>> Support for Heroin: A Commonwealth Crisis comes from Caron Treatment Centers operating a facility in Wernersville, Pennsylvania, focused on a 12-step recovery program with a clinical component; information at caron.org or on Twitter at carontreatment; HealthSouth Nittany Valley Rehabilitation Hospital, providing in-patient and out-patient services for illness or injury; HealthSouth for a higher level of care, nittanyvalleyrehab.com; White Deer Run treatment facilities, providing all levels of care for drug and alcohol addiction; 24-hour a day admissions at 866-769-6822. Learn more at whitedeerrun.com and from viewers like you. Thank you. From the Outreach Building on the University Park Campus of Penn State University. This is Heroin: A Commonwealth Crisis with host, Patty Satalia. >> Patty Satalia: Good evening and thank you for joining us for Heroin: A Commonwealth Crisis. I’m Patty Satalia. Heroin use in Pennsylvania has reached epidemic proportions. Once thought to be strictly an urban problem, these dangerous drugs are now readily available in rural and suburban neighborhoods and young people are at particular risk. Tonight in this live statewide program our panel of experts will explain what led to this deadly health problem and provide information on prevention and treatment. They’ll also take your questions. Our toll-free number is 1-800-543-8242. You can also email us at [email protected] You may also tweet your questions or comment to @WPSU CONNECT and use hashtag PAHEROINCRISIS. Now let’s meet our guests. Dr. Ward Donovan is Medical Toxicologist and Professor Emeritus of Emergency Medicine at the Penn State College of Medicine. Dr. Joseph Troncale, Medical Director at the Retreat of Lancaster County, a private drug and alcohol treatment center. The Honorable Nancy Butts, President Judge of Lycoming County and Alison Turley, Prevention Coordinator at the Centre County Youth Service Bureau. Thank you all so much for joining us. I’ll begin with you Dr. Troncale. How has what’s been described as Pennsylvania’s heroin epidemic touched you personally? What brings you to this conversation? >> Dr. Joseph Troncale: Well, I’m a medical director for an alcohol and drug treatment center that’s 140 beds in Lancaster called The Retreat. And I’ve been in drug and alcohol treatment for about 15 years. And what I see now is there’s a trend towards more and more young people coming in for opiate detoxification and treatment. It used to be that there were probably about 50 percent alcohol and 50 percent other drugs and that sort of thing. We feel that it’s kind of swung to about 80 percent opiates and maybe about 20 percent other drugs. >> Patty Satalia: And when you say opiates and we’ll talk more about this, you’re not just talking about heroin. You’re talking about prescription drugs. >> Dr. Joseph Troncale: Right, pain pills, anything that we would consider an opiate or an opiate-like narcotic. >> Patty Satalia: Alright, Allie Turley what brings you to this conversation? >> Alison Turley: Sure. I work at the Centre County Youth Service Bureau, which is a local non-profit agency in Centre County. And we provide prevention services for kids and families in our area. So we’re working with kids to help them learn the risks associated with using drugs and alcohol and also to help support families and teach parents how to talk with their kids about drugs and alcohol so that their kids can grow up happy and healthy. >> Patty Satalia: And we’ll be talking more about that. Dr. Donovan. >> Dr. Ward Donovan: Well I’m a medical toxicologist and I direct a in-patient toxicology treatment program at Pinnacle Health Systems, primarily Harrisburg Hospital in Pennsylvania and I’ve been a toxicologist since 1986. And as previously mentioned it wasn’t until about the last 10 years that we saw this just huge epidemic increase in the abuse of opiates by not only young people but by the middle aged. And I treat those patients who do manage to survive in the hospital. The second reason I’m here is unfortunately a personally tragic one. I lost my only son to a prescription opiate overdose. >> Patty Satalia: So you know this first hand? Dr. Butts, what brings you to this conversation? >> Honorable Nancy Butts: Well I’m the only non-medical related person here. I’m the President Judge of Lycoming County. I’m a treatment court Judge. I have been for the last 17 years. We have a drug court and a DUI court so we see not only drug-related offenses but also DUI offenders now abusing prescription medication as well as heroin. And then last September there was kind of a call to arms in Lycoming County and I brought together a number of people across the community to come together to sit down and discuss the issue. And we’ve had a number of meetings, created a task force, created a steering committee. We’ve been doing outreach gatherings, education, whether they be at school or town hall meetings. And so I’ve kind of taken two roles, one as seeing it on a day to day basis as a Judge, a presiding Judge but also as what I perceive to be my responsibility as a leader in the community to bring people of all experiences and interests together, to come together to put aside the issues of turf wars and deal with each. >> Patty Satalia: Running a drug court is a completely different responsibility and not every Judge is willing to take that on. Why in your opinion is it worth it and has it paid off? >> Honorable Nancy Butts: Well I think some Judges feel in some ways that they’re being like a social worker that when you go into the law you’re an advocate and when you’re a judge you’re still involved in primarily the law. When you’re involved with a treatment court you’re aggressively involved in it. It’s not just presiding over a legal case or you know a criminal justice case. You have to be familiar with treatment modalities. You have to understand motivational interviewing, which sometimes we learn by doing and not necessarily by training so that you have to engage the participants. You have to reach out and understand why the treatment provider thinks you should recommend for this participant they do that. It’s not just somebody telling me okay, now do this to them. You have to– it’s one on one conversation with a participant that you have to basically on the fly come up with a plan sometimes. >> Patty Satalia: But are you seeing what’s happing nationwide with drug courts, a lower recidivism rate, a second chance for people to straighten out their lives and savings to taxpayers? >> Honorable Nancy Butts: Absolutely. They say you can save anywhere from one to seven dollars per person per day with treatment court as opposed to the traditional put them in jail. There’s no treatment provided in there, no counseling where when you’re working with someone in treatment court they’re not in jail. You get them either involved in intensive out-patient or a partial hospitalization program. You see them every other week. You get them to break away from the people, places and things that kept them locked into this cycle of addiction and show them