the most recent in MetroWest to announce they would begin stocking it.
For a typical response call, two officers will be present, along with three or four firefighters and at least one ambulance with two EMTs, plus two additional medical staff. Framingham Police are paid about $35 an hour, on average, $45 an hour with overtime. A single fully-staffed ambulance costs about $150 per hour, according to Chris Stawasz, regional director at American Medical Response, which supplies ambulances for Framingham and Natick.
According to Stawasz, emergency personnel may spend about an hour on a single overdose scene, from resuscitation to hospital transport. Framingham Police Lt. Stephen Cronin estimates about an hour and a half. Emergency workers are never sure what they are going to encounter at a scene either, Cronin said. Often, when a patient is taken out of the overdose by Narcan he or she will become angry, combative and may immediately go into withdrawal— meaning police must stick around to provide security.
In 2015, many cities nationwide saw prices of a single dose of Narcan double. But in Massachusetts, police pay $20 a dose, plus $3.76 for the atomizers used to administer the drug nasally.
Attorney General Maura Healey was a major proponent of keeping the life-saving drug affordable. Last summer municipalities were paying anywhere from $30 to $65 per dose, making it more expensive than the heroin it's meant to counteract. According to Healey, the state and her office worked to reach a settlement with Amphastar Pharmaceuticals, the maker of Narcan, paying $325,000 to offset the price. To date, 115 municipalities have affordable Narcan at $20 a dose.
"This is about saving lives," Healey said. "Without a decrease on the price, the drug could not be as available to first responders as it is now."
At Milford Regional Hospital, doctors in the emergency department are seeing overdose patients with alarming frequency. According to Dr. Jeffrey Hopkins, chairman of the department of emergency medicine, patients aren't just showing up in ambulances, but friends or family may leave them at the door.
Because Narcan only has a half-life of 60 minutes, it's possible that patients can fall back into an overdose if they have taken a particularly strong batch or heroin or other opioids. The spread of fentanyl, a synthetic opioid that is 50 to 100 times more powerful than morphine and frequently cut with heroin, is sending more people to the ER. Doctors will try to keep patients under observation for at least 90 minutes, to ensure the Narcan has worked, but because the patient is now legally sober, they are under no obligation to stay.
"We want to advocate for our patients. If someone is awake and alert they don't have to abide by what we say," he said. Often, patients will storm out of the emergency department.
If a patient cannot be revived with Narcan, he or she may need to be sent to the Intensive Care Unit, which can rack up more costs. According to Dr. Gert Paul Walter at Emerson Hospital in Concord, doctors are frequently unaware of what drugs patients have taken. Some may be on four or five different substances— and medicines may not work to reverse the effects of all of them. In the ICU, patients may be hooked up to ventilators, given blood pressure medication to keep their heart rate up and treated with fluids.
Because emergency room doctors will take any patient, regardless of ability to pay, hospitals tend to lose a lot of money on ER visits. But where economics truly take a toll on addicts is in post-treatment. While there are patients who will leave the hospital and go right back to using, many more will attempt— and frequently fail —to get into inpatient rehab programs.
Hopkins said there is a pressing need for mental and behavioral health parity among insurance companies, who "traditionally have not reimbursed for mental health and substance abuse issues." And since MassHealth and Medicaid reimburse facilities less than private insurance companies, rehab centers are unable to take all patients.
"Facilities can't stay open if all payers are uninsured or on MassHealth," Hopkins said. "We can't get people into the services they need. They either have the wrong insurance, are too acute or not acute enough for detox, there are huge barriers. These same barriers don't exist for physical medical issues."
Mike Duggan, founder and CEO of Wicked Sober, knows a lot about getting treatment because he has been through it himself. His organization works with addicts to get them into programs where they can get clean.
Insurance will pay for 14 days of detox and care, but trying to find long-term treatment can be a struggle. Inpatient programs can cost patients and their families upwards of $16,000 to $20,000.
"With private health insurance you're paying for convenience," Duggan said. "With Medicaid, unfortunately, the reality is there is a lack of beds available. And by the time a bed opens up they may not be willing to get treatment anymore ... In the private sector, deductibles and out-of-pocket costs seem to be getting higher. It's a barrier to people getting care and to receive a bill after the fact can be another stresser in their lives, or an upfront barrier."
Treating addiction can be difficult enough, but, unfortunately, it doesn't always end at one disease. Opioid addicts frequently find themselves contracting physical diseases as well, including HIV, liver damage, abscesses and hepatitis.
Although hepatitis C can be a devastating illness, there is a treatment for it— but like Narcan it is caught in a price war. The Attorney General's Office is working to combat the price of an expensive hepatitis C drug known as Sovaldi, manufactured by Gilead. The entire treatment can cost between $84,000 and $94,000, Healey said, and Gilead made more than $20 billion on the drug in the first 21 months it was on the market.
Between 2002 and 2014, Healey said, there was a 138-percent increase in hepatitis C cases among 15- to 29-year-olds.
"Where I'm coming from is that we have an infectious disease that is on the rise and here we have a drug to cure it," Healey said. "And unfortunately, that drug is too expensive."
In spite of the number of lives saved by the use of Narcan, the number of deaths from heroin and now fentanyl is continuing to skyrocket. Long-term drug treatments such as suboxone, Vivitrol and methadone exist, but many addicts continue to relapse.
If no one calls 911, or if a person is too far gone by the time someone calls for help, it's possible the drug user becomes another face of an epidemic that is crashing down on families in all communities.
At Fitzgerald & Collins Funeral Home in Marlborough, owner Richard Collins is seeing the real cost of the epidemic up front. Most of the families, he said, come unprepared.
"Just look at the number of GoFundMe pages," Collins said. "There's an increase in families needing to raise money. It's an unexpected expense for a 25-year-old who planned on getting up the next day."
A funeral he said, including burial, costs about $8,000. Direct cremation with no services is $2,700.
Back at Milford Regional Hospital, Dr. Hopkins is treating patients regularly and just last week he sat down with a woman in her 60s who came in seeking treatment. The woman, he said, had become addicted to heroin after her pain medication ran out and she needed a rehab program. After sitting down for an hour, struggling and failing to find a place that could accept her immediately, she left in frustration and has not come back.
"I can guarantee that woman went out and said 'they didn't do anything for me,"' Hopkins said. "We are trying our best, but we need the resources. I want to advocate for my patients. They should be treated like any other."
Information from: MetroWest Daily News (Framingham), http://www.metrowestdailynews.com