In the one-year period between Aug. 22, 2018, and Aug. 22, 2019, at least 540 Alabamians died of opioid drug overdoses, according to state and county data. 

That includes 11 in Morgan County, 12 in Limestone and five in Lawrence.

The fresh statistics — compiled by the Alabama Department of Forensic Sciences and the Jefferson County Coroner’s Office — signal that the state’s battle with opioids, particularly fentanyl, is far from over.

What began as a prescription drug problem in Alabama, an over-prescribing of painkillers, is now largely an illegal drug problem as the state cracks down on prescribing practices.

”The general trend in our opioid overdose deaths has been moving away from individuals abusing the prescription medications, and moving to overdosing on illicit drugs, like heroin,” said ADFS Director Angelo Della Manna.

As that fight continues, collecting more data on opioids’ impact on the state is a priority.

Della Manna is part of the multi-agency effort by the Alabama Opioid Overdose and Addiction Council, the group tasked with finding ways to reduce opioid-related deaths in the state. One of the group's goals: creating a centralized data repository to track reports of opioid drug use in real time, including calls to poison control or emergency room visits.

“The end goal of a centralized data repository is to identify a cluster of activity in a specific area and pass along that knowledge to the relevant health care and law enforcement professionals in near time or real time, ideally before you end up with a large number of people overdosing and starting an epidemic,” Della Manna said.

Council co-chair and State Health Officer Dr. Scott Harris said the repository, which is still in development, is a “heavy lift” for the state but when complete will give state health, public service and law enforcement leaders access to trends they haven’t seen before.

“Ideally, you would have a large database that could inform policy decisions,” Harris said.

Another benefit, Della Manna said, is that the same infrastructure could be used in the future, should other drugs emerge as significant public health risks.

Tracking opioid statistics, even deaths, is a challenge. The recent numbers given to Alabama Daily News from ADFS, which investigates suspicious, unattended and potentially criminal deaths in all Alabama counties except Jefferson, appear to show an increase in deaths, at least from 2017. Official 2018 numbers have not yet been released, but several state officials, including Harris, say overdose deaths are likely under-reported for a variety of reasons.

“Whatever numbers we have, we’re pretty sure they’re low,” Harris said this week.

Meanwhile, Della Manna thinks emergency responders’ increased access to and use of the overdose-reversing drug naloxone is skewing the overdose and opioid epidemic numbers. Getting naloxone to more emergency and first responders has been a priority of the council.

“If you have an overdose and people survive that event as a result of being treated with naloxone, that’s great,” Della Manna said. “But it’s difficult to assess if any trend in decreased overdose deaths are attributable to increased access to naloxone for first responders, stricter control on access to prescription opioids, or a combination of several of these factors.”

Naloxone is also available over-the-counter without a prescription, and some Montgomery pharmacies sell it for about $130.

In recent years, ADFS has also tracked fentanyl, a powerful synthetic opioid.

“It’s a major concern because it’s a significant contributor to overdose deaths,” Della Manna said. “People may think they’re ingesting just heroin, but if it’s laced with fentanyl … it often ends up as one of our overdose-death cases.”

By the end of this year, Della Manna expects the number of overdose cases where fentanyl is present to surpass the levels from previous years.

The centralized data repository, once finalized, is expected to also have statistics available on opioid prescriptions, infant withdrawal syndrome and hospital admissions and emergency room responses.

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Hospitals react, refer

Alabama hospital emergency departments are part of the front line battling the epidemic.

Dr. Sherrie Squyers, director of the Huntsville Hospital emergency department, agrees that the epidemic is still under-reported. Squyers is also medical director at the ambulance provider Huntsville Emergency Medical Services.

She said opioid victims die of trauma, including in car wrecks.

“I think any stats you see are gross underestimates,” Squyers said recently.

The emergency department at the University of Alabama Birmingham sees an overdose or withdrawal case nearly every shift, according to Dr. Erik Hess.

More than half the patients the department sees have an opioid on their medication lists, he said.

The department has often seen the same patients with opioid withdrawal, Hess said. The standard care was to hydrate them and give them something for nausea and headache — short-term help.

“It was a revolving door; it was a frustrating situation and demoralizing for the physicians,” he said.

Earlier this year, Hess and UAB launched an emergency department-based program to try to get those with opioid issues into long-term treatment. The Medication Assisted Treatment Protocol, or ED MAT, is funded by a $1.5 million grant from the Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services.

The protocol has multiple steps, including the use of buprenorphine and naloxone in the emergency department to treat the symptoms of opioid withdrawal and to decrease cravings, followed by a short-term prescription, if appropriate, and a take-home naloxone kit, according to UAB.

Besides medication, ED MAT refers patients to follow-up treatment and services through the Recovery Resource Center of Jefferson County at Cooper Green Mercy Services.

“This year alone, there have been 253 referrals to Recovery Center from UAB,” Hess said in September.

“It’s an effort to save lives.”

Addiction isn’t limited by income, education or background, Squyers said.

“We have doctors whose kids we’ve seen with overdoses,” she said. “There is no community spared from this.”

She’s seen family members of addicts who said they put their financial resources into treatment, only to end up in the emergency department again.

Like Hess at UAB, Squyers sees repeat visitors.

“We saw one a few weeks ago, we tried to keep her and get help,” Squyers said. The woman refused.

“The next week, she was found dead,” she said.

Often, those suffering from addiction need more than just drug treatment.

“By the time they see (us), they’re down and out,” Hess said. “They don’t have a job, their family has estranged them, they probably don’t have health insurance.

“If they need housing, they’re not going to get their addiction taken care of unless they get shelter.”

Asked what possible actions she’d like to see from state officials, Squyers said more access to rehabilitation for opioid users and cheaper access to naloxone for users’ families.

To stop the epidemic, she said, efforts need to focus on keeping people from becoming addicts.

“Once they become addicted — there are people who get off it and lead normal lives, but there are a lot who don’t,” Squyers said.

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