a different way. >> Patty Satalia: Dr. Donovan, what happened in the 90s? There was an aggressive push for doctors to treat pain more aggressively. What impact did that have on this whole opiate problem that we see not just in Pennsylvania but nationwide? >> Dr. Ward Donovan: That’s an important point and is really the origin of much of our problem. The use of prescription opiates became not only more widely accepted but evenly highly encouraged, to the point where I think the pendulum swung too far. And now there is widespread prescription misuse and abuse and miswriting by physicians across not just the Commonwealth but the country. Those drugs make their way to the medicine cabinets of homes and both the young people and middle-aged people as well get into them. They’re more widely available on the streets because they’re diverted. People obtain these prescriptions under sometimes false pretenses of having great pain and then sell those drugs on the street. I’m sure that the drugs that killed my son, for example, were obtained through false pretenses and then sold to him by the dealer. >> Patty Satalia: Why Dr. Troncale have so many switched from these prescription drugs to heroin? And what difference does it make to the human brain whether you’re taking a prescription opiate or heroin? >> Dr. Joseph Troncale: If I could just back up one second. If you start as a 12-year-old or something that’s either smoking pot, doing alcohol and that sort of thing in high school, what happens there’s a progression. If you could be a fly on the wall in my exam room, you would hear the same story over and over again. What’s happening is, is that young people get started on whatever you want to call them, gateway drugs or whatever. Then pills become available to them generally speaking much easier than heroin when they’re in a high school setting or something like that. >> Patty Satalia: And we tend to think they’re safer. >> Dr. Joseph Troncale: Well, they’re definitely not. >> Patty Satalia: It really is– they think it’s– >> Dr. Joseph Troncale: Definitely not, right. But what happens is, is there’s a cost thing that comes into to it and they can’t afford their pills anymore and they can get heroin cheaper than they can get their pills. >> Patty Satalia: I’ve read Oxycontin on the street can go for 80 dollars a pill and you can get a hit of heroin for 10 dollars. >> Dr. Joseph Troncale: Right. It’s about a dollar a milligram for those of you who are keeping score, but it’s– but you can get a dime bag, ten dollar bag of heroin you know. So the point just being that it’s a stereotypic progression for all these young people and they basically come to a place where they go from using pills to snorting heroin to injecting heroin. And the one statistic that I’d just like to say is that if you are injecting heroin you have a 64 time greater morbidity and mortality than the general population. It’s not like two times. It’s not like five times, it’s 64 times. And so what we’re dealing with is not just a drug epidemic but it’s a public health epidemic and these people die. You don’t see a lot of old heroin addicts. >> Patty Satalia: This used to be considered drug use, heroin use specifically. Allie Turley it used to be considered sort of a solitary activity. It’s now become a social thing among teens. >> Alison Turley: Um huh, um huh. We absolutely see that. Oftentimes kids tell us, we do an awful lot of surveying of kids so that we really understand where they’re coming from, what they’re experience is and oftentimes what we’re seeing is that kids don’t think that they’re going to become addicted to these substances. They don’t think that they’re going to be that person who is seeking you know heroin in an alley and you know shooting up. That’s just not a reality for them. So when they start experimenting and having those early experiences with drugs and alcohol it’s really fun. And it’s what they do socially and it’s what their peer group is doing and then that kind of addiction kicks in and we see kids making really poor choices. >> Patty Satalia: You say one of the problems the parents make is normalizing that activity saying no this is a rite of passage. >> Alison Turley: Right. >> Patty Satalia: We all did this. >> Alison Turley: Absolutely and not really understanding the degree to what their children you know are using and how often they’re using it. You know this isn’t you know drinking a beer one time in their lifetime before the age of 21. >> Patty Satalia: What’s the likelihood and then I’ll go, I’ll take our first phone call, but Dr. Donovan what’s the likelihood if you use opiates as prescribed, that you’ll develop a problem? >> Dr. Ward Donovan: If you’re using them as prescribed you still are going to develop a dependence on that drug. And many of the patients we see become accidentally through no fault of their own addicted to these drugs and develop a gradual and increasing tolerance and needing more and more of the drug to achieve the same result to the point where they finally are using so much that they do develop serious health problems and end up oftentimes in my hands in the emergency department in the critical care unit suffering from an opiate overdose. >> Patty Satalia: Can you talk a little bit about something that’s new, that we recently just heard about although now not to you, new in the emergency room, but an antidote to overdose that we’re reading such more about NARCAN, which could be used as a nasal spray or the injectable. >> Dr. Ward Donovan: Yes, I’m glad you brought that up because it allows me the opportunity to plug some legislation that’s currently being considered in Pennsylvania. Naloxone, its brand name is NARCAN is the antidote for an opiate overdose and it’s extremely effective up to 100 percent effective if used early. And that’s the point, it must be used early. And, of course, naloxone is something that has been around since I began practicing medicine which is more years than I care to say in the emergency departments and it’s only available in the emergency departments and from paramedics and, of course, in the hospital. If this drug was available in homes and homeless shelters and prisons, in treatment centers, families and friends had access to naloxone, we would see a magnificent drop and it has happened. There are at least about 10,000 known survivors from home use of naloxone, because there are centers that are actually already distributing naloxone. >> Patty Satalia: But there are governors, like the governor of Maine who says, but this is just an enabler. This will allow people to go out and use drugs. >> Dr. Ward Donovan: Actually that’s been shown to not be true where Naloxone has been made available to the public. Actually it has been shown to be a decrease in the use of naloxone. It is not an enabler. It is a lifesaver. The House Bill in Pennsylvania is House Bill 2090. It’s been moved out of committee and potentially we hope soon will come to the floor to be voted on in the house. I encourage all of you to contact your state representatives and ask them