DULUTH — On Tuesday, July 23, Sue Purchase loaded up the trunk of her car outside her Duluth home and drove to the Fond du Lac Reservation to make a delivery.
“I was making sure she had a sharps container, Narcan, (fentanyl) test strips, HIV information,” Purchase said later.
Born in Duluth, raised in Cloquet and a veteran of social service activism in Minneapolis, Purchase started a delivery service that plays a unique role in the fight against drug overdoses and death in rural parts of the Northland.
It’s a tough fight in places that lack the resources metropolitan areas have.
“It’s difficult enough for people to make a decision to seek care,” said Debra Wamsley, a behavioral health specialist at the University of Minnesota’s College of Continuing and Professional Studies.
“Then when you have external barriers that are in place, whether it’s distance, lack of access, lack of treatment facilities, lack of choice about the types of treatments that a person might seek, it makes it even more difficult for people to get the care that they need. And ultimately, yes, it results in overdoses and deaths.”
Those involved in the fight in northern Minnesota point to gains when it comes to life-or-death situations.
Narcan (aka naloxone), a drug used to reverse opioid overdoses, is saving lives in rural areas as well as in cities, they report. Carlton County Sheriff Kelly Lake recounted 12 overdoses her deputies have responded to since 2017. In six, the victim had revived by the time deputies arrived and was taken by ambulance to a hospital. In the other six, the deputies administered Narcan.
“I do believe the Narcan definitely saved them in these cases,” Lake wrote in an email.
But there’s less help in rural areas to address the underlying problem, according to Adam Shadiow, executive director of the Arrowhead EMS Association, which represents first responders in northeastern Minnesota.
“We need to expand programs to help people out of the cycle of addiction to these drugs,” he wrote in an email. “There is a tool to help first responders reverse an opioid overdose once it has occurred, but there is little help for the person that overdosed after they have been treated and released.”
Treatment options limited
Although it may seem counterintuitive, medication-assisted treatment — the use of drugs to combat drug addiction — is recommended in concert with counseling and behavioral therapy by the Substance Abuse and Mental Health Services Administration.
In Minnesota, 12 of the 16 medication-assisted treatment providers are located in the seven-county Twin Cities metro area, Wamsley said. One of the remaining four is in Duluth, at the Center for Alcohol and Drug Treatment. Only such providers can dispense methadone, an opioid that’s used in regulated doses to control cravings for other opioids. That means people from across the Arrowhead and Iron Range seeking treatment with methadone must travel to Duluth. And not just occasionally.
“Because it’s so tightly regulated, patients typically have to visit a methadone clinic each day for their daily dose,” said Colin Planalp, a senior research fellow at the State Health Access Data Assistance Center, which is affiliated with the University of Minnesota.
“So, access is limited to people in rural areas, unless … they’re able to drive large distances to obtain their daily dose of methadone,” Planalp said. “And that makes it difficult to just lead daily lives, to hold a job, that kind of thing.”
There are other medication treatment options, each with its own barriers, he said. Unlike methadone, buprenorphine can be prescribed by your physician — if he or she has obtained a federal government waiver to do so.
“And they can take that medication home with them and take their daily dose so they don’t have to drive, in some cases, miles and miles to a methadone clinic,” Planalp said. “(But) there’s a shortage of health care providers who have those waivers to prescribe buprenorphine. And that particularly affects rural areas.”
Finally, there’s naltrexone (aka Vivitrol), which unlike methadone and buprenorphine isn’t an opioid but instead an “antagonist” that blocks the opioid receptors in the brain. Physicians don’t need a waiver to prescribe naltrexone, Planalp said, but many of them decline to do so because they don’t feel they have the necessary training.
Again, that’s especially true in rural areas. In metropolitan areas, the physician can consult with or refer patients to addiction specialists, he said. “But in a rural area, where primary care providers know they don’t necessarily have access to those same specialists in their region, that may contribute to their hesitation to go down that path of prescribing naltrexone.”
The new meth
Although heroin and other opioids might be thought of as an urban phenomenon, the number of deaths from opioids has been increasing at a greater rate in greater Minnesota than in the Twin Cities metro area, Planalp said. From 2000 to 2017, deaths from opioids increased by five-and-a-half times in the Twin Cities; in greater Minnesota, deaths increased by about 12 times.
