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North Dakota faces record drug deaths

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Kyle Clayton remembers waking up in an ambulance after being revived with Narcan following a heroin overdose.

"It just felt like death, just the overall feeling," the 35-year-old Mandan father of two said. "The Narcan, it takes over the feeling of the heroin, and it's not a good combination. I mean, it saves your life but it drains you physically, and just your blood pressure being so low and not having blood to extremities, and the oxygen deprivation to the brain, I wasn't right for weeks afterward."

It took four or five doses of the nasal spray to revive him from what was his second overdose, in 2015. He remembers losing his motor skills and speech after using heroin, then waking up in the ambulance. Someone had called 911 after he fell from a second-story apartment balcony.

Clayton, who found recovery in 2018 with methadone treatment at Heartview Foundation in Bismarck, said his drug use escalated over years, culminating in countless jail time, two prison terms and a realization one day that he was "sick of just being a nobody."

Now he's a recovery coach and peer support specialist at Heartview, helping others with addiction.

"The weird thing about it is being out in the community as a drug user and then coming to work here, all the people that have come in through the doors I have either bought drugs from or sold drugs to or done drugs with, I'd say 80% of the people that have come through here," Clayton said. "And every single one of them is like, 'Of all the people I've ever met, you were not the one person that's going to be working at Heartview.'"

Addiction and recovery have grown as a public health focus in recent years in North Dakota, with champions as powerful as the governor and first lady, herself a recovering alcoholic. The couple this month are seeking public input on addiction through an online survey available at bit.ly/3lCugT3, open through Aug. 31.

Most state efforts have targeted expanding treatment access, boosting Narcan training and distribution, and raising public awareness of addiction as a disease. 

Last year, North Dakota logged a recent record 118 drug-related deaths of residents, the most in a decade and a 49% increase from 2019, according to the state Division of Vital Records. Accidental deaths from narcotics were the most common type of drug-related death, at 49 instances. 

The U.S. Centers for Disease Control and Prevention last month released provisional data showing a record 93,000 drug overdose deaths in 2020, including 123 in North Dakota.

The state compiles the data as "drug-related deaths" based on terminology of the International Classification of Diseases, which the CDC also uses. Deputy State Registrar Carmell Barth said the CDC likely does more in-depth study beyond the underlying cause-of-death coding the state uses.

Police and public health and treatment professionals see isolation from the coronavirus pandemic as a factor in the increase, but also insidious drugs such as fentanyl, a deadly synthetic opioid becoming widely available.

"We're hearing from a lot of our patients that are coming from using on the streets that fentanyl is certainly readily available in our communities, not only from a specifically fentanyl perspective, but many of the other substances that they're using are oftentimes unknowingly laced with fentanyl as well," Heartview Foundation Chief Operating Officer Jessica Brewster said.

Rapid rise

Bismarck police responded to 34 overdoses in 2019, 74 in 2020 and 72 as of mid-July 2021. Sgt. Mike Bolme said "You know that there's tons more that (people) didn't call the police on."

Bismarck overdose deaths went from four to eight to 11 in those same years, police said.

Mandan police responded to 20 overdoses in 2019, 31 in 2020 and 21 through mid-2021, with four deaths in 2019, one in 2020 and none as of mid-July 2021, Deputy Chief Lori Flaten said. Bismarck and Mandan police both carry Narcan.

Burleigh and Morton counties had 10 overdose deaths in 2019 and 14 in 2020, according to Vital Records.

Fentanyl has become a primary driver of overdoses the last two years, according to Bolme.

Fear of getting in trouble keeps some people from reporting overdoses, he said. But North Dakota has a 2017 Good Samaritan law that grants immunity “if in good faith that individual seeks medical assistance for another individual in need of emergency medical assistance due to a drug overdose.”

Then-Sen. Kelly Armstrong in 2017 discusses a bill for immunity from prosecution for people reporting drug overdoses.

"We not only honor the letter of the law as far as the Good Samaritan law, but we honor the spirit of the law also, so even a close judgment call, we'll do the right thing there," Bolme said. "None of this stuff is worth dying over. We just really need people to understand that they're going to be safe if they call emergency services and then stick around and let us know what they took, because that's important for the medical staff also."

The 2021 Legislature passed a law for enhanced penalties for people who provide controlled substances that result in an overdose death.

"With the proliferation of drugs and the rates of addiction in our state ... and with the lacing of some drugs yet with other drugs ... this is important," Speaker Kim Koppelman, R-West Fargo, told the Senate Judiciary Committee in March.

Sen. JoNell Bakke, D-Grand Forks, discusses a bill for enhanced penalties for drug dealers resulting from overdose deaths.

'Vital' public health partners

Bismarck-Burleigh Public Health focuses on prevention, efforts that include medication take-back and disposal bags and Narcan trainings.

The public health department provides training for the public and distributes the nasal spray subsequently to training, both at no cost. North Dakota's Department of Human Services also makes available a free 2-dose Narcan kit through an online order form.