to support House Bill 2090, the legalization or availability of naloxone to the public. >> Patty Satalia: It’s a lifesaver. Alright, we go to Debbie who’s calling us from Harrisburg. What’s your question please? >> Debbie: Hi. My son is a heroin addict and he feels that Suboxone is the only treatment for him. And he’s going to a clinic in Pittsburgh. But what I see is he’s paying once a week to see a doctor who’s giving him a prescription but there’s no therapy involved. He doesn’t have insurance. What other options do we have? >> Patty Satalie: Dr. Troncale >> Dr. Joseph Troncale: I’d like to speak to that. Suboxone just for the audience’s sake is an opiate analog that– it’s a narcotic agonist antagonist and it’s not worth going into all of the pharmacology with that. But what I just want you to understand is that the caller is correct in that if you’re going to use Suboxone it needs to be given in, and this is my opinion, but I believe my opinion is backed up by good science. If you’re going to give somebody Suboxone, which would be like methadone or other opiate analogs, the reason that you would do that would be to keep the person free from cravings and that sort of thing. But the problem is, is that Suboxone just like other opiates has a street value and so if people are not carefully monitored from the– with the use of Suboxone then what happens is, is that they can divert it just like they can divert other opiates and that sort of thing. I’m personally very much in favor of running a good Suboxone program if somebody needs Suboxone. But on the other hand, that needs to be carefully monitored just like you would carefully monitor somebody with diabetes. You wouldn’t give somebody insulin and not check their sugars. What happens now is, is that it’s legal for some doctors, it’s legal for doctors who have the special DEA certification to prescribe Suboxone, but if they’re not doing it in the context like I’m talking about where people are carefully monitored, it’s just as dangerous. >> Patty Satalia: But it sounds like she’s also concerned that what about addressing the underlying problems that got him to use drugs in the first place, whether they’re psychological, vocational, legal? >> Dr. Joseph Troncale: Absolutely. Again I believe that Suboxone can be used if it’s used in the context of a total treatment program. Unfortunately it can be prescribed right out of the office and there are a number of doctors across the country, Pennsylvania included, where people are just handing somebody a prescription for it and basically it ends up getting diverted. Some people use it properly. >> Patty Satalia: As abused is what got them in trouble in the first place. >> Dr. Joseph Troncale: It is. It’s a really complicated issue and I don’t think we have enough time to continue, I mean to completely go into it but it’s, it’s a– I don’t want people to either take it that Suboxone is a bad drug. It’s not a bad drug. It just has to be used properly just like opiates have to be used properly, so. >> Patty Satalia: Okay, any advice for her, for her going forward? >> Dr. Joseph Troncale: I would try to find a doctor or a clinic or a Suboxone clinic where there is other adjunct programs going on with out-patient therapy, frequent visits, drug testing, all these sorts of things so that you know that the person is using the drug properly. >> Honorable Nancy Butts: Would you also recommend that she also find out if there’s an R-ANON or an AL-ANON meeting in that community as well, which supports the family members of those that are addicted. So it’s possible through that connection that she could develop some resources that would enable her son to meet maybe a sponsor to be able to be introduced to 12-step traditions and 12-step meetings so that they cannot just not use the drug anymore, but understand that there’s a different way of life that you need to live? >> Patty Satalia: And the reality is, is that 80 to 90 percent of people who go into rehab or into treatment will fail. It takes typically three times before people are successful. So this is, it’s a long haul. >> Dr. Joseph Troncale: Can I just say one other thing? >> Patty Satalia: Sure. >> Dr. Joseph Troncale: I just wanted to say that the– it’s very important for people to understand that there’s a difference between heroin use and heroin addiction. Not everybody that uses drugs is an addict. And about 10 percent of the population are genetically predisposed to having addiction. So we see people who abuse substances and don’t end up addicted to substances and it gets very confusing for people who are not familiar with the neurobiology of addiction to see people use it. And then they say well he’s using it or she’s using it and she’s not addicted. But, so anyway it gives people a false sense of security. >> Patty Satalia: Okay. We have a question from the audience, this one. What can family members of addicts do to help them gain strength and courage to fight their addiction? How can we support them best when they are at their lowest? We’ll begin with you Allie Turley. >> Alison Turley: Sure, sure. I think just recognizing that there is an addiction, that there is a problem that the family needs to address and be really supportive of that program, supportive, getting them to their meeting, supporting getting them to their appointments, their counseling sessions, monitoring kind of their prescriptions and things like that. And also having high expectations of what you expect from them. So, you know whatever your family rules are for that, your family guidelines are for living in the house with you and you know what your role is in the family and being really strict about following through. >> Patty Satalia: Dr. Donovan, anything to add to that? >> Dr. Ward Donovan: Well my expertise actually is in the treatment of overdoses rather than the counseling and rehabilitation but I would say mostly that if your family member, friend is unfortunately involved in the law because of their drug use or has gotten into trouble with the law drug courts are a fabulous resource and have the best success rates that we know of. And so, although it sounds perhaps cruel or difficult to in some ways your– the addict is lucky to get into the arms of the law, to get into the legal system and then be fortunate enough to live in a county where there’s a drug court system. >> Patty Satalia: I want to follow up on that in just a moment. Thank you for tuning in to Heroin: A Commonwealth Crisis. Our panel of experts is ready to answer your questions. Our toll-free number is 1-800-543-8242. If drug courts are so successful, I wonder why only a fraction of those 1.2 million drug addicted people actually have access to one. >> Honorable Nancy Butts: Well, as we talked about earlier, some counties the Judges don’t feel comfortable. They don’t feel like they’re able to manage the population. Sometimes the individual has to choose it. At this point at least in Lycoming County we don’t order people into treatment court. And many people they spend a month, two months, three months in