Meanwhile, methamphetamine, a drug that’s especially identified with rural America, has returned in a new form.
“The meth that you’re seeing now is not the homemade lab stuff that we saw 10 to 15 years ago,” said Lt. Jeff Kazel, commander of the Lake Superior Drug and Violent Crime Task Force. “That’s pretty much dried up. When they implemented the law changes, it really did a good job of drying up those labs.
“The cartels in Mexico picked up on that. They flooded the market. There’s a lot of methamphetamine.”
It may be more deadly than before.
“In rural America, methamphetamine never left,” said Marc Condojani, director of adult treatment and recovery for Colorado’s Office of Behavioral Health. “It is now surging again. It is on the rise. This one will be different, because it will include a higher mortality rate. We’re already seeing it.”
The reason, Condojani told a group of journalists in Denver last month: Unbeknownst to users, some of today’s meth is laced with fentanyl, the extraordinarily powerful opioid that’s also blamed for deaths when added to other opioids, such as heroin.
“And I don’t know that that’s an intentional process by the drug dealers or if it is unsanitary practices,” he said. “One grain of fentanyl on your scales as you’re measuring out different products can be fatal. So we don’t know — we just know that the drug supply is tainted now.”
The U.S. Centers for Disease Control and Prevention reported that in 2016, 11% of overdose deaths involving meth also involved fentanyl. (A larger chunk, 22%, involved heroin.)
Kazel hasn’t had reports of meth with fentanyl in northeast Minnesota, he said. But he’s well aware of that sort of scenario.
“You don’t know what you’re getting out on the street,” he said. “You might have someone saying this is a bag of heroin, and it turns out to be pure fentanyl … Buying on the street is a crapshoot.”
That’s not what consumers perceive, however, said Marcia Gurno, of the substance abuse prevention and intervention team for St. Louis County Public Health and Human Services. “They will tell us, adults and kids, ‘I trust my dealer.’”
Whatever the reason, more deaths are being attributed to methamphetamine. The CDC report showed methamphetamine as eighth among drugs involved in overdose deaths in 2011, with 1,887. Meth remained eighth in 2012, then rose to seventh in 2013 and 2014, fifth in 2015 and fourth in 2016 (behind fentanyl, heroin and cocaine) with 6,762 deaths — an increase from 2011 of more than 250%.
As Kazel noted, the volume of meth appears to be high. The U.S. Drug Enforcement Administration reported last week that its Omaha Division had seen a 31% increase in methamphetamine seizures during the first half of 2019. Total for the division, which includes Minnesota, Iowa, Nebraska and North and South Dakota, was about 1,437 pounds, or $9 million worth of meth.
The fight against drug overdoses in rural areas is a multi-pronged effort involving law enforcement, social service agencies, faith-based organizations, public health, medical personnel … and Sue Purchase.
After working on the frontlines to fight drug addiction in Minneapolis for more than 20 years, Purchase returned to the Northland a year ago, “wanting to arrest the gaps that I’ve always known have existed up here, particularly for people who are poor and using drugs.”
Purchase, who works part-time for the Rural AIDS Action Network in Duluth and Virginia, is taking that agency’s needle exchange on the road with what she calls Harm Reduction Sisters. Harm reduction is the idea behind a needle exchange. The thinking is that people who choose to shoot up drugs at least will have the opportunity to do so in a sanitary way.
But Purchase knew that some people couldn’t easily get to RAAN’s storefront on First Street in Duluth or to its satellite office in Virginia. That’s why, in May, she launched a mobile needle exchange, bringing the syringes and other harm-reduction tools to them. In that time, she has distributed 10,000 syringes, Purchase said last week.
“This is all donations,” Purchase said. “I am not funded. But I’m good at scaring up supplies.”
It’s not just syringes but other supplies such as Narcan and the strips that can tell a user if any fentanyl is in the drug that’s about to be consumed.
She’ll gladly deliver the supplies herself.
Purchase’s visit last week was to a household that had seen overdoses “over and over and over again,” she said.
“It was the best experience,” Purchase said. “We were able to have an amazing conversation. (The householder) talked about how she wanted to get to Duluth but couldn’t because she didn’t have a car.”