Numbers of doses administered and people revived by Narcan provided by Bismarck-Burleigh Public Health increased from 51 doses and 32 saves in 2019 to 144 doses and 91 saves in 2020. Some people need more than one dose to be revived, Substance Abuse Prevention Coordinator Sue Kahler said.

Sue Kahler, substance abuse prevention coordinator for Bismarck-Burleigh Public Health, demonstrates Narcan, which revives people from opioid overdoses

Local public health units have been "vital" to overdose prevention, according to Pamela Sagness, who heads the Behavioral Health Division of the state Department of Human Services.

Social isolation due to the pandemic increased people's behavioral health needs, she said. Some people at times in the pandemic didn't feel comfortable seeking services due to the coronavirus, she said. And key for reversing an overdose is "someone needs to be present," she said. 

"With the pandemic and having individuals that are isolated or not around other people socially, there just wasn't the access for family members and friends to potentially save a life administering Narcan when they did have an overdose," Sagness said.

Preventive measures include awareness of who is most at risk of overdosing, such as someone who might relapse after a period of sobriety, she said. 

"Their body has changed, they maybe have been incarcerated or they've started treatment or they've found recovery in another way, and so their body isn't at that same level of tolerance," she said. People just released from prison have fatally overdosed on their way home, she said. 

Increasing access to Narcan and medication-assisted treatment are important efforts toward reducing deaths, she said. Preventing substance abuse in the first place also is key, she said.

In 2019, the state Health Department began tracking in detail deaths such as homicides, suicides and fatal overdoses through the North Dakota Violent Death Reporting System, using multisource data.

State health officials are just beginning to analyze the 2020 data for circumstances and factors in the deaths, said Health Department epidemiologist Kodi Pinks, who oversees the reporting system. 

While detailed specifics of the 2020 overdose deaths aren't yet known, there are some logical parallels, according to James Knopik, addiction and prevention program and policy manager for the Behavioral Health Division. He oversees substance abuse prevention efforts and licensing of treatment programs, and also serves as North Dakota's state opioid treatment authority.

In a spring 2020 North Dakota COVID-19 community impact survey, 68% of respondents indicated "increased mental health struggles (including increased depression and/or anxiety)."

Knopik said "I can't 100% correlate and show you a connection there, but that definitely would seem that that could have played a role."

Treatment and prevention

Isolation and distancing due to the pandemic are "the complete opposite" of the social aspects of recovery, said Brewster, of Heartview. But throughout the pandemic, Heartview saw more people.

"Even though we were telling people to social distance and to practice isolating measures, we continued to see people at increasing rates calling us and walking through our doors to access our services," she said.

About 300 patients are being served in Heartview's medication-assisted treatment programs. Medicaid last fall began covering methadone.

Despite the pandemic's upheaval, people still prioritized their recovery, Brewster said.

"It takes a big leap of faith for people to make those phone calls and for people to access treatment," she said.

Clayton helps people without jobs or driver's licenses get to appointments and navigate food banks, Medicaid and other resources.

"I kind of consider myself a glorified taxi driver at times because I'm constantly giving people rides," he said. 

'We have gotten smarter'

The Legislature has spent millions of dollars in recent years to increase treatment access.

The 2015 Legislature created the substance use disorder treatment voucher, which is used to cover gaps in people's abilities to access services close to them. For example, someone in a rural town who lives far from a publicly funded state human service center could use a voucher to obtain services from a local private provider.

The 2021 Legislature boosted the voucher's two-year funding to $15 million after the $8 million set in 2019 ran out last year. Lawmakers this year also approved two $1 million grants for establishing 16-bed treatment centers in underserved areas in North Dakota.

The 2019 Legislature created "medication units," or satellites of licensed opioid treatment programs for daily dosing of medication. Opioid treatment programs that are licensed in North Dakota are Heartview Foundation in Bismarck and Community Medical Services in Minot and Fargo. The state Human Services Department has not received applications to establish a medication unit.

Addiction has become more prominent in recent years as awareness has grown and more people have encountered the issue, said Sen. Judy Lee, R-West Fargo, who chairs the Senate Human Services Committee.

"We have gotten smarter about the fact that this also is a disease and if we can intervene before it becomes lethal, it's better for the person and ... it's also cheaper than caring for people for many years at the end of life or paying for a whole bunch of medical issues that turn up," Lee said.

Clayton, who aspires to be an auto dealer one day, perceives a lot of people who frown upon methadone for "replacing one drug with another." But he's now able to work and "actually have control of my life." He's worked at Heartview for two years come September.

"I can't say that I'd be where I am without the methadone program," he said. "A lot of the time, it wasn't getting high anymore, it was just trying to not be sick and trying to actually have to end up using heroin just so you can get up and do the day's events, just so you can clean your house, so you could take your kids to school registration, so you could whatever, and it cost $100 (in drugs) every time you have to do something."

"I just didn't want that anymore," he said.

Reach Jack Dura at 701-250-8225 or jack.dura@bismarcktribune.com.

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