jail. They haven’t used in that period of time. I’ve got this kicked. I don’t need this. It’s not problem. They are released, you know they’re sentenced or they go through the system and they don’t involve drug courts as part of their sentence or any kind of treatment component. They go out. They start hanging around with the people. They do the things that they used to do and hang around the places they used to be and they just get sucked right back in. >> Patty Satalia: How do you respond to critics who say the problem with drug courts is that they’re inherently coercive, that you’re not going to be as successful with rehabilitation if you’ve been made to do this as opposed to volunteered? >> Honorable Nancy Butts: Well, I think I can argue both sides. I can tell you that statistics show that there’s a slightly better success rate on people that are ordered into treatment than those that volunteer for treatment. But from our perspective we’re a post-conviction program, so that an individual that comes in with us is either on supervision already and has still an addiction problem that we then kind of bring them in and put them through our program or they plead guilty, which they have an absolute right to go to trial. We don’t take that away from them. They come to us and choose us. And then once they choose us and they meet criteria then we accept them in the program. >> Patty Satalia: Alright. We’re going to take another phone call. Is John from McKeesport still on the line? >> John: Ah, yes. Here is my question I would like to ask. About seven, eight years ago I had a minor back operation and I was plied with drugs. Now I am in a out-patient Suboxone clinic. What I’d like to know is how is it that when you go to these clinics that usually are run by a bunch of retired doctors, if you have no insurance you are paying close to 200 dollars a month for a prescription of Suboxone and then you can even [inaudible] the 13 dollars a piece it costs to fill it. You would think they would give this stuff away for free instead of– I mean what you know addict can come up with this kind of money to buy this kind of stuff to stay off of dope. >> Patty Satalia: Dr. Troncale. >> John: That’s my question. >> Patty Satalia: Thank you. >> Dr. Joseph Troncale: Thank you. It’s an excellent question. We actually had a drug task force meeting this morning in Lancaster County where they were trying to talk about these sorts of issues. You see everybody is in a silo, pharmaceutical companies make money. Doctors make money. Everybody, it’s all money driven unfortunately both on the side of you can be a drug dealer or you can basically prescribe drugs. I’m not impugning physicians in general or across the board or anything like that. What I’m trying to say is, is that when there’s money involved there’s problems involved with it. For this gentleman who is calling in, what I would just say to him is, is that the cost of the drugs is not controlled by the doctors that are prescribing it. Again, we have a bigger systemic problem. If we are going to try to subsidize Suboxone I have no problem with that. It’s just that somebody is going to have to pay for that. I think the– we could also talk at great length about how this whole Suboxone thing came about and again, we’re probably not– there’s probably not enough time to discuss. >> Patty Satalia: Well, I guess my question is how long do you anticipate that someone like John, our caller, would need to be on Suboxone? At what point could he be weaned from any assistance? >> Dr. Joseph Troncale: Well, again it varies on the individual. What we’re trying to prevent is that business of people going to the streets and killing themselves with opiates. If the person needs to stay on Suboxone to keep themselves alive, obviously however much money that was, which again I’m not justifying, I’m just saying that’s cheaper than a funeral. The problems that we see with getting people off of Suboxone is the same problems we see as detoxifying people from other opiates. It’s not a pleasant process. It does take time. It takes a lot of resources to get people weaned down. We do it. I have a family member that was on Suboxone, is not on Suboxone anymore. I consider Suboxone something that saved my family member’s life, but it was not an easy process. It took a lot of very careful treatment and that sort of thing. So it can be done. It’s just a difficult problem. >> Patty Satalia: It was pain that brought John to his problem and that brings me to this question, Dr. Donovan. There are many who say that this goal of zero pain is a dangerous and an unrealistic one. >> Dr. Ward Donovan: Yes, I certainly agree with that. There are many ways to treat pain and too often the doctor just reaches for a prescription and often is forced because of time constraints now on physicians. It’s a lot easier to reach for that prescription, write a prescription for an opiate than to counsel them about the other methods for pain treatment. One excellent resource is a good reliable ethical pain management center. There are pain management centers that are simply nothing more than opiate, opioid mills. There are others that do an excellent job of treating pain without the use of, heavy use of opiate prescriptions. >> Dr. Joseph Troncale: Can I say one other thing? There was a– there’s a famous pain doctor in Philadelphia, Dr. Ashburn who has shown that once you get past 120 milligrams of Oxycontin you’re not going to treat pain anymore. You’re basically just going to develop tolerance. And so again, a lot of doctors and people who treat pain or are trying to treat pain don’t really again understand pain as well as they probably should. >> Patty Satalia: Alright. If you’re just joining us I’m Patty Satalia and this is Heroin: A Commonwealth Crisis. Let me reintroduce our guests. Dr. Ward Donovan is Medical Toxicologist and Professor Emeritus of Emergency Medicine at the Penn State College of Medicine. The Honorable Nancy Butts, President Judge of Lycoming County. Dr. Joseph Troncale, Medical Director at the Retreat of Lancaster County, a private drug and alcohol treatment center and Alison Turley, Prevention Coordinator at the Centre County Youth Service Bureau. You can join the discussion by calling our toll-free number, 1-800-543-8242, or by sending an email to [email protected] You may also tweet your question or comment to @wpsuconnect and use hashtag PAHEROINCRISIS. And we’ll go now to Tim who has been patiently holding on in Penn Hills. Thanks so much for your call. >> Tim: Hello. >> Patty Satalia: Hi. What’s your question for our panel? >> Tim: I would like to thank everybody that’s on the panel. And my question is that if there’s a couple that’s addicted to heroin, using it on a daily basis, and one of them passes, whose fault is it? >> Dr. Joseph Troncale: Well, I– >> Tim: Hello. >> Patty Satalia: Yes. Well, we’re– >> Dr. Joseph Troncale: Yes we’re here. Again, I don’t– we’re not here to sort of blame anybody. It’s just like again, if we could just get the concept that addiction is a disease and understanding that both of those people have a disease and that one passed away because of their disease it would be no different than if two people smoked and one of them had a heart attack, in my mind. I mean I don’t know if that’s a good analogy or not. But all I’m just trying to say is, is that this whole thing with addiction is and treatment of addiction is not about laying blame. It’s about getting people adequate treatment and trying to keep people safe. >> Honorable Nancy Butts: And one of the things that we should also say that Dr. Donovan talked about the House Bill 2090, it’s not just about NARCAN, it’s also Good Samaritan legislation as well, which is– >> Patty Satalia: And– >> Honorable Nancy Butts: Go ahead, I’m sorry. >> Patty Satalia: Good Samaritan allows you to make that phone call to 911 so that you don’t have to watch a loved one die because you’re afraid that you’re going to be prosecuted for using drugs. >> Honorable Nancy Butts: So that’s– I think that’s an indirect answer to the question in that if you see a situation you need to call for help and not have to worry about the possible ramifications that could happen to you, that the police could arrest you for something. >> Patty Satalia: So what is the status of the Good Samaritan law in Pennsylvania? We don’t have one do we? >> Honorable Nancy Butts: Not for this particular issue, but it is tied to the NARCAN legislation. >> Dr. Ward Donovan: And I’d like to add comments about the addiction and whose fault it is and the expense also. And it all goes back to, and I’m not afraid to say this, that the health insurance industry is complicit in the addiction problem that we have. It is not looked upon by health insurance companies. I think still as a disease it’s looked upon as a personality disorder and they are actually allowed to place limits on the duration of treatment and how much they will spend and how long people will be hospitalized. We would never dream of limiting the number of treatment visits, hospital visits, hospital stays for someone with diabetes, for example, and yet we do for addiction. >> Patty Satalia: Actually there is a mandate and it’s rare in Pennsylvania that insurance, commercial insurance providers must provide 30 days of in-patient rehabilitation and 45 with a doctor’s order, but it’s not always honored. >> Dr. Joseph Troncale: Which is– >> Patty Satalia: It’s not honored. >> Dr. Ward Donovan: No it’s neither honored nor is it enough. >> Patty Satalia: Nor is it– >> Dr. Ward Donovan: It’s not enough. >> Honorable Nancy Butts: And sometimes even accessing that insurance is a slow process. So sometimes that’s why people get involved in the criminal justice system because you get arrested, presumably you’re going to be in jail. You’re going to be abstinent while you’re in the county prison waiting for your insurance to kick in. >> Dr. Joseph Troncale: Then the insurance won’t cover you because your urine is clean now and so– >> Honorable Nancy Butts: Correct. >> Dr. Joseph Troncale: And so you don’t need detox anymore but you suffered through detox. And then, well I’d just like to say just like what we were just talking about, if diabetics had their pancreas in their brain there’d be diabetics in jail. >> Honorable Nancy Butts: Right. >> Dr. Joseph Troncale: You know. In other words it’s the same thing you know what I mean. If you– we just look at it because it’s a brain disease and it affects behavior then it’s a bad thing. No other disease is thought of that way because it doesn’t affect behavior. So because of that, it’s stigmatized. >> Patty Satalia: And, of course, one of the most dangerous periods for a drug addict is right after rehab. They go out. They think one last hit and, of course, they’re tolerance has changed because they’ve been clean for 30 days. >> Dr. Joseph Troncale: Well see, it’s important to understand that brain chemistry only changes gradually. And so you’re at the highest risk of relapse right after you’ve had some clean time. And the more time that you have away from your drug the better chance you have of staying abstinent. And so, that’s why it’s really important to get what we’re talking about here with more time for treatment because people don’t all heal at the same rate. >> Honorable Nancy Butts: And part of training as a Judge, we’ve even been shown MRI scans of people who are a year out, two years out, five years out on addiction and it’s really not until you get that many years out that the brain actually starts to recover. So you really need a long period of time. >> Patty Satalia: And 50 percent of crime I’m reading is connected, linked directly to drug addiction. >> Honorable Nancy Butts: Oh, I’m sure in my county it’s even higher. >> Patty Satalia: Even higher. >> Honorable Nancy Butts: Probably about 85 percent. >> Patty Satalia: Okay. I want to talk with Allie Turley in a minute about risk factors and how we can enhance protective factors. But first I’m going to take this phone call from Kristin in Duncannon. Go ahead please Kristin. >> Kristin: Yes. Thank you. In the Susquenita School District in Perry County they start random drug testing in 5th grade for students that are involved in sports and extracurricular activities. Is that the answer? >> Patty Satalia: Maybe– >> Honorable Nancy Butts: I was just going to say, I believe that education is the answer, but go ahead. >> Alison Turley: I agree too. I think a really strong approach where schools are involved, families are involved, the community is involved, law enforcement is involved and everybody is working together to solve the problem is the best answer. Drug testing might be a piece of that, but it’s just one small piece. It could be a deterrent for some kids, but it probably isn’t a deterrent for everybody. >> Patty Satalia: In some ways it sounds like it’s criminalizing childhood. I think to some that’s the way it could feel. But you wanted to add something Dr. Troncale. >> Dr. Joseph Troncale: I was just going to say that drug testing is a small part. In other words like if you have somebody that you think is at risk or in other words just like they do at places of employment, if you have some sort of reasonable cause then drug testing is, can be very helpful. I don’t necessarily favor just across the board drug testing just to be drug testing. >> Patty Satalia: Well the interesting thing about what our caller is saying is we’re talking about 5th graders. But when it comes to heroin use we’re seeing age of first use is younger and younger. It was 26. The average age now is 23 and it’s not unusual for someone 12 years old, I’m wondering if you’ve seen someone in their early teens Dr. Donovan presenting at the emergency room? >> Dr. Ward Donovan: I mostly see in the very young the use of prescription opiates. >> Patty Satalia: That they get from a medicine cabinet? >> Dr. Ward Donovan: Yes, probably the youngest heroin overdose I’ve seen is probably in the 12 to 14 year age group, but certainly it is being seen in the younger and younger population. >> Patty Satalia: Okay, I’ll take a phone call in a moment, but I wanted to get back to you Allie about risk factors and enhancing those protective factors. What can parents do? >> Alison Turley: Sure. So risk factors are the factors that make it more likely that kids will have negative outcomes or we’ll see problem behavior as like drug and alcohol use. And it’s really important to look at all of the ways that young people are affected. So, kids own resiliency and their own temperament play into this. Their peer group plays into this, who they’re spending time with. Their family plays into it. Their school plays into it. The community plays into it. And when we have high risk factors when families aren’t monitoring behavior, when they are not bonding well with their children, when they don’t have high expectations for behavior. And when a young person’s peer group is using and they are a high risk sensation seeking kind of kid, when we start looking at all these risk factors piling on top of each other we can see more undesirable behavior, like using drugs and alcohol. So what we want to do with a community and with kids and families is really increase the protective factors. So those are the factors that are going to make it more likely that this kid is going to make it through and make good choices; so families that have high expectations. Schools that reward for social behavior, communities that really support kids who are making good decisions. Those kind of things that keep kids really safe and connected to communities and bonded with people who care about them, adults who care about them, they are more likely to not use. >> Patty Satalia: And this sounds like it’s probably more effective than scare tactics. If you do this, this could kill you. >> Alison Turley: Absolutely. Absolutely. There’s a ton of research around this scared straight idea and just doesn’t work. They don’t think that’s going to happen to them and that’s not reality for people that they see. It’s not reality necessarily for them. And you know it just doesn’t work. >> Patty Satalia: It’s harder and harder. I think a lot of parents would say it’s harder to stay connected. Kids today have cell phones, so you know when I grew up my parents talked with my friends on the phone when they called to ask me to go out. That doesn’t happen anymore. >> Alison Turley: No. And that’s why guidelines at home are so important and parents and other adults in the community who care about kids they need to be involved and present, just really mindful, really mindful parenting skills, being really involved in what their kids are doing knowing their kids friends, knowing their kids friend’s parents, making sure and following up on them. You know if a kid says they’re going somewhere, go there and see that they’re there. And oftentimes phones should not be in bedrooms, computers should not be in bedrooms. That stuff should be turned in at the end of the night, because there’s just so much access to so much more. And we’re basically just giving it to our kids. >> Honorable Nancy Butts: And how about– >> Dr. Ward Donovan: To add to this discussion I’d like to interject a– is that parents can play a huge role in recognizing the changes in behavior of their children associated with the development of using drugs. Sudden changes, deterioration in grades, changes of their friends to friends that are perhaps not as desirable as their previous friends, behavioral changes at home, obstinance, difficulty in their personality and their interactions with parents, these are all warning signs that drug use may be developing. >> Alison Turley: And what’s so challenging– I’m sorry. I was going to say what’s so challenging about that is we see a lot of those behavior changes in teenagers anyway. So you know, does my kid have a drug or alcohol problem, is this just normal teenage things. You know peer groups change and interests change, but recognizing that and having that really strong relationship with your child so that you can have those conversations and say, I’m really concerned about this. I’m noticing this. This is different. What’s going on? >> Patty Satalia: Okay. Oh good. >> Honorable Nancy Butts: I was just going to say that one of the things that we’ve discovered in our community is education for the parents. >> Alison Turley: Absolutely. >> Honorable Nancy Butts: Is that it is non-existent because it’s an inner city different population problem. It’s not in my backyard. It’s not in my school district and they’re not even willing to understand what those signs and symptoms are. >> Patty Satalia: And the new stats say it absolutely is in your community whether it’s a rural community or a suburban community and, in fact, 80 percent of those who are going in for treatment are white males not people from cities. >> Honorable Nancy Butts: Absolutely. >> Dr. Joseph Troncale: I just wanted to say also that once addiction is identified in a teenager, for instance, everything switches around and it’s very difficult for parents to go from being nurturing to now having to be, use tough love. >> Honorable Nancy Butts: Right. >> Dr. Joseph Troncale: And that’s a transition that parents need to be taught as well and it’s a very difficult transition for them to make many times because they went from being you know close and all this sort of stuff. And then their child is lying to them and that sort of thing. Now they have to go and be very strict, tough, whatever it’s going to take to get them into treatment, all those sorts of things. And so that’s very hard on parents. >> Alison Turley: Yeah. >> Honorable Nancy Butts: Because, I’m sorry. What we see is that by the time an individual gets arrested by the police for some crime outside the home they have stolen from their parents multiple, multiple times and the parents have either been afraid to hold their children accountable or they just turn a blind eye because they don’t want the police to know what’s going on in their family. And there’s a huge sense of shame in the fact that this is touching my family and I don’t want the world to know and that really does everyone a huge disservice. >> Patty Satalia: I’m going to take a Twitter question. This one I think we’ve sort of answered. What type of advocacy can Pennsylvanians participate in to help combat this problem? >> Honorable Nancy Butts: My advocacy or my belief is that you need to get involved and that’s what we’ve done in Lycoming County. We’ve brought people together. We want them to not be afraid to talk about it. We have open town hall meetings where we bring experts in. And the feedback from these meetings is phenomenal about parents going “oh my gosh, I didn’t even know what to look for.” I mean when I went to school, it was alcohol. It was marijuana. We would have no idea what to look for in terms of paraphernalia, the signs and symptoms that a person could be using. We are doing presentations at the schools for the SAAD chapter, in support of the SAAD chapters or just for the teachers now who want to know, what should we be looking for, because clearly – >> Patty Satalia: In fact you’ve started two committees in your heroin task force. One is youth and the other one is research. Why those two things? >> Honorable Nancy Butts: Well youth is because if we believe from our PAYS [phonetic] data, the surveys that we know that middle school is our appropriate target range, I’m old. I don’t speak in the same language. I don’t use the same social media that my son who’s 12 is already accustomed to. We need them to speak the language so that the youth will hear it. And that when we see them with their life is the anti-drug or these great t-shirts that we know that they believe in, that we want them to spread the word. And we figure, we believe that that was the best way. >> Patty Satalia: Kids need to be involved and that’s part of communities that care. >> Alison Turley: Absolutely. >> Honorable Nancy Butts: Absolutely. But also research in to collect the data to see if what we’re doing is working and if it isn’t, how should we change it up? And what already evidence-based programs are there out there that we can bring into our community to our schools, to our middle schools, to all of our grades to be able to educate everyone. >> Patty Satalia: Alight, we go now to a question. This one from Amy who is calling us from Ephrata. Go ahead please Amy. >> Amy: Hi, yes. My question is I have three children that age from 16 down to 10 and with the epidemic getting so big, I don’t know how much information to give them. I mean I tell them that you know drugs are bad, that this is going on. They’ve seen it with friends, children going through things, but I don’t know how much I should actually show them. Should they be sitting down, at least my 16 year old sitting down watching something like this to get the information to see that this is what could happen if this is what’s going on out there? >> Alison Turley: I would say absolutely. I would say you know all of your children, it would be appropriate. >> Honorable Nancy Butts: Yes. >> Alison Turley: There’s an age appropriate level for this conversation starting with kids as early as three and four, but especially your 16 year old and it’s really important for parents to understand that. Kids are getting their information from somewhere and they should get it from you. You know so my guess is he could probably tell you more than you want to know about it. Because kids they experience this. This is their reality. So, kind of not talking about it is really harmful. >> Dr. Joseph Troncale: I was going to say that Betty Ford, the Betty Ford Foundation puts out a comic book for people, for kids all the way down to like kindergarten to talk about addiction, because again, many children are affected by addiction. And they need to understand to have some sort of a handle on it. So there is literature out there that parents can obtain to try to help educate their kids at an age-appropriate thing so they’re not having to watch this television program, for instance. But they have more age appropriate sorts of materials. >> Honorable Nancy Butts: And probably the question would be who would call. I would recommend to call the SCA, the Single County Authority, the drug and alcohol agency for each county. Each county has at least one. Some county sheriff, an SCA, and they can point to you to prevention, they can point you to treatment providers. They can be a funding source for treatment if you’re in crisis. But they would be the best resource. >> Patty Satalia: I want to follow up on something you said earlier and that was that families don’t want to involve the police. They’re ashamed that this, this problem has hit them and yet if you talk with someone who’s using heroin they say there is no stigma attached to using heroin today. It’s not this back alley problem that– of the past. I think there still is a huge stigma along with any addiction whether it be alcohol, marijuana, heroin, prescription medication. There’s a stigma. The person is weak of moral character and that if they really wanted to beat this they could. And again, we refer back to if you were diabetic and you really want to be this, you can’t just will yourself to be off insulin. You’ve got to have therapy. You’ve got to have treatment and lifestyle changes. Maybe you exercise more, maybe you eat properly and then maybe you can wean off of insulin. It’s the same– it’s the exact same thing with drug addiction. >> Patty Satalia: Dr. Donovan. >> Dr. Donovan Ward: I agree that there’s still a huge stigma and something that perhaps we should have emphasized in the beginning of this program is that addiction crosses all socioeconomic classes, all ethnic groups and yet people often think that well this is only an inner city problem. And if it does happen in their children they’re embarrassed and they don’t want it known and they try to hide it. I also would want to emphasize just to drive home how serious this point is, that as of 2008 there are more deaths from drug overdoses in the United States then there are deaths from automobile accidents. >> Patty Satalia: And most of them from prescription drugs, not from illicit drugs. >> Dr. Ward Donovan: About half of those are from either prescription opiates or illicit drugs like, or a little over half, like heroin. >> Patty Satalia: Alright. >> Dr. Joseph Troncale: And also there’s– people are using combinations of drugs which are quite lethal. In other words people don’t generally just use heroin although some people do, but they start mixing benzodiazepines with their heroin. They start using other combinations and the combinations are more lethal than just the single drug itself. >> Patty Satalia: And what I understand is that the quality of the heroin that’s available in Pennsylvania is quite high, quite pure, which really is a sign that it’s quite accessible. >> Dr. Joseph Troncale: It’s quite accessible. >> Patty Satalia: We’ll go to Richard who is calling us from Pittsburgh. What’s your question please Richard? >> Richard: Where is there such poor law enforcement? You can drive any city or town and you can see drug dealers operating out in the open day or night. In fact, they even advertise. They have calling cards. They hang a pair of shoes over telephone wires and that tells you exactly where they are. And you can drive around your city and you’ll see that. Why can’t the police be proactive and shut these people down? >> Honorable Nancy Butts: Well, I know that in my community when funding goes away sometimes police officer positions go away. It would be great to have community police officers out there, grant funding on the federal level for that has been gone for maybe five years or so. That’s the way, that’s the real way to solve a– to solve this problem is to be proactive. It’s to tell the world we don’t tolerate this type of behavior in our community. So it would be great to have that, but realistically whether it be the state police or your municipal police agencies, they’re not going to be able to do it. So what you need to do is as an interested neighbor you have to make the phone calls. You have to be the eyes and the ears for the police and let them know what’s going on. >> Patty Satalia: And I’m wondering how many people in here knew that tennis shoes hanging over a telephone wire was a sign? A couple of hands went up. >> Audience speaker: Urban legend. It’s not true. >> Patty Satalia: Oh, okay. Okay. >> Audience Speaker: It’s not true. Look it up on Snopes. >> Patty Satalia: Okay. Okay alright so we will look that up on Snoop. And we’ll go now to a phone call from Carolyn from Pittsburgh. Go ahead please Carolyn. Are you there Carolyn? >> Carolyn: Yes, I’m here. I have a question. I would like to know if Oxycontin and heroin have the same chemical makeup. >> Dr. Ward Donovan: Yes, they’re opiates. There are differences in how long they last. Heroin fortunately I guess I have to say has a very short half-life. That means it doesn’t last long. A single dose of naloxone will typically save the patient who is suffering from a heroin overdose. But if it’s an Oxycontin overdose they typically will need multiple doses of naloxone. So, it’s what we call pharmacokinetics, the duration of action of the drug, the onset of action. But in terms of its basic pharmacology they’re all opiates and they work the same way. And the way they work is they depress respiration. They ultimately can cause direct lung injury. They can cause damage to the heart. It depends on how long the person survives or whether they recover, whether they’re resuscitated successfully early. Many of the patients that we see end up in the hospital for days and weeks with what’s called multi-organ failure. The opiate has affected every organ in their body because they’ve been comatose, unconscious, not breathing well, with low blood pressure for hours and hours and no one is there to tend to them and save them. And that’s why I go back to again the concept of having naloxone in the home, in the community where if there is someone who’s knowledgeable about the use of naloxone and finds this individual the earlier treatment happens, the less likely they are to die. >> Patty Satalia: And this naloxone basically tells your brain breathe again. >> Dr. Ward Donovan: Well, naloxone just displaces the drug from what’s called the receptor, the opiate receptor. And so instead of the opiate affecting that opiate receptor and causing respiratory depression naloxone is essentially an inert drug that takes the place of that opiate and prevents the opiate from working. >> Patty Satalia: How do you respond to those who say that this is just another crutch and another potential addiction, using some of these other drugs? >> Dr. Ward Donovan: Using– >> Patty Satalia: Using Suboxone for example to get off heroin. >> Dr. Ward Donovan: Well Suboxone and methadone also, but I think particularly Suboxone have been shown to be safer than seeking drugs on the street. I often tell my patients, teach my residents that you don’t know what you’re buying when you’re buying something on the street. With the Suboxone you know what you’re getting, you know the dose, it’s being hopefully in a controlled, prescribed in a controlled setting and one advantage of Suboxone is that it has a threshold level where it reaches a point where it can’t do any more harm. And methadone does not have that protection and so I advocate Suboxone rather than methadone now as a preferred treatment program or maintenance treatment program drug. >> Patty Satalia: Alright, I’d like to begin with you Allie Turley with your take home message. >> Alison Turley: Sure. So I think take home is that it is a community issue. It’s not just a school issue, it’s not just a family issue, everybody needs to get involved and be aware of what’s happening and educate themselves and really understand the facts and really get involved in being part of the solution. So, joining local communities that care, organizations, being involved with young people in the community, having high expectations for what you want in your community and what you want in your family and make those choices that make that possible for your family. >> Patty Satalia: Dr. Troncale. >> Dr. Joseph Troncale: Well, the opiate epidemic is real and beyond all the other problems it causes, it kills people. And so it’s very important for us to understand it as a part of the disease of addiction and we need to do whatever it is that we can do to advocate for getting people the care that they need. >> Patty Satalia: Well speaking of the care that they need, most people spend more time picking a new car than they do picking a treatment center. So what should we look for? >> Dr. Joseph Troncale: Well, it’s difficult to measure quality but I think that again there’s certain things that like we talked about with the Suboxone clinics; if they’re doing drug testing, if there’s comprehensive care, if there’s licensed professionals, all these sorts of things that you look for and there– if you go to the American Society of Addiction Medicine website they will help you make those kinds of choices. >> Patty Satalia: Okay, Dr. Donovan. >> Dr. Ward Donovan: I would answer that question not as a physician but as a father and I would go back to parents recognizing the potential warning signs that their children are getting into drugs. And then taking whatever it takes, whatever steps it takes to prevent further treatment, to treat the addiction if they do get into the addiction point. A previous caller talked about the expense and then it was mentioned, well it’s cheaper than a funeral. So, if you have to mortgage your home to save your child, do so. If you have to put your child in a difficult position of punishment and being placed in treatment programs that they may not want to go into, do it. In other words, tough love. Be aware of what’s going on and do whatever it takes. >> Patty Satalia: Judge Butts. >> Honorable Nancy Butts: I think just to follow up on what the doctor has said. I think you begin your child’s life in that you set the standard. If you accept this type of behavior then that’s what you’re going to get. And if you don’t hold them accountable then we’re going to see them. >> Patty Satalia: Okay. And we are out of time. Thank you to our guests tonight, Dr. Ward Donovan, Professor Emeritus of Emergency Medicine at the Penn State College of Medicine, the Honorable Nancy Butts, President Judge of Lycoming County, Dr. Joseph Troncale of Lancaster County and Alison Turley of Centre County Youth Service Bureau. I’m Patty Satalia, thanks for joining us. Good night. >> Support for Heroin: A Commonwealth Crisis comes from Caron Treatment Centers operating a facility in Wernersville, Pennsylvania, focused on a 12-step recovery program with a clinical component; information at caron.org or on Twitter at carontreatment; HealthSouth Nittany Valley Rehabilitation Hospital, providing in-patient and out-patient services for illness or injury; HealthSouth for a higher level of care, nittanyvalleyrehab.com; White Deer Run treatment facilities, providing all levels of care for drug and alcohol addiction; 24-hour a day admissions at 866-769-6822. Learn more at whitedeerrun.com and from viewers like you. Thank you.